RESUMO
BACKGROUND: Despite international bodies calling for increased patient and family involvement, these concepts remain poorly defined within literature on critical and intensive care settings. OBJECTIVE: This scoping review investigates the extent and range of literature on patient and family involvement in critical and intensive care settings. Methodological and empirical gaps are identified, and a future agenda for research into optimizing patient and family involvement is outlined. METHODS: Searches of MEDLINE, CINAHL, Social Work Abstracts and PsycINFO were conducted. English-language articles published between 2003 and 2014 were retrieved. Articles were included if the studies were undertaken in an intensive care or critical care setting, addressed the topic of patient and family involvement, included a sample of adult critical care patients, their families and/or critical care providers. Two reviewers extracted and charted data and analysed findings using qualitative content analysis. FINDINGS: A total of 892 articles were screened, 124 were eligible for analysis, including 61 quantitative, 61 qualitative and 2 mixed-methods studies. There was a significant gap in research on patient involvement in the intensive care unit. The analysis identified five different components of family and patient involvement: (i) presence, (ii) having needs met/being supported, (iii) communication, (iv) decision making and (v) contributing to care. CONCLUSION: Three research gaps were identified that require addressing: (i) the scope, extent and nature of patient involvement in intensive care settings; (ii) the broader socio-cultural processes that shape patient and family involvement; and (iii) the bidirectional implications between patient/family involvement and interprofessional teamwork.
Assuntos
Cuidados Críticos , Unidades de Terapia Intensiva , Participação do Paciente , Assistência Centrada no Paciente , Relações Profissional-Família , Relações Profissional-Paciente , Visitas a Pacientes , Acesso à Informação , Comportamento Cooperativo , Humanos , Disseminação de InformaçãoRESUMO
Informal continuing interprofessional education (CIPE) can be traced back decades in the United States; however, interest in formal CIPE is recent. Interprofessional education (IPE) now is recognized as an important component of new approaches to continuing education (CE) that are needed to increase health professionals' ability to improve outcomes of care. Although there are examples of CIPE programs that are being successfully implemented, a clearly articulated, step-by-step planning process to help guide educators in providing effective CIPE programs is lacking. This lack of guidance poses a significant barrier to increasing the number of CIPE programs in the United States. In this article, we describe a process for developing, implementing, and evaluating CIPE programs using the familiar systematic CE planning process. Limitations of traditional CE also are addressed, and the relationship between CIPE and other new approaches to CE is clarified. Four examples of CIPE programs are provided to illustrate how the planning process can be adapted to include IPE, while implementing recommended changes in traditional CE offerings. The article is concluded with a discussion of some of the challenges that will face CE educators in moving toward a new vision of CE integrated with IPE.
Assuntos
Educação Continuada/organização & administração , Relações Interprofissionais , Currículo , Educação Médica Continuada/organização & administração , Feminino , Guias como Assunto , Humanos , Masculino , Competência Profissional , Desenvolvimento de Programas , Avaliação de Programas e Projetos de Saúde , Integração de SistemasRESUMO
Interprofessional education for collaborative practice is an important innovation globally and in US health professions education. The recent spotlight on interprofessional education in the United States was launched by a series of reports in the US Institute of Medicine's Quality Chasm series. They raised concerns over medical errors and health care quality as significant sources of morbidity and mortality in the United States and proposed health professions' education for patient-centered, team-based care as one means to address these concerns. Starting in 2007, binational, biennial conferences on interprofessional education have been held to synergize interprofessional education developments in the United States and Canada. In 2011, Collaborating Across Borders III, in Tucson, Arizona, drew 750 participants from 11 countries. The conference focused on interprofessional competency frameworks; strategies for preparing students for interprofessional practice; tailoring of learning environments for interprofessional education; and developing policy, infrastructure, culture, and faculty leadership for interprofessional education.
Assuntos
Comportamento Cooperativo , Ocupações em Saúde/educação , Relações Interprofissionais , Equipe de Assistência ao Paciente/normas , Canadá , Congressos como Assunto , Feminino , Ocupações em Saúde/tendências , Humanos , Masculino , Equipe de Assistência ao Paciente/organização & administração , Equipe de Assistência ao Paciente/tendências , Qualidade da Assistência à Saúde , Estados UnidosRESUMO
BACKGROUND: To support the process of effective family decision making, it is important to recognize and understand informal roles that various family members may play in the end-of-life decision-making process. OBJECTIVE: To describe some informal roles consistently enacted by family members involved in the process of end-of-life decision making in intensive care units. METHODS: Ethnographic study. Data were collected via participant observation with field notes and semistructured interviews on 4 intensive care units in an academic health center in the mid-Atlantic United States from 2001 to 2004. The units studied were a medical, a surgical, a burn and trauma, and a cardiovascular intensive care unit. PARTICIPANTS: Health care clinicians, patients, and family members. RESULTS: Informal roles for family members consistently observed were primary caregiver, primary decision maker, family spokesperson, out-of-towner, patient's wishes expert, protector, vulnerable member, and health care expert. The identified informal roles were part of families' decision-making processes, and each role was part of a potentially complicated family dynamic for end-of-life decision making within the family system and between the family and health care domains. CONCLUSIONS: These informal roles reflect the diverse responses to demands for family decision making in what is usually a novel and stressful situation. Identification and description of these informal roles of family members can help clinicians recognize and understand the functions of these roles in families' decision making at the end of life and guide development of strategies to support and facilitate increased effectiveness of family discussions and decision-making processes.
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Tomada de Decisões , Família/psicologia , Cuidados para Prolongar a Vida/psicologia , Assistência Terminal/psicologia , Centros Médicos Acadêmicos , Adulto , Idoso , Cuidadores/psicologia , Feminino , Humanos , Unidades de Terapia Intensiva , Entrevistas como Assunto , Masculino , Pessoa de Meia-Idade , Relações Profissional-Família , Estudos Prospectivos , Papel (figurativo) , Estados UnidosRESUMO
PURPOSE: Traditional expectations of the single attending physician who manages a patient's care do not apply in today's intensive care units (ICUs). Although many physicians and other professionals have adapted to the complexity of multiple attendings, ICU patients and families often expect the traditional, single physician model, particularly at the time of end-of-life decision making (EOLDM). Our purpose was to examine the role of ICU attending physicians in different types of ICUs and the consequences of that role for clinicians, patients, and families in the context of EOLDM. METHODS: Prospective ethnographic study in a university hospital, tertiary care center. We conducted 7 months of observations including 157 interviews in each of four adult critical care units. RESULTS: The term "attending physician" was understood by most patients and families to signify an individual accountable person. In practice, "the attending physician" was an ICU role, filled by multiple physicians on a rotating basis or by multiple physicians simultaneously. Clinicians noted that management of EOLDM varied in relation to these multiple and shifting attending responsibilities. The attending physician role in this practice context and in the EOLDM process created confusion for families and for some clinicians about who was making patient care decisions and with whom they should confer. CONCLUSIONS: Any intervention to improve the process of EOLDM in ICUs needs to reflect system changes that address clinician and patient/family confusion about EOLDM roles of the various attending physicians encountered in the ICU.
Assuntos
Tomada de Decisões , Unidades de Terapia Intensiva , Corpo Clínico Hospitalar , Assistência Terminal , Adulto , Idoso , Idoso de 80 Anos ou mais , Humanos , Entrevistas como Assunto , Pessoa de Meia-Idade , New York , Estudos ProspectivosAssuntos
Atenção à Saúde/organização & administração , Pessoal de Saúde/educação , Relações Interprofissionais , Equipe de Assistência ao Paciente/organização & administração , Competência Profissional , Comportamento Cooperativo , Educação Profissionalizante/organização & administração , Reforma dos Serviços de Saúde , Humanos , Assistência Centrada no Paciente/organização & administração , Gestão da Qualidade Total , Estados UnidosRESUMO
CONTEXT: Despite rapid proliferation of hospital-based palliative care consultation services (PCCSs) across the country, there is little description of the dynamic processes that the PCCS and the non-PCCS hospital cultures experience during the institutionalization of a successful PCCS. OBJECTIVES: To describe the institutionalization of a new PCCS in a quaternary care academic medical center (AMC) and highlight two themes, cost and quality, that pervaded the dynamics involved from the inception to the successful integration of the service. METHODS: Ethnography using longitudinal field observations, in-depth interviews, and the collection of artifacts. The study was performed in a 750-bed quaternary care AMC in the northeastern region of the U.S. Participants were a purposefully selected sample (n=79) of 1) senior-level institutional administrators, including clinical leaders in nursing, medicine, and social work, 2) clinicians who used the PCCS, either commonly or rarely, and 3) members of the PCCS core and extended teams. RESULTS: Key infrastructure components that contributed to the successful integration of the PCCS included top level interprofessional administrative buy-in to the quality and cost arguments for PCCS, PCCS leadership selection, robust data collection strategies emphasizing quality outcome data, the adoption of the "physician referral only" rule, and incremental and sustainable growth. The PCCS service grew an average of 23% per year from 2003 to 2009. CONCLUSION: An in-depth understanding of the dynamic interaction of the infrastructures and processes of a successful institutionalization, in their unique complexity, may help other PCCSs identify and negotiate attributes of their own circumstances that will increase their chances for successful and sustainable implementation.
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Centros Médicos Acadêmicos/organização & administração , Cuidados Paliativos/organização & administração , Encaminhamento e Consulta/organização & administração , Centros Médicos Acadêmicos/economia , Centros Médicos Acadêmicos/normas , Custos de Cuidados de Saúde , Humanos , Corpo Clínico Hospitalar , Profissionais de Enfermagem , Cuidados Paliativos/economia , Cuidados Paliativos/normas , Equipe de Assistência ao Paciente , Médicos , Encaminhamento e Consulta/economia , Encaminhamento e Consulta/normasRESUMO
Objective. To illustrate distinctions and intersections of palliative care (PC) and end-of-life (EOL) services through examples from case-centered data of older adults cared for during a four-year ethnographic study of an acute care hospital palliative care consultation service. Methods. Qualitative narrative and thematic analysis. Results. Description of four practice paradigms (EOL transitions, prognostic uncertainty, discharge planning, and patient/family values and preferences) and identification of the underlying structure and communication patterns of PC consultation services common to them. Conclusions. Consistent with reports by other researchers, study data support the need to move beyond equating PC with hospice or EOL care and the notion that EOL is a well-demarcated period of time before death. If professional health care providers assume that PC services are limited to assisting with and helping patients and families prepare for dying, they miss opportunities to provide care considered important to older individuals confronting life-limiting illnesses.
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This article describes the emergence of the American Interprofessional Health Collaborative to rebuild capacity for interprofessional education and care in the U.S. through an inclusive, evidence-based and open exchange of information and resources. Also described are the historical context and the national and international climate for its emergence.
Assuntos
Pessoal Técnico de Saúde/educação , Pessoal Técnico de Saúde/história , Educação Profissionalizante/história , Estudos Interdisciplinares , Modelos Educacionais , Comportamento Cooperativo , Avaliação Educacional/história , História do Século XX , História do Século XXI , Humanos , Relações Interprofissionais , Estados UnidosRESUMO
PURPOSE: Prior researchers studying end-of-life decision making (EOLDM) in intensive care units (ICUs) often have collected data retrospectively and aggregated data across units. There has been little research, however, about how cultures differ among ICUs. This research was designed to study limitation of treatment decision making in real time and to evaluate similarities and differences in the cultural contexts of 4 ICUs and the relationship of those contexts to EOLDM. MATERIALS AND METHODS: Ethnographic field work took place in 4 adult ICUs in a tertiary care hospital. Participants were health care providers (eg, physicians, nurses, and social workers), patients, and their family members. Participant observation and interviews took place 5 days a week for 7 months in each unit. RESULTS: The ICUs were not monolithic. There were similarities, but important differences in EOLDM were identified in formal and informal rules, meaning and uses of technology, physician roles and relationships, processes such as unit rounds, and timing of initiation of EOLDM. CONCLUSIONS: As interventions to improve EOLDM are developed, it will be important to understand how they may interact with unit cultures. Attempting to develop one intervention to be used in all ICUs is unlikely to be successful.
Assuntos
Tomada de Decisões , Unidades de Terapia Intensiva , Cultura Organizacional , Assistência Terminal , Adulto , Antropologia Cultural , Humanos , Unidades de Terapia Intensiva/organização & administração , Cuidados para Prolongar a Vida , Mid-Atlantic Region , Equipe de Assistência ao Paciente/organização & administração , Papel do Médico , Relações Profissional-Família , Estudos Prospectivos , Ordens quanto à Conduta (Ética Médica) , Assistência Terminal/organização & administração , Fatores de Tempo , Suspensão de TratamentoRESUMO
Expert opinion supports the application of broad interdisciplinary team approaches to the care of the dying patient in the intensive care unit (ICU). Current literature contains many suggestions about how core team members-physicians, nurses, and patients/family members-could systematically enhance interdisciplinary collaboration in the care of the dying patient. In the few studies of ICU interdisciplinary collaborative care of the dying patient, investigator shave demonstrated improvement in care. In addition, ethics consultants and interdisciplinary palliative care teams, working with the core team members, have improved care for the dying. Further studies are needed to document alternative interdisciplinary models for achieving improved and durable patient, family,and provider outcomes in the care of the dying ICU patient.
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Cuidados Críticos , Equipe de Assistência ao Paciente/organização & administração , Papel Profissional , Assistência Terminal , Planejamento Antecipado de Cuidados , Comportamento Cooperativo , Cuidados Críticos/ética , Cuidados Críticos/organização & administração , Cuidados Críticos/psicologia , Tomada de Decisões Gerenciais , Documentação , Consultoria Ética/organização & administração , Humanos , Relações Interprofissionais/ética , Modelos Organizacionais , Equipe de Assistência ao Paciente/ética , Guias de Prática Clínica como Assunto , Papel Profissional/psicologia , Relações Profissional-Família , Assistência Terminal/ética , Assistência Terminal/organização & administração , Assistência Terminal/psicologia , Gestão da Qualidade Total/organização & administração , Suspensão de TratamentoRESUMO
The purpose of this paper is to describe how Sally Gadow's perspectives on existential advocacy as the moral framework for the nurse-patient relationship were synthesized with a general theory of motivation, self-determination theory (SDT), to inform the design of a study in which the influence of interpersonal care on the process of tobacco dependence treatment was explored. Consistent with the tenets of existential advocacy, participants who perceived their care providers as interpersonally sensitive and bringing more of their whole selves to the care encounter reported more autonomous motivation and felt competence for stopping smoking. The integration of existential advocacy with SDT, which led to the empirical work in which Gadow's ideas were actualized and her model supported, is described. Study findings are discussed in light of Gadow's philosophical views, and implications for nursing highlighted.