Interprofessional collaboration in family health teams: An Ontario-based study.

OBJECTIVE: To examine family health team (FHT) members' perspectives and experiences of interprofessional collaboration and perceived benefits. DESIGN: Qualitative case study using semistructured interviews. SETTING: Fourteen FHTs in urban and rural Ontario. PARTICIPANTS: Purposeful sample of the members of 14 FHTs, including family physicians, nurse practitioners, nurses, dietitians, social workers, pharmacists, and managers. METHODS: A multiple case-study approach involving 14 FHTs was employed. Thirty-two semistructured interviews were conducted and data were analyzed by employing an inductive thematic approach. A member-checking technique was also undertaken to enhance the validity of the findings. MAIN FINDINGS: Five main themes are reported: rethinking traditional roles and scopes of practice, management and leadership, time and space, interprofessional initiatives, and early perceptions of collaborative care. CONCLUSION: This study shows the importance of issues such as roles and scopes of practice, leadership, and space to effective team-based primary care, and provides a framework for understanding different types of interprofessional interventions used to support interprofessional collaboration.

Interprofessional primary care protocols: a strategy to promote an evidence-based approach to teamwork and the delivery of care.

Primary care reform involving interprofessional team-based care is a global phenomenon. In Ontario, Canada, 150 Family Health Teams (FHTs) have been approved in the past few years. The transition to a FHT is complex involving many changes and the processes for collaborative teamwork are not clearly delineated. To support the transition to team-based care in FHTs, a project was undertaken to develop and implement a series of interprofessional protocols in four clinical areas. These interprofessional protocols would contain relevant and evidence-based resources to support both a team and evidence-based approach to care. This paper reports on a qualitative study to examine the process of interprofessional protocol development and pilot implementation. Adopting an exploratory case study approach (Robson, 2002 ), 36 interviews were conducted with health professionals and community group members who participated in the creation and piloting of the protocols, and with project managers. In addition, observational and documentary data were gathered on the protocol development and implementation processes. The findings from the protocol development stage demonstrate the value of the focus on evidence and team, the process of assessing and targeting FHT needs, inter-organizational and interprofessional sharing, the importance of facilitation and support, and expectations for implementation. The findings from the pilot implementation stage report on the importance of champions and leaders, the implementation strategies used, FHT and organizational factors affecting implementation, and outcomes achieved. Findings are discussed in relation to the knowledge translation and interprofessional literature. Research is ongoing to examine the effectiveness of dissemination of the protocols to FHTs across the province of Ontario and its impact on health care outcomes.

Are nonphysician health care providers prepared and supported to teach in family medicine?

BACKGROUND AND OBJECTIVES: Understanding how nonphysician health care providers (NPHCPs) teach medical trainees is integral to optimizing family medicine education. The objective of this study was to examine the teaching roles, level of preparation and support, and the challenges encountered by NPHCPs. METHODS: A cross-sectional web-based survey of NPHCPs was conducted across academic teaching units affiliated with the University of Toronto's Department of Family and Community Medicine (DFCM). The level of preparation for educational roles, perceived support, challenges encountered, and educational training needs of NPHCPs were examined. Variables associated with preparedness to teach were also identified. RESULTS: Of the 193 NPHCPs surveyed, 166 (86%) completed the questionnaire. A total of 126 (82%) of NPHCP educators (nurses, social workers, dietitians, and pharmacists) reported teaching medical trainees. Most did not hold faculty appointments. The majority had no formal training in teaching, and less than half felt prepared for their academic responsibilities. NPHCPs perceived a lack of support for their teaching. NPHCPs also identified predictable challenges such as lack of time and lack of funding. Challenges specific to cross-professional teaching were also identified. NPHCPs expressed an interest in receiving continuing education to improve their teaching skills. NPHCPs' self-reported level of preparedness to teach was variable and associated with years of teaching experience, information received about trainees, challenges faced, and continuing education needs. CONCLUSIONS: NPHCPs are extensively involved in teaching medical trainees. There is variability in their preparation level, and they encounter significant challenges. To advance effective and sustainable inter-professional education (IPE) within family medicine, addressing these issues is crucial.

Guideline harmonization and implementation plan for the BETTER trial: Building on Existing Tools to Improve Chronic Disease Prevention and Screening in Family Practice.

BACKGROUND: The aim of the Building on Existing Tools to Improve Chronic Disease Prevention and Screening in Family Practice (BETTER) randomized controlled trial is to improve the primary prevention of and screening for multiple conditions (diabetes, cardiovascular disease, cancer) and some of the associated lifestyle factors (tobacco use, alcohol overuse, poor nutrition, physical inactivity). In this article, we describe how we harmonized the evidence-based clinical practice guideline recommendations and patient tools to determine the content for the BETTER trial. METHODS: We identified clinical practice guidelines and tools through a structured literature search; we included both indexed and grey literature. From these guidelines, recommendations were extracted and integrated into knowledge products and outcome measures for use in the BETTER trial. End-users (family physicians, nurse practitioners, nurses and dieticians) were engaged in reviewing the recommendations and tools, as well as tailoring the content to the needs of the BETTER trial and family practice. RESULTS: In total, 3-5 high-quality guidelines were identified for each condition; from these, we identified high-grade recommendations for the prevention of and screening for chronic disease. The guideline recommendations were limited by conflicting recommendations, vague wording and different taxonomies for strength of recommendation. There was a lack of quality evidence for manoeuvres to improve the uptake of guidelines among patients with depression. We developed the BETTER clinical algorithms for the implementation plan. Although it was difficult to identify high-quality tools, 180 tools of interest were identified. INTERPRETATION: The intervention for the BETTER trial was built by integrating existing guidelines and tools, and working with end-users throughout the process to increase the intervention's utility for practice. TRIAL REGISTRATION: ISRCTN07170460.

Uncomplicated urinary tract infection in women. Current practice and the effect of antibiotic resistance on empiric treatment.

OBJECTIVE: To review treatment recommendations for empiric therapy of uncomplicated urinary tract infection (uUTI) in light of evolving antibiotic resistance and to consider use of guidelines to promote optimal practice. QUALITY OF EVIDENCE: PubMed was searched and additional relevant references were identified by reviewing articles found in the search. Guidelines were identified through discussion with family practitioners. Level of evidence was assessed for recommendations. MAIN MESSAGE: Many women have uUTIs. The treatment approach is usually empiric antimicrobial therapy without obtaining pretherapy cultures. Trimethoprim-sulfamethoxazole is standard first-line empiric treatment. While resistance to this drug is increasing, it remains only about 10% in community-acquired Escherichia coli in Canada. Concerns about increased resistance have contributed to greater use of fluoroquinolones, but widespread empiric use of this class of medications might promote resistance to fluoroquinolones. Hence, fluoroquinolones should not be considered first-line therapy. While guidelines for treatment of uUTIs have been developed, their usefulness is compromised by their conflicting recommendations. CONCLUSION: Trimethoprim-sulfamethoxazole and nitrofurantoin remain first-choice empiric therapy for uUTIs. Development of guidelines relevant to family physicians and community education programs that incorporate local susceptibility patterns are important strategies for promoting optimal practice.