Interprofessional communication in the care of adults with cancer: exploring clinicians' perceptions of team rounding.

Interprofessional communication (IPC) is important for the inpatient oncology team due to the complexity and acuity of oncology patients. One intervention used to improve IPC is team rounding, yet few researchers have explored experiences of team members with team rounding. In this study, 12 interviews were conducted with providers from five different professions: Nursing Assistant, Registered Nurse, Pharmacist, Advanced Practice Provider, and Physician. We aimed to identify communication barriers and explore providers' perceptions of team rounding and IPC through semi-structured interviews on the adult inpatient oncology unit. Interviews were coded and conventional content analysis used. Facilitators identified were: effective team communication: (a) including interprofessional stakeholders in rounding and communication; (b) the importance of "real-time" communication; and (c) team dynamics. Barriers identified were: effective team communication: (a) workflow-related issues and (b) team dynamics. Findings from this study indicate each profession had unique perceptions, but all had a positive outlook on the necessity of IPC in the delivery of optimal cancer care.

A review to characterise and map the growth mindset theory in health professions education.

INTRODUCTION: Growth mindset is a motivation theory proposed by Carol Dweck that posits our beliefs about intelligence, and the ability to change mindsets can have impacts on how we approach challenges, respond to criticism challenges and orient our goals. This study characterised articles on growth mindset theory in health professions education to: summarise the aspects of growth mindset being researched, describe the discussed benefits of growth mindset theory and outline strategies discussed that may promote a growth mindset. METHODS: A systematic review of the literature yielded 4927 articles-articles were reviewed and excluded if they were outside of health professions education and did not discuss Dweck's growth mindset theory. The final review yielded 14 research articles and 13 commentaries, which were characterised and analysed using content analysis. RESULTS: The included articles were published in 2016 and beyond; the articles represented a diverse context, participant type and approach. Most research studies measured participant mindsets and evaluated the correlation with other variables (eg grit, well-being, anxiety). Articles often highlighted benefits and strategies to promote a growth mindset at the learner, educator and organisation level. The most common learner benefits were to help them be more receptive to feedback as well as increased resiliency and perseverance, educator benefits focused on supporting collaborative relationships and safe learning environments. The most prevalent strategies discussed were teaching learners about growth mindset theory, shifting faculty feedback to emphasise effort and to prioritise feedback across the organisation. CONCLUSION: The growth mindset framework has been shown in other fields to help others manage educational challenges and enhance learning environments. Researchers are encouraged to explore how interventions such as teaching about and prioritising a growth mindset can support learners, health care professionals, educators and organisations.

An Appraisal of School Nurse Health Services and Programs in North Carolina Public Schools, 2006-2016.

School nurses are instrumental in delivering health services to children in schools. This study addresses the gap in school nurse health services data, examining patterns in health services and programs provided by school nurses between 2006 and 2016 for students in North Carolina public schools. This study focused on services and programs related to asthma and diabetes, two health conditions that affect millions of children in the United States. Over 1.46 million children attend North Carolina public schools. In 2006, the average school nurse-to-student ratio was 1:1,340. By 2016, the average school nurse-to-student ratio decreased to 1:1,086, a 19% improvement. Over the 10-year study time period, there were statistically significant increases in the rate of occurrence of all health conditions that students received health services for (p < .001), asthma (p < .001), type I diabetes (p = .0003), orders for all health-care procedures (p = .01), all school nurse-led health counseling (p = .004), and diabetes health counseling (p < .01).

Interprofessional collaboration between health sciences librarians and health professions faculty to implement a book club discussion for incoming students.

BACKGROUND: The following case example provides an overview of one innovative way to engage health professions faculty with health sciences librarians in the development of an interprofessional book discussion and identifies strategies to address implementation challenges. Academic health sciences librarians worked with the Interprofessional Education (IPE) Steering Committee to organize interprofessional book discussion groups for incoming health professions students. This inaugural book discussion brought together students and faculty of different disciplines to engage students in "learning from, with, and about" other professions. CASE PRESENTATION: When Breath Becomes Air, by Paul Kalanithi, allowed involved discussions on important health sciences issues. The project included outreach, designing pre- and post-surveys, scheduling participants, and communicating with all participants before, during, and after the event. A total of seventy-nine students and thirty-six faculty, representing all health professions schools, participated in the small group IPE book discussions over two weeks. CONCLUSIONS: Small group book discussions have been shown to be an effective tool to engage students and faculty in IPE. The results of the participant surveys were positive, and the IPE Steering Committee found value in including health sciences librarians throughout the process. Lessons learned from the pilot project include needing an efficient scheduling system, strongly communicating at all stages of the project, and starting the planning process months ahead of time. The IPE Steering Committee plans to conduct similar book discussions every fall semester moving forward and explore options for other IPE events.

Call for ACTion: Transforming Dental Education at the University of North Carolina at Chapel Hill.

The University of North Carolina at Chapel Hill Adams School of Dentistry is developing a transformative curriculum that prepares students to enter contemporary practice. The Advocate, Clinician, and Thinker (ACT) framework will provide the basis for developing a resilient workforce capable of meeting emerging health care needs over the next 40 years.

Exploring New Paradigms for Team-Based Care.

In this issue of the North Carolina Medical Journal we have focused on team-based care and recognized some of the innovative models of true collaboration aiming to improve patient and population health outcomes. This issue offers examples for integrating care in behavioral health, hospice, and primary care as well as strategies for creating unique partnerships with churches, legal services, and public health workers. We will also explore the role technology plays as a team member and the financial implications of team-based care.

The Impact of Caring: Teaching Students Empathy Through the Patient Voice.

The purpose of this educational brief is to describe an innovative learning experience focused on teaching students empathy for chronic illness, using patient voices. Panel members of individuals who had experienced acute and chronic illness from either the perspective of the patient or caregiver participated in a one-time session for undergraduate baccalaureate nursing students. Panel members presented their narrative to the students, engaging them in a question-and-answer session about the impact of nursing care on their experience. Both the panelists and the students found the experience meaningful. Over time the panel has varied in format, but has consistently humanized the patient experience, highlighted the importance of empathy, and conveyed the impact that nurses have on their patients and families. This innovative strategy proved to be very beneficial for students transitioning into their first clinical experience.

A new mindset for quality and safety: the QSEN competencies redefine nurses' roles in practice.

Preventable errors are a major issue in health care. The complexity of health care requires interactions among numerous providers for any patient multiple times a day. Nurses are the constant presence with patients and have an important role in coordinating the contributions of the myriad of caregivers. Nurses are also the last line of defense. Increasingly, it is recognized that nurses need to be better prepared with quality and safety competencies to have a leading role in making our healthcare system safer.This article presents evidence related to quality and safety, describes the six core competencies from the Quality and Safety Education for Nurses (QSEN) project for integration in nursing practice, describes a practice based on inquiry and engagement, and presents a toolkit for developing a new mindset based on new quality and safety science.

Exploring the impact of augmenting sedation assessment with physiologic monitors.

BACKGROUND: Pharmacological sedation is a necessary tool in the management of critically ill, mechanically ventilated patients. The intensive care unit (ICU) sedation strategy is to use the least amount of medication to meet safety and comfort goals. Titration of pharmacological agents is currently guided by clinical assessment tools. The purpose of this study was to determine whether the addition of a neurophysiological monitor, bispectral index (BIS), aided the ICU nurse in reducing the amount of drug used, compared to a clinical tool alone, in a general critical care population. METHODS: In this prospective clinical trial, mechanically ventilated adults (N=300) were randomised to sedation assessment using only the observational assessment tool (RASS) or a combination of observational and physiologic measures (RASS+BIS). Subjects were enrolled from a medical ICU (N=154), a trauma ICU (N=72) and a general mixed-use ICU (N=74). RESULTS: BIS-augmented sedation was only associated with the reduction of drug use when patients were sedated with propofol or narcotic agents (propofol [1.61 mg/kg/h vs. 1.77 mg/kg/h; p<0.0001], fentanyl [54.73 mcg/h vs. 66.81 mcg/h; p<0.0001], and hydromorphone [0.97 mg/h vs. 4.00 mg/h: p<0.0001] compared to RASS alone. In contrast, patients sedated with dexmedetomidine or benzodiazepines were given higher doses under the BIS-augmented dexmedetomidine [0.46 mcg/kg/h vs. 0.33 mcg/kg/h; p<0.0001], lorazepam [4.13 mg/h vs. 3.29 mg/h p<0.0001], and midazolam [3.73 mg/h vs 2.86 mg/h; p<0.0001]) protocol compared to clinical assessment alone. CONCLUSION: The clinical evaluation of depth of sedation remains the most reliable method for the titration of pharmacological sedation in the critical care unit. However, BIS-augmented assessment is helpful in reducing the amount of propofol and narcotic medication used and may be considered an adjunct when these agents are utilised.

A new mindset for quality and safety: the QSEN competencies redefine nurses' roles in practice.

Preventable errors are a major issue in health care. The complexity of health care requires interactions among numerous providers for any patient multiple times a day. Nurses are the constant presence with patients and have an important role in coordinating the contributions of the myriad of caregivers. Nurses are also the last line of defense. Increasingly, it is recognized that nurses need to be better prepared with quality and safety competencies to have a leading role in making our healthcare system safer. This article presents evidence related to quality and safety, describes the six core competencies from the Quality and Safety Education for Nurses (QSEN) project for integration in nursing practice, describes a practice based on inquiry and engagement, and presents a toolkit for developing a new mindset based on new quality and safety science.

Using a change management model to develop and implement dental curricula: A case study.

Curriculum transformation is a guiding principle and driving force to continued institutional growth and innovation in oral health education. The transformation process starts from the need and desire for change to achieve the strategic goals of curriculum invocation. The design and implementation process must follow a systematic approach to ensure the oral health curricula are meeting the demands of preparing learners for their future careers and are in line with the institutional strategic goals and processes. The process of curriculum transformation needs to be carefully crafted and implemented to include all constituents and have clear and measurable outcomes to define its path and results. The University of North Carolina at Chapel Hill Adams School of Dentistry is undergoing the journey of oral health curriculum innovation and transformation. The goal of this paper is to describe the change management process using Kotter's organizational model that may apply to other schools aiming to innovate dental curricula.

Promoting Whole Health in the Dental Setting: Steps Toward an Integrated Interprofessional Clinical Learning Environment Involving Pharmacy, Social Work, and Nursing.

INTRODUCTION: Dental settings have not traditionally functioned as access points to the health care system, however they can serve patients who may not otherwise seek routine health care. Millions of Americans annually visit either a dental or primary care provider, but not always both as recommended, even though multiple health co-morbidities can manifest in and impact oral health. Offering multidisciplinary health services in a dental setting has potential to reach unserved populations. DESCRIPTION: Innovative partnerships between schools of dentistry, pharmacy, social work, and nursing were designed to promote integrated service delivery in the emerging workforce and the purposeful inclusion of oral health in integrated care settings. DISCUSSION: Oral complications of systemic disease and systemic complications of oral disease impose significant burdens on populations and the public health infrastructure in terms of economic cost, disability, and mortality. Exacerbated by the lack of integrated services, intersecting social, economic, and health issues perpetuate disparities and negative health outcomes. Care is often focused on reactive rather than preventive measures therefore addressing only the acute issue instead of the underlying, causative problem(s). CONCLUSION: We describe steps for integrated, whole-health services and lessons learned for other academic health institutions and interprofessional settings considering integrated clinical models.

Increasing Home Healthcare Referrals and Access to Community Resources in Response to High Emergency Department Utilization.

The goal of this interprofessional quality initiative project was to decrease emergency department (ED) visits for nonemergency health problems by referring superutilizers to home healthcare or connecting them with existing community resources. An interprofessional team of students from schools of nursing, public health, and occupational therapy collaborated on a community assessment, investigated and gathered community resources, and interviewed key stakeholders at a rural ED to identify the root causes of high utilization. Using these data, we designed an algorithm for ED clinicians that provided an organized community resource collection and electronic resources for ED staff. We focused on encouraging an increase in the evaluation of patients for eligibility to receive home healthcare services.

Experiential clinical learning for newly licensed PhD students: Transforming nursing PhD education through academic-practice partnerships.

The growing national and international need for nurse scientists to transform health care has encouraged advances in nursing doctoral programs. The Hillman Scholars in Nursing Innovation, a program integrating BSN and PhD education, inspired the creation of the Hillman Clinical Fellowship ("Fellowship"). The Fellowship helps students transitioning from the BSN to PhD gain clinical experiences as newly graduated registered nurses, thus mitigating a common concern that students are naïve about the clinical setting. In collaboration with a practice partner, the Fellowship fosters development of clinical skills consistent with Patricia Benner's Novice to Expert Model. Fellows build clinical skills concurrent with the development of research proficiencies in the PhD program. This Fellowship can be adapted by other schools seeking to introduce curricular innovations that address the needs of early career PhD students, enhance academic-practice partnerships, and meet the growing need for more clinically focused PhD prepared nurses.

Impact of School Nurse Ratios and Health Services on Selected Student Health and Education Outcomes: North Carolina, 2011-2016.

BACKGROUND: Determination of adequate school nurse staffing is a complex process. School nurse-to-student ratios and the health services school nurses provide to students should be considered. The purpose of this study was to examine the impact of North Carolina school nurse-to-student ratios and school nurse health services on the health and education outcomes (eg, absences, grades, self-management) of students receiving services for asthma and diabetes. METHODS: This study of all 115 school districts in North Carolina used the Annual School Health Services Report Survey from 2011 to 2016. Descriptive statistics for health services, programs and outcomes, and generalized linear modeling were used to estimate the association of ratios and health services with asthma and diabetes outcomes. RESULTS: By the 2015-2016 school year, the average ratio decreased to 1:1086 in North Carolina public schools. Annually, 100,187 students received services for asthma, 3832 students received services for type 1 diabetes, and 913 students received services for type 2 diabetes. Lower ratios and nurse health services were associated with improved student outcomes, including decreased absences (p = .05), improved grades (p = .05), and student self-management of their health condition (p = .05). CONCLUSIONS: Lower school nurse-to-student ratios and services were associated with improvements in students' health and education outcomes.

Instrument development measuring critical care nurses' attitudes and behaviors with end-of-life care.

BACKGROUND: Although critical care nurses are expected to focus on providing life-sustaining measures, many intensive care patients actually receive end-of-life care. OBJECTIVES: The aim of this study was to develop an instrument to measure nursing attitudes and behaviors regarding end-of-life care. METHOD: Phase 1 was focused on item development from a content analysis of the literature and qualitative interviews of critical care nurses. Phase 2 consisted of content validity assessment and pilot testing. Phase 3 included field testing, factor analysis, and reliability estimation. RESULTS: The Values of Intensive Care Nurses for End-of-Life (n = 695) was found to have four factors: Self-appraisal, Appraisal of Others, Emotional Strain, and Moral Distress. Reliability estimates ([alpha]) were acceptable at .59-.78, but the interitem range (.12-.78) was wider than desirable. Test-retest reliability was deemed adequate based on Pearson's correlations (.68-.81) and intraclass correlation coefficients (.65-.79) but less so when considering [kappa] (.05-.30). The Behaviors of Intensive Care Nurses for End-of-Life (n = 682) was found to have two factors: Communication and Nursing Tasks. Reliability estimates were adequate when considering internal consistency ([alpha] = .67 and .78, respectively), item total correlations (.30-.61), and test-retest as judged by Pearson's and intraclass correlations (.77-.81) but not when [kappa] was considered (.02-.40). The interitem correlations (.20-.35) were also lower than desirable. DISCUSSION: Both the Values of Intensive Care Nurses for End-of-Life and the Behaviors of Intensive Care Nurses for End-of-Life were found to have conceptually linked factors and acceptable internal consistency estimates ([alpha]). However, test-retest estimates were inconsistent, suggesting that further work needs to be done on the stability of these instruments.

Characteristics of High-Performing Interprofessional Health Care Teams Involving Student Pharmacists.

Objective. To identify key themes of interprofessional models of care that offer experiential education opportunities for pharmacy learners. Methods. Six pharmacists from four Area Health Education Centers in North Carolina participated in individual, 60-minute interviews. Using two pre-established frameworks, the data were analyzed qualitatively by two members of the research team to identify the characteristics of interdisciplinary care teams. Results. At the level of the organization or health care system, the theme of appropriate resources and procedures emerged. At the level of the team, the themes of appropriate resources and procedures, communication, appropriate skill mix, climate, quality and outcomes of care, and respecting and understanding roles emerged. At the level of the individual, the themes of communication, respecting and understanding roles, and individual characteristics emerged. Three themes identified in a previous study failed to emerge in the interviews: leadership and management; personal rewards, training and development; and clarity of vision. Conclusion. Although a growing body of evidence highlights the importance of designing practice models to achieve interdisciplinary care that is patient-centered and effective, capacity to support learners and effectively educate them in the principles and practices of team-based care is limited. This study provides critical insight into characterizations of interprofessional models that integrate pharmacy learners. Further research is needed to better understand the barriers to designing and implementing IPE in experiential settings.

Developing a curriculum blueprint and taxonomy: Process, progress, and pivots.

Curriculum transformations represent opportunities to innovate; however, there are few examples to inform this process. In 2018, the University of North Carolina at Chapel Hill (UNC) Adams School of Dentistry began to transform the predoctoral curriculum to improve content integration, enhance team-based experiences, and develop leaders. Part of this experience has been crafting a conceptual curriculum guide or "blueprint" that outlines a vision for the design process and ensures the transformation achieves its goals. We describe how we created the UNC Blueprint for our revised curriculum, which defines who our graduates are, what they know, and what they can do. This approach has led us to develop a mapping taxonomy to ensure the student outcomes are appropriately aligned with content, instruction, and assessment throughout the curriculum. Last, we encourage others to be agile in their approach, create a common language among their teams, and frequently engage faculty to facilitate the process.

The nature of advocacy vs. paternalism in nursing: clarifying the 'thin line'.

AIM: This paper is an exploration of the concepts of advocacy and paternalism in nursing and discusses the thin line between the two. BACKGROUND: Nurses are involved in care more than any other healthcare professionals and they play a central role in advocating for patients and families. It is difficult to obtain a clear definition of advocacy, yet the concepts of advocacy and paternalism must be compared, contrasted, and discussed extensively. In many situations, only a thin line distinguishes advocacy from paternalism. DATA SOURCES: A literature search was conducted using PubMed and CINAHL databases (2000-2008) as well as a library catalogue for texts. DISCUSSION: Four case stories were described in order to discuss the 'thin line' between advocacy and paternalism and develop communication strategies to eliminate ambiguity. Weighing the ethical principles of beneficence and autonomy helps to clarify advocacy and paternalism and provides an avenue for discussion among nurses practicing in a variety of settings. IMPLICATIONS FOR NURSING: Advocacy and paternalism should be discussed at interdisciplinary rounds, and taken into consideration when making patient care decisions. It is difficult to clarify advocacy vs. paternalism, but strategies such as knowing the patient, clarifying information, and educating all involved are initial steps in distinguishing advocacy from paternalism. CONCLUSION: Truly 'knowing' patients, their life experiences, values, beliefs and wishes can help clarify the 'thin line' and gain a grasp of these difficult to distinguish theoretical concepts.