How does mHealth influence consulting practice between health professionals and individuals with low back pain? - A qualitative study from the perspective of health professionals.

PURPOSE: This study explored how health professionals experience in what way a digital self-monitoring solution influences their consulting practice targeting individuals with low back pain. MATERIAL AND METHODS: This was a qualitative study adopting a constructivist grounded theory approach. Nineteen health professionals participated in the pilot test of the digital self-monitoring solution BackTrace. Data were collected cross-sectionally and consisted of: (a) audio recordings from focus groups with health professionals, (b) field notes from participant observation of online meetings with health professionals, (c) field notes from participant observations of consultations between health professionals and individuals with low back pain and (d) audio recordings from workshops with health professionals. RESULTS: Two main themes and one sub-theme were identified, describing how BackTrace enabled more focused consulting practices, supported patient-self management and improved the relationship between individuals with low back pain and health professionals. Barriers were identified describing how the implementation of digital health solutions required a change in workflow, resources and culture - as well as management support. CONCLUSIONS: Findings indicated a need for a change at the system level, including a changed view of digitisation in healthcare systems containing a more supporting approach.

Low back pain is a leading cause of disability which not only impacts physically but restricts quality of life.This study shows how health professionals experience in what way digital self-monitoring solutions influence their consulting practices targeting individuals with low back pain.A digital self-monitoring solution may contribute to a more focused consulting practice and improve the quality of the relationship between individuals with low back pain and health professionals but require changes at a system level.A change in workflow and culture is recommended if digital health is to be a success.

Emerging Neurotechnologies: Implications for Professional Relations and Communication.

Rapid advances in neurotechnology and neurosurgery are positioned to revolutionize care for patients suffering from debilitating neurological and psychiatric disease. Enthusiasm for the adoption of these technologies is tempered by ethical dilemmas regarding resource allocation, provision of care, communication with patients and other providers, and other potential pitfalls. In the present work, we discuss bioethical implications of novel neurotechnologies for medical practice. In particular, we examine the implications of neurotechnological advancement through the lens of professional communication. Emerging challenges within this domain are presented in the context of physician interactions with four key partners: (i) patients; (ii) other physicians; (iii) industry; and (iv) society-at-large. Anticipated issues as well as mitigation strategies are discussed as they relate to communication with these stakeholders.

Health professionals' experiences of rapport during telehealth encounters in community palliative care: An interpretive description study.

BACKGROUND: Despite the reported importance of rapport, there are knowledge gaps in the ways rapport is developed and experienced by health professionals during telehealth calls in palliative care. AIM: To gain an understanding about developing rapport during telehealth calls by exploring the experiences of health professionals in community palliative care. DESIGN: A qualitative Interpretive Description study was conducted with semi-structured interviews and focus groups between November 2020 and May 2021. Data was audio recorded, transcribed, and analysed using Reflexive thematic analysis. A COREQ checklist was completed. SETTING/PARTICIPANTS: Thirty-one palliative care professionals who had participated in telehealth calls were recruited from four hospice locations in Aotearoa, New Zealand. RESULTS: There were two themes identified: (1) 'Getting on together', which included how rapport shows up in telehealth, with examples of calls with rapport and without rapport, and (2) 'Rapport is a soft skill', which identified health professionals using body language and listening in specific ways in telehealth, while being aware of the privacy of calls, and lack of training concerns. CONCLUSION: Based on health professionals experiences of rapport it was determined that rapport is vitally important in telehealth calls, as it is in-person interactions. Rapport is a soft skill that can potentially be learned, practiced and mastery developed, although rapport in each interaction is not guaranteed. Patient and family experiences of rapport in the palliative telehealth area warrants further research and there is some urgency for health professional training in telehealth interpersonal skills.

Cost-Effectiveness of Inter-Professional Collaboration to Reduce Hospitalisations in Nursing Home Residents: Results from the German Interprof ACT Trial.

Background: The German multi-centre cluster-randomised controlled trial interprof ACT investigated interventions to increase inter-professional collaboration between nursing home (NH) staff and local general practitioners to reduce hospitalisations and improve nursing homes residents' (NHRs) quality of life. The trial was funded by the German Health Care Innovation Fund. Methods: Cost-effectiveness of interprof ACT interventions was evaluated and compared to current standard of care (SOC) over 12 months, including 622 NHRs in 34 NHs in Germany. Multiplying resource use of healthcare services with German-specific unit costs generated costs. Health outcome was measured in quality-adjusted life-years QALYs), utility by multiplying EQ-5D-5L values with German-specific utility weights. Incremental cost-effectiveness analysis used an intention-to-treat approach and scenario analyses (SAs). Net-benefit-regression and cost-effectiveness acceptability curves addressed uncertainty. A German healthcare insurance perspective was assumed. Results: Base case results showed non-significant cost savings of 851.88€ and non-significant QALY loss of -0,056. Discussion: Dependency levels at baseline were non-significantly higher in IG compared to control group (CG). Lack of baseline costing data eliminated possibility to evaluate changes in costs due to the interprof ACT measures for both groups. Conclusion: Interprof ACT interventions are not cost-effective compared to current SOC.

Rapport: A conceptual definition from the perspective of patients and families receiving palliative care.

OBJECTIVE: To explore patient and family perceptions of rapport in interactions with health professionals and use the findings to develop a conceptual definition of rapport. METHODOLOGY: We undertook a qualitative Interpretive Description study; semi-structured interviews were conducted between November 2020 and May 2021. Participants included 18 patients and 11 family members recruited using a random approach from four hospice locations in Aotearoa, New Zealand. Interviews were audio recorded, transcribed, and analysed to develop a conceptual definition of rapport using guidelines (Podsakoff et al., (2016). A COREQ checklist was completed. RESULTS: Four dimensions of rapport were identified which formed the basis of a conceptual definition: 1) the type of relating, 2) the essence of rapport experienced, 3) key communication characteristics, and 4) the effect on interactions. CONCLUSION: Based on patient and family experiences of rapport, this study formulated a conceptual definition of rapport. This definition will support clinical education and practice and inform future research related to rapport. PRACTICE IMPLICATIONS: A conceptual definition of rapport can provide clarity for both research and clinical practice. It may be used as a tool for health professionals to reflect upon their experiences with rapport and develop expertise in this area.

Violence against women and perceived health: An observational survey of patients treated in the multidisciplinary structure 'The Women's House' and two Family Planning Centres in the metropolitan Paris area.

It is unknown how many women seeking care at French Family Planning Centres (FPCs) endure, or have endured intimate partner violence (IPV). To assess the prevalence of IPV, we surveyed women seeking care at three FPCs in the metropolitan Paris area (Seine-Saint-Denis). We examined the associations between IPV, socio-demographic characteristics and perceptions of health according to six indicators. Of the FPCs included in our survey, two are standalone facilities and one is located in The Women's Home, a multidisciplinary structure dedicated to serving survivors of violence. We conducted an observational survey from December 2018 to February 2019. All women aged 18 years and older were eligible. We solicited data on socio-demographic factors, general stability and history of violence. We measured health status on a 10-point scale for six different symptoms. Of the 274 women who participated, 27% had experienced IPV. Women who reported experiencing, or having experienced IPV were more likely to be between 25 and 44 years old (than under 25), temporarily documented or undocumented, unemployed or seeking employment, and experiencing housing insecurity. Women seeking care at The Women's House were more than twice as likely to report IPV (42%) than those visiting FPC-2 or FPC-3 (20% and 16%, respectively). Reports of violence increase among women with uncertain legal status, housing, employment and lower self-rated health. Results suggest that a FPC located in a structure specifically dedicated to serving women victims-survivors of violence like the Women's House may be more attractive to survivors.

Interprofessional Education and the Diagnostic Radiography curriculum: Students' perceived value of a case-based, whole day activity.

INTRODUCTION: This study aimed to examine Diagnostic Radiography (DR) students' perceptions and attitudes towards the Health Collaboration Challenge (HCC), as an interprofessional learning opportunity. METHODS: DR students participated in the HCC, an annual intensive interprofessional collaboration and assessment activity involving case-based learning. Students' attitudes towards Interprofessional Education (IPE) were measured using a modified version of the Interprofessional Socialisation and Valuing Scale (ISVS-21) and a bespoke questionnaire with items relating to the HCC. Subsequent focus groups explored students' experience of IPE within the HCC context. RESULTS: Survey results (n = 30) suggested a mostly positive attitude towards IPE alongside other health care students, acknowledging the value of interprofessional teams in patient health care. Qualitative themes from focus group participants (n = 8) revealed that DR students, while appreciating the value of shared-decision making, found the HCC assessment distracting. Challenges included the intensive nature of the HCC, roles that DR students undertook in addressing assessment criteria, case complexity and opportunities for DR students to showcase their knowledge. CONCLUSION: Results suggest that the intensive and assessable nature of the HCC can overshadow the value of IPE for DR students, and immersive or staggered approaches to IPE could better align with DR professionals' unique role within the patient care spectrum. IMPLICATIONS FOR PRACTICE: Revised IPE models for DR students could include a more immersive environment, conducted over a longer period of time, with meetings at semi-regular intervals to promote an interprofessional-focus over a task-focus approach.

Supervisors' pedagogies for supporting interns to learn intra- and interprofessional collaboration: a qualitative and quantitative ego network analysis.

This work aims to understand intra- and interprofessional networks of general practitioners (GPs) and ear, nose, and throat specialists (ENT specialists), and in what manner supervisors in these specialties involve interns in their professional network to help them learn intra- and interprofessional collaboration. An egocentric social network approach was used to collect and analyze quantitative as well as qualitative data. For this, semi-structured interviews were held with ten GP and ten ENT specialists. GPs had significantly more interprofessional contacts than ENT specialists (p < .01), with no significant difference in the network sizes of both professions (p = .37). All supervisors involved interns in their (ego)network actively as well as more passively. They actively discussed how collaboration with other professionals evolved, or passively assumed that an intern would learn from observing the supervisors' network interactions. Many supervisors considered the interns' initiative essential in deciding to involve an intern in their network. Although the workplace of GPs differed notably from hospital settings where ENT specialists work, the network sizes of both were comparable. Clerkships at the general practice seemed to provide more opportunities to learn interprofessional collaboration, for example with the medical nurse. Supervisors in both specialties could involve interns more actively in their intra- and interprofessional network while interns could take more initiative to learn collaboration from their supervisors' network.

Abandono docente en américa latina: revisión de la literatura / Labandon de la carrière de lenseignement en amérique latine : révision de la littérature / Abandono docente na américa latina: revisão da literatura / Teacher turnover in latin america: a literature review

Resumen La cantidad de docentes que deciden abandonar el aula antes de cumplir cinco años de experiencia es una preocupación creciente a nivel internacional. Para contribuir a la discusión, este estudio realiza una revisión sistemática de la literatura en torno al abandono docente producida en América Latina. El texto se focaliza en las razones aludidas por los/as docentes para irse del aula que se desprenden de las investigaciones realizadas en este contexto geográfico específico. Dentro de nuestras conclusiones vemos al encuentro con la vida escolar como una razón para dejar el aula. Por esto, aludimos al concepto de alfabetización micropolítica como una manera de abordar el fenómeno estudiado.

Résumé Le nombre d'enseignants qui décident d'abandonner la salle de classe avant cinq années en métier est une préoccupation croissante à l'échelle internationale. Pour contribuer à la discussion, cette étude effectue une révision systématique de la littérature sur le sujet en Amerique Latine. Appuyé sur des recherches menées dans ce contexte géographique l'accent est mis sur les raisons invoquées par les enseignant.e.s pour décrocher. En conclusion, nous avons identifié que la principale raison de leur abandon du métier est la confrontation avec la vie professionelle en école et cela nous a, par conséquent, amené vers le concept d'alphabétisation micro-politique en tant que moyen d'aborder le phénomène.

Resumo A quantidade de docentes que decidem abandonar a sala de aula antes de cumprir cinco anos de experiência é uma preocupação crescente em nível internacional. Para contribuir com tal discussão, este estudo realiza uma revisão sistemática da literatura produzida na América Latina em torno do tema. Por meio das pesquisas realizadas nesse contexto geográfico específico, são abordadas as razões apontadas pelos/as docentes para abandonar a sala de aula. Em nossas conclusões, consideramos que a vida escolar seria a razão principal para desistir da profissão. Por isso, apontamos o conceito de alfabetização micropolítica como uma maneira de abordar o fenômeno estudado.

Abstract Growing numbers of teachers are leaving the classroom before having served five years, and this is increasingly becoming an international concern. To contribute to the discussion, this study systematically reviews the literature on teacher attrition in Latin America, focusing on the reasons teachers give for abandoning their profession, in this specific geographical context. The results point to encountering school life as the main reason for leaving a teaching career; thus, we use the concept of micropolitical literacy to approach the phenomenon studied.

Effect of combined individual-collective debriefing of participants in interprofessional simulation courses on crisis resource management: a randomized controlled multicenter trial. / Efecto de un debriefing (reunión informativa) combinado en los participantes en cursos de simulación interprofesional para la gestión de recursos de crisis: un estudio aleatorio, controlado y multicéntrico.

OBJECTIVES: Interprofessional simulation (IPS) training is an effective way to learn crisis resource management. The type of debriefing used in IPS training may affect participants' performance and their level of psychological safety. We aimed to assess and compare performance after standard collective debriefing versus a combination of individual and collective debriefing ("combined" approach). MATERIAL AND METHODS: Randomized, controlled multicenter trial. IPS sessions were randomized to have either standard or combined debriefing. Each team's performance in the IPS session was assessed with the Team Emergency Assessment Measure. The participants assessed the debriefing quality with the Debriefing Assessment for Simulation in Healthcare. RESULTS: Forty IPS sessions were randomized, and 30 were analyzed, 15 using standard collective debriefing and 15 the combined individual-collective method. Teams' performance improved with both types of debriefing, based on pre-post testing (P<.01), and there were no significant differences in overall performance scores between the 2 types of debriefing (P=.64). However, the combined approach was associated with higher scores for leadership skills (P<.05) and psychological safety, and the participants' learning experience was better (P<.05). CONCLUSION: During IPS courses on crisis resource management, debriefing improves participants' performance, but similar overall results can be obtained with both debriefing methods. Combined debriefing might be more effective for improving participants' leadership skills and psychological safety and also provide a better learning experience.

OBJETIVO: La simulación interprofesional (SIP) es eficaz para aprender gestión de recursos de crisis. La modalidad de debriefing utilizada en la SIP puede influir en el rendimiento de los participantes y en su integridad psicológica. Se evalúa y compara el rendimiento de un debriefing estándar (DE) ­colectivo­ con un debriefing combinado (DC) ­individual y colectivo­ en cursos de SIP en escenarios que simulan pacientes con patología aguda y grave. METODO: Ensayo controlado, aleatorizado y multicéntrico. Se aleatorizó el tipo de debriefing realizado (DE o DC) en las sesiones de SIP. El rendimiento del debriefing se evaluó con la escala TEAM (Team Emergency Assessment Measure). La calidad de la SIP fue valorada por los participantes con la escala DASH (Debriefing Assessment for Simulation in Healthcare©). RESULTADOS: Se aleatorizaron 40 cursos de SIP de los que se analizaron 30. Quince realizaron DE y 15 DC. Ambos grupos mejoraron entre la pre y la posprueba (p < 0,01), pero no hubo diferencias en el rendimiento global entre ambas modalidades de debriefing (p = 0,64). El DC obtuvo mejores resultados que el DE en la capacidad de liderazgo (p < 0,05), en la percepción de seguridad psicológica y en la experiencia de aprendizaje eficaz (p < 0,05). CONCLUSIONES: Durante la SIP en situaciones de crisis, el debriefing mejora el rendimiento de los participantes, sin diferencias entre un DE y un DC. El DC podría ser más efectivo para mejorar la capacidad de liderazgo, la seguridad psicológica y la experiencia del aprendizaje.

Capturing interprofessional collaboration between physicians and nurses in an acute care setting. A validation study of the revised German version of the Collaborative Practice Scales.

The relevance of interprofessional collaboration (IPC) is widely acknowledged. Given the lack of a fully validated instrument in the German language for measuring the level of IPC, we built upon the current, albeit psychometrically weak, German-language version of the instrument to devise a new version with improved wording and for subsequent psychometric testing. In a tertiary hospital in German-speaking Switzerland, 160 physicians and 374 nurses completed the revised Collaborative Practice Scales in German (CPS-G) and additional scales regarding positive and negative activation at work and regarding job demands and job resources. A confirmatory factor analysis of the CPS-G was performed, and internal consistency estimates were computed. Partial correlations between the CPS-G and the additional scales were examined for criterion validity. The model fit of the CPS-G was good for physicians (χ2/df = 2.38, p < .001; CFI = .923; RMSEA = .051, 90%-CI (0.037-0.065)) and moderate for nurses (χ2/df = 5, p < .001; CFI = .919; RMSEA = .087, 90%-CI (0.072-0.102)) supporting the two-factor structure of the original English version. Reliability was acceptable in all sub-scales for physicians (inclusion, α = 0.79; consensus, α = 0.80) and nurses (assertiveness, α = 0.77; understanding α = 0.82). As expected, the CPS-G physicians' subscales correlated positively with positive activation and job resources and negatively with negative activation and job demands, albeit not always statistically significantly. Similar correlations were found with the CPS-G nurses' subscales other than in one instance. The CPS-G showed good construct and criterion validity and acceptable internal consistency. It consequently represents a valid instrument ready for application to measure the level of interprofessional collaboration between nurses and physicians in acute care settings.

Taking the pulse of multidisciplinary cancer conferences for breast cancer care in Canada: A stocktake of current practice.

AIM: International guidelines highlight the importance of implementation supports and quality monitoring of multidisciplinary care for breast cancer. In Canada, Ontario has standards for formal multidisciplinary cancer conferences (MCCs), but other provinces/territories do not. This study aimed to stocktake MCCs for breast cancer in Canadian sites participating in the RUBY cohort study (Reducing the Burden of Breast Cancer in Young Women) to better understand variations in multidisciplinary care across Canada and to add to the international literature. METHODS: A cross-sectional survey was conducted with surgeons and surgical oncologists representing 34 clinical centres participating in RUBY. Questions were grouped according to: type of multidisciplinary care, implementation, function, practice, participation and presentation, operation, and demographics, and included a mix of Likert-based, tick box and open-ended questions. RESULTS: Twenty-two responses (65%) were received. 91% of respondents reported that formal MCCs are part of regular practice. However, variation exists in the supports in place for ongoing implementation of MCCs, the understanding of the functions of MCCs, and the patients presented for discussion. Results also suggest less formalized processes for MCC in provinces without practice standards. CONCLUSIONS: Response differences between Ontario and elsewhere suggest that standards for MCC and supports for their implementation make a positive difference in their operation. However, ongoing operational challenges and issues with attendance exist for all sites and suggest that along with development of practice standards, incentives for participation and further education on benefits and function of MCC may support uptake of MCCs in clinical practice.

Factors that may promote the learning of person-centred care: an ethnographic study of an implementation programme for healthcare professionals in a medical emergency ward in Sweden.

While person-centred care has gained increasing prominence in recent decades as a goal for healthcare systems, mainstream implementation remains tentative and there is a lack of knowledge about how to develop person-centred care in practice. This study therefore aimed to explore what may be required in order for person-centred care programmes to be successful. The study used an ethnographic method of data collection. This consisted of closely following an implementation programme on a medical emergency ward in a Swedish hospital. Data consisted of participant observation and informal interviews with healthcare providers and their management leaders while they were in the process of training to use person-centred care. These interlocutors were using action learning methods under the guidance of facilitators. Our findings revealed that although the programme resulted in some of the processes that are central for person-centred care being developed, organisational factors and a lack of attention to ethics in the programme counteracted these positive effects. The study highlights the importance of facilitating mechanisms to produce desired results. These include management leaders' learning about the dynamic and collective nature of learning processes and change. They also include allowing for inter-professional dialogue to enable managers and professionals to reflect deeply on professional boundaries, disciplinary knowledge and power relations in their teams. Teamwork is essential for the development of person-centred care and documentation, in accordance with this specific implementation programme, is also indispensable. The space for inter-professional dialogue should also accommodate their various perspectives on the aims of care and organizational reality.

Purposeful interprofessional team intervention improves relational coordination among advanced heart failure care teams.

Effective delivery of healthcare is highly interdependent within and between interprofessional (IP) care teams and the patients they serve. This is particularly true for complex health conditions such as advanced heart failure (AHF). Our Academic Practice Partnership received funding to carry out IP workforce development with inpatient AHF care teams. Our objectives were to (a) identify challenges in team functioning that affected communication and relationships among the AHF care teams, (b) collaboratively identify a focal work process in need of improvement, and (c) test whether facilitated the implementation of team training and work process changes would lead to improvements in team communication, relationships, and process outcomes. The health-care team identified implementation of structured IP bedside rounds (SIBR) as the preferred approach to improving collaborative care. Utilizing a cross-sectional pre/post design, changes in team communication and relationships before and after a team intervention that included TeamSTEPPS training and SIBR implementation, were assessed using a validated Relational Coordination (RC) survey. The study population included AHF care team members (n ~ 100) representing seven workgroups (e.g., nurses, pharmacists) from two inpatient cardiology units at a 450-bed academic medical center in the Pacific Northwest during 2015-2016. Improvements in RC scores were demonstrated across all seven RC dimensions from baseline (Year 1) to follow-up (Year 2). Percent change on each of the seven dimensions ranged from 3.57% to 9.85%. Changes were statistically significant for improvements between baseline and follow-up on all but one of the seven RC dimensions (shared knowledge). The IP team intervention was associated with improvements in RC from baseline to follow-up. Additional research is needed to assess patient perspectives and outcomes of the IP team intervention. Findings of this study are consistent with the growing body of RC and SIBR research and provide a useful model of an IP team-based intervention in clinical practice.

The establishment of a shared care plan as it is experienced by elderly people and their next of kin: A qualitative study.

One strategy to achieve coordination of care for older people with complex care needs is the establishment of shared care plans. The aim of this study was to explore the process of establishing a shared care plan from the perspective of elderly people and their next of kin. Data were collected via 12 semi-structured interviews with 12 older persons targeted in joint care planning and 11 next of kin, either alone or together. The analysis was conducted using content analysis. The results reflect the process of establishing a shared care plan in the three categories; Preparation, Content and Results with belonging sub-categories. Preparation showed that the possibility to influence the preparation of the joint care plan meeting was sometimes limited and the purpose was not always clear. The Content category showed that the meeting was sometimes experienced as an unstructured, general conversation or focused on practical matters. And Results of the process were shown to be successful in terms of having positive effects or fulfilling needs, but also sometimes as being pointless. Thus, the results show that the process of establishing a shared care plan is somewhat unclear to the older person and their next of kin and that they are rarely involved in the decisions regarding when and if a shared care plan is needed. If joint care planning is expected to serve as a tool to accomplish a more person-centred care, then the person must be regarded as an equal partner all throughout the decision-making and planning process.

Psychiatry in American Medical Education: The Case of Harvard's Medical School, 1900-1945.

As American psychiatrists moved from the asylum to the private clinic during the early twentieth century, psychiatry acquired a growing presence within medical school curricula. This shift in disciplinary status took place at a time when medical education itself was experiencing a period of reform. By examining medical school registers at Harvard University, records from the Dean's office of Harvard's medical school, and oral histories, this paper examines the rise in prominence of psychiatry in medical education. Three builders of Harvard psychiatry - Elmer E. Southard, C. Macfie Campbell, and Harry C. Solomon - simultaneously sought to mark territory for psychiatry and its relevance. In doing so, they capitalized on three related elements: the fluidity that existed between psychiatry and neurology, the new venues whereby medical students gained training in psychiatry, and the broader role of patrons, professional associations, and certification boards, which sought to expand psychiatry's influence in the social and cultural life of twentieth-century America.

Collaboration in teams with nurse practitioners and general practitioners during out-of-hours and implications for patient care; a qualitative study.

BACKGROUND: Increasingly, nurse practitioners (NPs) are deployed in teams along with general practitioners (GPs) to help meet the demand for out-of-hours care. The purpose of this study was to explore factors influencing collaboration between GPs and NPs in teams working out-of-hours. METHODS: A descriptive qualitative study was done using a total of 27 semi-structured interviews and two focus group discussions. Data was collected between June, 2014 and October, 2015 at an out-of-hours primary care organisation in the Netherlands. Overall, 38 health professionals (GPs, NPs, and support staff) participated in the study. The interviews were audio-taped and transcribed verbatim. Two researchers conducted an inductive content analysis, involving the identification of relevant items in a first phase and clustering into themes in a second phase. RESULTS: The following four themes emerged from the data: clarity of NP role and regulation, shared caseload and use of skills, communication concerning professional roles, trust and support in NP practice. Main factors influencing collaboration between GPs and NPs included a lack of knowledge regarding the NPs' scope of practice and regulations governing NP role; differences in teams in sharing caseload and using each other's skills effectively; varying support of GPs for the NP role; and limited communication between GPs and NPs regarding professional roles during the shift. Lack of collaboration was perceived to result in an increased risk of delay for patients who needed treatment from a GP, especially in teams with more NPs. Collaboration was not perceived to improve over time as teams varied across shifts. CONCLUSION: In out-of-hours primary care teams constantly change and team members are often unfamiliar with each other or other's competences. In this environment, knowledge and communication about team members' roles is continuously at stake. Especially in teams with more NPs, team members need to use each other's skills to deliver care to all patients on time.

Inter-professional Relationships Issues among Iranian Nurses and Physicians: A Qualitative Study.

INTRODUCTION: Nurse-physician inter-professional relationship is an important issue in health care system that can affect job satisfaction and patient care quality. The present study explores the major issues of nurse-physician inter-professional relationships in Iran. MATERIALS AND METHODS: In this in-depth qualitative content analysis study conducted in 2014, 12 participants (5 physicians and 7 nurses) were recruited from two educational hospitals. The data were collected from deep, open, and unstructured interviews, and analyzed based on content analysis. RESULTS: The participants in this study included 12 individuals, 6 females and 6 males, with the age ranging 27-48 years and tenure ranging 4-17 years. Four themes were identified, namely, divergent attitudes, uneven distribution of power, mutual trust destructors, and prudence imposed on nurses. CONCLUSIONS: The results revealed some major inter-professional issues and challenges in nurse-physician relationships, some of which are context-specific whereas others should be regarded as universal. It is through a deep knowledge of these issues that nurses and physicians can establish better collaborative inter-professional relationships.