Committee for assessing progress on implementing the recommendations of the institute of medicine report the future of nursing: leading change, advancing health

Interprofessional collaboration is a key factor in initiatives designed to increase the effectiveness of health services currently offered to the public. It is important that the concept of collaboration be well understood, because although the increasingly complex health problems faced by health professionals are creating more interdependencies among them, we still have limited knowledge of the complexity of interprofessional relationships. The goal of this literature review was to identify conceptual frameworks that could improve our understanding of this important aspect of health organizations. To this end, we have identified and taken into consideration: (A) the various definitions proposed in the literature and the various concepts associated with collaboration, and (B) the various theoretical frameworks of collaboration. Our results demonstrate that: (1) the concept of collaboration is commonly defined through five underlying concepts: sharing, partnership, power, interdependency and process; (2) the most complete models of collaboration seem to be those based on a strong theoretical background, either in organizational theory or in organizational sociology and on empirical data; (3) there is a significant amount of diversity in the way the various authors conceptualized collaboration and in the factors influencing collaboration; (4) these frameworks do not establish clear links between the elements in the models and the outputs; and (5) the literature does not provide a serious attempt to determine how patients could be integrated into the health care team, despite the fact that patients are recognized as the ultimate justification for providing collaborative care.

The conceptual basis for interprofessional collaboration: Core concepts and theoretical frameworks

Background: These recommendations have been developed to improve the care of intensive care unit (ICU) patients during the dying process. The recommendations build on those published in 2003 and highlight recent developments in the field from a U.S. perspective. They do not use an evidence grading system because most of the recommendations are based on ethical and legal principles that are not derived from empirically based evidence. Principal Findings: Family-centered care, which emphasizes the importance of the social structure within which patients are embedded, has emerged as a comprehensive ideal for managing end-of-life care in the ICU. ICU clinicians should be competent in all aspects of this care, including the practical and ethical aspects of withdrawing different modalities of life-sustaining treatment and the use of sedatives, analgesics, and nonpharmacologic approaches to easing the suffering of the dying process. Several key ethical concepts play a foundational role in guiding end-oflife care, including the distinctions between withholding and withdrawing treatments, between actions of killing and allowing to die, and between consequences that are intended vs. those that are merely foreseen (the doctrine of double effect). Improved communication with the family has been shown to improve patient care and family outcomes. Other knowledge unique to endof-life care includes principles for notifying families of a patient’s death and compassionate approaches to discussing options for organ donation. End-of-life care continues even after the death of the patient, and ICUs should consider developing comprehensive bereavement programs to support both families and the needs of the clinical staff. Finally, a comprehensive agenda for improving end-of-life care in the ICU has been developed to guide research, quality improvement efforts, and educational curricula. Conclusions: End-of-life care is emerging as a comprehensive area of expertise in the ICU and demands the same high level of knowledge and competence as all other areas of ICU practice. (Crit Care Med 2008; 36:953‐963)

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Recommendations for end-of-life care in the intensive care unit: A consensus statement by the American College of Critical Care Medicine

Successful collaboration in health care teams can be attributed to numerous elements, including processes at work in interpersonal relationships within the team (the interactional determinants), conditions within the organization (the organizational determinants), and the organization's environment (the systemic determinants). Through a review of the literature, this article presents a tabulated compilation of each of these determinant types as identified by empirical research and identifies the main characteristics of these determinants according to the conceptual work. We then present a "showcase" of recent Canadian policy initiatives--The Canadian Health Transition Fund (HTF)--to illustrate how the various categories of determinants can be mobilized. The literature review reveals that very little of the empirical work has dealt with determinants of interprofessional collaboration in health, particularly its organizational and systemic determinants. Furthermore, our overview of experience at the Canadian HTF suggests that a systemic approach should be adopted in evaluative research on the determinants of effective collaborative practice.

The determinants of successful collaboration: a review of theoretical and empirical studies.

Over the past decade the Improving Outcomes Guidance (IOG) document has led to service re-configuration in the NHS and there are now 41 specialist centres providing oesophageal and gastric cancer care in England and Wales. The National Oesophago-Gastric Cancer Audit, which was supported by the British Society of Gastroenterology, the Association of Upper Gastrointestinal Surgeons (AUGIS) and the Royal College of Surgeons of England Clinical Effectiveness Unit, and sponsored by the Department of Health, has been completed and has established benchmarks for the service as well as identifying areas for future improvements.1–3 The past decade has also seen changes in the epidemiology of oesophageal and gastric cancer. The incidence of lower third and oesophago-gastric junctional adenocarcinomas has increased further, and these tumours form the most common oesophago-gastric tumour, probably reflecting the effect of chronic gastro-oesophageal reflux disease (GORD) and the epidemic of obesity. The increase in the elderly population with significant co-morbidities is presenting significant clinical management challenges. Advances in understanding of the natural history of the disease have increased interest in primary and secondary prevention strategies. Technology has improved the options for diagnostic and therapeutic endoscopy and staging with cross-sectional imaging. Results from medical and clinical oncology trials have established new standards of practice for both curative and palliative interventions. The quality of patient experience has become a significant component of patient care, and the role of the specialist nurse is fully intergrated. These many changes in practice and patient management are now routinely controlled by established multidisciplinary teams (MDTs) which are based in all hospitals managing these patients.

The original guidelines described the management of oesophageal and gastric cancer within existing practice. This paper updates the guidance to include new evidence and to embed it within the framework of the current UK National Health Service (NHS) Cancer …

https://gut.bmj.com/content/gutjnl/60/11/1449.full.pdf

Guidelines for the management of oesophageal and gastric cancer

Objective:To explore registered nurses’ and attending physicians’ perspectives on caring for dying patients in intensive care units (ICUs), with particular attention to the relationships among moral distress, ethical climate, physician/nurse collaboration, and satisfaction with quality of care.Desig

Nurse-physician perspectives on the care of dying patients in intensive care units: collaboration, moral distress, and ethical climate.

Background: Although moral distress is increasingly recognized as an important problem that threatens the integrity of health care providers and health care systems, few reliable and valid measures of moral distress are currently in use in research or clinical practice. This article describes the development and testing of a revised measure of moral distress, the Moral Distress Scale–Revised (MDS-R), designed for use in multiple health care settings and with multiple disciplines. Methods: After instrument development and content validity testing, a survey methodology was used to assess reliability and construct validity of the MDS-R. Registered nurses (n = 169) and physicians (n = 37) in eight intensive care units (ICUs) at an academic medical center in the southeastern United States participated; the survey was administered during a 2-week period in January 2011. Results: Adequate reliability and evidence of construct validity were demonstrated. Moral distress was significantly higher for nurses than phy...

https://www.tandfonline.com/doi/pdf/10.1080/21507716.2011.652337

Development and Testing of an Instrument to Measure Moral Distress in Healthcare Professionals

Purpose
Moral distress is a phenomenon affecting many professionals across healthcare settings. Few studies have used a standard measure of moral distress to assess and compare differences among professions and settings.

Design
A descriptive, comparative design was used to study moral distress among all healthcare professionals and all settings at one large healthcare system in January 2011.

Methods
Data were gathered via a web-based survey of demographics, the Moral Distress Scale-Revised (MDS-R), and a shortened version of Olson's Hospital Ethical Climate Scale (HECS-S).

Findings
Five hundred ninety-two (592) clinicians completed usable surveys (22%). Moral distress was present in all professional groups. Nurses and other professionals involved in direct patient care had significantly higher moral distress than physicians (p = .001) and other indirect care professionals (p < .001). Moral distress was negatively correlated with ethical workplace climate (r = -0.516; p < .001). Watching patient care suffer due to lack of continuity and poor communication were the highest-ranked sources of moral distress for all professional groups, but the groups varied in other identified sources. Providers working in adult or intensive care unit (ICU) settings had higher levels of moral distress than did clinicians in pediatric or non-ICU settings (p < .001). Providers who left or considered leaving a position had significantly higher moral distress levels than those who never considered leaving (p < .001). Providers who had training in end-of-life care had higher average levels of moral distress than those without this training (p = .005).

Conclusions
Although there may be differences in perspectives and experiences, moral distress is a common experience for clinicians, regardless of profession.

Clinical Relevance
Moral distress is associated with burnout and intention to leave a position. By understanding its root causes, interventions can be tailored to minimize moral distress with the ultimate goal of enhancing patient care, staff satisfaction, and retention.

Moral Distress Among Healthcare Professionals: Report of an Institution-Wide Survey

Background: As ongoing research explores the impact of moral distress on health care professionals (HCPs) and organizations and seeks to develop effective interventions, valid and reliable instrume...

Enhancing Understanding of Moral Distress: The Measure of Moral Distress for Health Care Professionals.

PART I. Historical and Developmental Aspects of Advanced Practice Nursing 1. History and Evolution of Advanced Practice Nursing 2. Conceptualizations of Advanced Practice Nursing 3. A Definition of Advanced Practice Nursing 4. Role Development of the Advanced Practice Nurse PART II. Competencies of Advanced Practice Nursing 5. Direct Clinical Practice 6. Expert Coaching and Guidance 7. Consultation 8. Research 9. Clinical and Professional Leadership 10. Collaboration 11. Ethical Decision Making PART III. Advanced Practice Roles: The Operational Definitions of Advanced Practice Nursing 12. The Clinical Nurse Specialist 13. The Primary Care Nurse Practitioner 14. The Acute Care Nurse Practitioner 15. The Blended Role of the Clinical Nurse Specialist and the Nurse Practitioner 16. The Certified Nurse-Midwife 17. The Certified Registered Nurse Anesthetist 18. The Advanced Practice Nurse Case Manager 19. Evolving and Innovative Opportunities for Advanced Practice Nursing PART IV. Critical Elements in Managing Advanced Nursing Practice Environments 20. Business Planning and Reimbursement Mechanisms 21. Marketing and Contracting Considerations 22. Understanding Regulatory, Legal, and Credentialing Requirements 23. Health Policy Issues in Changing Environments 24. Strengthening Advanced Nursing Practice in Organizational Structures and Cultures 25. Outcome Evaluation and Performance Improvement

Ann B. Hamric

Papers

Nurse-physician perspectives on the care of dying patients in intensive care units: collaboration, moral distress, and ethical climate.

Development and Testing of an Instrument to Measure Moral Distress in Healthcare Professionals

Moral Distress Among Healthcare Professionals: Report of an Institution-Wide Survey

Enhancing Understanding of Moral Distress: The Measure of Moral Distress for Health Care Professionals.

Advanced Practice Nursing: An Integrative Approach