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Developing collaborative person-centred practice:A pilot project on a palliative care unit
PIPPA HALL, LYNDA WEAVER, DEBBIE GRAVELLE, &
HELENE THIBAULT
SCO Health Service, Ottawa, Ontario, Canada
AbstractMaximizing interprofessional collaborative patient-centred practice holds promise for improvingpatient care and creating satisfying work roles. In Canada’s evolving health care system, there aredemands for increased efficiency, cost-effectiveness, and quality improvement. Interprofessionalcollaboration warrants re-examination because maximizing interprofessional collaboration, especiallynurse-physician collaboration, holds promise for improving patient care and creating satisfying workroles. A palliative care team seized the opportunity to pilot a different approach to patient and familycare when faced with a reduction in medical staff. Grounded in a collaborative patient-centred practiceapproach, the Canadian Hospice Palliative Care Association’s National Model to Guide HospicePalliative Care (2002), and outcomes from program retreats and workgroups, a collaborative person-centred model of care was developed for a 12-bed pilot project. Preliminary findings show that the pilotproject team perceived some specific benefits in continuity of care and interprofessional collaboration,while the presence of the physician was reduced to an average of 3.82 hours on the pilot wing, comparedwith 8 hours on the non-pilot wings. This pilot study suggests that a person-centred model, whenfocused on the physician-nurse dyad, may offer improved efficiency, job satisfaction and continuity ofcare on a palliative care unit. Incorporating all team members and developing strategies to successfullyexpand the model across the whole unit are the next challenges. Further research into the impact ofthese changes on the health care professionals, management and patients and families is essential.
Keywords: Interprofessional collaboration, collaborative patient-centred practice collaborativeperson-centred care
Introduction
Given the complexity of caring for chronic and severely ill patients, each health care
professional has information the other needs to practice successfully. In the interest of safe
patient care, no profession can stand alone, making good collaboration skills essential
(Lindeke & Sieckart, 2005; Arford, 2005).
According to Herbert (2005, p. 2) collaborative patient-centered practice ‘‘is a practice
orientation, a way of health care professionals working together and with their patients/
families. It involves the continuous interaction of two or more professions or disciplines,
organized into a common effort, to solve or explore common issues with the best possible
participation of the patient. (It) is designed to promote the active participation of each
Correspondence: Dr Pippa Hall MD, CCFP, MEd, FCFP, Assistant Professor, Department of Family Medicine, University of
Ottawa; Program Director, Palliative Medicine Residency Program, SCO Health Service, 43 Bruyere St, Ottawa, ON, K1N 5C8.
Tel: þ1 613 562 4262 ext 4014. Fax: þ1 613 562 6371. E-mail: [email protected]
Journal of Interprofessional Care,
January 2007; 21(1): 69 – 81
ISSN 1356-1820 print/ISSN 1469-9567 online � 2007 Informa UK Ltd.
DOI: 10.1080/13561820600906593
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discipline in patient care. It enhances patient and family-centered goals and values, provides
mechanisms for continuous communication among caregivers, optimizes staff participation
in clinical decision-making within and across disciplines, and fosters respect for the dis-
ciplinary contributions of all professionals’’.
This type of practice orientation is promoted as a model of care that will enable our health
care system to address the complex health needs of patients and their families suffering with
chronic complex illnesses (Herbert, 2005). However, health care practitioners receive little
preparation during their education to work in collaborative team settings. The current
educational system encourages each health care profession to learn within its own silo,
ensuring its exclusive members have common experiences, values, problem-solving
approaches, and language for professional tools (Hall, 2005). In collaborative patient-
centered practice (CPCP), each professional must interpret information in the light of his/
her own learning and then share this with the other team members using collaborative skills.
These skills facilitate the development of an inclusive, common language among team
members (Cowley et al., 2002) and a conceptual framework (Sands et al., 1990) based on
common values which transcend and overlap professional boundaries. Effective professional
collaborative relationships require mutual respect (Kramer, 2003), and places patient and
family goals central to the team’s focus. Each team member develops realistic expectations
of the team’s work and understands his/her contributions to the achievement of the goals.
Nurse-physician collaboration is a central component of CPCP (Carson et al., 1997;
Dougherty & Larson, 2005; Burke et al., 2004; Zwarenstein & Reeves, 2000). Research also
suggests that this approach to care can result in improved job satisfaction, especially for
nurses working to their full scope of practice, which results in lower rates of staff turn-over
(Lindeke & Sieckart, 2005).
This paper discusses a pilot project to improve collaborative person-centred practice
(Rothstein, 2005) within the nurse-physician dyad of an existing interprofessional team on a
palliative care unit. CPCP focuses on both the patient and family and was developed to
foster a status-equal foundation between the physician and nurse, which is considered a
necessity for collaborative teamwork (Ben-Syra & Szyf, 1992; Taylor, 2002).
Background
The Palliative Care Team working in Ottawa, Canada, seized the opportunity to investigate
a different approach to patient and family care when faced with a reduction in its medical
staff. Prior to the initiation of the pilot project, three palliative care physicians were
physically present full time on the unit and responsible for 12 patients each, scattered across
the 36-bed unit. Due to external factors, the medical staff was reduced to two full-time
physicians.
A new model of care was developed using the approach of collaborative patient-centered
practice (D’Amour et al., 2005; Hall & Weaver 2001). Also integrated were the results
of program retreats, workgroups and the Canadian Hospice Palliative Care Association
(CHPCA) National Model to Guide Hospice Palliative Care (2002). As noted above this
model of care focused on the physician-nurse dyad and was person-centred (family and
patient) in nature.
CPCP model development
The project ran for 12 weeks and was conducted on one of the three wings of the 36-bed
palliative care unit (PCU). The pilot wing included 12 contiguous beds. The project required
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one physician to work collaboratively with two nurses and one registered practical nurse.
A physician, whose additional clinical responsibilities in the community and significant
administrative/research responsibilities precluded the possibility of remaining full-time on
the unit, was assigned to the pilot project. Another physician covered when the primary
physician was away. The nurse-patient ratio was maintained at the normal levels for
the palliative care unit (1:4). Care on the rest of the unit followed the usual model, with two
palliative care physicians available full-time, each following 12 patients scattered over the
remaining 24 beds.
Of the six key steps of care defined by the CHPCA Model to Guide Hospice Palliative Care
(2002) the project team selected and grouped the following four for the focus of the CPCP
model: assessment and effective information sharing; shared decision-making and care plan-
ning. The remaining two steps, care delivery and confirmation, were used in the evaluation.
Assessment and effective information sharing
Upon arrival each morning, day shift nurses read the progress notes written in their assigned
patients’ charts and reviewed all assessment/evaluation tools to identify any issues/concerns
that the patient and family might have had during the past 24 hours. Nurses received a verbal
report directly from the previous shift nurse if there was an urgent, unusual or unexpected
issue.
Day shift nurses then conducted a quick assessment of their patients, administered
medications and prepared patients for breakfast. Before the physician arrived on the unit at
9:00 am, the nurses met together and developed a priority list that identified the patients and
families requiring the physician’s assessment that day. The physician made walk-about
rounds with the individual nurses on a schedule defined by the priority list, jointly
reassessing the identified patients’ and families’ needs. Thus, the priority list was a tool to
provide immediate information to the physician on his/her arrival on the unit and to lay the
foundation for the team’s workday.
The walk-about rounds allowed for joint nurse-physician discussion of their assessment
findings, sharing their perspectives of the issues, and clarifying their understandings in the
light of the other’s point of view. During the joint assessments, they had discussions with the
patient and/or family, thus ensuring consistency of information exchange with patient/family
goals.
Shared decision-making and care planning
Following the joint assessment of the patient/family, reviewing the patient and family’s goals,
and discussing the issues, the nurse and physician jointly developed the patient’s plan of care
for the day. Necessary orders were written and the plan of care was updated on the
Interdisciplinary Care Plan in the patient’s chart. Any later adjustment in the plan of care
was done only after discussion between the nurse and the physician. The physician’s
assessment was always done in the presence of the nurse. After walk-about rounds, the
physician left the unit and was available by phone or pager.
The patient admission process was revised for this pilot project. Initial intake and
assessment was done by the nurse. The physician was then notified as soon as possible. If
possible, the physical exam was done together. The care plan was developed collaboratively,
based on the patient and family’s goals of care.
Families were directed to discuss their concerns and questions with the nurse, who then
triaged the issues that required the intervention of the physician. If families and patients
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required more formal meetings with the team, family meetings were scheduled to ensure
both nurse and physician could be present.
One-hour interprofessional team rounds, attended by all pilot project nurses, the
physician and most allied health care team members, occurred one afternoon per week.
A registered practical nurse covered the pilot project beds during the team rounds.
Implementation strategy
Every nurse in the pilot project attended a mandatory four-hour education session. The
session reviewed: physical assessment skills; the four most common symptoms seen in the
palliative care population; the meaning of palliative care/end of life care; the definition of
CPCP; documentation tools; communication strategies; and the implementation strategy.
Information sessions were held with all allied health care team members to discuss changes
that would occur on the unit. Education sessions were held with the physicians involved to
review the definition of CPCP and the new model of care. Case studies and role playing
were used to review communication strategies, shared decision-making and care planning
concepts. The Advanced Practice Nurse (APN) was available on the unit every day when the
pilot project began. The Nurse Manager worked with the APN to support nurses and allied
health care team members with the change process.
Evaluation methods
The evaluation questions to be answered for this project were ‘‘What processes worked?
What did not work? What should be improved?’’ The study was treated as a case study
(Yin, 2003), appropriate for exploring this complex situation with multiple evaluation
respondents, flexible study design, a clinical practice approach. A multi-faceted strategy was
designed by an in-house evaluation specialist (LW), with input from the care team members
as to what data were important to collect. A plan was drawn up based on the six essential
steps for care (assessment, information-sharing, decision-making, care planning, care
delivery, confirmation). For each step, the new procedures were listed, as were process and
impact indicators and their sources of data. This planning ensured that every question in the
data collection tools had a purpose and that all aspects of the new model were being assessed
in some way.
The data sources reported included:
. Daily logs of activities and satisfaction with new procedures by nurses and physicians
with binomial (yes, no) responses for statements for listed activities, 4-point scales
(not at all, somewhat, quite, very satisfied) for satisfaction questions, and open-ended
questions.
. Pre/post administration of two published scales to assess interprofessional collaboration.
(1) The Interdisciplinary Team Process and Performance Scale (ITPPS)
(Temkin-Greener et al., 2004) with a 5-point Likert scale (strongly disagree,
disagree, neither disagree nor agree, agree, strongly agree) for statements.
See Table I for list of the six domains. The questionnaire was modified by using
only those questions that appeared in the appendix of Temkin-Greener et al.
(2004).
(2) The Nurse-physician Collaboration Scale (Way et al., 2001) with the same 5-point
Likert scale for statements as above but reversed from original to match the ITPPS
scale. See Table I for the major topics of the eight questions.
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. Interviews with the day and evening Ward Clerks who worked on the pilot wing, asking
what they found to be different compared to previous, usual care.
. Separate focus groups with nurses from the pilot wing and non-pilot wings asking their
perception of their leadership roles.
For confidentiality reasons, as one of the two physicians in the pilot project was a project
team member (PH), no formal interviews were held. As there was no regular surveying or
interviewing of patients and families on the PCU, the project team decided to simply
monitor the usual unsolicited feedback (e.g., thank you letters from families) over the
duration of the project.
Quantitative data from the daily logs, ITPPS and Nurse-physician Collaboration Scale
were entered and analyzed in SPSS. Qualitative data from the focus groups and interviews
with Ward Clerks were transcribed into MS Word and sorted by content analysis into
themes.
Respondents
Two physicians (one worked nine weeks; one three weeks) and 15 day-shift nurses partici-
pated in this 12-week pilot study. The physicians completed 22 daily logs from 4 April 4 to 2
May, for weekdays only. Day shift nurses were the only ones asked for their data as it was this
shift that was most affected by the new model. They completed 58 daily logs from 7 April to
24 May, seven days a week. The physicians and nurses were allowed to stop completing the
logs before the end of the pilot to reduce the administrative burden and because the research
team concluded that one month’s worth of data would be sufficient for analysis.
Out of the 10 nurses from all shifts on the pilot wing, six (60%) completed the pre-test for
the two interprofessional scales, and eight (80%) completed the post-tests. The non-pilot
return rate was three out of 10 for the pre-tests (30%) and four out of eight (50%) for the
post-tests (two nurses were unavailable for the post-test).
Focus groups were attended by five RN/RPNs from the pilot wing, and four RN/RPNs
from the non-pilot wings, respectively. The day-shift and the evening-shift Ward Clerks who
worked on the pilot wing were interviewed at the end of the pilot period.
Results
It was found that there was a good level of comparability between the pilot and non-pilot wings.
See Table II for similarities in relation to data on ward admissions deaths and discharges.
Table I. Interprofessional scales.
Question topics: Nurse-Physician
Collaboration Scale (Way et al., 2001)
List of domains: Interprofessional Team Process and
Performance Scale (Temkin-Greener et al., 2004)
1. Plan together 1. Conflict management
2. Communicate 2. Coordination
3. Share 3. Communication
4. Cooperate 4. Team cohesion
5. Consider each other’s opinions 5. Team effectiveness
6. Demonstrate trust 6. Leadership
7. Respect
8. Collaborate
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In terms of physician presence in the study, however, it was found that the presence of the
physician was reduced to an average of 3.82 hours on the pilot wing, compared with 8 hours
on the non-pilot wings. In addition, in the daily logs, pilot wing physicians reported that they
charted, provided direct patient/family care and did the assessment walkabout with nurses
every day. They reviewed charts on 83% of the days. They reported participating in other
activities, including team meetings, filling out forms, conducting admissions and discharges,
family meetings, dictation and phone calls, on 9% to 29% of the days.
Nurses saw all four of their patients every day, and charted and provided direct patient/
family care every day. They were involved in walkabouts 81% of the days, and reported that
on two days there was no need for a walk-about because all the patients were stable and did
not need to see the physician. They participated in other activities (e.g., team meetings,
completing forms,) from 2% to 38% of the days.
Results are reported here according to the essential steps for providing care.
Assessment and information-sharing
Data from the daily logs showed that the nurses felt that their morning priority-setting was
done in a reasonable amount of time, at the time expected, comfortably and with the
equipment they needed 86 – 96% of the times. They rated their satisfaction with this process
as three or four on the 4-point scale 76% of the times. The physicians found the nurses’
information about the patients accurate, useful, and available when needed 91% of the
times. They were satisfied with the process (either three or four on the 4-point scale) 100%
of the times.
The day nurses took an average of 9 minutes to review their patients’ charts and identify
issues to review. Information from the previous shift was found to be useful and done in a
reasonable amount of time 98% of the times. They found the process comfortable 100% of
the time, and found the chart was an efficient way to share information 98% of the times. On
the 4-point scale, satisfaction with how information was obtained from the previous shift was
rated at three or four 75% of the days.
The physician-nurse walk-about each morning was done in a reasonable amount of time,
with the equipment necessary and comfortably 98% of the time, according to the nurses.
Physicians found the walkabouts to be useful, done in a reasonable amount of time and
comfortably 90 – 95% of the times. They were satisfied (three or four out of four) 95% of the
times, while the nurses reported the same ratings 75% of the times.
In the first two weeks of the pilot, several comments in nurses’ and physicians’ daily
logs noted that walkabouts were delayed because they often occurred when nurses took
their breaks. A few times nurses had to change their break schedule to make sure the
nurse with the next highest priority patient was there when it was his/her turn to do the walk-
about with the physician. A change was noticed at week three; a physician commented
that ‘‘we’re flexible with priorities if nurse is not available when it’s her patient’s turn.
Table II. Admissions, deaths and discharges.
4 April – 4 July 2005 Pilot wing Non-pilot wing A Non-pilot wing B
Total no. of patients 56 60 33
No. of deaths 36 39 12
No. of discharges 6 5 4
No. of admissions 44 48 26
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We adapt priority to the first available nurse’’. At first, nurses and physicians reported
some confusion as some night staff continued to use the old methods for communicating
with the next shift. One physician noted that s/he struggled with having to ignore her/his
desire to see patients even though they were deemed stable and not needing medical
assessment.
One day in the first week was particularly chaotic, coinciding with a special staff
retirement event on the PCU. The physician commented that ‘‘the patient was not at the
centre of focus today. There was poor communication, poor prioritizing, frustration, and
discomfort’’. Spontaneously, the nurses discussed the problem, and it never recurred. In
weeks two and three, one of the nurses commented that s/he found it confusing to care for
some patients on the pilot wing and some on the non-pilot wing at the same time, as she had
to work with two different physicians, teams and procedures. In weeks three and five, the
nurses and physician commented that the discharge process (not changed from usual
practice) needed to be streamlined as it was ‘‘unorganized, caused extra work’’ and
‘‘need[ed] to improve communication with pharmacy, doctors, nurses’’. Also in week five,
both the nurses and physicians said that they needed a routine to have the physician see the
stable patients once a week.
Shared decision-making and care planning
Satisfaction with communication, collaborative decision making and care planning by
nurses and physicians was captured in several questions on the daily logs. Physicians and
nurses said they could find the other 88% and 89% of the times, respectively. They resolved
their differences (when they had any) 100% and 97% of the times, respectively. They found
the walkabouts sufficient for assessing and sharing information about the patients and
families 95% and 93% respectively. Physicians reported that nurses’ information was
sufficient for them to provide optimal patient care 95% of the times.
Problems were reported in weeks five and seven with other staff members not in the pilot
project. One weekend, a non-pilot physician changed the medication orders for a pilot wing
patient. Those orders were changed back by the pilot physician on Monday. Nurses reported
problems with an allied health professional that worked with a pilot patient and talked only
with the physician, not the nurses. Another nurse commented:
I was a bit put aback when the physician started the admission without me. When it was
time to complete [interprofessional care plan] for the admission, the physician was ready
to confer with another physician on a patient unrelated to our admission. [The physician]
saw I was not pleased and re-focused.
Weekly rounds were rated as useful and comfortable 100% of the times by both the
nurses and physicians. The physicians felt they were done in a reasonable amount of
time 100% of the times, whereas the nurses said it 92% of the time. The physicians and
nurses rated their satisfaction with rounds as three or four 75% and 86% of the times,
respectively.
Care delivery and confirmation
On the daily logs, there were also satisfaction questions with patient care and with
interprofessional team work. The nurses were satisfied with patient care at a three or four
level 85% of the time, while the physicians were similarly satisfied 88% of the times. Nurses
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were satisfied with their interprofessional team work 71% of the times. Physicians reported
satisfaction 95% of the times. One nurse said in the open-ended comments: ‘‘Patient needs
are met first thing in the morning, (walkabouts) are done, then patients and families seem
more relaxed, not waiting for MD (medical doctor) all day.’’
On the Physician-Nurse Collaboration Scale, the pilot nurses gave themselves higher
ratings at the end of the pilot than they had at the beginning, for all seven questions.
Similar data from the non-pilot nurses was higher than the pilot nurses at the beginning of
the pilot, except for the questions on communicating and considering the other pro-
fession’s opinions. Their post-test scores were generally not as high as pilot nurses’ post
ratings, except for the question on considering the other profession’s opinions (see Figures
1 and 2).
Figures 3 and 4 list the domain scores from the ITPPS. As these figures indicate, the pilot
nurses rated themselves slightly higher on the post test than the pre test for all six domains.
The non-pilot nurses also rated themselves slightly higher on the post test, except for the
Team Cohesion domain. Tests for significance were not conducted due to the small number
of respondents.
The two Ward Clerks were interviewed separately to find out what they felt was different
about their work during the pilot phase. They both stated that, because the physician left
earlier and did not change orders in the afternoons, they had more time to do other work.
Clerks also noticed improved communication between nurses and physicians: ‘‘Before, the
physicians used to come to the clerk with orders without discussing them with the team,
then the nurse would come with something different.’’ They also found that there were
fewer orders to change after the weekends. ‘‘Before, the weekend doctor would change
things, then on Monday, the doctor would have to change it back . . . . [now that doesn’t
happen anymore]’’.
There was no change in the regular unsolicited feedback received by the team and
management from patients and families during the pilot project.
Figure 1. Pilot wing ratings from Nurse-Physician Collaboration Scale.
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In the focus groups, pilot wing nurses stated that the new model of care affected their
leadership by ‘‘empowering’’ them. When probed as to what this meant, they said ‘‘allowing
us to practice at the full scope of our practice’’. Another nurse added ‘‘It encourages us. It
actually fosters it and promotes it. The other method did not. It was very stifling. Your
opinion is more valued. Your input is valued’’. Probing still further as to how the model that
does this for them, the nurses said:
The one-on-one contact with the doctor and then you and the doctor going to see the
patient.
Figure 2. Non-pilot wings ratings from Nurse-Physician Collaboration Scale.
Figure 3. Pilot wing scores from the Interprofessional Team Process and Performance Scale.
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I think we used to be so task-involved that we were put aside from the decision
making . . . Now we’re . . . changing the way we do our tasks.. in order to be able to take
better leadership roles.
Non-pilot wing nurses said they too felt they were leaders. ‘‘It’s total patient care. You have
your patients and you do all the care for your patients and everyone is independent, only
responsible for their patients’’. They said the doctors rely on them for information about the
patients: ‘‘they rely on us, on the information and . . . that’s what they want. I have the feeling
they know we are their eyes when they are not around. And they trust our judgment’’. One
nurse found that the culture had been changing in the last few years towards more respect
for the nurses: ‘‘I think the whole team listens more and more because . . . most of the time
we’re the person being beside the patient . . . (original was spoken in French) we’re taking
more of our space now, we’re taking our place now’’. One of the other nurses found that she
had been ‘‘living that for a long time. It’s not new for me’’.
Of interest from the non-pilot group was their perspective on communication: ‘‘I think
communication is (everything). I’m not saying that we are not communicating well but there
are still big gaps,’’ and ‘‘sometimes we do get accurate information but sometimes you
don’t’’. They also brought up the subject of the nurses and doctors duplicating the
assessment process: ‘‘(the doctors) are not doing (the assessment) completely but it’s better
than it was. I think there’s a line where the people still feel, professionally speaking, that they
have to do it even if somebody else did it’’.
Non-pilot nurses also noted that the new model had already started to influence them and
other team members. ‘‘I think we’re all looking forward to the new changes’’. ‘‘But you
know what? I think we’re having it on [our wing]. . . . . It’s crept slowly and I think it’s going
to be easier now’’. ‘‘I don’t think it will make much change. We’ll just have to be more
concrete’’. ‘‘More structured.’’ ‘‘More aligned with the priorities’’.
Discussion
Given that the interprofessional team on the PCU already has an excellent reputation for its
collaborative teamwork, the pilot project would succeed only if it did not fall below these
Figure 4. Non-pilot wing scores from the Interprofessional Team Process and Performance Scale.
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high standards. The results indicate that the pilot team believes the patients’ and families’
needs are met at least as well as by the CPCP model as by the usual model of care on the
PCU. Their comments suggest that these needs may be even better addressed by the CPCP
model, through the development of a collaborative person-centred care plan which remains
consistent with the patients’ and families’ goals of care.
The pilot project demonstrated that the physician did not need to be physically present
full-time on the PCU. By increasing the assessment responsibilities of the nurses and
developing strategies for effective information exchange and shared, collaborative decision-
making based on patients’ and families’ goals of care, the care needs of this complex patient
population can be addressed with approximately halving the physician’s time. This allowed
the physicians to undertake other clinical, educational and administrative responsibilities.
This may lead to better job satisfaction, as well as effective use of the physician’s time.
Compared to the physicians, the nurses’ overall satisfaction with patient care and with
interprofessional teamwork was lower. This may reflect the nurses’ perspective seeing room
for more improvement or the physicians’ lack of awareness of limitations.
There was some cross-pollination of the pilot project into two non-pilot wings. The
geographic grouping of the pilot beds resulted in less scatter of the non-pilot physicians’
patients, and thus interaction with fewer nurses. This could have allowed for more
consistent nurse-physician communication, possibly enhancing the collaborative care.
Members of the pilot team frequently discussed the model with their colleagues. The results
of Physician-Nurse Collaborative Scale and the ITPPS show that the pilot project did not
detract from team function. The pre-scores of the pilot project team were lower (more
critical of themselves) than the non-pilot teams’, perhaps due to the pilot team’s awareness
of the potential for greater interprofessional assessment and decision making coming with
the new CPCP model. The post-study results show some improvement in the pilot project
team’s collaborative planning skills, communication effectiveness, sharing of responsibil-
ities, considering each other’s perspectives, cooperating and coordinating with each other,
demonstrating collaborative teamwork skills, and respecting each other. The ITPPS shows
some improvement in the pilot project teams conflict management skills, coordination skills,
communication skills and team cohesion. The non-pilot teams showed higher initial scores
for all the scales, and some improvement in the all areas of the scales, although not as great
as those of the pilot project. This may indicate their confidence in the usual model of care.
In the focus group, the pilot team nurses used expressive words such as ‘‘empowered’’,
‘‘blooming’’, ‘‘fostering’’ and ‘‘learning’’ to describe how the new model affected their
leadership at the bedside. While the non-pilot team also praised their work, they were not as
enthusiastic or verbose as the pilot team. The sense at the focus group with the pilot team
was of high energy, motivation and self-confidence.
The pilot project developed strategies and tools to enhance CPCP on the PCU by:
. Increasing the assessment skills and responsibilities of the nurses
. Improving effective information exchange within the nurse-physician dyad
. Improving collaborative decision-making and care planning, based on patients’ and
families’ goals of care.
There are obvious limitations to this study. The small number of respondents to the ITPPS
and the Nurse-physician Collaboration Scale makes the generalizability of the results
limited. The short timeframe of the study also only provides a look at the early phase of
implementation and not of the long-term effects on the staff and processes. Another
limitation is that the Nurse-physician Collaboration Scale has not been validated, and the
Developing CPCP in palliative care 79
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ITPPS was modified from its original. Neither had been used before as a pre-post test. Also,
the questionnaires made specifically for this project captured the staff’s perceptions rather
than unobtrusive data. However, viewed as a case study (Yin, 2003), the results provide
initial insights into the complex arena of interprofessional collaborative practice.
Allied health care professionals must now be integrated into the model. Not all
communication tools and processes have been optimized as needed. Learners coming to the
palliative care unit also need to be oriented into the CPCP model.
Expansion of the pilot project to the entire unit was necessary, before the evaluation
results were available. The implementation process was not smooth. Team members
more comfortable with the usual model had to become role models in the new model, even
if they were not yet convinced that it worked. Implementing the new model with the pilot
staff who were motivated and ready to try a change in their practice is quite different from
doing the same with staff who do not really see the need for change, as indicated by the
interprofessional team rating scales. A work group is now established to identify challenging
issues, develop solutions and evaluate the outcomes.
The CPCP model yielded high satisfaction from the physicians and enabled the nurses to
work to the full scope of their practice. The results suggest the model increased system
efficiency and participants had high job satisfaction. This pilot provides a concrete example
of successfully applying theory to practice.
Acknowledgements
The authors would like to acknowledge the editorial contributions from Liliane Locke, RN,
MPA, from SCO Health Service and Dr Pierre Allard, Robin Kells, MA, and Dawn
Mullins, MSc, from the Elisabeth Bruyere Research Institute.
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