An action research protocol to strengthen system-wide inter-professional learning and practice [LP0775514]

Too much theory and not enough practice? The challenge of implementation science application in healthcare practice

BACKGROUND

Implementation science (IS) should contribute to maintaining high standards of care across healthcare systems and enhancing care practices. However, despite the evident need for greater and more rapid uptake and integration of evidence in practice, IS design and methodology fall short of the needs of effective translation.

AIM

In this paper we examine what it is about IS that makes it so appealing for effective uptake of interventions in routine practice, and yet so difficult to achieve. We propose a number of ways that implementation scientists could build mutual relationships with healthcare practitioners and other stakeholders including public members to ensure greater shared care practices, and highlight the value of IS training, collaborative educational events, and co-designed research.

DISCUSSION

More consideration should be given to IS applications in healthcare contexts. Implementation scientists can make a valuable contribution by mobilizing theory and improving practice. However, goals for an evidence-based system may be more appropriately achieved through greater outreach and collaboration, with methods that are flexible to support rapid implementation in complex adaptive systems. Collective learning and mutual trust can be cultivated by embedding researchers into healthcare services while offering greater opportunities for practitioners to learn about, and engage in, implementation research.

CONCLUSION

To bridge the worlds of healthcare practice and IS, researchers could be more consistent in the relationships they build with professionals and the public, communicating through a shared language and co-joining practical approaches to effective implementation. This will build capacity for improved collaboration and foster respectful, interdisciplinary relationships.

Older People With Type 2 Diabetes-Individualising Management With a Specialised Community Team (OPTIMISE): Perspectives of Participants on Care

Despite the high prevalence of diabetes in older people, there is limited information on optimal methods to support their diabetes management, including how to incorporate technology. This article reports on the results of semi-structured interviews with 41 adult participants with type 2 diabetes (mean age 74 ± 7 years) on their perspectives of a new model of care (the Older People With Type 2 Diabetes-Individualising Management With a Specialised Community Team [OPTIMISE] program) for older people with type 2 diabetes. The OPTIMISE program involved telemedicine consultations, home visits by a credentialed diabetes educator, and intermittent flash glucose monitoring. Human connection and relationships were key to the positive perspectives expressed by participants in this program that used technology to enhance the care of older people in their homes.

The three numbers you need to know about healthcare: the 60-30-10 Challenge

BACKGROUND

Healthcare represents a paradox. While change is everywhere, performance has flatlined: 60% of care on average is in line with evidence- or consensus-based guidelines, 30% is some form of waste or of low value, and 10% is harm. The 60-30-10 Challenge has persisted for three decades.

MAIN BODY

Current top-down or chain-logic strategies to address this problem, based essentially on linear models of change and relying on policies, hierarchies, and standardisation, have proven insufficient. Instead, we need to marry ideas drawn from complexity science and continuous improvement with proposals for creating a deep learning health system. This dynamic learning model has the potential to assemble relevant information including patients' histories, and clinical, patient, laboratory, and cost data for improved decision-making in real time, or close to real time. If we get it right, the learning health system will contribute to care being more evidence-based and less wasteful and harmful. It will need a purpose-designed digital backbone and infrastructure, apply artificial intelligence to support diagnosis and treatment options, harness genomic and other new data types, and create informed discussions of options between patients, families, and clinicians. While there will be many variants of the model, learning health systems will need to spread, and be encouraged to do so, principally through diffusion of innovation models and local adaptations.

CONCLUSION

Deep learning systems can enable us to better exploit expanding health datasets including traditional and newer forms of big and smaller-scale data, e.g. genomics and cost information, and incorporate patient preferences into decision-making. As we envisage it, a deep learning system will support healthcare's desire to continually improve, and make gains on the 60-30-10 dimensions. All modern health systems are awash with data, but it is only recently that we have been able to bring this together, operationalised, and turned into useful information by which to make more intelligent, timely decisions than in the past.

Capturing the patient voice: implementing patient-reported outcomes across the health system

PURPOSE

Supporting the capture and use of patient-reported outcomes (PROs) at the point-of-care enriches information about important clinical and quality of life outcomes. Yet the ability to scale PROs across healthcare systems has been limited by knowledge gaps around how to manage the diversity of PRO uses and leverage health information technology. In this study, we report learnings and practice insights from UW Medicine's practice transformation efforts to incorporate patient voice into multiple areas of care.

METHODS

Using a participatory, action research approach, we engaged with UW Medicine clinical and administrative stakeholders experienced with PRO implementation to inventory PRO implementations across the health system, characterize common clinical uses for PROs, and develop recommendations for system-wide governance and implementation of PROs.

RESULTS

We identified a wide breadth of PRO implementations (n = 14) in practice and found that nearly half (47%) of employed PRO measures captured shared clinical domains (e.g., depression). We developed three vignettes (use cases) that illustrate how users interact with PROs, characterize common ways PRO implementations support clinical care across the health system (1) Preventive care, (2) Chronic/Specialty care, and (3) Surgical/Interventional care), and elucidate opportunities to enhance efficient PRO implementations through system-level standards and governance.

CONCLUSIONS

Practice transformation efforts increasingly require integration of the patient voice into clinical care, often through the use of PROs. Learnings from our work highlight the importance of proactively considering how PROs will be used across the layers of healthcare organizations to optimize the design and governance of PROs.

The co-design of timely and meaningful information needed to enhance social participation in community aged care services: Think tank proceedings

OBJECTIVE

To determine what information from community aged care social participation and quality of life assessments needs to be captured, and meaningfully utilised as part of an integrated information and communication technology system.

METHODS

Two think tank sessions comprised of community aged care staff and researchers (n = 9) were conducted over 5 weeks. The sessions were guided by the Continuous Quality Improvement framework. Thematic analysis was used to categorise the think tank data.

RESULTS

To monitor progress over time, participants needed more contextual information captured in the assessment forms, such as client goals and outcomes of assessments. The aged care provider agreed to embed outcome measure score and action following assessment into its information and communication technology system.

CONCLUSION

Collaboration between aged care staff and researchers resulted in adjustments to the aged care provider's information and communication technology system to better target the monitoring and planning of its clients' psychosocial needs.

Interprofessional learning in immediate life support training does effect TEAM performance during simulated resuscitation

Aim of the study

To assess performance in a simulated resuscitation after participating in either an interprofessional learning (IPL) or uniprofessional learning (UPL) immediate life support (ILS) training course.

Introduction

The Team Emergency Assessment Measure (TEAM) is routinely used in Resuscitation Council (UK) Advanced Life Support courses. This study used the psychometrically validated tool to assess if the delivery of an IPL ILS to final year medical and nursing students could improve overall behavioural performance and global TEAM score.

Methods

A randomised study of medical (n=48) and nursing (n=48) students, assessing performance in a simulated resuscitation following the IPL or UPL ILS courses. Postcourse completion participants were invited back to undertake a video-recorded simulated-resuscitation scenario. Each of these were reviewed using the TEAM tool, at the time by an experienced advanced life support instructor and subsequently by a clinician, independent to the study and blinded as to which cohort they were reviewing.

Results

Inter-rater reliability was tested using a Bland-Altman plot indicating non-proportional bias between raters. Parametric testing and analysis showed statistically significant higher global overall mean TEAM scores for those who had attended the IPL ILS courses.

Conclusion

Our results demonstrate that an IPL approach in ILS produced an increased effect on TEAM scores with raters recording a significantly more collaborative team performance. A postscenario questionnaire for students also found a significantly improved experience within the team following the IPL course compared with those completing UPL training. Although this study shows that team behaviour and performance can change and improve in the short-term, we acknowledge further studies are required to assess the long-term effects of IPL interventions. Additionally, through this type of study methodology, other outcomes in regard to resuscitation team performance may be measured, highlighting other potential benefit to patients, at level four of Kirkpatrick’s hierarchy.

Implementing a collaborative coaching intervention for professionals providing care to children and their families: An exploratory study

The growing complexity of healthcare requires family and interprofessional partnerships to deliver effective care. Interprofessional coaching can enhance family-centred practice and collaboration. The purpose of this study was to explore the acceptability and feasibility of collaborative coaching training to improve family centredness within acute paediatric rehabilitation. Using a participatory action design, service providers (SPs; n = 36) underwent a 6-month coaching programme involving coaching workshops, learning triads, and tailored sessions with a licensed coach. The feasibility and acceptability of coaching on SPs' family interactions and care was explored. Measure of Processes of Care (MPOC) and MPOC-SP, a coaching skills questionnaire, and focus groups were used to evaluate the acceptability of coaching training. We found that structured coaching training was feasible and SPs reported significant improvements in their coaching skills; however, MPOC and MPOC-SP scores did not reveal significant differences. Qualitative themes indicated that clinicians are developing coaching competencies and applying these skills in clinical practice. Participants perceived that the coaching approach strengthened relationships amongst colleagues, and they valued the opportunity for interprofessional learning. Findings suggest that coaching offers promise as an approach to facilitate successful patient outcomes and improve processes of care. Preliminary findings indicate that interprofessional coaching training is acceptable, feasible, and can significantly improve SP coaching skills and improve team cohesion. Further research to study the effects of coaching on interprofessional care using validated outcome measures and to assess the impact on service delivery is recommended.

[Training and action research in a short-stay geriatric oncology unit]

A participative action research project was undertaken in a geriatric oncology hospital unit. It resulted in the training of paramedical staff regarding the specific care to be provided to elderly people with cancer.

Bridging gaps to promote networked care between teams and groups in health delivery systems: a systematic review of non-health literature

OBJECTIVES

To assess non-health literature, identify key strategies in promoting more networked teams and groups, apply external ideas to healthcare, and build a model based on these strategies.

DESIGN

A systematic review of the literature outside of healthcare.

METHOD

Searches guided by Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) of ABI/INFORM Global, CINAHL, IBSS, MEDLINE and Psychinfo databases following a mind-mapping exercise generating key terms centred on the core construct of gaps across organisational social structures that uncovered 842 empirical articles of which 116 met the inclusion criteria. Data extraction and content analysis via data mining techniques were performed on these articles.

RESULTS

The research involved subjects in 40 countries, with 32 studies enrolling participants in multiple countries. There were 40 studies conducted wholly or partly in the USA, 46 wholly or partly in continental Europe, 29 wholly or partly in Asia and 12 wholly or partly in Russia or Russian federated countries. Methods employed included 30 mixed or triangulated social science study designs, 39 qualitative studies, 13 experimental studies and 34 questionnaire-based studies, where the latter was mostly to gather data for social network analyses. Four recurring factors underpin a model for promoting networked behaviours and fortifying cross-group cooperation: appreciating the characteristics and nature of gaps between groups; using the leverage of boundary-spanners to bridge two or more groups; applying various mechanisms to stimulate interactive relationships; and mobilising those who can exert positive external influences to promote connections while minimising the impact of those who exacerbate divides.

CONCLUSIONS

The literature assessed is rich and varied. An evidence-oriented model and strategies for promoting more networked systems are now available for application to healthcare. While caution needs to be exercised in translating outside ideas and studies, drawing on non-health ideas is useful in providing insights into other sectors.

Environmental scan of interprofessional collaborative practice initiatives

Interprofessional collaboration in health care is high on the policy agenda in Canada. There is evidence that governments, academic institutions, regulatory bodies and health services are developing directions, policies and strategies with collaboration in mind. The Ottawa Hospital (TOH) received governmental funding to implement The Ottawa Hospital Inter-Professional Model of Patient Care.Prior to implementing our model, we conducted an environmental scan to identify initiatives related to interprofessional collaboration in clinical settings. A historical method was used to understand the chronological development of interprofessional collaboration within the health field over the last 10 years. Critical browsing was used to search, select and summarize information found on the web. Fifty two documents were critically reviewed; 27 documents were retained for further analysis and inclusion.The information was analyzed according to three main parameters: source, summary and relevance to our project. The five broad themes identified are: promotion, networking, evidence, resources and linkage between interprofessional education and care. This seems an accurate reflection of the current state of this area; there is active promotion and networking, concrete frameworks and funds but few published results regarding the efficacy of implementing IPC in health care organizations. As experience with the approach accumulates, evidence should grow

On a wing and a prayer: an assessment of modularized crew resource management training for health care professionals

INTRODUCTION

Evidence suggests that Crew Resource Management (CRM), a form of team training, is beneficial. In CRM training, participants learn individual portable team skills such as communication and decision making through group discussion and activities. However, the usual 1-day course format is not always compatible with health care organizational routines. A modular training format, while theoretically sound, is untested for interprofessional team training. The aim of this study was to explore the potential for modularized CRM training to be delivered to a group of interprofessional learners.

METHOD

Modularized CRM training, consisting of two 2-hour workshops, was delivered to health care workers in an Australian tertiary hospital. Kirkpatrick's evaluation model provided a framework for the study. Baseline attitude surveys were conducted prior to each workshop. Participants completed a written questionnaire at the end of each workshop that examined their motivations, reactions to the training, and learner demographics. An additional survey, administered 6 weeks post training, captured self-assessed behavior data.

RESULTS

Twenty-three individuals from a range of professions and clinical streams participated. One in 5 participants (22%) reported that they translated teamwork skills to the workplace. While positive about the workshop format and content, many respondents identified personal, team, and organizational barriers to the application of the workshop techniques.

DISCUSSION

CRM training when delivered in a modular format has positive outcomes. Following the training, some respondents overcame workplace barriers to attempt to change negative workplace behavior. This progress provides cautious optimism for the potential for modular CRM training to benefit groups of interprofessional health staff.

A systematic review of the effectiveness of interprofessional education in health professional programs

OBJECTIVE

The objective of this systematic review was to identify the best available evidence for the effectiveness of university-based interprofessional education for health students.

BACKGROUND

Currently, most health professional education is delivered in a traditional, discipline specific way. This approach is limited in its ability to equip graduates with the necessary knowledge, skills and attitudes for effective interprofessional collaboration and for working as part of a complex health care team. Interprofessional education is widely seen as a way to improve communication between health professionals, ultimately leading to improved patient outcomes.

INCLUSION CRITERIA

The review included all randomised controlled trials and quasi-experimental studies in which two or more undergraduate or post-graduate health professional groups are engaged in interprofessional education.

REVIEW METHODS

A three-stage comprehensive search of ten electronic databases as well as grey literature was conducted. Two independent reviewers assessed each paper prior to inclusion using the standardised critical appraisal instruments for evidence of effectiveness developed by the Joanna Briggs Institute.

RESULTS

Nine published studies consisting of three randomised controlled trials, five controlled before and after studies and one controlled longitudinal study were included in the review.

CONCLUSION

Student's attitudes and perceptions towards interprofessional collaboration and clinical decision-making can be potentially enhanced through interprofessional education. However, the evidence for using interprofessional education to teach communication skills and clinical skills is inconclusive and requires further investigation.

IMPLICATIONS FOR RESEARCH

Future randomised controlled studies explicitly focused on interprofessional education with rigorous randomisation procedures, allocation concealment, larger sample sizes, and control groups, would improve the evidence base for interprofessional education.

Continuing differences between health professions' attitudes: the saga of accomplishing systems-wide interprofessionalism

OBJECTIVE

To compare four health professions' attitudes towards interprofessional collaboration (IPC) and their evaluations of a programme aimed at enhancing IPC across a health system.

DESIGN

Questionnaire survey.

SETTING

Australian Capital Territory health services.

PARTICIPANTS

Sample of medical (38), nursing (198), allied health (152) and administrative (30) staff.

INTERVENTION

s) A 4-year action research project to improve IPC.

MAIN OUTCOME MEASURE

Questionnaire evaluating the project and responses to the 'Attitudes toward Health Care Teams' and 'Readiness for Interprofessional Learning' scales.

RESULTS

Significant professional differences occurred in 90% of the evaluation items. Doctors were the least and administrative staff most likely to agree project aims had been met. Nurses made more favourable assessments than did allied health staff. Doctors made the most negative assessments and allied health staff the most neutral ratings. Improved interprofessional sharing of knowledge, teamwork and patient care were among the goals held to have been most achieved. Reduction in interprofessional rivalry and improved trust and communication were least achieved. Average assessment of individual goals being met was agree (31.9%), neutral (56.9%) and disagree (11.2%). On the two attitude scales, allied health professionals were most supportive of IPC, followed by nurses, administrators and doctors.

CONCLUSIONS

Although overall attitudes towards IPC were favourable, only a third of participants reported that project goals had been achieved indicating the difficulties of implementing systems change. The response profiles of the professions differed. As in the previous research, doctors were least likely to hold favourable attitudes towards or endorse benefits from social or structural interventions in health care.

A four-year, systems-wide intervention promoting interprofessional collaboration

Background

A four-year action research study was conducted across the Australian Capital Territory health system to strengthen interprofessional collaboration (IPC) though multiple intervention activities.

Methods

We developed 272 substantial IPC intervention activities involving 2,407 face-to-face encounters with health system personnel. Staff attitudes toward IPC were surveyed yearly using Heinemann et al's Attitudes toward Health Care Teams and Parsell and Bligh's Readiness for Interprofessional Learning scales (RIPLS). At study's end staff assessed whether project goals were achieved.

Results

Of the improvement projects, 76 exhibited progress, and 57 made considerable gains in IPC. Educational workshops and feedback sessions were well received and stimulated interprofessional activities. Over time staff scores on Heinemann's Quality of Interprofessional Care subscale did not change significantly and scores on the Doctor Centrality subscale increased, contrary to predictions. Scores on the RIPLS subscales of Teamwork & Collaboration and Professional Identity did not alter. On average for the assessment items 33% of staff agreed that goals had been achieved, 10% disagreed, and 57% checked neutral. There was most agreement that the study had resulted in increased sharing of knowledge between professions and improved quality of patient care, and least agreement that between-professional rivalries had lessened and communication and trust between professions improved.

Conclusions

Our longitudinal interventional study of IPC involving multiple activities supporting increased IPC achieved many project-specific goals. However, improvements in attitudes over time were not demonstrated and neutral assessments predominated, highlighting the difficulties faced by studies targeting change at the systems level and over extended periods.

Contested innovation: the diffusion of interprofessionalism across a health system

OBJECTIVE

Interprofessionalism (IP) has emerged as a new movement in healthcare in response to workforce shortages, quality and safety issues and professional power dynamics. Stakeholders can push for IP (e.g. education providers to the health system) or pull (e.g. the health system to the education provider). Based on innovation theory, we hypothesized that there would be unequal forces within and across stakeholder domains which would work to facilitate or resist IP. The strongest pull pressures would be from the health system and services; push pressures for IP would come from government and higher education; with weaker push forces and levels of resistance, from protectionist professional bodies.

DESIGN

SETTING AND PARTICIPANTS

/st> Our model was tested in a geographically bounded health jurisdiction. Information was gathered and analysed via individual (n= 99 participants) and group (n= 372 participants) interviews with stakeholders, and through document analysis.

RESULTS

/st> The health system and services exerted the strongest pull in demanding IP. The strongest push factor was individual champions in positions of power. Professional bodies balanced their support of IP competencies with their role as advocates for their individual professions. A weak push factor came from government support for health workforce reform.

CONCLUSIONS

/st> Our hypothesis was supported, as were our predictions that the strongest pull would be from the providers and the strongest push from government and higher education. Our original model should be extended to account for contextual factors such as large-scale workplace and professional reform, which worked both for and against, IP.

Owning solutions: a collaborative model to improve quality in hospital care for Aboriginal Australians

Well-documented health disparities between Aboriginal and Torres Strait Islander (hereafter referred to as Aboriginal) and non-Aboriginal Australians are underpinned by complex historical and social factors. The effects of colonisation including racism continue to impact negatively on Aboriginal health outcomes, despite being under-recognised and under-reported. Many Aboriginal people find hospitals unwelcoming and are reluctant to attend for diagnosis and treatment, particularly with few Aboriginal health professionals employed on these facilities. In this paper, scientific literature and reports on Aboriginal health-care, methodology and cross-cultural education are reviewed to inform a collaborative model of hospital-based organisational change. The paper proposes a collaborative model of care to improve health service delivery by building capacity in Aboriginal and non-Aboriginal personnel by recruiting more Aboriginal health professionals, increasing knowledge and skills to establish good relationships between non-Aboriginal care providers and Aboriginal patients and their families, delivering quality care that is respectful of culture and improving Aboriginal health outcomes. A key element of model design, implementation and evaluation is critical reflection on barriers and facilitators to providing respectful and culturally safe quality care at systemic, interpersonal and patient/family-centred levels. Nurses are central to addressing the current state of inequity and are pivotal change agents within the proposed model.

The effectiveness of interprofessional education in university-based health professional programs: A systematic review

EXECUTIVE SUMMARY

Background: A key responsibility of universities is to prepare health professional graduates for their roles as effective members of the health care team. Currently, most university-based health professional education is delivered in a traditional, discipline specific way. This approach is limited in its ability to equip graduates with the necessary knowledge, skills and attitudes for effective interprofessional collaboration and for working as part of a complex health care team. Interprofessional education occurs when learners from two or more professional groups learn about, from and with each other. The fundamental premise of interprofessional education is that if health professional students learn together they will be better prepared for interprofessional collaboration ultimately leading to improved patient outcomes.Objective -The objective of this systematic review was to identify the best available evidence for the effectiveness of university-based interprofessional education.Inclusion criteria -The review included all randomised controlled trials and quasi-experimental studies that assessed the effectiveness of interprofessional education in university-based health professional programs. All studies that included two or more undergraduate or post-graduate health professional groups engaged in interprofessional education were considered. Outcome measures included objectively measured or self-reported educational outcomes and/or professional competencies related to interprofessional education as assessed by validated instruments such as the Readiness for Interprofessional Learning Scale and the Interdisciplinary Education Perception Scale.

SEARCH STRATEGY

A three-stage comprehensive search strategy was utilised to search across ten electronic databases. English language studies published between January 2000 and February 2011 were considered for inclusion.Methodological quality: Two independent reviewers assessed the methodological quality of each study selected for retrieval using standardised Joanna Briggs Institute critical appraisal tools.Data collection and synthesis: Data were extracted from studies using the standardised data extraction tool from the Joanna Briggs Institute. Meta-analysis was not possible because of the different outcomes, control groups and interventions of the selected studies; and the findings are therefore presented in narrative form.

RESULTS

Nine published studies consisting of three randomised controlled trials, five controlled before and after studies and one controlled longitudinal study were eligible for inclusion in this review. Four studies reported significant improvement in attitudes and perceptions of interprofessional education. In addition, five studies reported a mixed set of outcomes related to interprofessional education interventions.

CONCLUSIONS

Student's attitudes and perceptions towards interprofessional collaboration and clinical decision making can be potentially enhanced through interprofessional education. However, the evidence for using interprofessional education to teach interprofessional communication skills and clinical skills such as resuscitation to health professions students is inconclusive and needs further investigation IMPLICATIONS FOR RESEARCH: Future randomised controlled studies explicitly focused on interprofessional education with rigorous randomisation procedures and allocation concealment; larger sample sizes; and more appropriate control groups, would improve the evidence base of interprofessional education.

Auditing an organization's interprofessional learning and interprofessional practice: the interprofessional praxis audit framework (IPAF)

Interprofessional learning (IPL) and interprofessional practice (IPP) are strategies for healthcare services' striving to improve patient care. While health professionals are enacting IPL and IPP, the capacity to understand and comprehensively map IPL and IPP activities has remained elusive. Additionally, understanding and accounting for the impact of organizational context and culture on IPL and IPP requires attention. This paper presents the "interprofessional praxis audit framework" (IPAF), which is a unique tool to address these two issues. The IPAF comprises five components: context, culture, conduct, attitudes and information. Conjoined, the components facilitate examination of an organization's enactment of IPL and IPP. Utilized within an action research methodology, the IPAF enables a synchronized inspection, whereby similarities and differences of the components are considered simultaneously, and the knowledge developed is used to promote change projects to improve patient care.

Developing inter-professional learning: tactics, teamwork and talk

Teamwork and collaboration between all health professionals results in high quality clinical care, and increased job satisfaction for staff. Encouraging inter-professional learning (IPL) may be advantageous in developing more effective teams. There is little rigorous research in this area, but many small uncontrolled studies do demonstrate positive results. IPL involves structured learning opportunities that enhance problem-solving abilities and conflict resolution. It should be clearly differentiated from shared teaching (or multidisciplinary/multiprofessional learning), where common content is taught to many professions without any intention to develop interaction. To counteract the sometimes negative attitudes in both students and staff, educators need to commence IPL early in the programme, base it in both theoretical and clinical placements and ensure that it is valued and assessed. Difficulties with timetabling and accommodation need to be solved prior to commencement. A facilitator should be employed, and a team of committed lecturers developed, with an emphasis on teamwork and the discouragement of individualism. Opportunities for student interaction and ways of improving group dynamics within non-threatening learning environments should to be sought, and instances of conflict embraced and resolved. Future IPL programmes should be rigorously evaluated and may demonstrate enhanced inter-professional relationships and improved quality of patient/client care.