"I don't see the whole picture of their health": a critical ethnography of constraints to interprofessional collaboration in end-of-life conversations in primary care

CONTEXT

Interprofessional collaboration is recommended in caring for frail older adults in primary care, yet little is known about how interprofessional teams approach end-of-life (EOL) conversations with these patients.

OBJECTIVE

To understand the factors shaping nurses' and allied health clinicians' involvement, or lack of involvement in EOL conversations in the primary care of frail older adults.

METHODS/SETTING

A critical ethnography of a large interprofessional urban Family Health Team in Ontario, Canada. Data production included observations of clinicians in their day-to-day activities excluding direct patient care; one-to-one semi-structured interviews with clinicians; and document review. Analysis involved coding data using an interprofessional collaboration framework as well as an analysis of the normative logics influencing practice.

PARTICIPANTS

Interprofessional clinicians (n = 20) who cared for mildly to severely frail patients (Clinical Frailty Scale) at the Family Health Team.

RESULTS

Findings suggest primary care nurses and allied health clinicians have the knowledge, skills, and inclination to engage frail older adults in EOL conversations. However, the culture of the clinic prioritizes biomedical care, and normalizes nurses and allied health clinicians providing episodic task-based care, which limits the possibility for these clinicians' engagement in EOL conversations. The barriers to nurses' and allied health clinicians' involvement in EOL conversations are rooted in neoliberal-biomedical ideologies that shapes the way primary care is governed and practiced.

CONCLUSIONS

Our findings help to explain why taking an individual-level approach to addressing the challenge of delayed or avoided EOL conversations, is unlikely to result in practice change. Instead, primary care teams can work to critique and redevelop quality indicators and funding models in ways that promote meaningful interprofessional practice that recognize the expertise of nursing and allied health clinicians in providing high quality primary care to frail older patients, including EOL conversations.

'It's not hands-on therapy, so it's very limited': Telehealth use and views among allied health clinicians during the coronavirus pandemic

BACKGROUND

Telehealth services have helped enable continuity of care during the coronavirus pandemic. We aimed to investigate use and views towards telehealth among allied health clinicians treating people with musculoskeletal conditions during the pandemic.

METHODS

Cross-sectional international survey of allied health clinicians who used telehealth to manage musculoskeletal conditions during the coronavirus pandemic. Questions covered demographics, clinician-related factors (e.g. profession, clinical experience and setting), telehealth use (e.g. proportion of caseload, treatments used), attitudes towards telehealth (Likert scale), and perceived barriers and enablers (open questions). Data were presented descriptively, and an inductive thematic content analysis approach was used for qualitative data, based on the Capability-Opportunity-Motivation Behavioural Model.

RESULTS

827 clinicians participated, mostly physiotherapists (82%) working in Australia (70%). Most (71%, 587/827) reported reduced revenue (mean (SD) 62% (24.7%)) since the pandemic commenced. Median proportion of people seen via telehealth increased from 0% pre (IQR 0 to 1) to 60% during the pandemic (IQR 10 to 100). Most clinicians reported managing common musculoskeletal conditions via telehealth. Less than half (42%) of clinicians surveyed believed telehealth was as effective as face-to-face care. A quarter or less believed patients value telehealth to the same extent (25%), or that they have sufficient telehealth training (21%). Lack of physical contact when working through telehealth was perceived to hamper accurate and effective diagnosis and management.

CONCLUSION

Although telehealth was adopted by allied health clinicians during the coronavirus pandemic, we identified barriers that may limit continued telehealth use among allied health clinicians beyond the current pandemic.