Do multidisciplinary integrated care pathways improve interprofessional collaboration?

Authors



Kay Caldwell, Postgraduate Programme Co-ordinator, School of Health and Social Science, Middlesex University, The Queensway, Enfield, Middlesex, EN3 4SF, UK. E-mail: k.caldwell@mdx.ac.uk

Abstract

This paper reports on the evaluation stage of an action research project on interprofessional collaboration in discharge planning. Findings from interviews with health care professionals working in the acute sector had revealed concerns about discharge planning and multidisciplinary teamwork. In the United Kingdom the National Health Service (NHS) Plan has reinforced the need for an integrated approach to health care. Effective health care integration requires effective communication, teamwork and the commitment to deliver integrated care. Integrated documentation is a key strategy for enhancing interprofessional collaboration and reducing the isolation of professionals, and has been successfully implemented in a range of health care settings. Presented with the concerns about the collaborative process in discharge planning, an action research strategy was chosen to bring about change in an orthopaedic ward in one London teaching hospital. This paper will evaluate the implementation of an integrated care pathway with fractured neck of femurs in one London teaching hospital. Care pathways facilitate the management of defined patient groups using interdisciplinary plans of care. The emphasis will be on understanding whether integrated care pathways enhance and develop interprofessional collaboration and enable effective information access and flow across the professions and the organization. The criteria for evaluation, forming the hypotheses of the study, were that interprofessional nonverbal and verbal communication would be enhanced and that interprofesisonal collaboration would increase. Methods of evaluation used were: (i) stakeholder interviews, (ii) interprofessional audit and (iii) analysis of the variances from the integrated care pathway. The evaluation revealed that although integrated care pathways led to improved outcomes for the health care trust there was little evidence to suggest that interprofessional relationships and communication were enhanced. Furthermore, key factors in discharge delays appeared to be organizational rather than professional.

Introduction

Interprofessional working, integrated care, interagency working, and collaboration are all terms, which are currently, cited in government documents in the United Kingdom (1, 2). Jong and Jackson (3) suggest that in health the term integration be used to denote multidisciplinary management, care collaboration, serviceco-ordination or linkage. Whilst interprofessional and interorganizational collaboration is an essential component of best practice the rules of collaboration and teamwork are often difficult to put into practice. One means of enhancing interprofessional and interorganizational relationships is through integrated care pathways. The National Health Service (NHS) Plan (1) emphasizes the importance of planning care around the patient and the use of protocols for each condition to ensure best evidence-based practice.

The management of patients with a fractured neck of femur is dependent on the team approach and the operation is only one part of the rehabilitation process. Hip fractures have been recognized as a significant health problem because of the projected increase in incidence. The Royal College of Physicians (4) estimated that the growth in population would produce 60 000 cases each year by 2016. Hip fractures are particularly common in elderly people with 80% of them occurring in women (5). Thus considerably more resources will be needed to manage this growth rate which creates serious social and economic problems (6). Discharge planning is an important process, not only for ensuring that patients are not in receipt of acute care past the time that they cease to benefit, but also for ensuring bed availability for new admissions. Furthermore, the importance of discharge planning has increased since the publication of the NHS Plan (1) which highlighted the importance of freeing up acute beds and looking at alternative and creative ways of rehabilitating and discharging patients. Additionally it emphasized the importance of collaboration between health and social services.

This paper will discuss the findings of a study that aimed to evaluate the effectiveness of integrated care pathways for patients admitted with fractured neck of femurs. The emphasis will be on understanding whether integrated care pathways enhance and develop interprofessional collaboration and enable effective information access and flow of communication across the professions and the organization.

Integrated care pathways

The problems in describing integrated care pathways are caused by the many similar terms that exist within the literature. Integrated care pathways are also called critical paths, care maps, collaborative plan of care, multidisciplinary action plans, care paths, and anticipated recovery paths. Care pathways began in the early 1980s in the USA (7) and are currently being used in the UK NHS as a means to implement the components of clinical governance (8, 9). Care pathways have been widely promoted as a managed care paradigm. The aim of managed care is to standardize the delivery of health care, the length of stay in the hospital and the clinical management of the patient (10). Ignatavicius and Hausman (11) refer to integrated care pathways as interdisciplinary plans of care that outline the optimal sequencing and timing of interventions for patients with a particular diagnosis, procedure or symptom.

Integrated care pathways can be used to facilitate the development and implementation of multidisciplinary guidelines, minimize delays and use of resources while maximizing the quality of patient care, specifying each anticipated treatment event and the communication process (11, 12). Benefits include increased collaboration, increased professionalism, more effective clinical care, improve clinician–patient communication and patient satisfaction (13–16). Disadvantages of this approach have been identified as the limited evidence for their potential to improve patient care, their focus on cost rather than quality, a dissonance between the managerial and clinical expectation and limited scope for professional development. In addition it has been suggested that they led to a reduction in clinicians' status and discouraged appropriate clinical judgement being applied to individual cases (9, 10, 12). Jones (17) raises the interesting question as to how the different professionals respond to having their philosophy and practice shaped to fit the requirement of a care pathway. Criticism is directed towards researchers for not commenting on inteprofessional relationships when designing care pathways and presuming that professionals will readily deliver their interventions via such a pathway. Luc (9) is of the opinion that the process of developing the pathway is an ideal opportunity to develop multidisciplinary teamwork. Currie and Harvey (8) suggest that to overcome the problems of ‘cookbook’ medicine a programme of education is needed, which reinforces the message that the pathway should only be used for guidance. However White et al. (10) are of the opinion that managed care has a profound effect on interprofessional collaboration and teaching. However, managed care did not encourage doctors and nurses to share knowledge and hence learn from one another.

Background to study

This study is part of an action research project, located in a large acute NHS Trust. This project aimed to analyse and improve multidisciplinary teamwork in discharge planning, and was supported by both the hospital management and the Local Research Ethics Committee. The total project involved a series of interrelated stages:

  • 1Video recording and analysing, using Bales' Interaction Analysis of multidisciplinary team meetings. In total 14 meetings were attended in elder care, orthopaedics, and seven in acute medicine;
  • 2Interviews with 48 health care professionals using the critical incident approach to explore their perceptions and attitudes relating to discharge planning;
  • 3A Delphi survey which aimed to ascertain consensus regarding the formulation of an interprofessional model.

This paper focuses on the last two stages, namely:

  • 1The development and implementation of an integrated care pathway for patients admitted with a fractured neck of femur;
  • 2The evaluation of the integrated care pathway, including stakeholder interviews, analysis of case notes to determine variances and a comparative audit of the comprehensiveness of case notes pre and postimplementation of the integrated care pathway.
  • The research questions being addressed in this stage of evaluation were:

    • 1Does the introduction of an integrated care pathway improve interprofessional collaboration?
    • 2Does the introduction of an integrated care pathway improve communication within the multidisciplinary team?
    • 3Does the introduction of an integrated care pathway lead to better patient outcomes?

Analysis of the interviews revealed that lack of time was reported to be a major factor for not participating in multidisciplinary team meetings. Furthermore, the aim of multidisciplinary meetings was to discuss discharge problems as opposed to planning discharges. During the interviews health care professionals identified that they were reluctant to express opinions during multidisciplinary team meetings for fear of being scapegoated and blamed for preventing a discharge from occurring. As a means of resolving these problems an action research group was formed on one orthopaedic ward consisting of representatives from the major disciplines involved in the care of this client group: medicine, nursing, physiotherapy, occupational therapy and care management. It was anticipated that by strengthening interprofessional working this would in turn improve the quality of care.

Research design

Action research is defined by Carr and Kemis (18) as a:

‘Type of self-reflective enquiry undertaken by participants in social situations in order to improve the rationality and justice of their own practices, their understandings of these practices and the situations in which these practices are carried out.‘

The emancipatory action research model was used as it provides a framework for understanding organizational change, ‘best practice’ and encourages organizational learning and development of the ‘learning organization’ (19). This model designed for organizational change has been developed in a five-step process by adapting and extending the organizational change models of Lewin (20) and Beer et al. (21) and integrating them into the action research model. Zuber-Skerritt (19), the creator of the model, claims that it is the most effective way to achieve organizational change and learning. It is a five-step process which includes strategic planning, implementing the plan (actions), observation, evaluation and self evaluation, critical and self critical reflection which require the action research group to make decisions for the next cycle of action research. The revised plan is then implemented and followed by action and reflection (22). Action researchers use multiple methods, which can be both qualitative and quantitative to implement and evaluate change. In this part of the study both quantitative (audit and analysis of variance) and qualitative (stakeholder interviews) methods were used.

Formation of the integrated care pathway

It was fundamental for all members of the multidisciplinary team to agree on the format and content of the integrated care pathway. In addition it was essential to ensure that the documentation met the standards set by the different professional bodies. If documentation was to be fully integrated then all health care professionals must use one set of integrated notes only and disband their own professional notes. After careful negotiation the occupational therapists and care managers agreed to complete the integrated care pathway but insisted on maintaining their own professional notes. Goal setting is of particular importance as teamwork is the means whereby its members work together to achieve a defined common goal. The setting and revaluation of goals enables progress to be measured, plans to be evaluated and changed according to the patients needs. Thus, at the beginning of each day, goals were to be recorded and evaluated by members of the multidisciplinary team.

It was essential to include both the orthopaedic and the accident and emergency department as the latter ‘kick starts’ both the admission and the discharge process. In addition the nursing care plan should be integrated between accident and emergency and the orthopaedic ward, ensuring that the planned care was identified and commenced on admission, and followed the patient through until eventual discharge. A multidisciplinary social admission form was formulated to allow one designated person to collate the social and functional history on admission. This would meet the needs of all members of the team and encourage information to be retrieved from a wide variety of sources. Information would be collated from carers and relatives, general practitioners, social services and ambulance crews who often have in-depth information about the patient and their home. The multidisciplinary social admission form could be used as the referral form to social services that would provide care management with accurate information.

The role of the researcher was vital to the success of the project. Credibility of the researcher was enhanced by the fact that she had previously worked in the hospital, and this enabled a relatively smooth integration into the clinical team. Bias was minimized, as the researcher had not worked directly with the clinical team previously, although was known to them, and during the project was funded by the University and was not an employee of the hospital, but a full-time researcher. During this project the researcher took on the role as project manager and integrated care pathway lead clinician. The role of the action research investigator was to document and provide feedback on the change process so that it could be structured, modified or accelerated. It is suggested that action researchers need to have a good understanding of research methods and excellent communication, team building and negotiation skills.

Evaluation

Evaluation is central to health service research as it aims to record what changes occurred, what led to these changes and establish whether there is a relationship between theory and practice. Evaluation should enable practitioners, managers and patients to make informed decisions regarding resource allocation, the effectiveness of treatments and whether treatments and changes, which have been implemented, provide value for money. Ovretveit (23) had defined evaluation as a process, which is:

‘Attributing value to an intervention by gathering reliable and valid information about it in a systematic way, and by making comparisons, for the purpose of making more informed decisions or understanding causal mechanisms for general principles.’

The criteria for evaluation was that interprofessional written and verbal communication would be improved, that interprofessional collaboration would be enhanced and that patient outcomes would be better. The evaluation of the success of the integrated care pathway included stakeholder interviews, interprofessional audit and analysis of the variances of the integrated care pathway.

Stakeholder interviews

Interview guides were constructed from the findings of the critical incident interviews undertaken in an earlier stage of the project. After piloting the interview guide six interviews with stakeholders in the project were carried out. An unstructured audio taped interview technique was used to ascertain the action research users' perceptions of the model, its impact on the team and the discharge process. Guba and Lincoln (26) introduce the term ‘stakeholder’ into evaluation research. Stakeholder is defined as ‘Having something at stake in the evaluation and the entity being evaluated.’ Thus stakeholders are at risk should the evaluation result in negative findings. Thus it is suggested by Guba and Lincoln (26) that groups who are at risk must have the opportunity to raise any question which is deemed appropriate, particularly as stakeholders are the users of evaluative information. Stakeholders were chosen because they had the time and the special knowledge to give purposeful insightful accounts that are often denied through randomized designs. In total six were interviewed: four nurses, one occupational therapist and one care manager. The interview technique was piloted on two nurses who deliberately gave both negative and positive perceptions of the discharge model. The audiotapes were transcribed and then grouped by themes for the development of the coding frame. One independent judge was appointed to ensure dependability of the coding. The judge independently coded two pages of transcripts. The two transcripts were then compared and disagreements amongst the judge and the investigator were discussed. An agreement of 82% was recorded. The same procedure was repeated two-thirds through completion of the study to ensure that was a high agreement maintained amongst the two judges. A high consistency of agreement was maintained (85%).

Interprofessional audit

An audit tool was developed that enabled case notes to be audited against predetermined clinical standards established by the hospital in line with professional body recommendations. The Department of Health (28) reports that the features of successful clinical audit are that it is multidisciplinary, although it has been noted that many professionals may regard it as threatening. Thus considerable time was spent negotiating the construction of the audit tool. This process was extremely difficult because each professional group had their own perception regarding what constitutes quality based on their professional values and closely associated with the interests of the different members of the team, but eventually consensus was reached. In total 11 sets of case notes were audited prior to the implementation of the integrated care pathway, and 11 sets postimplementation. The audit took place between October and December 1997. Crombie et al. (27) describe audit as: ‘The process of reviewing the delivery of health care to identify deficiencies so that they may be remedied.’ It was essential for the researcher to consider who may be harmed by these findings, particularly as professionals are used to evaluating their own practice and thus may resent the intrusion. The tool was piloted on two sets of notes selected at random.

Variance analysis

Variance analysis is a process that has been specifically designed to evaluate and critically analyse clinical pathways (24). A variance is regarded as any deviation from the proposed standard of care listed in the pathway. Health care professionals on the integrated care pathway recorded variations from the pathway along with the appropriate reasons. These were then collated and then categorized. The recording of variances gives staff a means to practice professional autonomy as it enables them to individualize care and addresses the concerns of those critics who regard them as rigid and fixed, thus ensuring that cookbook medicine does not occur. The variance may be either positive or negative, compared with previously established standards. For example, a positive variance will occur if the patient progresses faster than expected whilst a negative variance occurs when activities on the clinical pathway are not completed within the designated time frame, costs are higher than expected, or the patient does not meet the expected outcome. The variation from the pathways identifies patients who are not progressing as expected and allows for early and appropriate intervention to be instigated. Improvement in the quality of care is achieved by frequently revising the pathway which provides quality, relevant, prospective information on current clinical practice (25). Variances from the pathway were recorded and key themes were identified and grouped.

Results

Interprofessional communication

In theory multidisciplinary integrated care pathways should improve the communication process. One staff nurse commented on the positive impact which multidisciplinary integrated care pathways made to interprofessional communication:

‘If you compare some of the patients with other problems you notice much more with the new ICPs (integrated care pathways) that things are done much more thoroughly and that people do work together better than if a patient came in with a different problem.’

One care manager reported that he only really read the occupational therapists' entries in the integrated notes. Multidisciplinary care pathways were criticized by staff nurses for not acknowledging that patients are individuals and for being prescriptive ‘I think that those ICPs treat you like you are a bit thick so…you don’t need to show initiative. They are so regimented' (Staff nurse). Although another staff nurse reported that they were extremely helpful in educating junior nurses and ensure that there is continuity. ‘I don’t think it is degrading I think it is a good checklist'.

A care manager remained critical of the fact that professionals did not make the effort to update him on the progress of the patient. Thus multidisciplinary care notes, whilst evaluating care through the variances, are still dependent on professionals participating in interprofessional communication. If this does not occur then delays in the process occur:

‘To a greater extent I have to go looking for the information… It is not like people will call me and say the OT did the home visit and this was the result…some times the OT will actually call me because we work quite closely with the OT but you don’t get really any other communication from anybody else… We are the ones who have to wait basically until everyone else has their stuff done before we can really do our part…and yet they don't really tell me that they are done...and if I don't come regularly looking to find that out then I wouldn't know.'

If professionals do not complete integrated notes correctly the management of the patient may become unsound, disorganized and fragmented: ‘When it is done right it works’ (Staff nurse). This increases the risk of litigation especially when professionals forget to sign parts of the integrated care pathway.

Three staff nurses in orthopaedics accused doctors and occupational therapists of not completing the multidisciplinary integrated care pathways, which resulted in communication becoming fragmented. A staff nurse commented that there was still duplication as nurses would write on the integrated care pathway and then on a separate piece of paper. Professionals complained that other professionals used jargon and abbreviations that was often difficult to understand by all members of the multidisciplinary team. One occupational therapist criticized occupational therapy language as meaningless: ‘Which doesn’t promote communication at all.' In contrast a staff nurse reported that she did not have any problem with abbreviations.

Interprofessional documentation

Prior to the implementation of the integrated care pathway it had been difficult to ascertain whether the occupational therapy assessment occurred within the time frame of the integrated care pathway and that care had been re-evaluated. The data from the audit October–December 1997 (Table 1) found that in 10 cases out of 11 (91%) an occupational therapy assessment was not documented in the medical notes, and in 10 cases (91%) it was not possible to determine whether reassessment had occurred. Since the introduction of the multidisciplinary integrated care plans one was able to demonstrate that in nine cases (73%) there was evidence of reassessment and in 10 cases (91%) the assessment was documented in the interdisciplinary notes. In addition the data from both audits demonstrated that physiotherapists assessed mobility within the time of the integrated care pathway and reassessed care (100%).

Table 1.  Audit of documentation standards: Preimplementation of ICP (October–December 1997) and postimplementation of ICP (November 1998–January 1999)
ProfessionStandardNo. meeting standard
(Preimplementation)
n = 11
No. meeting standard
(Postimplementation)
n = 11
MedicinePreoperative social history  4 (36%)11 (100%)
Preoperative cognition  0 (0%)11 (100%)
Preoperative function  3 (27%)11 (100%)
NursingPressure area risk11 (100%)11 (100%)
Reassessment11 (100%)11 (100%)
Pain assessment11 (100%)11 (100%)
Reassessment11 (100%)11 (100%)
Nutrition assessment11 (100%)11 (100%)
Reassessment11 (100%)11 (100%)
Social history  4 (36%)11 (100%)
Functional history  2 (18%)11 (100%)
Occupational therapyFunctional history (within time frame of ICP)  1 (9%)10 (91%)
Reassessment  1 (9%)  9 (82%)
Referral actioned within time frame of ICP  3 (27%)  8 (73%)
PhysiotherapyMobility and transfers (within time frame of ICP)11 (100%)11 (100%)
Reassessment11 (100%)11 (100%)
Care managerCare plan recorded  3 (27%)  8 (73%)

The introduction of the multidisciplinary assessment form resulted in discharge planning beginning as soon as the patient arrived in the accident and emergency department. The data from the audit between October and December 1997 found that in only one case was there evidence that discharge plans had been made within 48 hours of admission. This improved dramatically to 100% when the notes were re-audited (Table 2). All the professionals viewed the multidisciplinary social and functional history form positively. The audit, performed from October to December 1997 demonstrated that in the medical notes the social history was recorded in four instances (36%), cognition in zero cases (0%) and function in three instances (27%). In the nursing notes the social and primary care history were not recorded in seven cases (63%) and only two sets (18%) fully recorded the functional history. The audit of the care pathway demonstrated that all three components were recorded in all instances (100%). A staff nurse expressed her disinterest in the social history: ‘Well I don’t read it because it is already done…until the OT asks me.' Whilst another staff nurse stated that time prevented nurses from reading the assessment:

Table 2.  Audit of discharge and multidisciplinary collaboration standards: Preimplementation of ICP (October–December 1997) and postimplementation of ICP (November 1998–January 1999)
StandardNo. meeting standard
(Preimplementation)
n = 11
No. meeting standard
(Postimplementation)
n = 11
Discharge planning  commenced within  48 hours of admission1 (9%)11 (100%)
Evidence of MDT goals5 (45%)  6 (55%)
Patient consent  to discharge5 (45%)  6 (55%)
Carer/family consent  to discharge5 (45%)  6 (55%)
Professional consent  to discharge0 (0%)  3 (27%)

‘If you actually get time to read it then yeah you have got a good mental picture but there never seems to be that time…whether the nurse actually knows it is a different story.’

Interprofessional conflicts on goals

Professionals who were confident with their assessment and role are content to discuss and share care. However, goals were rarely recorded. It is suggested that some professionals had difficulty accepting this concept. For example, improving the patient's confidence is an interprofessional goal that could be incorporated into the care of the patient in a number of ways. Nurses and occupational therapists perceived it as a time-consuming process and another occupational therapist stated that occupational therapists wished to maintain their own notes in order to retain their professional identity:

‘I think it is trying to keep a professional identity…they are so scared that OTs are frowned upon and laughed at… I think it is more of a rebellion they (Occupational therapists) feel that something has been taken away from them…they have less control over what is going on…or whether people don’t like change… I think it halts communication.'

The data from the preimplementation audit (Table 2) found that in five cases (45%) there was evidence of joint goals being set. The data from the postimplementation audit found that this still only occurred in six cases (55%). Furthermore, one staff nurse was of the opinion that goals should not be recorded unless: ‘The patient actually falls out of the integrated care pathway’, whilst another argued that the variances were in fact the goals and the treatment plan for the patient. An analysis of the variances demonstrated that interprofessional differences in the management of the patient caused discharge delays. One discharge was delayed because of a conflict of opinion between the occupational therapist and physiotherapist regarding a patient's level of mobility. Another was delayed by a difference of opinion between the patient, their family and members of the team. A staff nurse highlighted these differences by reporting that: ‘Some patients who don’t need very much are being held back because they are being offered too much.'

The researcher, who was present at the team meetings, identified that there was little evidence of the team openly discussing the management of the patient. However, the introduction of the multidisciplinary integrated care pathways rather than reducing conflict exacerbated it as professionals were increasingly aware of why discharge delays were occurring: ‘It has highlighted areas that are lacking...areas where we can improve and areas that people actually haven’t paid attention to' (Staff nurse). Whilst another stated:

‘The OT s they were frustrating because there was...there is such a barrier there and whenever anything is questioned what is written – you can’t get through but I think that is more deep seated than just this ICP.'

Organizational aspects

It is significant that there were many organizational causes of discharge delays such as waiting for test results and X-rays. Considerable delays were caused by the occupational therapists being unable to carry out home visits on patients living outside of the Trust catchment area. Lack of weekend working contributed to discharge delays with the analysis of the variance demonstrating that on average 4 days were lost per admission due to the unavailability of occupational therapists and physiotherapists. A staff nurse expressed her frustration with the lack of forward planning:

‘Most of the people on the ICP are going to need the same sort of equipment and that has not been recognized…maybe have a base where they can get this equipment and pay back or whether this equipment is ordered in or some-thing… I think the system isn’t learning from what it knows.'

On reflection it is probable that the researcher did have an influence on the success of the project as the researcher wanted the project to succeed. Furthermore the researcher was extremely motivated and enthusiastic which could have transferred to the action research participants. This does, perhaps, demonstrate the importance of identifying a committed change agent for such action research projects.

Discussion

It is suggested that the stakeholder interviews, the audit tool and the variance analysis, whilst demonstrating improved outcomes, did not demonstrate an overall improvement in the team process. However, the analysis of the variances has enabled members of the team to evaluate and question current practice. This finding supports the work of Currie and Harvey (8) who suggest that professionals regard variance analysis and clinical audit as forming part of the quality assurance process. By integrating practice there was a considerable improvement in the quality of the management of patients and a reduction in the length of stay with the model having potential benefits both for the patient, professionals and the organization. Thus the findings of the research support the assumptions that underpin the NHS Plan (1). Many of the problems that were identified as adversely influencing the discharge planning need to be resolved at Trust level, such as weekend working. The integrated care pathway does not alleviate the pressures and constraints of working in the acute environment. Few organizations find themselves in an environment that is not in a consistent state of flux and factors such as time and the shortage of acute hospital beds have a direct impact on the discharge process. However, the multidisciplinary integrated care pathway does enable professionals to identify why discharge delays have occurred, assists time management and improves communication patterns.

Integrated documentation is a necessity for collaboration and ensures that care is co-ordinated if professionals complied with the protocol. However, if they are not implemented successfully then it will lead to fragmentation of care with detrimental effects. One needs to note that although integrated care pathways encourage written communication the face to face communication may diminish. The data of the research supports the findings of White et al. (10). A further barrier to interprofessional teamwork is the failure of professionals to regard goal setting as a priority. Furthermore, the failure to record goals is an indication that the team has no clear purpose and that team members have different expectations. Furthermore, the research findings contradict those of Currie and Harvey (8) who suggest that integrated care pathways facilitate greater collaboration between professionals and interprofessional education.

The introduction of multidisciplinary integrated notes alone cannot equip professionals with the skills to become competent team players. Furthermore, clinical audit does not measure the competence of professionals. Educational establishments must equip students with the necessary skills that will enable them to become competent interprofessional practitioners. Furthermore, these skills should be nurtured and developed as professionals gain in expertise. Action research was an effective approach for this project, it enabled the clinical team to retain ownership of the project whilst empowering them to be innovative and creative in a secure environment. They acquired new skills and knowledge as well as an effective tool for patient care.

Conclusion

In conclusion it can be seen that several important findings emerged from this evaluation:

Stakeholder interviews

The key themes identified from the stakeholder interviews were:

  • 1Time constraints prevented professionals from completing and reading the multidisciplinary integrated care pathway;
  • 2Goal setting was regarded as time consuming.

Interprofessional audit

The postimplementation of the integrated care pathway improved the quality of care as discharge plans were made within 48 hours (100%), and the social history was recorded in all cases (100%). In addition there was evidence of increased number of assessment and reassessments being recorded and actioned within agreed time frames of the integrated care pathway (occupational therapy, care management). There was, however, little indication of improved multidisciplinary collaboration due to the limited evidence of improved multidisciplinary goal setting, and the recording of discharge consent.

Variance analysis of the integrated care pathway

The key findings from the analysis of the interprofessional integrated care pathways were:

  • 1Interprofessional differences in the management of the patient caused discharge delays;
  • 2Discharges were not delayed by social services but by organizational aspects It is suggested that the successful interprofessional team care is dependent on the successful management of change. The introduction of integrated care pathways can only help to break down professional boundaries if there is a real commitment to interprofessional teamwork within the team. Interprofessional collaboration requires an investment in people and in progress. However, effective change takes time and is a developmental process; thus individuals cannot become interprofessional practitioners overnight. The success of the discharge process is dependent on the skills and expertise that the multidisciplinary integrated care pathway can only encourage.

If interprofessional working is to be encouraged there must be a real commitment to this process. Health care professionals must be able to state their opinions freely, be willing to share information, set goals with both the patient and other members of the team and be able to understand the value base of other professionals.

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