Self-Care

Collaboration in practice: A framework for team-based care

Since passage of the Affordable Care Act in 2010, alternate care delivery models such as patient- centered health homes and accountable care organizations have emerged as tools for payment and healthcare delivery system reform. The intent of such clinical integration models is to drive improvement in individual and population health outcomes and in the quality and efficiency of healthcare service delivery.Although these models hold promise in moving our healthcare system from a disjointed paradigm to a seamless, value-driven standard, fragmentation persists at all levels of the healthcare continuum. Establishment of a well-functioning team is one mechanism by which healthcare providers (HCPs) can achieve the goal of patient-centric, well-coordinated, safe, and responsive healthcare.2

Healthcare providers have been challenged to respond to an evolving health policy landscape that demands movement to coordinated, value-driven care models in the face of HCP shortages and shrinking resources. In response to this changing landscape, and, reflective of his own commitment to a team approach to care, John Jennings, ACOG’s 2014 President, chose—as the priority issue of his presidential year—revision of ACOG’s Guidelines for Implementing Collaborative Practice (1995) to better reflect the demands of today’s healthcare system. To meet this charge, ACOG convened an interdisciplinary task force comprising delegates from nine different organizations representing physicians, nurse practitioners, midwives, physician assistants, clinical pharmacists, and consumers. The resulting Collaboration in Practice: Implementing Team-Based Care represents a paradigm shift for healthcare service delivery in which patients are integral participants; all team members are valued equally; and all HCPs are supported in practicing to the full extent of their education, certification, and experience and accept accountability for their practice. To date, this document has been endorsed or supported by 21 national organizations, including NPWH and our sister NP organizations AANP, GAPNA, NAPNAP, and NONPF.3 The Executive Summary of this document is available here.

Team-based care and collaboration

In crafting this document, the writing team worked with the following definitions. Team-based care is defined as the “provision of health services to individuals, families, and/or their communities by at least two healthcare providers who work collaboratively with patients and their families…to accomplish shared goals…”Effective implementation of team-based care requires interprofessional collaborationdefined as “a process involving mutually beneficial participation between autonomous individuals whose relationships are governed by shared norms and visions.”3

The terms team-based care and collaboration have sometimes been used in regulatory policies in a way that places barriers to qualified HCPs’ ability to practice to the full extent of their education, certification, and experience. However, implementing team-based care delivery models does not require team-based licensure or integrated regulatory frameworks. In some cases, linked licensure and restrictive regulations may inhibit the flexibility and innovation required for team-based, patient-centered care. Of note, the ACOG document uses the terms team-based care and collaboration in their truest forms, denoting an equitable practice environment wherein each team member’s knowledge and skills are valued contributions to the team’s work. As such, the terms team-based care and collaboration should not be construed as recommended policy constructs within the context of this document.

Core concepts: Application to women’s health practice

Collaboration in Practice identifies six principles as core components guiding team-based care, all of which are relevant to women’s healthcare and WHNP practice. First and foremost, successful team-based care recognizes the patient and family as central, actively engaged members of the healthcare team.4 In 2008, the National Priorities Partnership identified patient and family engagement as one of six priorities with the most potential to reduce harm, eliminate disparities, decrease disease burden, and remove inefficiencies in healthcare delivery.4 Given the disparities in maternal/child and women’s health outcomes across the lifespan,5 a team-based approach that supports active patient engagement and shared decision making holds merit as one strategy to improve women’s health outcomes.

The second, third, and fourth guiding principles recognize the importance of shared vision, role clarity, and accountability, respectively, as important components of team-based care. These principles underscore the value of mutual respect that recognizes the expertise of each team member. Likewise, there exists an expectation of professional accountability to one’s own practice and to the team. Maintaining competencies through continuous learning is an expectation within an accountable practice. Although regulation of scope of practice resides within the purview of each state, the document urges professional organizations to continue to provide guidance for clinical practice and promote uniform educational requirements and standards of care and conduct. The Women’s Health Nurse Practitioner: Guidelines for Practice and Education, 7th edition (2014), available hereprovides a population-focused framework for WHNPs.

Communication, the fifth guiding principle, underscores the need for clear transfer of information regarding patient status and team tasks. The document recognizes the fluid nature of teams and appreciates evolving trends in healthcare. Teams range from a typical model wherein care is provided at a discrete location by a selected team of HCPs to virtual teams wherein care is provided by multiple HCPs across a variety of settings in disparate locations—in some instances using telehealth as a tool to expand access.The sixth guiding principle recognizes the fluid and dynamic nature of patient-centered care. Team leadership is described as being situational and dynamic. Within this principle, team leadership is determined in response to patient need at any given moment in time, rather than ownership by a specific role or discipline.

Women’s healthcare providers practicing in the maternal/child healthcare field may recognize parallels between team-based care and perinatal regionalization, a concept supported by the maternal/child healthcare community for more than two decades. Perinatal regionalization, which seeks to assure that high-risk pregnant women and/or infants receive the appropriate level of care at the appropriate time in order to optimize patient outcomes in high-risk situations, can be viewed as a key example of a virtual model for team-based care. In this model, communication to facilitate seamless transitions in care among community-based HCPs and perinatal care providers must be established to achieve optimal pregnancy outcomes. In-person or virtual consultation, education, and skill building help support open communication, professional accountability, and fluid team leadership. Just as the team-based care model recognizes the important role of each member, perinatal regionalization recognizes the important role of the community-based team, the perinatal center team, and wraparound service providers, all of whom contribute to an optimal outcome.7,8 Although perinatal regionalization serves as one example of the breadth of a team-based care model, the concept is transferable across a variety of healthcare settings and specialties, within a traditional or a virtual setting.

Conclusion

Women’s healthcare has always been a team-based endeavor recognizing the important role of access to gender-focused care throughout the lifespan, with attention to the realities of women’s lives outside the hospital and clinic walls. In this regard, it is especially fitting that women’s healthcare providers led the way in bringing together a diverse group of HCPs to chart a path applicable across specialties and disciplines. Furthermore, the collaborative process used in developing this document mirrored the equitable, collaborative approach recommended as a pathway to successful implementation of team-based care. NPWH was proud to be part of the working group that helped shape the concepts put forth in this document.

The aforementioned Executive Summary of the Collaboration in Practice document provides an overview of the process and key points. All of the essential elements of the work, including recommendations for implementing an equitable, accessible, reimbursable, patient-centric model of care, are elaborated in the full report. The Collaboration in Practice team invites you to consider how the full report can be used to enhance your practice and improve patient outcomes.

Susan Kendig is a teaching professor and WHNP Emphasis Area Coordinator at the University of Missouri- St. Louis; a consultant at Health Policy Advantage,LLC, in St. Louis, Missouri; and Director of Policy for the National Association of Nurse Practitioners in Women’s Health (NPWH). She served as the NPWH delegate to ACOG’s Collaborative Practice Task Force. She can be reached at 314-629-2372 or at skendig@npwh.org.

References

1. Guterman S, Drake H. Developing innovative payment approaches: finding the path to high performanceThe Commonwealth Fund. May 2010.

2. Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academies Press; 2001.

3. Executive Summary: Collaboration in Practice: Implementing Team-Based Care. Report of the American College of Obstetricians and Gynecologists’ Task Force on Collaborative Practice. Obstet Gynecol. 2016;127(3):612-617.

4. National Priorities Partnership. National Priorities and Goals: Aligning Our Efforts to Transform America’s HealthcareWashington, DC: National Quality Forum; 2008.

5. Kendig S. Women’s health: more than an annual event. Womens Healthcare. 2014;2(3):36-39.

6. ACOG Task Force on Collaborative Practice. Collaboration in Practice: Implementing Team-Based CareWashington, DC: ACOG; 2016.

7. American Academy of Pediatrics, American College of Obstetricians and Gynecologists. Guidelines for Perinatal Care, 7th edition. Elk Grove Village, IL: AAP; Washington, DC: ACOG; 2012.

8. Obstetric Care Consensus No. 2: Levels of Maternal Care. Obstet Gynecol. 2015;125(2):502-515.

Barriers to care for sexual assault survivors of childbearing age: An integrative review

Research indicates that only a small fraction of sexual assault survivors seek comprehensive care—including physical and mental healthcare, forensic evidence collection, victim services, and legal support—after the assault. This integrative review was conducted to identify barriers that may be keeping sexual assault survivors of childbearing age from receiving such comprehensive care.

Key words: sexual assault, barriers to care, comprehensive care

For women in the United States, one of the most likely causes of severe psychological trauma is sexual assault, defined as unwanted sexual contact in any form that occurs without a person’s consent.1,2 Survivors of a completed rape have a 32%-80% incidence of posttraumatic stress disorder (PTSD), versus a rate of 9%-15% in the general population.3-6 In addition to psychological harm, sexual assault survivors may experience physical consequences such as bodily injury, sexually transmitted infections (STIs), and pregnancy. In the immediate aftermath of a sexual assault, about half of survivors show evidence of physical trauma, up to 30% contract an STI, and 5% become pregnant.7,8 Furthermore, survivors are up to 9 times more likely than the average woman to attempt suicide.9 Despite these potential health risks, a major gap exists between reported rates of sexual assault and rates of comprehensive care seeking following the assault.

Statement of the problem

In this country, 1 of every 4-5 women is raped in college,10,11 and lifetime prevalence of rape is 1 in 6-10 women.1,12 Following sexual assault, women may have a need for comprehensive care provided at a rape crisis center or hospital emergency department (ED)—ideally by a specially trained sexual assault nurse examiner (SANE). Recommended comprehensive care following a sexual assault includes treatment of physical injuries and other sequelae, pregnancy prevention, STI screening and treatment, psychological support and care for potential PTSD, forensic evidence collection, victim services, and legal support.1,13-16

Many sexual assault survivors do not receive the comprehensive care they need. In one analysis of post-assault care seeking, only one-third of rape survivors sought assistance from one or more of the following: the legal system, the medical system, the mental healthcare system, a rape crisis center, and/or the religious communi­ty.17 Another report indicated that 4 million U.S. women have not received medical attention focused on preventing or treating the physical and emotional effects of rape.8

The study

The author conducted an integrative literature review to ascertain the barriers that may be keeping childbearing-age women from seeking comprehensive care following sexual assault. The review was focused on survivor, advocate, healthcare provider (HCP), police, and student perspectives.

Method—Five steps were used: problem identification, literature search, data evaluation, data analysis, and presentation.18 An integrative review was appropriate because of the mix of quantitative and qualitative data that were available.18,19Problem identification. The author analyzed empirical studies and national surveys completed between 1990 and 2012. The research question guiding the review was “What are the barriers that may prevent sexual assault survivors of childbearing age from receiving comprehensive care?”

Literature search. The review was conducted at a university library using the search terms sexual assault, rape, barriers to care, barriers, inhibitors, impede, comprehensive care, health care, and health care access. The search utilized a variety of databases. National surveys were identified separately by searching national websites. Only studies whose purpose was to identify barriers to care for sexual assault survivors of childbearing age were included. These studies had to be written in English in the form of scholarly works, dissertations, or qualitative or quantitative research. Excluded were papers unrelated to the research question, commentaries, literature reviews, and papers not written in English.

The initial search elicited 220 articles with the following distribution: Cochrane Database of Systematic Reviews (n = 3), CINAHL (n = 12), EMBASE (n = 101), ISI Web of Knowledge (n = 52), PubMed (n = 37), and PsycINFO (n = 15). Many of these 220 articles were duplicates, and only 11 met all inclusion criteria. By hand-searching the references of these 11 articles, the author found 1 additional article for inclusion, resulting in a total of 12 empirical articles. In addition, 4 national surveys described in 6 different reports met inclusion criteria.

Data evaluation and analysis. Data extraction for the 4 national surveys and 12 empirical studies was conducted with use of a table to identify key components. The author extracted data about the sample, study design, outcomes measured, instruments utilized, results related to the research question, validity, and notes. Results related to the research question were reviewed for common themes using a technique similar to the constant comparative method of analysis outlined by Glaser.20 This technique entailed reading through the results to glean general thoughts, followed by a line-by-line review to evaluate for general themes using a color-coding system. Further review elicited core themes. The data were reviewed again to find commonalities in themes among the studies. Finally, the data were compiled into over­arching themes related to the research question and assessed for the information they represented.

Whittemore and Knafl18 noted that the diverse array of primary sources in an integrative literature review increases the complexity in evaluating the quality of the literature. Also, in an integrative review with a diverse collection of studies, various threats to internal validity must be addressed.19,21 These threats were determined by assessing the studies’ methodology and data relevance.

Results—
National surveys. Four national surveys were reported in 6 different studies (Table 1).1,2,8,10,22,2Empirical studies. Table 2 lists the 12 empirical research studies that met inclusion criteria. As shown in Table 3, these studies used a cross-sectional methodology24-29 or a descriptive or exploratory qualitative method­ology.30-35 All of the studies’ research questions elicited the barriers that prevented sexual assault survivors of childbearing age from accessing community services such as police re­porting,24 mental healthcare,27 medical care,25 and sexual assault centers.26,29Themes. Several themes describing barriers to care emerged. These themes, subdivided into personal and environmental factors, are described in detail using the results from all 18 studies—that is, the 6 reports on national survey data and the 12 empirical studies.

PERSONAL FACTORS. The overarching theme of personal factors encompassed barriers to care inherent to a survivor herself. This broad theme included three subfactors: emotional states, fear of external exposure, and lack of knowledge.

Emotional states. Certain emotional states experienced by a woman after a sexual assault could preclude her from seeking physical, mental, or legal care. These emotional states were identified in 11 (61%) of the 18 studies.1,22,24,26-32,35 Emotional states most commonly cited as barriers were shame,24,28-31 embarrassment or humiliation,1,24,26-29,32,35 guilt,26,28,30,35 and self-blame.22,26Fear of external exposure. Fear of external exposure was described in 12 studies (67%).1,2,8,10,23,24,26,28,29,31,32,35 Fears cited by survivors included bad treatment by the criminal justice system,2,10,23 not being believed,24,28,29 lack of confidentiality,22,24,26,28,29,31,32 going to trial,24 the assailant,1,2,10,23,24,28,31,32,35 and public exposure.8,29 Fears related to the assailant involved fear of retaliation1,10,23,24,28,31,32,35 and, conversely, the possibility of jail for the assailant because the survivor had some type of relationship with the assailant.24 Fear of public exposure was often cited by members of groups such as immigrants, persons with disabilities, sexual minority members, and racial minority members.28 Many of these women feared that their minority status would bring them greater stigma and potentially unfair treatment.

Lack of knowledge. Lack of knowledge regarding post-assault services was identified as a barrier to care in 6 studies (33%).2,23,27,28,31,32 This knowledge deficit encompassed factors such as not knowing which services were needed,31,32 where or how to get services,2,23,28,31,32 and how to pay for services.27,31,32

ENVIRONMENTAL FACTORS. The broad theme of environmental factors captured barriers to care due to outside forces and not within a survivor’s immediate control. These factors were noted in 11 of the 18 studies and included themes of structural/organizational barriers and societal rape myths.

Structural or organizational barriers. Barriers to comprehensive care can include factors related to how these services are accessed. Structural/organization barriers were elicited from 6 studies (33%).25,31-35 For instance, many survivors cited a lack of availability or limited services as a barrier to receiving care.31-33,35 Organizational barriers reported by HCPs included inexperience in treating sexual assault survivors, inadequate time, and personal discomfort.27 Rape victim advocates noted insufficient funding resources as barriers that might compromise survivors’ ability to receive support.33,34Societal myths. Twelve studies (67%) noted the perpetuation of rape myths by society as a factor in preventing survivors from accessing care.1,10,23,24,25,27,29-32,34,35 Many of these myths are propagated through biases related to race, gender, disability, sexual orientation, and class.34 Subsumed within this category is survivors’ perception of the social stigma attached to naming the incident and the belief that the assault was not serious enough to warrant using services.1,10,23,27,29 Societal myths noted by persons in the service sector included police attitudes, including blame and insensitivity24,31,32 and doubt about the validity of the sexual assault accusations.35 Some HCPs perceived that survivors would return to partners who had perpetrated the assault.25Discussion—This review has shown that from survivor, advocate, HCP, police, and student perspectives, numerous barriers to care—encompassing both personal and environmental factors—may prohibit a woman of childbearing age from seeking care after a sexual assault. The overarching theme of personal factors comprised the survivor’s emotional state, her fear as it related to external exposure of the survivor and the assailant, and a lack of knowledge about post-assault services. These results coincide with past research, which has shown that many survivors, especially members of ethnic minorities, lack awareness about post-assault services such as rape crisis centers.17 The broad theme of environmental factors included subthemes of structural/organizational barriers and societal myths. Past research has shown that survivors needed to sit for extended periods of time while they waited to be seen by HCPs who did not have training on the physical or mental aspects of performing a forensic exam.36 In addition, rape myths are known to affect how a survivor deals with an assault, including acquisition of care.37,38 The themes subsumed under environmental factors are long-standing issues that must be addressed using a team approach to improve acquisition of comprehensive care by sexual assault survivors.

Limitations. This review could not completely separate the research articles that dealt with sexual assault and intimate partner violence. One person may be a survivor of both crimes within the same relationship; therefore, many researchers combine the topics. All data were collected via cross-sectional surveys or qualitative interviews and are thus correlational in nature. These data are subject to the possible weaknesses of responses affected by social desirability bias (wherein a respondent wishes to please a researcher) and complicated by the stigma of the topic itself and by problems of recall of traumatic events post-assault.

A limitation specific to the studies in this review was the potential for limited generalizability due to homogenous samples, small sample sizes, and failure to expound on study characteristics. However, the four studies that enrolled college students had fairly heterogeneous samples in terms of age and ethnicity,26,27,29 and most qualitative studies had heterogeneous samples as evidenced by demographic variables and identified themes consistently reported within their study samples.31,32,34

Because a validated and psychometrically sound barriers-to-care scale for sexual assault survivors does not exist, all of the cross-sectional studies used questionnaires specifically created for the purposes of their study. These surveys may not have captured the full range of barriers to care perceived by these survivors.

Strengths. This integrative review demonstrates many strengths within this body of literature. The barriers identified within each individual study, when compared as a group, were consistent. Furthermore, the studies sampled a wide range of individuals. This broad range of participants, coupled with the large geographic region they represent, provides strong evidence for the overall generalizability of the results. Finally, the exploratory and descriptive natures of the included studies have served the purpose of identifying which barriers to care exist for sexual assault survivors of childbearing age.

Implications for practice and research

For nurse practitioners (NPs) working on the front line with survivors of sexual assault, one way to begin to overcome barriers to care is to change the societal atmosphere that perpetuates rape myths. Underlying this atmosphere are patriarchal attitudes and a history of male dominance, both of which support the perpetuation of sexually violent behaviors.

Nurse practitioners need to identify and treat survivors of sexual assault, an all-too-common crime. NPs should consider using screening techniques to identify these survivors, which could simply involve asking about sexual trauma in childhood and adulthood. NPs must also be aware of potential psychological and physical manifestations of past sexual assault, including increased mental health complaints and somatic symptoms, in order to identify hidden survivors who may not freely disclose their history. Universal screening for sexual assault is controversial because of the paucity of research regarding the benefits of early identification and of treatment once a survivor is identified.39 However, NPs do have a responsibility to understand their patients’ histories and their healthcare needs.

In addition, NPs and other HCPs, mental HCPs, and members of the legal system need to know about structural barriers that may exist within their professional realm. One way to surmount these barriers is to promote and expand the use of SANE programs in all EDs. These programs, in which specially trained nurses address survivors’ emotional and medical needs while performing high-quality evidence collection, are a viable alternative to the traditional medical system.13

Nurse practitioners need to advise survivors of their options for pregnancy prevention, STI testing, care of physical injuries, and mental healthcare. And for survivors who have not yet sought post-assault care, NPs can place useful, easy-to-read brochures in public locations such as lavatories, homeless shelters, and community centers. NPs can get brochures and pamphlets from organizations such as the National Sexual Violence Resource Center or the Rape, Abuse & Incest National Network. Additional research is needed to determine the resources that survivors would find most valuable, as well as the easiest ways in which these resources could be provided. For instance, would survivors prefer to receive information about community resources at HCP visits, when they fill prescriptions (e.g., for contraceptives), or through other sources?

Conclusion

Educating women about available resources and recommended care after a sexual assault can help remove personal barriers to care. However, NPs must keep in mind that the community is responsible for minimizing structural barriers. Community members must work together to prevent the occurrence of sexual assault; to provide resources on care, social support, and legal advocacy for instances in which sexual assault has occurred; and to continue to speak with community allies and survivors to determine their needs.

Michelle L. Munro is a research fellow at the University of Michigan School of Nursing in Ann Arbor. The author states that she does not have a financial interest in or other relationship with any commercial product named in this article.

Acknowledgment

The author thanks Dr. Julia Seng and Dr. Kimberlee Gretebeck for the comments and support they provided on this manuscript. The author also gratefully acknowledges grant support by the National Institutes of Health and National Institute of Nursing Research, 5 T32 NR007073-19.

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