Applied Science, Faculty of
Nursing, School of
DSpace
UBCV
Cairns, Catherine
Master of Science in Nursing - MSN
University of British Columbia
Wound management is a common healthcare concern that affects many people across the span of their lives. The complexity of wound care results in the necessity of an interdisciplinary approach with many team members communicating and sharing information. Communication can be a challenge in the complex and constantly evolving healthcare system. Describing the current state of processes of interdisciplinary wound care communication, as informed by complex adaptive systems theory, adds to the existing research regarding complex adaptive systems, communication and technology use in health care. In this thesis I used ethnographic methods and a complex adaptive systems analytic framework to explore the processes surrounding interdisciplinary wound care communication. Interviews were conducted with nine healthcare providers and facilitated through the use of professional personas. Through the interviews, categories and themes were identified and the results were reviewed to see to what extent wound care communication processes are reflective of complex adaptive systems. Three main themes were identified: How context shapes interdisciplinary communication; Navigation of tools and technologies; and Efficiency and trust in face-to-face communication. Each wound care communication category mapped to a minimum of two complex adaptive systems properties while some illustrated all eleven properties. Overall, the wound care communication categories exemplify the properties of a complex adaptive system which suggests that interdisciplinary wound care communication is a complex adaptive system. Despite the different technologies available to mediate interdisciplinary communication there was a resounding preference for face-to-face and in person communication whenever possible.
CHARACTERISTICS OF COMPLEX ADAPTIVE SYSTEMS IN TECHNOLOGY-MEDIATED WOUND CARE COMMUNICATION PROCESSES by Catherine Cairns BSN, British Columbia Institute of Technology, 2010 BA, University of British Columbia, 2006 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE IN NURSING in THE FACULTY OF GRADUATE AND POSTDOCTORAL STUDIES THE UNIVERSITY OF BRITISH COLUMBIA (Vancouver) July 2020 © Catherine Cairns, 2020 ii The following individuals certify that they have read, and recommend to the Faculty of Graduate and Postdoctoral Studies for acceptance, a thesis entitled: Characteristics of Complex Adaptive Systems in Technology-Mediated Wound Care Communication Processes. submitted by Catherine Cairns in partial fulfillment of the requirements for the degree of Master of Science in Nursing Examining Committee: Leanne Currie, RN, PhD, Associate Professor, School of Nursing, UBC Supervisor Barbara Eddy, MN-NP, Adjunct Professor, School of Nursing UBC Supervisory Committee Member Tarnia Taverner, PhD, MSc, RN Clinical Associate Professor, School of Nursing, UBC Supervisory Committee Member iii Abstract Wound management is a common healthcare concern that affects many people across the span of their lives. The complexity of wound care results in the necessity of an interdisciplinary approach with many team members communicating and sharing information. Communication can be a challenge in the complex and constantly evolving healthcare system. Describing the current state of processes of interdisciplinary wound care communication, as informed by complex adaptive systems theory, adds to the existing research regarding complex adaptive systems, communication and technology use in health care. In this thesis I used ethnographic methods and a complex adaptive systems analytic framework to explore the processes surrounding interdisciplinary wound care communication. Interviews were conducted with nine healthcare providers and facilitated through the use of professional personas. Through the interviews, categories and themes were identified and the results were reviewed to see to what extent wound care communication processes are reflective of complex adaptive systems. Three main themes were identified: How context shapes interdisciplinary communication; Navigation of tools and technologies; and Efficiency and trust in face-to-face communication. Each wound care communication category mapped to a minimum of two complex adaptive systems properties while some illustrated all eleven properties. Overall, the wound care communication categories exemplify the properties of a complex adaptive system which suggests that interdisciplinary wound care communication is a complex adaptive system. Despite the different technologies available to mediate interdisciplinary communication there was a resounding preference for face-to-face and in person communication whenever possible. iv Lay Summary Wounds are a common issue in developed countries and impact both the patient and the healthcare system. An interdisciplinary healthcare team is involved in providing wound care, which makes communication imperative but complex. This study examined interdisciplinary wound care communication that occurs in the community healthcare setting. Eleven healthcare providers were interviewed and results were grouped into categories and themes. Themes were: How context shapes interdisciplinary communication; Navigation of tools and technologies; and Efficiency and trust in face-to-face communication. A subanalysis was performed using a complex adaptive system analysis framework. Wound care communication categories were found to reflect all properties of complex adaptive system. Some had two properties of complex adaptive system while others reflected all eleven properties, which suggests that interdisciplinary wound care communication can be a considered a complex adaptive system. v Preface The study was conceived of by Catherine Cairns with extensive support from the supervisory committee. It was inspired by ongoing research into wound care technologies that has been conducted by peers at the University of British Columbia and looked to apply a theoretical framework for future research. I wrote the entire thesis with editorial and substantive support from the thesis committee. Ethics approval was received from UBC Research Ethics Board and operational approval was received from VCHRI. • UBC REB Certificate H18-00919 vi Table of Contents Abstract ......................................................................................................................................... iii Lay Summary ............................................................................................................................... iv Preface .............................................................................................................................................v Table of Contents ......................................................................................................................... vi List of Tables ................................................................................................................................ xi List of Figures .............................................................................................................................. xii Acknowledgements .................................................................................................................... xiii Dedication ................................................................................................................................... xiv Chapter 1: Introduction ................................................................................................................1 1.1 Background ..................................................................................................................... 1 1.2 Complex Adaptive Systems and Interdisciplinary Communication ............................... 2 1.3 Burden of Wounds and Associated Care ........................................................................ 2 1.4 Importance of Communication and Collaboration ......................................................... 3 1.5 Interdisciplinary Communication and Wound Care ....................................................... 4 1.6 Technology to Support Communication about Wounds ................................................. 5 1.7 Significance..................................................................................................................... 5 1.8 Research Questions ......................................................................................................... 6 1.9 Summary ......................................................................................................................... 7 Chapter 2: Literature Review .......................................................................................................8 2.1 Interprofessional Versus Interdisciplinary ...................................................................... 8 2.2 Literature Review Methodology ..................................................................................... 9 2.3 Databases Searched, Search Strategy and Inclusion/ Exclusion Criteria ....................... 9 vii 2.4 Interdisciplinary Communication and Collaboration about Wound Management ....... 10 2.5 Technology Use and Virtual Care in Wound Management .......................................... 12 2.5.1 Mobile Phone Cameras to Support Physician Decision Making .............................. 12 2.5.1.1 Database Application for Desktop and Mobile Phone ...................................... 13 2.5.2 Digital Images ........................................................................................................... 14 2.5.3 Telemedicine ............................................................................................................. 15 2.5.4 Smart Glasses and Smart Phones .............................................................................. 15 2.5.5 Digital Pen and Paper................................................................................................ 16 2.5.6 E-Messaging ............................................................................................................. 19 2.5.7 mHealth Applications ............................................................................................... 22 2.6 Technology for Interdisciplinary Communication (non-wound care context) ............. 22 2.7 Summary ....................................................................................................................... 24 Chapter 3: Methods .....................................................................................................................25 3.1 Research Questions ....................................................................................................... 25 3.2 Study Design ................................................................................................................. 25 3.3 Theoretical Lens............................................................................................................ 26 3.4 Ethical Considerations .................................................................................................. 27 3.5 Sample........................................................................................................................... 28 3.5.1 Sample Population .................................................................................................... 28 3.5.2 Recruitment Methods ................................................................................................ 29 3.5.3 Sampling Technique ................................................................................................. 29 3.5.4 Inclusion and Exclusion Criteria ............................................................................... 30 3.6 Data Collection ............................................................................................................. 30 viii 3.6.1 Participant Demographics ......................................................................................... 30 3.6.2 Observations ............................................................................................................. 31 3.6.3 Persona Development as Interview Artifact ............................................................. 31 3.6.4 Interviews .................................................................................................................. 32 3.7 Data Analysis ................................................................................................................ 33 3.8 Maintaining Trustworthiness and Integrity in Qualitative Design ............................... 33 3.8.1 Method to Reduce Sampling Bias............................................................................. 33 3.8.2 Methods to Maintain Trustworthiness during Data Collection................................. 34 3.8.3 Method to Maintain Rigour During Data Analysis ................................................... 35 Chapter 4: Results........................................................................................................................36 4.1 Overview ....................................................................................................................... 36 4.2 Research Questions ....................................................................................................... 36 4.3 Demographics ............................................................................................................... 37 4.4 Persona Validation ........................................................................................................ 39 4.4.1 Registered Nurse ....................................................................................................... 40 4.4.2 Case Manager............................................................................................................ 42 4.4.3 Primary Care Provider .............................................................................................. 44 4.5 Setting ........................................................................................................................... 45 4.6 Processes of Communication ........................................................................................ 46 4.6.1 Care Coordination ..................................................................................................... 47 4.7 Similarities and Differences in Processes of Wound Care Communication ................. 47 4.8 Communication Tools and Technologies ..................................................................... 48 4.8.1 Electronic Health Records ........................................................................................ 48 ix 4.8.2 Electronic Information Resources ............................................................................. 49 4.8.3 Other Technologies to Support Communication ...................................................... 50 4.8.4 Written Non-Electronic ............................................................................................. 51 4.9 Themes and Subthemes Related to Communication .................................................... 51 4.10 How Context Shapes Interdisciplinary Communication............................................... 52 4.10.1 Culture in the Clinical Setting............................................................................... 52 4.10.2 Physical Layout and Physical Proximity .............................................................. 53 4.11 Navigating Communication Tools and Technologies................................................... 54 4.11.1 The Dream for One Electronic Health Record ..................................................... 55 4.11.2 Keeping Current using Electronic Knowledge Resources .................................... 57 4.11.3 Concern about Using Fax for Communication ..................................................... 58 4.12 Efficiency and Trust in Face-to-Face Communication ................................................. 59 4.12.1 Ensuring the Message is Received ........................................................................ 61 4.12.2 Synchronous Communication via Telephone ....................................................... 62 4.12.3 A Picture says a Thousand Words - The Value of Photos .................................... 62 4.12.4 Smartphones: An Improvement for Convenient Communication ........................ 63 4.12.5 Trust in Paper Documents ..................................................................................... 64 4.13 Communication and Complex Adaptive Systems ........................................................ 64 4.14 Complex Adaptive System Properties in Wound Care Communication ...................... 68 4.14.1 Adaptable Elements .............................................................................................. 68 4.14.2 Attractors............................................................................................................... 70 4.14.3 Co-Evolution ......................................................................................................... 71 4.14.4 Context and Embeddedness .................................................................................. 72 x 4.14.5 Emergent Behaviour ............................................................................................. 74 4.14.6 Inherent Order ....................................................................................................... 75 4.14.7 Non-Linearity ........................................................................................................ 76 4.14.8 Porous Boundaries ................................................................................................ 77 4.14.9 Self-Organization .................................................................................................. 78 4.14.10 Simple Rules ......................................................................................................... 79 4.14.11 Unpredictability .................................................................................................... 80 4.15 Synthesis of CAS Results ............................................................................................. 82 4.16 Summary of Results ...................................................................................................... 83 Chapter 5: Discussion ..................................................................................................................85 5.1 Overview of Chapter ..................................................................................................... 85 5.2 Wound Care Communication as a Complex Adaptive System .................................... 85 5.3 Processes of Communication ........................................................................................ 87 5.4 Wound Care Communication ....................................................................................... 88 5.5 Limitations .................................................................................................................... 96 5.6 Implications for Nursing Practice ................................................................................. 97 5.7 Implications for Nursing and Healthcare Policy ........................................................... 99 5.8 Implications for Nursing and Healthcare Research .................................................... 100 5.9 Summary of Discussion .............................................................................................. 101 References ...................................................................................................................................103 Appendices ..................................................................................................................................108 Appendix A: Demographic Survey ......................................................................................... 108 Appendix B: Interview Questions ........................................................................................... 110 xi List of Tables Table 3.1 Chaffee and McNeill (2007) Properties of Complex Adaptive Systems ...................... 27 Table 4.1 Demographics ............................................................................................................... 37 Table 4.2 Professional Experience ................................................................................................ 38 Table 4.3 Summary of CAS Properties Present in Wound Care Communication Categories ..... 66 xii List of Figures Figure 4.1 Registered Nurse Persona ............................................................................................ 40 Figure 4.2 Case Manager Persona ............................................................................................... 42 Figure 4.3 Primary Care Provider Persona ................................................................................... 44 xiii Acknowledgements I would like to express my sincere gratitude to my supervisor and thesis committee for the extensive support, feedback and encouragement that they provided. Thank you to Leanne Currie for your support, time and dedication to this research and for helping me see this thesis through to completion. Thank you to Barbara Eddy and Tarnia Taverner for the time, thoughtful feedback and careful insights that you shared. The discussions that we had and the questions that you asked allowed for new perspectives to emerge and challenged me to critically think. I would like to express my gratitude to the managers and directors of the health organization where this research was conducted. I truly appreciate the support you provided in opening up your health centres to me. Last but not least, thank you to the clinicians who helped me recruit in the health centres and to the participants themselves. The support you provided and the information you shared was invaluable and made this thesis possible. I would also like to thank my family for their support throughout the process. xiv Dedication Dedicated to my family. 1 Chapter 1: Introduction 1.1 Background Patients with wounds are common in the Canadian healthcare system (Canadian Home Care Association [CHCA], 2016; Edwards et al., 2013). Many different patient populations have wounds and as a result the wounds are of numerous aetiologies (CHCA, 2016; Dailey, 2005; Edwards et al., 2013). Wounds can affect individuals throughout their lifespan and may be acute or chronic in nature (Dailey, 2005; Edwards et al, 2013). The wide variety of wound origins and affected populations results in psychosocial and financial burdens on patients and their families (CHCA, 2016; Dailey, 2005). It is estimated that in Canada approximately one-third of patients requiring home and community care have a wound that requires management (CHCA, 2016). This results in a cost to the Canadian healthcare system of nearly $4 billion annually (CHCA, 2016). Wound management varies by patient; while acute wounds may only require short-term treatment, chronic wounds can be complex, requiring a team of specialists to be involved in care (Dailey, 2005). Another complicating factor is that wounds often occur while a patient is managing other medical conditions. All of these elements necessitate a holistic, team approach to treatment and management of patients with wounds (Edwards et al., 2013). A team approach requires careful attention from all care providers to ensure that information is shared in the appropriate manner, with the right individuals, at the right time, and across space while taking into consideration the different knowledge and responsibilities of those involved. The process of communicating about patients with wounds is complicated and multi-layered; there are many 2 moving and evolving components that need to be navigated to ensure that information is shared appropriately. Thus, effective communication becomes essential. 1.2 Complex Adaptive Systems and Interdisciplinary Communication The health care environment in which wound care occurs can be considered a complex adaptive system (CAS) because it is complex, evolving, contains many parts and is influenced by external and internal factors (Clancy, 2014). CAS is defined as a system that demonstrates discernable characteristics of: embeddedness (in the context of their histories), self-organization, non-linearity, and unpredictability (Chaffee & McNeill, 2007; Notarnicola et al., 2017). The theoretical lens of CAS was used to underpin methods in this thesis, and CAS is described in more detail in Chapter 3. The goal of this study was to focus on the processes of interdisciplinary communication surrounding wound care and to examine these using complex adaptive systems theory. 1.3 Burden of Wounds and Associated Care Edwards et al. (2013) examined chronic leg ulcers focusing on the effects of wounds on the health care system as well as the individual patient. It was suggested that the average duration of a leg ulcer is 13 months, that 60-70% of adults have recurring leg ulcers lasting up to 15 years, and 24% of people with chronic wounds require hospitalization (Edwards et al., 2013). In developed nations, it is estimated that 2 to 3% of healthcare costs are related to the care and management of chronic wounds and that the incidence of wounds increases as people age (CHCA, 2016; Edwards et al., 2013). These costs are only set to rise with the aging populations in these countries (Edwards et al., 2013). The cost of wounds to the Canadian health care system 3 is approximately $3.9 billion annually (CHCA, 2016). In the United States (US), it is estimated that chronic wound care costs over $3 billion a year and results in the loss of over 2 million work days (Edwards et al., 2013). In the United Kingdom (UK) treatment costs for wounds are approximately £400 million a year, while in Australia it has been recorded that dressing patients’ wounds are the second most frequent procedure performed by family physicians (Edwards et al., 2013). In the UK and Australia, 22-50% of care provided by community nurses was chronic wound care (Edwards et al., 2013). Edwards et al. (2013) and CHCA (2016) discuss that in addition to the direct costs of chronic wounds there are the indirect costs to the patient and their community such as decreased mobility, decreased functional ability, social isolation and inability to participate in the workforce and society. All of these additional and indirect side effects can have a further burden on the healthcare system in the form of co-morbidities and mental health issues (CHCA, 2016; Edwards et al., 2013). Wounds tend to not be a condition that can be treated as a singular problem, but commonly present with concomitant complaints and comorbidities that complicate management and require simultaneous attention (Edwards et al., 2013). Thus, the high prevalence and widespread impact of wounds and wound care warrants further research into wound care processes which may help to improve care provided. 1.4 Importance of Communication and Collaboration Communication and collaboration are essential in all aspects of healthcare. The healthcare context requires that communication about wounds involves many different care providers across time, varied locations, and with differing levels of knowledge and expertise (Dailey, 2005; Edwards et al., 2013). Dailey (2005) discussed how physicians and nurses are challenged to work collaboratively on costly and complex conditions. The concept of 4 collaboration and communication as a necessity extends to all healthcare professionals (Dailey, 2005). Edwards et al. (2013) suggests that wound care cannot be provided in isolation, and that patients who require wound care often have complex conditions that also needed treatment. Dailey (2005) explained that single-discipline views about wound care need to be replaced by cooperative relationships that maximize the contribution of each professional. Complex patients are often treated by different care providers across the healthcare continuum making it essential that effective communication is taking place between all those involved in care. 1.5 Interdisciplinary Communication and Wound Care Interdisciplinary communication in wound care is thought of as a critical component to care in relation to many care settings and conditions (Gerrity, 2005; Cornforth, 2013). Communication can occur in many different ways, from verbally to written to electronically. Gerrity (2005) suggests that increased communication and collaboration ensures that barriers to care are resolved in a timely manner, that safety is maintained and that attention is given to comorbidities, environmental and psychosocial factors that may complicate the treatment of chronic wounds. Cornforth (2013) discussed the role that holistic and standardized wound assessment could play in wound management and care. This concept was proposed to facilitate increased communication and promote clinicians from different disciplines to communicate using the same terminology (Cornforth, 2013) which might help clarify and streamline both communication and care. 5 1.6 Technology to Support Communication about Wounds Several researchers have explored the use of technology to support interdisciplinary communication and management of patients with wounds or other chronic conditions (Chittoria, 2012; Friesen, Hamel & McLeod, 2013; Jeines, 2011; King, 2014; Mundt et al., 2016; Lyngstad, Grimsmo, Hofoss & Helleso, 2014; Lyngstad, Grimsmo, Hofoss & Helleso, 2015; Santamaria & Kapp, 2013; Sikka et al., 2012; Vowden & Vowden, 2013; Ye et al., 2016). These studies focused on several areas: telemedicine, documentation using electronic health records, and technology for communication about health care. They did not, however, address the processes of interdisciplinary communication between the professions of interest in regards to wound care communication. One study was identified that examined interdisciplinary communication patterns for diabetes management (Mundt et al., 2016). They found that having more people involved in separate face-to-face communications with the provider worsened care outcomes, instead communications with between one specific nurse and one care provider had better patient outcomes (Mundt et al., 2016). The study also found that the number of EHR communications did not impact team climate nor lead to better patient outcomes (Mundt et al., 2016). Given these disparate findings and disparate communication tools, a deeper understanding of technology use for interdisciplinary communication is warranted. 1.7 Significance The significance of wound management to the healthcare system is well established. In developed nations, it was estimated that 2 to 3 percent of healthcare costs are associated with the care and management of chronic wounds (Edwards et al., 2013). It is predicted that with aging populations these costs will continue to rise (Edwards et al., 2013). Wounds also take a toll on 6 the patient; it is estimated that wounds impact mobility, functional ability and can result in social isolation and an inability to participate in the workforce (Edwards et al., 2013). People with chronic wounds tend to receive care in the communities in which they live, either at clinics or through home care services (Edwards et al., 2013). In these setting, despite having many healthcare professionals involved in a patient’s care, at each visit the care is performed by one clinician (Edwards et al., 2013). This clinician is not necessarily the same person each visit. This means that care providers are relying on information that a previous professional has documented or conveyed verbally ahead of time (Edwards et al., 2013). Without effective communication between care providers the appropriateness and timeliness of treatments becomes impossible to maintain (Gerrity, 2005). Therefore, in this study the processes of interdisciplinary wound care communication, as informed by CAS theory, are examined to help to guide future activities related to interdisciplinary wound management. 1.8 Research Questions The research questions that were explored through this study are as follows: Research Question 1: What are the processes surrounding interdisciplinary wound care communication between health care professionals in community settings? Sub-Question 1A: What are the similarities and differences in processes of wound care communication across the different disciplines? Sub-Question 1B: What tools/technologies are used for interdisciplinary communication related to wound management? Research Question 2: To what extent are wound care communication processes reflected in complex adaptive systems theory? 7 1.9 Summary In this thesis I used ethnographic methods and a complex adaptive systems framework to explore the processes surrounding interdisciplinary wound care communication. Wound management is a common healthcare concern that affects many people across the span of their lives. The complexity of wound care results in the necessity of an interdisciplinary approach with many team members communicating and sharing information. Communication can be a challenge in the complex and constantly evolving healthcare system. Describing the current state of processes of interdisciplinary wound care communication, as informed by CAS theory, adds to the existing research regarding complex adaptive systems, communication and technology use in health care. 8 Chapter 2: Literature Review A literature review was undertaken to explore existing research on wound care communication between interdisciplinary team members, including but not limited to: Registered Nurses (RN), Licensed Practical Nurses (LPN), Primary Care Providers (Physicians, Nurse Practitioners (NP)), Wound Ostomy Continence Nurses (WOCN) and allied health professionals. The topics that guided the literature search were: interprofessional communication about wound management, technology for interprofessional communication in healthcare, technology in wound management, and technologies for interprofessional communication about wound care management. 2.1 Interprofessional Versus Interdisciplinary Interprofessional and interdisciplinary were terms found to be used interchangeably in the research. Interprofessional was defined “as a group of individuals from different disciplines working and communicating with each other” (Texas Tech University Health Sciences Centre, 2016). Interdisciplinary was defined as “involving two or more academic, scientific, or artistic disciplines” (Merriam-Webster, 2017). During the literature review the terms ‘interprofessional’ and ‘interdisciplinary’ were used to construct searches and articles found using each term separately were applicable to the topic of interest. Therefore, both terms were included in the searches. However, for the purposes of this thesis and for consistency, the term interdisciplinary is used from this point onwards. 9 2.2 Literature Review Methodology The literature review involved the following steps: First the concept of ‘interdisciplinary communication about wound management’ was explored. Then the topic of ‘technology in wound management’ was searched. This was focused on documentation and information communication technologies. Next, the concept of ‘technology for interdisciplinary communication’ was searched. Finally, the topic of ‘interdisciplinary communication about wounds’ was searched. Literature up to May 2017 was included. 2.3 Databases Searched, Search Strategy and Inclusion/ Exclusion Criteria The databases and search engines used for this literature review were PubMed, Medline, CINAHL and Engineering Village. To start the search, different combinations of the words ‘wound care’, ‘wound management ‘AND ‘home care’ OR ‘community’ OR ‘primary care’ AND ‘communication’ OR ‘interprofessional communication’ OR ‘interdisciplinary communication’ AND ‘technology’. The search with the above listed terms was first conducted in PubMed to ensure appropriate MeSH terms were identified. Once MeSH terms were found and confirmed a search was done in Medline and Engineering Village. Separate searches were conducted using CINAHL search terms. Articles were reviewed if they were published in English. Articles from all dates were screened, although none were found to be relevant before 2000. If a title was promising or did not clearly meet exclusion criteria, the abstract was further reviewed for inclusion. The terms used to search PubMed and Medline were ‘wound care’ OR ‘wound management’ AND ‘communication’ OR ‘interdisciplinary communication’ AND ‘technology’. The terms used for CINAHL search were ‘wound care’ OR ‘wound healing’ OR ‘wound management’ AND ‘communication’ OR ‘interdisciplinary communication’ AND 10 ‘technology’. When searching Engineering Village, the terms ‘wound care’ OR ‘wound management’ AND ‘communication’ OR ‘interdisciplinary communication’ AND ‘technology’ were used. Based on this search criteria, 14 relevant articles were found and reviewed in detail. Articles were analysed and organized using Garrard’s Matrix Method (Garrard, 2016). The purpose of the paper was identified along with study design, sample, methods, intervention, control, outcome measure, findings, strengths and limitations. This technique helped to identify themes in the existing literature and informed the gap in practice that this thesis looks to address. Several themes became apparent in the research: communication for the purposes of collaboration, communication for wound assessment and management, various telemedicine interventions, and documentation in the form of information systems. A study that looked at use of technology for communication in relation to team climate in the context of diabetes care was also reviewed for its contribution to the literature on interdisciplinary communication and technology. 2.4 Interdisciplinary Communication and Collaboration about Wound Management Three papers were found that focused on collaboration, wound management and assessment and addressed the role in interdisciplinary communication. Dailey (2005) and Gerrity (2005) both wrote about the importance of interdisciplinary collaboration when providing wound management in a home care setting. Dailey (2005) shared thoughts on healthcare changes, interdisciplinary care management and the importance of research into effective communication between physicians and nurses and the potential impact on decreasing omitted or contraindicated care. Dailey (2005) highlighted that performance initiatives to reduce avoidable adverse events 11 and costs have emphasized the need for improved physician and nurse communication and collaboration. Dailey (2005) called for healthcare professionals to leverage technology to streamline communication and share critical patient data. The need for evidence-based protocols, technology and information systems to aid in patient management was stressed (Dailey, 2005). It was suggested that these tools have been identified as key supporters in planning and coordinating quality patient care, and are recommended for improving physician and nurse collaboration (Dailey, 2005). Dailey (2005) suggested that physician-nurse communication breakdown was a core barrier to effective wound management. Gerrity (2005) reviewed the literature to outline the role that care management played in collaboration and improved communication around wound management in the home care setting. Gerrity (2005) also explored innovations such as evidence-based protocols to facilitate communication about care. Gerrity (2005) suggested exploring innovations such as the internet for patient education and interaction, electronic team status forms and information technology to help provide safe and quality wound care. The papers by Gerrity (2005) and Dailey (2005) had quite a few limitations. They were both over 10 years old, did not describe their literature review strategies and did not focus on the topic area of interdisciplinary communication. Furthermore, neither of the papers presented original research. They did however, help to establish the importance of general communication and the existence of a gap in the literature and have been included for this reason. Cornforth (2013) presented findings from a critical literature review. The focus of this paper was on how to develop and enhance professional and clinical assessment and evaluation skills in the context of wound care. The important components of comprehensive wound assessment were identified and recommendations were made for knowledge and skill application 12 (Cornforth, 2013). The author found that communication between interdisciplinary team members and patients was essential to thorough and accurate wound assessment (Cornforth, 2013). This paper’s strength was that the literature review strategy was clearly described and only drew on research published in the previous 10 years. While the paper did not directly look at communication, the conclusions drawn from the review of literature were that up-to-date knowledge, working effectively as an interdisciplinary team and effective communication were crucial to ensuring the delivery of effective wound assessment and care (Cornforth, 2013). 2.5 Technology Use and Virtual Care in Wound Management Many of the articles that were identified about the use of technology for wound care management fell under the classification of ‘virtual care’. This is a relatively new term that is being used to encompass the types of technologies that might be used in non-acute care settings and often non-face-to-face contexts. The definition that will be used for virtual care for the purposes of this paper is “virtual care encompasses a range of health care activities enabled by technology, including telehealth” (Virtual Care Community of Action, 2019). Nine papers were found that discussed technology (mobile phones, computers, and internet) and its use and value in wound management to provide virtual care. 2.5.1 Mobile Phone Cameras to Support Physician Decision Making Sikka et al. (2012) performed a descriptive cross-sectional study that included surveying patients. The goal of the research was to assess patients’ attitudes towards the use of mobile phone technology for laceration care and management (Sikka et al., 2012). The researchers looked at the possibility of using mobile phone cameras to send images of wounds to remote 13 providers who would then help guide care decisions (Sikka et al., 2012). The study had a sample of 199 patients who presented to an emergency department at a specific hospital in Washington D.C. USA (Sikka et al., 2012). The study used descriptive statistics to analyze the results from the survey (Sikka et al., 2012). Findings showed that the majority of patients were favourable to using mobile phones for laceration care (Sikka et al., 2012). One interesting finding was that patients had differing perceptions on the use of technology for a recommendation versus a diagnosis (Sikka et al., 2012). The recommendation was described as a therapeutic opinion and next steps for the patient to take which may include further follow-up with a physician while the diagnosis was considered the definite cause of the wound (Sikka et al., 2012). Patients were accepting of receiving a recommendation but less accepting of receiving a diagnosis using a mobile phone (Sikka et al., 2012). Patients indicated that they thought using mobile technology would reduce time, save costs and facilitate better communication between health care providers (Sikka et al., 2012). While having a relatively large sample size (N=194), the research was limited because it only occurred at one hospital in the United States (Sikka et al., 2012). People were given the option to decline to participate which may have skewed the data to a favourable outcome for technology use (Sikka et al., 2012). 2.5.1.1 Database Application for Desktop and Mobile Phone Jeines (2011) performed a qualitative descriptive study looking at a telemedicine system that had been implemented in Jutland, Denmark to address chronic wounds. This system used a desktop computer with camera and camera-equipped mobile phones to collect data on wound care (Jeines, 2011). The program of interest was downloaded onto the computers and mobile phones (Jeines, 2011). It included patient specific data on wounds and medical status (Jeines, 14 2011). Health care providers could review and enter pertinent clinical data related to wounds into this system (Jeines, 2011). The goals of this program and database were to improve interdisciplinary communication and access to care for the patients (Jeines, 2011). The study found that the waiting time for care was decreased along with required patient travel times (Jeines, 2011). The study utilized asynchronous communication techniques (Jeines, 2011). While the content was relevant to the research question of this thesis, there were some limitations with this study. It described the system implemented, but had limited evaluation criteria for the system. There were no control or baseline data presented to compare with the intervention findings. There was no feedback from users of the system about perceived utility of the system. The methods of the study were not well detailed. While being relevant to the topic area of interest, this study further highlighted the need for more research in the area of interdisciplinary communication about wounds and potential technological solutions. 2.5.2 Digital Images Chittoria (2012) reviewed existing literature on telemedicine and its application in surgical wound care. The focus was on how telemedicine could enhance communication and the effectiveness of using digital images to facilitate referral (Chittoria, 2012). The paper outlined the benefits and weaknesses of synchronous versus asynchronous communication. Even though the focus was on how communication could be enhanced using technology, the information was targeted to physician communication which may not be relevant when explored in an interdisciplinary context in a community setting. 15 2.5.3 Telemedicine Santamaria and Kapp (2013) wrote a discussion paper looking at the state of research and focused on types of wound care telemedicine systems used in the home care environment. The paper looked at asynchronous, synchronous and hybrid systems (Santamaria & Kapp, 2013). The authors highlighted the benefits that could be realized with proper telemedicine use, such as reduction in healthcare costs, decreased resource use and patient and clinician satisfaction (Santamaria & Kapp, 2013). The researchers also highlighted the system changes that need to be implemented to see the full realization of telemedicine benefits (Santamaria & Kapp, 2013). Standardized clinical decision support, evidence-based guidelines, connection to databases to create ‘big data’, technical and clinical design standardization and integration were all named as barriers that needed to be overcome to see the full impact of these systems on interdisciplinary communication (Santamaria & Kapp 2013). While this discussion paper nicely highlighted the types of technology available for use in interdisciplinary communication it did not explore the clinician perceptions of operationalization into existing workflows. The paper looked at existing research and literature to set the context. This paper did however highlight some of the complexities of wound care communication in a community environment (Santamaria & Kapp, 2013). 2.5.4 Smart Glasses and Smart Phones Ye et al. (2016) conducted a cohort study to look at the possibility of using mobile communication technology standard with smartphones or smart glasses for wound management. The goal was to create a real time, interactive platform for telemedicine to be used in wound dressing changes and operations (Ye et al., 2016). The telemedicine application was developed 16 and used by specialists in Shanghai providing expertise to remote wound care services (Ye et al., 2016). The study focused on user and patient acceptance. The application was used for 30 patients with lower extremity skin defects who required dressing changes or minor surgical procedures related to their wounds (Ye et al., 2016). Over the one-month trial the application was used 109 times for the 30 patients (Ye et al., 2016). Remote consultation resulted in the recommendation of dressings 53.3% of the time (16 patients) while minor operative procedures were guided 46.6% of the time (14 patients) (Ye et al., 2016). Two patients achieved wound healing during the time of the study while all others required dressing changes after a month (Ye et al., 2016). The researchers concluded that there was general acceptance of the tool by physicians (100%) and patients (83.3%), and that it was usable (Ye et al., 2016). The limitation with this study was that it did not focus on improved communication nor did it measure specifics about communication using the technology (Ye et al., 2016). 2.5.5 Digital Pen and Paper Vowden and Vowden (2013) performed a pilot randomized control trial to look at the effectiveness of a system using a digital pen and paper technology and a smartphone to remotely monitor and support wound management in nursing home residents. The researchers used computer assignment to randomize entire nursing homes in Bradford, United Kingdom (UK) to intervention or control groups (Vowden & Vowden, 2013). Sixteen nursing homes were matched for bed numbers prior to randomization (Vowden & Vowden, 2013). All patients with a wound of any etiology or severity who resided in the selected nursing homes were considered eligible to participate as long as they provided consent (Vowden & Vowden, 2013). These criteria resulted in 17 participants in the experimental group and 9 participants in the control group (Vowden & 17 Vowden, 2013). The control group received standard care, as determined by the nursing home, while the intervention group received standard care plus remote support from experts (Vowden & Vowden, 2013). The experimental group had a weekly assessment form and digital image completed online by nursing home staff (Vowden & Vowden, 2013). The control group also had weekly assessments completed and wound images taken by the research nurse (Vowden & Vowden, 2013). However, the experimental groups’ information was shared with the remote experts, while the control groups’ information was withheld until the end of the study (Vowden & Vowden, 2013). After control group information was shared with remote experts at the end of the study it was found that the experts would have altered the patient’s care plan in 7 of the 9 cases (Vowden & Vowden, 2013). For the experimental group, it was estimated that outcomes improved in 7 patients and the healing time was decreased in 5 patients (Vowden & Vowden, 2013). The study found that the remote support improved patient outcomes, had cost savings in the form of appropriate dressing selections, improved appropriate referral and improved healing times (median 10 months for intervention and 15 months for control) (Vowden & Vowden, 2013). This study suggests that technology may help improve interdisciplinary communication. This study had the strengths that it was randomized, the sample was stratified and data were collected on both the control and experimental groups. However, the sample size was small and neither wound healing time nor wound progression data were presented for each group. This study helps reaffirm the importance of research into wound care communication and the potential role of technology. King (2014) also conducted a pilot study that focused on a similar technology as Vowden and Vowden (2013). King (2014) explored the feasibility of providing a remote wound care 18 delivery system. The research used a digital pen and paper, digital photography and mobile phone technology to explore if sufficient wound data could be transmitted to remote experts who would then provide support to local health care providers (King, 2014). This study was conducted in a primary care and community setting with support provided by an acute care centre (King, 2014). Nurses were given computers to access patient data while providing care (King, 2014). Physicians had access to the same information in the form of an electronic medical record (EMR) (King, 2014). The study created a specific worksheet that was integrated into the EMR for nurses to use (King, 2014). This worksheet incorporated aspects that were considered essential to wound assessment (King, 2014). The goal was to promote communication with general practitioners through standardized assessment data and technology facilitated communication (King, 2014). The article does clarify the prevalence of wounds in the area in which the study was conducted but does not quantify a sample size. King (2014) just states that the study was conducted in the independent sector in the community and that low numbers of participants were recruited. While the study was conducted in a similar context as the thesis research, with a similar research question, there were no conclusions or findings related to communication. King (2014) suggested that the approach of having remote experts review and provide support to clinicians should improve the quality of wound care provision in larger teams. Further, they suggest that improved quality would be achieved through an increase in the productivity of WOCN, and reduce waste and inappropriate prescribing of wound care products. However, this hypothesis cannot be conclusively determined from the study as it is written. Limitations of this study were that the methodology used was not clearly outlined and, conclusions and findings were not 19 clearly described. King (2014) presented some perspectives of nurses, patients and providers but did not describe how this information was collected. 2.5.6 E-Messaging Lyngstad, Grimsmo, Hofoss and Helleso (2014) conducted a cross-sectional study looking into the experience of home care nurses with electronic messaging (e-messaging). In this study e-messaging was not clearly defined. The goal was to determine how e-messaging influenced communication between home care nurses and general practitioners (GPs). While this study focused on communication between providers and nurses in a home care environment, it did not focus on wounds as a topic for communication (Lyngstad, Grimsmo, Hofoss & Helleso, 2014). The study provided a questionnaire to nurses exclusively. The questionnaire was not validated but was reviewed by experts (Lyngstad, Grimsmo, Hofoss & Helleso, 2014). The Cronbach’s alpha of the questionnaire was tested and found to be greater than 0.7 (Lyngstad, Grimsmo, Hofoss & Helleso, 2014). This Cronbach alpha is less than the 0.8 recommended as the indication that a questionnaire acceptably tests the variable of interest (Polit & Beck, 2016). The questionnaire was given to a control group of nurses who worked in districts where the e-messaging had not yet been implemented along with an experimental group that used e-messaging (Lyngstad, Grimsmo, Hofoss & Helleso, 2014). RNs in both groups were employed in at least a 0.5 FTE position and could read and write in Norwegian. There were 632 nurses in the intervention group and 581 nurses in the control group who received questionnaires (Lyngstad, Grimsmo, Hofoss & Helleso, 2014). Four-hundred and twenty-five questionnaires were completed by the intervention group, while 364 questionnaires were completed by the control group (Lyngstad, Grimsmo, Hofoss & Helleso, 2014). The study found that e-messaging 20 resulted in reported decrease in faxes and an increase in identifiable standard communication procedures for the intervention group (Lyngstad, Grimsmo, Hofoss & Helleso, 2014). However, the researchers also discovered that there was no difference in timeliness of communication and there was no difference found between other non-electronic communication methods (Lyngstad, Grimsmo, Hofoss & Helleso, 2014). The study illustrated strengths in that the methodology was clearly described, some statistical analysis of the results was completed and there was a control. Lyngstad, Hofoss, Grimsmo and Helleso (2015) completed a follow-up study in 2015 which looked into nurses’ experience of e-messaging with GPs. The second study explored home care nurses’ assessment of the utility of an e-messaging system for communicating with GPs. (Lyngstad, Hofoss, Grimsmo & Helleso, 2015). The researchers used a similar study design to the previous (Lyngstad, Grimsmo, Hofoss & Helleso, 2014). Again, including a questionnaire that was created by the study team but it was not validated (Lyngstad, Hofoss, Grimsmo & Helleso, 2015). To make sure it assessed the intended purpose it was based on e-messaging standards from previous research (Lyngstad, Hofoss, Grimsmo & Helleso, 2015). Focus groups were conducted to refine the questions and then further reviewed by experts (Lyngstad, Hofoss, Grimsmo & Helleso, 2015). Once this was complete the questionnaire was piloted and further refined (Lyngstad, Hofoss, Grimsmo & Helleso, 2015). To participate in the study nurses had to have used e-messaging for more than 3 months, have a full time equivalent (FTE) of 0.5 or greater and be able to read and write Norwegian (Lyngstad, Grimsmo, Hofoss & Helleso, 2015). It was found that 632 nurses met these criteria and were provided with the questionnaire (Lyngstad, Grimsmo, Hofoss & Helleso, 2015). Of the 632 eligible participants 425 completed the questionnaire (Lyngstad, Grimsmo, Hofoss & Helleso, 2015). The answers to the Likert questionnaire questions were analyzed using logistic regression. Lyngstad, Hofoss, Grimsmo and 21 Helleso (2015) found that 97.2 percent of the nurses who completed the questionnaire thought that e-messaging was a useful tool for communicating with GPs and agreed that it was easy to use. The odds of reporting e-messaging was a useful tool were over 5 times higher if the nurses reported that e-messaging was easy to use (odds ratio [OR]=5.2 95% CI 2.3-9.8) (Lyngstad, Hofoss, Grimsmo & Helleso, 2015). One interesting finding was that as full-time employment status increased so did the likelihood that the e-messaging was rated as easy to use (Lyngstad, Hofoss, Grimsmo & Helleso, 2015). The odds were 1.03 times greater that the application would be rated as easy to use if the nurses had a higher FTE (OR=1.032 95% CI 1.001-1.064) (Lyngstad, Hofoss, Grimsmo & Helleso, 2015). It was found that reports of poor functionality and performance decreased likelihood that the e-messaging was rated easy to use (Lyngstad, Hofoss, Grimsmo & Helleso, 2015). The odds of rating the system easy to use were nearly 7 times higher if the system functionality was not rated poor (OR=6.914 95% CI 1.713-27.899) (Lyngstad, Hofoss, Grimsmo & Helleso, 2015). The researchers also found that the more training received by the nurses the higher the ratings of ease of use (Lyngstad, Hofoss, Grimsmo & Helleso, 2015). The odds of the nurse rating the e-messaging easy to use were over 6 times higher if the nurse had received training on how to use the application (OR=6.622 CI 2.515-17.437) (Lyngstad, Hofoss, Grimsmo & Helleso, 2015). While a strength of this study was that it clearly described research methods and performed statistical analysis, it did not look at wound management specifically. However, the results helped to inform the study design and research questions for this thesis. 22 2.5.7 mHealth Applications Friesen et al. (2013) discussed the findings of a user trial of an mHealth technology designed for documentation of pressure ulcers. A software application (app) had been created for mobile smartphones and tablets and was trialed in a nursing care home (Friesen et al., 2013). The intent of the app was to provide an EMR to replace paper-based charting that nurses had currently been using and was positioned for integration with the facilities eHealth initiative (Friesen et al., 2013). Training was provided to the users and after three weeks of app use a survey was sent to the users, which was later followed up with a focus group (Friesen et al., 2013). The survey contained open and closed questions and focused on nurses’ perceptions of the software (Friesen et al., 2013). The study found that most participants reported that the app was easy to use and integrate into daily care (4.57/5.00), however, some problems were reported with display size and functionality (Friesen et al., 2013). One key benefit that was highlighted was the value in wound images (Friesen et al., 2013). While this research talked about nurses, it did not mention providers, and did not focus on the implications of the application to communication. Friesen et al. (2013) did however, mention that some intended benefits were the capacity for remote consultation, data organization and analysis, built in alerts, and images, text and graphs based wound histories that could be shared. 2.6 Technology for Interdisciplinary Communication (non-wound care context) Mundt et al. (2016) explored primary care team communication networks, team climate, and their association with health outcomes, healthcare utilization and associated costs for patients with diabetes. While this study is not related to wound management, it was one of the few studies found that addressed technology for communication and direct impacts on health 23 outcomes of a patient population (Mundt et al., 2016). Data were collected through face-to-face structured questionnaires and addressed team climate and sociometric questions relating to communication with other people about a patient (Mundt et al., 2016). Staff were asked to identify who they communicated with, about a patient, and how often they communicated with them (Mundt et al., 2016). From this information, a communication matrix was created (Mundt et al., 2016). Data analysis was completed using generalized linear mixed models and looked at associations between team level communication network variables and patient outcome variables (Mundt et al., 2016). Mundt et al. (2016) found that teams with a greater number of face-to-face interactions among team members were associated with 52 percent fewer hospital days (odds ratio [OR]=0.48 95% CI 0.22, 0.94), and US $1220 (95% CI -US$2416, -US$24) lower health care costs per team diabetes patient in the previous year (Mundt et al., 2016). It was found that for every additional nurse who reported frequent daily face-to-face communication with the provider, the less controlled the HbA1c was (OR=0.83, 95% CI 0.66, 0.99), the higher the hospital days were (relative risk [RR] =1.57, 95% CI 1.10, 2.03) and the higher healthcare costs were (Beta= US$877, 95% CI $42, $1713) (Mundt et al., 2016). This suggested that having more people involved in separate face-to-face communications with the provider worsened care outcomes, indicated by higher HbA1c, increased hospital days and resulted in higher health care costs. One mediating factor of this was a reported shared team vision (Mundt et al., 2016). It was found that greater team vision was associated with an 11 percent decrease in urgent care visits (OR=0.889), a 49 percent reduction in hospital days (RR=0.512) and US$930 less in healthcare costs per patient (Mundt et al., 2016). It was also found that primary care providers 24 who had communications with one specific nurse had better patient outcomes than those teams that reported communication from multiple nurses (Mundt et al., 2016). The researchers concluded that team interconnections and team climate with shared vision or teamwork resulted in better quality of care for patients with diabetes (Mundt et al., 2016). The authors also looked at communications via EMR. Several RNs reported more frequent communication via EMR than face-to-face communication. However, the study found that the number of EMR communications did not impact team climate or lead to better patient outcomes (Mundt et al., 2016). While this study drew on aspects such as team climate, process and the impact of these on communication that were looked at in this thesis, it did not focus on wounds or the content of the interdisciplinary communication. It focused on who and how many times, which is only part of the processes surrounding communications (Mundt et al., 2016). This article was leveraged to inform the study design. 2.7 Summary Despite finding research that highlighted components of communication, wound care and technology, no research was found that examined the processes around technology-mediated interdisciplinary wound care communication. The literature revealed a focus on technology, but not how it works within the processes of a complex healthcare system. Thus, prior to the start of this study no research was identified that examined the processes of technology-mediated communication surrounding wound care in a complex adaptive environment like healthcare. 25 Chapter 3: Methods This research explored the processes surrounding technology-mediated interdisciplinary wound care communication. 3.1 Research Questions The following research questions were explored: Research Question 1: What are the processes surrounding interdisciplinary wound care communication between health care professionals in community settings? Sub-Question 1A: What are the similarities and differences in processes of wound care communication across the different disciplines? Sub-Question 1B: What tools/technologies are used for interdisciplinary communication related to wound management? Research Question 2: To what extent are wound care communication processes reflected in complex adaptive systems theory? 3.2 Study Design Ethnographic methods were used to explore the research questions. Ethnography is a qualitative method that uses a blended approach to data collection (Polit & Beck, 2016). This includes interviews, fieldwork and written text (Polit & Beck, 2016). Qualitative methods were chosen for this research as they are helpful when not much is known about a given subject, as is the case with the selected research questions and as indicated by the identified gap in the literature. Ethnographic methods were selected as they allowed for a focus on systems, processes, patterns and procedures surrounding a given activity, in this case interdisciplinary 26 communication (Polit & Beck, 2016). Ethnographic methods also supported an underlying assumption that groups develop a system of processes that can affect an individual member’s view of activities and their experiences (Polit & Beck, 2016). These foundational components of the ethnographic approach are why it was selected for this research. Because of the narrow topic area selected, a prolonged approach to fieldwork was not undertaken. This will be discussed further in study limitations. 3.3 Theoretical Lens The theoretical lens of Complex Adaptive Systems (CAS) theory was used during the creation of interview question and informed how data were analyzed. CAS is defined as a system that demonstrates discernable properties of: embeddedness (in the context of their histories), self-organization, non-linearity and unpredictability (Chaffee & McNeill, 2007). CASs are open systems, operate in conditions outside equilibrium, and the complexity results from patterns of interactions between components (Chaffee & McNeill, 2007; Holden, 2005). These characteristics are found in most healthcare settings and in day-to-day nursing practice (Notarnicola et al., 2017). CAS has been used in many fields ranging from economics to biology to healthcare with few studies applied to understand nursing practice (Chaffee & McNeill, 2007; Holden, 2005; Notarnicola et al., 2017). Several articles discussed using CAS as a model of both nursing and healthcare (Benham-Hutchins & Clancy, 2010; Clancy, 2014; Chaffee & McNeill, 2007; Holden, 2005; Notarnicola et al., 2017). Benham-Hutchins and Clancy (2010) discuss healthcare social networks as a hierarchy of embedded CASs. Chaffee and McNeill (2007) defined CAS and laid out properties (or characteristics) that are present in a CAS including: adaptable elements, 27 attractors, co-evolution, context and embeddedness, emergent behavior, inherent order, nonlinearity, porous boundaries, self-organization, simple rules and unpredictability. In this study CAS was used to explore the categories that emerged from interviews. Specifically, the properties identified by Chaffee and MacNeill (2007) were used to classify categories that emerged during this study. See Table 3.1 for definitions. Table 3.1 Chaffee and McNeill (2007) Properties of Complex Adaptive Systems Property of CAS Description Adaptable elements Elements in a CAS can evolve Attractors Catalysts in a CAS that allow new behaviours to emerge. Co-evolution Progress in the CAS occurs with constant tension and balance. Context and embeddedness The CAS resides within and interacts with other systems that influence it. Emergent behaviour New behaviour is a feature of the CAS represented by constant innovation and creativity. Inherent order Order is maintained in a CAS even without central control. Nonlinearity Implies that in response to a stimulus a variety of behaviours are possible, and the cause and effect relationship in not directly evident or linear. Porous boundaries The boundaries of the elements in a CAS are blurry and porous, allowing exchange and movement between them. Self-organization Process where many local interactions create order without direction from above. Simple rules Local application of simple rules can result in broad, complex outcomes. Unpredictability Forecasting is inexact in a CAS because elements change, behaviour is emerging and activities are nonlinear; the trajectory of a system is unknowable. NOTE: Reprinted from Nursing Outlook, 55(5), Chaffee & McNeill, A model of nursing as a complex adaptive system, 232-241., Copyright (2007), with permission from Elsevier 3.4 Ethical Considerations Prior to starting data collection, ethical approval was obtained from University of British Columbia’s (UBC) Behavioural Research Ethics Board (BREB) and operational approval was received from Vancouver Coastal Health Research Institute (VCHRI). Informed consent was 28 obtained from each participant prior to collecting data, interviewing participants or conducting observations. The consent forms reiterated that all participation was voluntary and that participants could withdraw at any time. Consent forms were emailed to participants at least 24 hours ahead of shadow shift or interview for review. At the start of the session the MSN researcher provided two copies of the consent for the participant to sign. One copy was kept by the researcher and one copy was given to the participant. Participants were offered a $12 coffee card as an honorarium for time volunteered. This amount was thought to not be enough sway or coerce participation. All documentation and results were stored securely in a locked cabinet or on password protected computer of thesis supervisor. When data needed to be transported it was done so on a password protected USB key or hard drive. Only the researchers listed in the ethics application had access to the information. Information provided by participants was de-identified and stored separately from consent forms. Consent forms were stored in a locked cabinet in the thesis supervisor’s office. Demographics were collected without participant’s names and were stored separately from consents. 3.5 Sample 3.5.1 Sample Population The target sample population included registered nurses (RN), licensed practical nurses (LPN), wound ostomy continence nurses (WOCN), primary care providers (physicians, nurse practitioners (NP)) and allied health care professionals, such as social workers and pharmacists, who work with patients to provide wound care in a home care, community and primary care 29 setting at a large health organization in Western Canada. Individuals from each of these groups were approached to join the study. Recruitment and interviews continued until data saturation was achieved as evidenced by no new themes being identified in the data. 3.5.2 Recruitment Methods Recruitment was carried out in several ways. Firstly, by placing posters in the home care and primary care clinics to make clinicians aware of the research study. The MSN researcher then reached out directly to Wound Ostomy Continence Nurses and other key informants to help gain entry to the sites. A prepared email was also sent to key individuals at the clinic for distribution to staff. The MSN researcher also attended clinic huddles and meetings about wound care to promote the study and recruit participants. Posters, emails and presentations invited interested persons to call or email the MSN researcher for more information on the study. Official confirmation of their participation occurred when they arrived for the session and signed the consent form. A $12 coffee card was provided as an honorarium to participants for time volunteered. 3.5.3 Sampling Technique Purposive sampling for participants was done through research team members who had entree to the sites and knew the clinical staff who were able to provide emic perspectives of the phenomenon in question. Purposive sampling is a non-probability sampling method based on the populations’ characteristics and study objectives (Polit & Beck, 2016). For this study, participants needed to have deep clinical knowledge of the topic area of wound communication, 30 therefore individuals from different clinical groups were targeted (RN, LPN, primary care providers, allied health). 3.5.4 Inclusion and Exclusion Criteria Individuals were eligible to participate if they worked in primary care, home care or community settings at the large health organization and were working as an RN, LPN, WOCN, primary care provider (NP or physician) or allied health care professional. They needed to work with patients to provide wound care and speak English. Because the study was looking for key informants for the interviews, as indicated with ethnographic methods, I discussed these factors with individuals to make sure they had experience in the setting of interest and knowledge of the research area. Individuals were excluded if they did not consent to participate in the research or did not meet the inclusion criteria. 3.6 Data Collection The MSN researcher participated in shadow shifts/ observation of the interdisciplinary team huddle and conducted the interviews with participants. This allowed for consistent questioning, note taking, data collection, interpretation and presentation. 3.6.1 Participant Demographics At the start of the interviews and shadow shifts a short demographic survey was completed (see Appendix A). Data included information about profession, length of time working in profession, training and computer use. No identifiable information was collected. Once completed the participant placed the survey in an unmarked envelope and returned it to 31 researcher. It was then stored in the office of the study’s Principal Investigator in a secured filing cabinet and opened later for analysis. Keeping these documents anonymous and separated from consents decreased the risk of bias by the MSN researcher that any of this information could cause. 3.6.2 Observations One observation lasting 4-hours was conducted in a primary care clinic. The first hour involved observing a team meeting (including 2 primary care providers (physician and NP), RNs, RPNs, LPNs, a pharmacist, case managers and a clinic coordinator) about patients who were receiving wound care. The remaining 3 hours were spent shadowing one RN who was documenting wound care that had been provided and updating care plans based on the team meeting. Field notes were collected during the clinic observation. At the end the shadow shift a short debrief occurred where the MSN researcher verbally summarized for the participant what was observed. The debrief provided an opportunity to correct any misinterpretations and allowed for member checking to occur immediately while the experience was fresh for both the researcher and participant. Patient information sheets explaining the research were prepared but not used since patients were not present during the shadow shift at the clinic, just clinicians. 3.6.3 Persona Development as Interview Artifact In order to facilitate the interviews, personas of each clinician type were created (see Section 4.4). Personas are described as a fictional character that represents a group of target users/ an audience who share common needs, characteristics, and goals (Miaskiewicz & Luxmoore, 2017; Wikberg Nilsson et al., 2010). Personas for this study were created using 32 Canadian Institute for Health Information (CIHI) data for different health care professions and described a generic scenario around wound care that was specific to the profession being interviewed. To validate the personas, participants were asked to describe the similarities and differences between the personas created and their experiences with wound care. This was done at the start of the interview for every participant. No changes were made to the personas throughout the process so each person saw the same persona for their appropriate professional designation. Feedback on personas is discussed further in Chapter 4. 3.6.4 Interviews Unstructured and semi structured interviews were conducted by the MSN researcher. Semi-structured questions and personas were used to guide the interviews. Personas were used to help anchor the interviews and used to support the conversation and interview questions. Interviews lasted for 30 to 90 minutes and occurred in a quiet room at the health clinic where the clinician worked or in their office. Notes of the interview were taken and the sessions were also audio-recorded for review and data analysis. The interviews were then transcribed verbatim from the audio-recordings by the MSN researcher. Guiding interview questions (Appendix B) were open ended and used in conjunction with personas. The intent was to allow participants to answer without being directed by the question. Not all questions were used in every interview. If the clinician answered a question indirectly through discussion of another question, the question was not asked again. Throughout the interview, member checking was done through prompts and clarifying questions. At the end of the interview the information was verbally summarized back to the participant and they had a chance to correct any misinterpretations of the information that was given. 33 3.7 Data Analysis As per ethnographic qualitative methods: content analysis, theme identification and artifact (i.e., technology tools) identification were conducted to analyze data that were collected during the shadow shifts and interviews. Field notes and audio recordings were reviewed in detail and themes identified, as well, artifacts that were identified during the interviews and shadow shifts were collected and reviewed. CAS theory was used to interpret the data and identify/organize categories and themes. Categories were then organized into a matrix to represent how they were reflected in the CAS theory. Demographic responses were summarized. Because there was only a small sample size, inferential statistics were not performed. Descriptive statistics including mean and percent were used where applicable to reflect quantitative results of the demographic survey. 3.8 Maintaining Trustworthiness and Integrity in Qualitative Design To maintain trustworthiness and integrity while conducting the study specific actions were taken. Throughout the entire process the MSN researcher kept careful documentation so there was a clear audit trail. 3.8.1 Method to Reduce Sampling Bias The study sample focused on a few qualified participants who provided rich information. Members of the research team had access to the community and assisted with identifying appropriate participants. Interviews and shadow shifts continued until saturation of data was achieved. Saturation was identified when new themes stopped emerging in the data that were being collected and analyzed (Polit & Beck, 2016). To help determine when saturation had been 34 achieved data were analyzed after each interview. As mentioned above, member checking with prompts and summaries at the end of interviews and shadow shifts was completed to confirm correct interpretation of data (Polit & Beck, 2016). 3.8.2 Methods to Maintain Trustworthiness during Data Collection Comprehensive field notes were maintained during data generation and collection. These were taken by hand during the interview, observation or shadow shift and then typed up after the completion of the encounter. This ensured that information was captured accurately and in a timely manner. Audio-recording of interviews allowed the MSN researcher to replay the information and helped facilitate accurate documentation of interviews. These recordings were transcribed verbatim by the MSN researcher and analyzed. Audio-recordings provide richer data than notes as they highlight emotion and change in tone of voice that was not captured in notes. This information helped with theme identification and analysis. Four types of triangulation were applied: 1) person, 2) space, 3) method, 4) time. Person triangulation is described as collecting data from different types or levels of people, such as various clinical staff, with the goal of validating data through multiple perspectives on a topic (Polit & Beck, 2016). Space triangulation is described by Polit and Beck (2016) as collecting data on the same phenomenon in multiple sites to look for consistency across areas. Method triangulation is described as using multiple methods to collect data, this helps to create the consistency of information collected about a phenomenon (Polit & Beck, 2016). Time triangulation is described but Polit and Beck (2016) as collecting data on the research topic multiple times over a period of time. 35 Person and space triangulation were done in this research by collecting data from different participants, from different professions, at two separate clinical sites (Polit & Beck, 2016). Having varied people, professions and settings allowed for person triangulation and space triangulation (Polit & Beck, 2016). Method triangulation was done by performing interviews, observations and using personas to inform interviews (Polit & Beck, 2016). Artifacts in the form of electronic resources were also collected and considered in the data analysis process allowing for further data triangulation (Polit & Beck, 2016). Interviews and observations occurred at different times over several months which provided time triangulation (Polit & Beck, 2016). 3.8.3 Method to Maintain Rigour During Data Analysis Data analysis included recorded interviews being transcribed after sessions, and thorough documentation of field notes were completed after shadow shifts. Information was organized and categorized into themes after each session. New categories were added as they were identified. Once new categories and themes stopped being identified it was maintained that data saturation had been reached. This was completed for the overarching themes that emerged from the research. All of the methods outlined in the section above helped ensure that research integrity was maintained (Polit & Beck, 2016). Data were analyzed and grouped into categories. These categories were then reviewed against the properties of CAS identified by Chafee and McNeill (2007) and mapped where quotes from participants illustrated properties of a CAS. 36 Chapter 4: Results 4.1 Overview In this chapter the results are presented. Research questions are reviewed followed by an analysis of participant demographic information. The use and validation of personas are then reviewed. The processes of communication as described by participants are identified and then the similarities and differences between professions will be discussed. The categories that emerged from coding are explored and then overarching themes are discussed. The themes and categories identified are looked at in relation to the Complex Adaptive System (CAS) properties outlined by Chaffee and McNeill (2007). 4.2 Research Questions The research questions that were explored through this study are as follows: Research Question 1: What are the processes surrounding interdisciplinary wound care communication between health care professionals in community settings? Sub-Question 1A: What are the similarities and differences in processes of wound care communication across the different disciplines? Sub-Question 1B: What tools/ technologies are used for interdisciplinary communication related to wound management? Research Question 2: To what extent are wound care communication processes reflected in complex adaptive systems theory? 37 4.3 Demographics The participants included 1 primary care provider (physician), 2 social worker case managers, 8 point of care clinicians (RNs) and one WOCN and pharmacist (observed but not interviewed). Saturation was achieved as evidenced by no new themes being identified in the interviews after the ninth person. The only outlier to this was the physician interview as this individual had a different work flow to the nurses and case managers interviewed. Due to time constraints and diversity of participants data saturation was only achieved with the nurses and case managers. The one physician participant brought forward some new information, however, it was not possible to obtain additional participants to validate this. Table 4.1 Demographics Sample Frequency (%) N=11 Age 20 to 29 years 30 to 39 years 40 to 49 years 50 to 59 years 60 to 69 years 3 (27%) 2 (18%) 3 (27%) 2 (18%) 1 (9%) Gender Female Male 9 (82%) 2 (18%) Education Bachelors Masters 10 (91%) 1 (9%) Frequency of Computer Use Outside of Work Several times/ day Once/ day Several times/ week Several times/ month Never Other 5 (45%) 3 (27%) 1 (9%) 1 (9%) - 1 (9%) Profession RN Physician Social Worker 8 (73%) 1 (9%) 2 (18%) 38 Most participants were female nurses with a bachelor’s degree. And most participants had relatively high levels of computer use. Table 4.2 Professional Experience Sample Frequency (%) N=11 Hours of Work per week Full Time Part Time Casual 7 (64%) 2 (18%) 2 (18%) Years’ Experience Less than one year 1 to 4 years 5 to 10 years 10 to 19 years 20 to 30 years 30+ years 3 (27%) 3 (27%) 2 (18%) 1 (9%) 1 (9%) 1 (9%) Years’ Experience with Wound Care* Less than one year 1 to 4 years 5 to 10 years 10 to 19 years 20 to 30 years 30+ years 3 (30%) 2 (20%) 1 (10%) 2 (20%) 1 (10%) 1 (10%) Years’ Experience in this Setting Less than one year 1 to 4 years 5 to 10 years 10 to 19 years 20 to 30 years 30+ years 3 (27%) 6 (55%) 1 (9%) 1 (9%) - *note 1 participant did not respond to this demographic question Of the RNs, there were three main groups: those who had a year or less of experience nursing (n=3), those who had 1 to 5 years’ experience nursing (n=3) and those who had between 10- and 20-years’ experience nursing experience (n=2). Most of the RNs (63%) worked full time, 25% worked part time and 12.5% were casual. The two case managers had 5- and 14-years’ 39 experience. Both worked full time. Both case managers were female. One was bachelors prepared while the other was masters prepared. The primary care provider (physician) had greater than 30 years’ experience, worked casually, was female and was bachelors prepared in family medicine. 4.4 Persona Validation Personas were created for each profession. The participants were asked to validate these at the start of the interview. All of the participants, RNs, case managers and the primary care provider agreed that the personas for the most part represented their experiences with wound care communication with a few exceptions. The personas were used to allow the same starting place for all participants. They provided a discussion starting point that could be drawn on throughout the interview. As illustrated below by the participants’ comments around the personas, they resonated with them. Participants opened up about their experiences in comparison to the persona. Because there were shared elements between the participants’ experiences and the professional personas they seemed to be happy to talk openly about the topic in questions and correct or build upon the items identified in the personas. In the next sections the validation of each professions’ personas are discussed in further detail. 40 4.4.1 Registered Nurse The registered nurse persona was reviewed and commented on by eight participants. Figure 4.1 Registered Nurse Persona The personal interests represented in the personas caused discussion. Most participants said that the interests did not reflect their interests. One RN participant stated “okay, well first my personal interests are completely different.” There was some discussion about communication tools used. Most RNs agreed with the tools suggested in the persona but two individuals stated they did not use FaceTime. One RN explained “we don't use FaceTime.” A second said, “I don't really use FaceTime. I do phone more than I text, the population that we're dealing with don't text as much as they used to.” The others did not comment on it. 41 Seven of the RN participants agreed that the frustrations identified in the personas were reflective of their experience and personal frustration. One person commented that some of the frustrations were accurate but that they had adequate time with their clients. One participant commented “umm I would say most of it, I mean I've only been nursing for five months so that part of it is not, I definitely have not been doing this for 21 years, but a lot of the like the feelings around like the frustrations what I would like to see are definitely applicable.” Another stated “like, seems like some of the concerns are quite similar and, like having all the information in one place and like having to go to different places to start and yeah, like, sounds quite familiar.” One participant wanted to add to frustrations. “I think I would add stuff to frustrations, like client not cooperating or lack of education or just not wanting to participate in care.” Another RN stated I do agree with the problem with having to look through too many different looking into too many different places for information instead of one place. That's a pain. Let's see. Too much time on charting. I mean, I'm getting used to that anyway. I think that part of that problem is that our software is poor. Not the wound software, the other software Paris, that's really frustrating piece of software. Sucks up a lot of time. Desires around wound management were echoed by a few participants. The two points that they mentioned as shared desires were interdisciplinary communication and one place to house all the relevant information surrounding their patients. One participant said, “yeah, that's pretty much it. Interdisciplinary wise. It's okay. Okay, except there's a, you know, it's hard to get a hold of GPs.” A second said something very similar, I found because we have everyone here, it's not too bad. It's more of contacting the GP, if they're not there. You can't get the antibiotics in or can't get the family members to tell you what's happening. That part is hard. So that is true, better coordination with in. 42 Another participant identified that they would like to add to desires. It was identified that they would like to add “desires are wound to heal or to transfer care to client where they can do self-care. Where they're educated enough to understand that.” 4.4.2 Case Manager The Case Manager persona was reviewed and commented on by two participants. Figure 4.2 Case Manager Persona The case manager persona was used for the case managers but it was learned that the professional designation for the case managers varies and the two that participated were social workers by background. Neither of the case managers commented on the personal interests identified in the persona beyond one clarifying that they applied to the clinician and were 43 arbitrary. Professional needs were not commented on by the participants. Communication tools used especially electronic health records were discussed by one participant in quite a lot of detail. The participant explained that, For example, we have our wound care thing here is only accessed by certain nurses even. Okay, so social workers, OT and we have whole new OTs, Community Liaison Workers (CLW), the counselors, they can't access that. Okay see that's where we put our plan for the client wound care. The participant also identified that they do not have the tools they need to do their job properly when on outreach. Again, I'm probably all over the map, but for us here because we aren't able, when I go out to the community I don't have any ability to chart in the community as things happen. So, I can't see, I can't even on outreach, keep it up to date. Okay. You know what I mean?” They have to “write it in a book, but then come back [and chart]. Frustrations around wound management were related to access to EHRs. Both permissions and training to use and access while on outreach. One of the case managers explained, So similar? For sure is I am not sure where to find the information. And I mean, I'd go one step further, not just not sure, but I may know where something is, but I can't access it because that's not my profession to be able to be allowed to access it. The other case manager did not indicate that access and charting were a concern to her as other people usually were doing the wound care and she was just reviewing and coordinating the patients overall care. “I'm not charting, it's not like that. So that doesn't take a lot of my time. It's more just in conversation and a lot of time I already would know what's happening because I am going in after.” Desires around wound management were clarified. One participant explained they were “not as concerned about access to latest research and equipment per se.” The clinician also expressed that, 44 So yes, my dream would be that we just have one health record. And I mean part of that even especially with a psychosocial standpoint. So, someone comes in for wound care, but we know they have some sort of mental health issue, then we can work with them while they're getting wound care both to either make the wound care successful, or engage the client around working on some of their mental health issues if need be or their psychosocial issues or whatnot. And generally, here, even though we open those things, I would say almost nobody has the time to read all the different charts. Yeah. To actually coordinate an interdisciplinary response to his or her wound care. 4.4.3 Primary Care Provider The primary care provider persona was reviewed and commented on by one participant, a physician. Figure 4.3 Primary Care Provider Persona Personal interests were not commented on specifically by the primary care provider (physician) interviewed. Professional needs, communication tools used, frustrations around 45 wound management and desires around wound management were also not directly addressed. The participant did however comment, I think basically, that's what it is. I think about the only thing added it is because I work in BC, only two years and more than 16 years in Nova Scotia. I don't know so much the connections and how to refer like a person who practice 14 years in BC. The primary care provider (physician) did confirm when asked that the items listed under the frustrations and desires made sense to them. 4.5 Setting The setting of this research consisted of two sites both located in an urban downtown centre. Site One is a community health centre. Multiple services are offered to patients including but not limited to public health, primary care, home care, mental health, home hospice/ palliative care. The site serves all ages and has a mobile home program as well as ambulatory and drop in clinics. The geographic area covered by this health centre is quite large and population dense. Site two is also a community health centre but it serves an extensive vulnerable population who experience barriers to accessing health care. The population served is located in a concentrated geographic location. Site Two provides clinic services, referral services, support groups, therapy and ambulatory nutrition care, and a full range of addiction and mental health services. They perform an extensive outreach service to reach their target population. The outreach service is called an Integrated Care Team which consists of primary care providers (general practice physicians and nurse practitioners), respiratory therapists, nurses, social workers, counsellors, peer specialists, community liaison workers, and psychiatrists. This team functions to provide on-site and outreach services to populations who experience barriers to accessing healthcare. 46 There are also occupational therapists, physiotherapists, WOCN, dietitians, pharmacists and other specialized care providers available on site to support patients. 4.6 Processes of Communication Processes of communication were considered when any participant response explained who, how, what, when and why communication occurred. For example, the steps taken to communicate about wound care was considered a process. One participant who was a case manager stated: And vice versa home support will communicate with me. Usually, they're the ones that call me first. Instead of me calling them because they'll see the body and then I would see if there's a nurse involved. I would go talk to the nurse. If there's not a nurse involved and I would talk to the triage nurse about getting a referral for wound management. When it comes to wound management, I don't really go to the OTs unless they already have a roe cushion and wheelchairs. In the above example the process of how the case manager communicated about wounds was outlined. Patterns were considered to occur when participants repeated similar steps or processes for communication. For example, one RN participant identified home support workers as integral to wound care communication. This then identified a pattern. The RN identified “the home support agency will call us if there's an issue with a wound or new wound.” It became clear that there were key players involved for certain parts of the wound management. Concerns about the wound or a worsening wound were communicated to the primary care provider (physician or NP) or the wound ostomy continence nurse (WOCN). If home support workers were involved in patient care they would communicate new or changing wounds to the nurse or case manager. If the wound was a pressure ulcer occupational therapists (OT) would be consulted. If there was 47 equipment involved in the cause of the wound, a physiotherapist would be consulted. If there were dietary concerns then someone from the care team would consult with a registered dietitian. If there was a concern about infection in the wound then the primary care provider would be contacted. If the treatment plan did not seem to be having the intended result then the WOCN nurse would be consulted. If a wound or skin concern was deemed chronic and minor then home support workers were involved in the care. 4.6.1 Care Coordination Care coordination emerged as a common purpose of interdisciplinary communication in the interviews. Six participants (75%) identified information about wound management that were examples of coordination. This was around the purpose of why the clinicians chose to communicate with other professions about their patient’s wound management. The physician, case managers, and three of the RNs identified coordinating care across the care team as a primary purpose for interdisciplinary communication. A case manager identified, There will be a nurse, and a case manager, LPN, and I guess rehab so that's supposed to help with the communication who's most, you know, who the most appropriate for what part of the work that we need to do? 4.7 Similarities and Differences in Processes of Wound Care Communication The process of how people got in contact with different professions varied slightly by discipline. Most nurses and case managers noted that they connected with other nurses, case managers, OTs and PTs in person if possible, then they would email, text or call depending on the urgency of the concern. Once the initial communication took place, the communication 48 would then be input into the EHR. All disciplines communicated with home support workers via phone call or a written letter called a Personal Assistance Guide (PAG). The WOCN was available in person, by phone and via text. The primary care providers were available through phone calls, fax and occasionally email. The OT and PT were initially communicated with in person and then referrals would need to be made through the EHR. The dietitian was usually accessed via a phone call. The modes of communication identified were classified into categories of their own and will be presented later in this document. The physician noted that they communicated with the nurses in person at times but mostly through their case notes in the EHR. They explained that if something was urgent they would call the pharmacist, dietitian or a consulting specialist and then use the EHR to create a consult. 4.8 Communication Tools and Technologies In the interviews several communication tools and technologies were consistently identified by participants. These consisted of EHRs, electronic resources, fax, messaging, phone call, photos, smartphones and written non-electronic communication. 4.8.1 Electronic Health Records Electronic health records (EHR) were frequently discussed and commonly used in day to day communication. The EHR was mentioned by all eleven participants. These are electronic tools provided by the health organization and are expected to be used for clinician charting. There were several different EHRs identified by all the participants: CareConnect, PARIS, Pixalere (Pixalere Healthcare, Inc), Pharmanet and Profile EMR. 49 CareConnect is described by clinicians to show lab results and information from acute care encounters. PARIS is the EHR that most clinicians within home health have access to and is where general patient charting and case notes are made (excluding providers). Pixalere is an EHR specifically designed for wound management and care plans. Pixalere is used by both home health and primary care. Pixalere is only accessible to clinicians providing direct wound care such as nurses and WOCN. This is where wound care documentation occurs. Profile EMR is used for case notes and charting in clinics and primary care. Profile EMR is the system primarily used by primary care providers but is not always accessible by other clinicians who are working in home health. 4.8.2 Electronic Information Resources Electronic resources were classified as information sources that were not patient specific in nature. They were used to communicate information and translate knowledge about wounds in general. Ten participants mentioned electronic resources that they utilized to help support wound management. The resources mentioned were professional association databases, evidence-based applications (both web-based and mobile), health organization clinical policies and decision support tools, provincial guidelines, EHR logic and product and vendor/ product related resources. A few of the nurses interviewed mentioned health organization clinical documents that were accessed through an online repository. Several nurses also mentioned Connecting Learners with Knowledge (CLWK) website, a provincial resource. 50 4.8.3 Other Technologies to Support Communication Several other communication tools were identified: fax, messaging, phone calls, photos, and smartphones. Seven participants identified fax as a commonly used communication method. They noted that this method was primarily used to contact the primary care providers who were usually located at a different location. Messaging was identified as a method of communication by nine participants. For the purposes of this thesis messaging consists of emailing and text messaging. Emailing was identified as a way of connecting with some primary care providers and other clinicians who may be involved in wound care. One nurse explained, …the emails that you know, the usual emails and stuff like that, which is nice now because I can find the surgeons name or the whatever in our email and a lot of the times I can email them. So because a lot of the doctors now are in our big email drive, so you just punch in the name and it comes out. Nine participants identified phone calls as a means to communicate about wound management. Phone calls were commonly used to contact the primary care provider or WOCN about wounds when there were concerns about by the clinician providing the wound care. Photos were identified as a method of communication by six participants. They were taken using the participants’ smartphones and were used to augment communication with clinicians who did not have access to the wound care electronic health record. Smartphones were identified by seven participants as a tool that was used commonly to help facilitate wound care. The smartphones were used to make phone calls and text in the field, access electronic resources, take photos and generally facilitate communication. 51 4.8.4 Written Non-Electronic All eleven participants mentioned that there is a component or written non-electronic communication that exists in their work sites. One clinic had a triage book, one had paper charts and files in addition to the EHRs. Kardex, which are non-legal sources of information about a patient used by the care team to communicate were also used at one health centre. The other written communication used in both units was the personal assistance guideline (PAG). This written letter was a communication to home support workers detailing the components of wound care that the nurses would like them to be responsible for. 4.9 Themes and Subthemes Related to Communication Three overarching themes related to communication emerged when the data was analyzed: How Context Shapes Communication, Navigating Communication Tools, and Efficiency and Trust in Face-to-Face Communication. Each of these themes had subthemes. 1. How Context Shapes Communication had subthemes: Culture in the Clinical Setting and Physical Layout and Physical Proximity 2. Navigating Communication Tools had subthemes: The Dream of One Health Record, Keeping Current using Electronic Resources, Concern about using Fax for Communication, 3. Efficiency and Trust in Face-to-Face Communication had the subthemes: Ensuring the Message is Received, Synchronous Communication via Telephone, A picture says a Thousand Words- the Value of Photos, Smartphones: An Improvement for Convenient Communication, Trust in paper documents. 52 4.10 How Context Shapes Interdisciplinary Communication The first theme that emerged was context. This consisted of comments from the participants that referenced unit culture and physical layout and proximity and the impacts that they had on interdisciplinary communication. This theme had two subthemes: Culture in the Clinical Setting, and Physical Layout and Physical Proximity. 4.10.1 Culture in the Clinical Setting Culture was classified as items that participants directly identified themselves as “culture” or items that were reasons the way things were done the way that they were that people could not explain. Culture is the unwritten rules that shaped wound care communication. The individuals had a shared understanding of the way things were done but they could not articulate why. Ten of the eleven participants (91%) identified items that were coded to culture. For example, one participant who was talking about the referral process to have patients with wounds seen by another discipline explained, I think it's a culture. It's like a culture of like, there's too much work. And so when you have someone talking to you about a referral, you're trying, like the on call person is trying to decide whether it's sort of important enough or urgent enough to have them seen. Another RN participant who worked part-time at multiple sites identified that communication style varied between different health units, and suggested that it was dependent on the staff preferences. “That would be the person. It depends on the unit. At this unit it's in person, when I’m at other units it might be through Pixalere.” Culture was found to influence the methods of communication that people chose and preferred. For example, most participants interviewed said that they preferred face-to-face communication about clients while the least preferred method of 53 communication was fax. This appeared to be the culture of both health centres where the interviews were conducted. 4.10.2 Physical Layout and Physical Proximity For the purposes of this study physical layout will be used to refer to the arrangement, physical structure and organization of the health centre while physical proximity will be used to describe location and physical closeness of individuals and professionals to one another. Physical proximity and physical layout were identified by four (36%) of the interview participants. One RN participant noted that having most interdisciplinary team members centrally located in the health centre (i.e., on the same floor) helped to facilitate communication. They noted, …because we have everyone here, it's not too bad. It's more of contacting the GP, if they're not there. You can't get the antibiotics in or can't get the family members to tell you what's happening. That part is hard. So that is true, better coordination with [the other members of the care team]. Another RN participant noted, “I think, because we're all in the same space that's helpful and I mean, most people know each other.” Most participants mentioned that their preference for communication was to look around and walk over to someone’s desk to have a conversation before they formally documented a referral in the EHR. One participant even described that in Site One all of the professions responsible for clients who resided in the same physical location were located together in the same area on the same floor so they could communicate readily. Overall, context was a consistent theme through all interviews. Most participants mentioned how unit culture and the physical layout and physical proximity of their work space to their peers helps to facilitate communication and acknowledged that it impacted how they prioritized selecting a method of communication. 54 4.11 Navigating Communication Tools and Technologies The next theme that emerged was that the tools and technologies used by clinicians to communicate and look up information required navigation. Each tool/technology served a slightly different purpose but they ended up overlapping in their use which led to confusion. Not everyone had access to all the tools or technologies used (particularly the EHRs) which resulted in documentation in multiple places, safe guards and work arounds to try and ensure that all the interdisciplinary team members had access to the information they needed to provide proper wound care. The environment in which clinicians worked helped shape how they used and navigated the tools and technologies available to them. Urgent issues requiring consultation were addressed preferentially through face-to-face in person communication. One key factor that facilitated this was when the individual who was being communicated with worked in the same clinic (shared physical location and had physical proximity). If they did not work in the same physical location or the physical layout or physical proximity did not facilitate in person communication, then a phone call would occur. If the call was not answered, a text or email was sent. In the case of trying to communicate with a primary care provider, the preferred communication method was a phone call and if that failed they resorted to fax despite concerns with the efficacy of this. RNs expressed that they would rather use email to connect with primary care providers than fax but the culture was not always supportive of this. While the EHRs had the capacity to connect professions there were some limitations in their functionality that prevented them from being used as the primary source of communication: 1) Clinicians did not know who had access to which EHRs, and even if they had access could 55 they see the same things that they did; and 2) The EHR did not match the workflow. For example, the referring clinician had to assign a priority for the receiving profession but the referring clinician did not understand the triage process used by the receiving profession. There was no way to change priority in the system after the referral was entered therefore the workaround was that a conversation needed before the referral was entered. All of these factors resulted in a unique workflow that required adaptation and decision making around interdisciplinary communication and the tools leveraged to facilitate this. Navigating Communication Tools had three subthemes: The Dream of One Health Record, Keeping Current using Electronic Resources, and Concern about using Fax for Communication, 4.11.1 The Dream for One Electronic Health Record The role of EHRs in interdisciplinary wound care communication became apparent throughout the interviews. There were many EHRs utilized by clinicians for various purposes. Not all participants had access to all the EHRs used across the health organization but they acknowledged that all the EHRs contained information that was relevant to wound care management. There was frustration expressed that they couldn’t access all the information they felt they needed to provide wound care because the systems functioned separately and did not share information between them. They also expressed concern that when they entered information in one EHR they were not sure who was receiving this information or if they needed to communicate directly with the other individual as they may not have access to or the type of access to the system needed to see the notes. 56 Some were concerned there were other systems that their discipline may not even know about. One mentioned “so I don't know if there's other… [systems] that I don't even know about.” Another participant expressed a similar frustration. The case manager explained, I am not sure where to find the information. And I mean, I'd go one step further, not just not sure, but I may know where something is, but I can't access it because that's not my profession to be able to be allowed to access it. One social worker case manager noted that sometimes she asked the nurses to see patient’s wound pictures in Pixalere. Sometimes I ask the nurse to look at Pixalere, because they'll be pictures there. I know we have to put stuff about pain level when clients talk about pain related to the wound. Sometimes it’s helpful to know okay, why is it so painful? What can help? Sometimes I look at the picture just so I know. The other information that was communicated regularly by participants was that the electronic systems did not contain the same information, the computer systems did not communicate with each other and you had to sign in to each EHR separately. Profile EMR did have some connections to other systems such as care connect that primary care providers navigated regularly. The physician mentioned, Through the EMR is connected, for example, to Care Connect. Somebody goes for any kind of emergency visit or whatever other specialists I have that connection and I have my connection in Paris. I have training in Paris, so if the person has mental health issues and other things, I can connect to that. And I have Medinet for the medication. Okay, so I can check that so everything is coordinated and in one system. This however was not reflected by the nursing and case manager experiences with the EHRs. One case manager explained, So yes, my dream would be that we just have one health record. And I mean part of that even especially with a psychosocial standpoint. So, if someone comes in for wound care, but we know they have some sort of mental health issue, then we can work with them while they're getting wound care both to either make the wound care successful, or engage the client around working on some of their mental health issues if need be or their psychosocial issues or what not. And generally here, even though we open those things, I 57 would say almost nobody has the time to read all the different charts. Yeah. To actually coordinate an interdisciplinary response to his wound care or her wound care. While the participants reported that some efforts had been made to integrate the EHR systems, it became evident very quickly that the EHR systems were not meeting the requirements to facilitate communication. Most clinicians mentioned that due to limitations of the system they were required to have an informal conversation with individuals that they were referring to prior to entering the referral in Paris. They also mentioned that they had to switch between EHRs to both document and gather information about wounds. Another concern that was raised was that the alerts built into Pixalere did not work with the workflow. Alerts with suggestions for wound care planning and referrals were generated at the time of charting which happened after wound care had already been completed and the clinicians were no longer in the presence of the client. While many efforts had been made for EHRs to help connect clinicians it seemed that disconnection was still a common theme. 4.11.2 Keeping Current using Electronic Knowledge Resources If information was needed, the clinicians would resort to electronic knowledge resources. The common purpose of accessing electronic knowledge resources was to stay current on evidence based wound care and to fill in gaps in knowledge that may exist. The physician interviewed mentioned a few electronic resources that they used to supplement wound care. If I want to connect, I will go to the college of family physicians, we have reviews for good care. I have another resource, which is the Canadian Medical Association. We can go to the job system and we can search anything about the latest research for wound care, different kinds of textbooks and booklets and they have books. One RN participant identified: 58 I refer a lot to product sheets that are available through the Pixalere system. You can find all the product sheets there and it takes you to the CLWK website. So, I guess I would use say I use product sheets. I don't use a lot of policy or procedure guidelines. One other nurse described that there is logic built in to the Pixalere system that helps to inform wound care. If you are new coming in, there are places where you can look and, even in Pixalere you can see and it guides you. It tells you if it's urgent you do 24-hour notice or whatever. And if it's not urgent it goes one to seven days, and you can find all the wound care products. And it actually, Pixalere will flag you saying- You've used this product for more than blah blah days or we have not seen an improvement in this wound in blah blah days. So that itself guides you. 4.11.3 Concern about Using Fax for Communication There was a common sentiment expressed around the expected use of fax as a communication tool. Most clinicians (RNs and case managers) expressed concern about such an old and unreliable technology being trusted and used heavily for interdisciplinary communication, especially when it was usually used as a tool to escalate concerns to primary care providers and attempt to adjust an intervention or treatment. One participant described that fax as a form of communication with primary care providers was common. The communication system with GPs is archaic. I can't, I honestly am astounded at how much faxing I do in this job. Considering there's other ways. We have no access to the GPs notes or what they've talked about with a client or anything so that can be like the lack of technology hinders that relationship I feel. Another nurse noted that they start by trying to call the primary care provider but if they can’t get through then they resort to faxing. “I call the GP. If they are not responsive, I send a letter through fax, which takes them time to reply as well.” Yet another participant explained, “based 59 on how little success with phoning I think it's easier just to send the fax and then it's kind of in their hands.” While many participants acknowledged the need to fax items most also expressed some concern with the practice. One participant stated, But it’s just faxing is definitely not the best way. And it's such a struggle, like it can’t go through but you didn't realize it until the next day, or they never got it and they told me to re-fax that it is so time consuming. Another explained, I feel like faxes aren't always the easiest way like you don't always get a fax back [from a physician]. And it would be nice to be able to see their charting sometimes on our systems so we know what is said to the clients. 4.12 Efficiency and Trust in Face-to-Face Communication Ten participants (91%) described face-to-face or in person communication as a valuable communication technique. This theme appeared as participants identified in person and face-to-face communication as a prioritized method to convey information between disciplines. This resulted greatly from unit culture, personal preference, physical layout, physical proximity, setting and gaps identified in other communication tools available to clinicians. The RNs and case managers explained that face-to-face communication was essential to successful wound management. This method required being physically close to the person being communicated with, such as being in the same room. One case manager described face-to-face communication, “I mean, it just depends on communication style, for me, I much prefer the face-to-face. Yeah. So first of all, I get to know my team.” This individual went on to explain that the reason they prefer face-to-face is because they find they get more information this way and get a better holistic view of the care being provided to the patient. Another RN participant explained 60 that they appreciated face-to-face communication as it was faster and more efficient. “If people actually spoke to me, then I kind of can get a clearer picture faster than going through the case notes and trying to figure them out.” Face-to-face communication was the preferred approach to consultation. Limitations of the EHR system that case managers and RNs used to enter referrals made it preferable to have an informal conversation in person before the formal referral was entered in to the EHR. Other types of face-to-face communication used in both the health units were team huddles and case conferences. These involved interdisciplinary teams coming together to discuss the care of individual patients. Sometimes these meetings occurred between two teams, the acute care team and the community team. One RN participant described, So we all get together, any OT, PT, case management, anybody involved. We sit down with that phone and we talked to the hospital and the hospital staff are their nurses, their Care Management Leader (CML), any doctors, their OT, their PT, everything. And then we have a team meeting about what to do. Another method of face-to-face communication used was wound care rounds or meetings although these were usually nursing specific and not interdisciplinary. These were used to look at specific unique care cases for educational purposes and were not used to coordinate ongoing patient care. Regardless of the type of face-to-face communication there seemed to be a prioritization and preference for this method. People enjoyed getting to know a bigger picture of their patients without having to search for the information in multiple places. The explained that this type of communication was timely, informative and helpful. 61 This theme had five subthemes: Ensuring the Message is Received, Synchronous Communication via Telephone, A picture says a Thousand Words- the Value of Photos, Smartphones: An Improvement for Convenient Communication, and Trust in paper documents. 4.12.1 Ensuring the Message is Received There was a clear hierarchy identified for the order in which to communicate as illustrated by this clinician’s response. I stand up first and look around and if I can't see them, then I go if they are working? Then it depends how urgent it is. If it's really urgent that I will text them or call them, okay, right? If it's not that urgent, I will notify them via Paris. Right? So yeah, or I will just stand up and look and hunt them down. Another clinician explained, “I try to talk to them in person. If I could. Yeah, that's the easiest. If not that I email them or call them. If I can't email them then I send the letters.” Emails and texts were usually a second- or third-line attempt to communicate. They were usually only selected if a face-to-face interaction or a phone call was not possible. The other occasion when texts and emails were used was when the clinician deemed that something was not critical and did not warrant an immediate response. Messaging was identified as a method to send images of wounds to the clinicians that don’t have access to the EHRs that stored the images or in urgent situations that required the pictures to be viewed quickly by a WOCN, primary care provider. This occurred while the clinician was in the patient’s home and the goal was immediate alteration to the care plan that required additional consultation. One participant explained, “I've been in a home, I don't really know what's going on [with a wound] and then I will send a photo. And then they will call me back or text back and say, here's the idea.” 62 4.12.2 Synchronous Communication via Telephone Phone calls were used quite frequently when immediate response was the goal and if clinicians were not in physical proximity to the person they needed to communicate with. One clinician explained. “I might text or call the wound clinician, which I did today, if I was at a visit and I didn't know what to do.” Another explained that “GPs I always get a hold of by calling, leaving a message with the receptionist or the MOA, and then waiting for a call back. Some GPs will take the call right away, and some will call you back.” Phone calls tended to be associated with some level of urgency that required a faster response time. One thing that was interesting was that when the RNs and case managers tried to connect directly with the primary care providers via telephone they still usually ended up having to connect to another individual first. Even though the goal was synchronous communication the result still tended to be asynchronous which seemed to cause some frustration. 4.12.3 A Picture says a Thousand Words - The Value of Photos Photos were described as very effective since they were objective in nature. One participant, an RN, described, So obviously pictures are great because now we can tell if they are improving or they are worsening. And when you say 100% slough versus 80%, red granulation whatever, it's harder to tell. It's quite subjective actually. Whereas if you look at the picture you can tell, so pictures are great for communicating with all the players. With the phone it is amazing like texting, phoning. And now I can send the pictures so I’ll send the pictures to OT and PT via text or via email, because they don't access pix [sic Pixalere]. One other example of this was from a nurse with a patient in assisted living. They explained how the ability to send pictures helps facilitate communication the primary care provider. 63 Her GP comes in to do home visits once a month so she likes to see how the wound progresses. She would ask us to take pictures and send it to the nursing staff at the assisted living and then when she comes over, she checks on the pictures. One RN clinician explained what an improvement it was to be able to take pictures of the wounds. Prior to this they had to draw images of the wound to scale or trace the wound on clear film while attempting to keep the wound sterile. 4.12.4 Smartphones: An Improvement for Convenient Communication Most participants mentioned that the addition of smartphones (since 2017) as a tool that they could utilize for wound care had a positive impact on communication. It was discussed by one RN participant that the addition of smartphones had been the biggest change to communication practices. They explained “I think the biggest change is the smartphones. Okay, the fact that we can email photos or text photos.” Another RN explained, But yeah, the phone situation is great. That's relatively new, like iPhones. I think we had the BlackBerry® before and before it was the flip phones, right. Yeah. So that was quite painful. So, I think this is relatively new too maybe like five years with the cell phones I think. They went on to say, “so the phone, this whole technology thing makes things much faster.” One RN participant explained that changing from digital cameras to just using the smartphone camera had made things simpler: I don't want to carry another item in my bag and have to reach into my bag again, when I have my phone that's available. And then plugging it in, like you can email your pictures yourself rather than having to like connect your phone to the computer. Another use that was identified for the smartphone was accessing electronic resources while the clinicians were in patient homes or away from the health clinic. One participant noted, “I've been 64 in a home and been like I don't really know what this is? And I just look it up because we have data on phones.” 4.12.5 Trust in Paper Documents Written communication was used in two ways. Official communications that needed to be documented and shared externally (beyond the health organization) and unofficial communications that were used internally among team members. One RN clinician explained, “there's some paper in the charts like a kardex. But I don't use that. I don't trust it because it's not a legal record. So, I go by the charting.” They considered this unofficial documentation. Both units used formal personal assistance guidelines (PAG) to communicate care delegation to home support workers or community health workers. PAGs are official letters that nursing staff will write that outlines the care a patient requires in detail so that it can be executed by a different individual, without nursing training. It is like a care plan. These PAGs are then provided to home support so they can carry out certain types of basic care under the direction of the nurse. A participant described this: PAG is a personal assistance guideline. What we'll have is, for example, if I see a client with a wound that they can do self-care or home support can do it I’ll write a letter to the agency that's receiving home support. Please take over this task. A lot of it is like cream applications if you have like redness to your bottom, that sort of thing, okay, or basic dressings like iodine and the dry dressing, that sort of thing. 4.13 Communication and Complex Adaptive Systems To explore the extent to which wound care communication is reflected in complex adaptive systems theory, the communication categories identified above were mapped to the 65 properties of complex adaptive systems as identified by Chaffee and McNeill (2007). To illustrate the results, a matrix was created to show which CAS properties are present in each category and theme that emerged from the data analysis of wound care communication (see Table 4.3). 66 Table 4.3 Summary of CAS Properties Present in Wound Care Communication Categories Category Adaptable Elements Attractors Co-evolution Context and Embeddedness Emergent Behaviour Inherent Order Elements in a CAS can evolve (Chaffee & McNeill, 2007) Catalysts in a CAS that allow new behaviours to emerge. (Chaffee & McNeill, 2007) Progress in the CAS occurs with constant tension and balance. (Chaffee & McNeill, 2007) The CAS resides within and interacts with other systems that influence it. (Chaffee & McNeill, 2007) New behaviour is a feature of the CAS represented by constant innovation and creativity. (Chaffee & McNeill, 2007) Order is maintained in a CAS even without central control. (Chaffee & McNeill, 2007) Coordination x x x x x x Culture x x x x x Physical Layout/ Proximity x Improvements x x x x x In Person/ Face-to-Face x x x x x Pattern x x x x x Process x x x x x x E H R x x x x x x Electronic Resources x x Fax x x Messaging x x x x x Phone Calls x x x x x Photos x x x x Smart Phone x x x Written Non-electronic x 67 Table 4.3 Summary of CAS Properties Present in Wound Care Communication Categories (con’t) Category Nonlinearity Porous Boundaries Self-Organization Simple Rules Unpredictability Implies that in response to a stimulus a variety of behaviours are possible, and the cause and effect relationship in not directly evident or linear. (Chaffee & McNeill, 2007) The boundaries of the elements in a CAS are blurry and porous, allowing exchange and movement between them. (Chaffee & McNeill, 2007) Process where many local interactions create order without direction from above. (Chaffee & McNeill, 2007) Local application of simple rules can result in broad, complex outcomes. (Chaffee & McNeill, 2007) Forecasting is inexact in a CAS because elements change, behaviour is emerging and activities are nonlinear; the trajectory of a system is unknowable. (Chaffee & McNeill, 2007) Coordination x x x x Culture x x Physical Layout/ Proximity x Improvements x x x x In Person/ Face-to-Face x x x x x Pattern x x x Process x x x x x E H R x x x x x Electronic Resources Fax x x Messaging x x x x Phone Calls x x x x Photos x Smart Phone x Written Non-electronic x 68 4.14 Complex Adaptive System Properties in Wound Care Communication Complex adaptive systems (CAS) are described by Chaffee and McNeill (2007) as having eleven properties as listed in Tables 3.1 and 4.3. In the following sections an analysis is presented to demonstrate the extent to which the wound care communication categories that emerged from interviews were reflected in each of the properties of CAS theory as proposed by Chaffee and McNeill. 4.14.1 Adaptable Elements The CAS property of adaptable elements is defined as elements in a CAS that can evolve (Chaffee & McNeill, 2007). Adaptable elements were identified in eight of the wound care communication categories that emerged. Coordination and in person/ face to face were illustrated by the quote from Participant 11 …I think we're still struggling with what we call a referral process… but I'll be honest this is not every social workers’ experience here or comfort….I don't wait for a referral…. I just did my own thing.…But that definitely, that is not something that's been formalized yet. This quote shows how the team members adapt and pivot to ensure the care required by a patient is received in a timely manner. This quote also describes how the individual doesn’t wait for formal referrals from peers since the process isn’t clearly defined. They just respond in the moment to requests and adapt to the situation. Adaptable elements were also illustrated by the category of culture. Participant 3 explained, …. You can't just refer through Paris…. But yeah, there’s this unofficial conversation that you have to have with whoever is on call. So whatever PT or OT or case manager or whatever is on call, then you have to have like a conversation with them and essentially get the okay. 69 The quote describes that even though there is an electronic way to refer and communicate with other professions the unit culture is to have an in person/face-to-face conversation before formalizing the referral in the systems. This adaptation in clinical workflow evolved and has become the accepted process. Adaptable elements were also seen in the category of pattern and process and were demonstrated by the following quote from Participant 11. How do we get referrals? I'm like, oh my god, they're everywhere. Yeah, but I … realized they were looking at…the paper that says you need to see so and so about such and such…. But that definitely is not something that's been formalized yet that. All disciplines are talking about it. This quote shows how the participant is required to be flexible in their workflow and adjust to the situation in the moment. To wait for a formalized, standard process for referrals is not an option when providing responsive, patient centered care. EHR, phone calls, messaging and photos were also demonstrated as adaptable elements by the quote from Participant 6, … So obviously pictures are great because now we can tell if they are improving or they are worsening. ...Pictures are great for communicating with all the players. The phone is amazing …[for]... texting, phoning. And now I can send the pictures to OT and PT via text or email, that sort of thing… With all the technology and tools now available to clinicians to facilitate communication they are required to be flexible and adaptable in their approach to communication. In this instance, the providers must make an assessment and determine the best method of communication for each given situation. These quotes show wound care communication occurs in an environment defined by an unclear referral processes, a culture that requires clinicians’ to be flexible and adapt to changing unit practices and respond to personal preferences of peers. It also shows the variety of tools that 70 all have similar but slightly different purposes. These factors make the environment in which wound care communication occurs an exemplification of the CAS property adaptable elements. 4.14.2 Attractors The CAS property of attractors is defined as catalysts in a CAS that allow new behaviours to emerge (Chaffee & McNeill, 2007). Attractors were evident in eleven of the fifteen categories identified in wound care communication. Two examples of catalysts which allowed for the emergence of new behaviours were: the presence of interdisciplinary trust, and the provision of smartphones to clinicians. As a result of trust and easily accessible smartphones, increased interdisciplinary communication occurred. Clinicians readily used the smartphones in the field to communicate with WOCNs about wounds. The following quotes illustrate this. Participant 10 described a culture of “communication and trust… we have to build through the months and the years" and this helped to fuel interdisciplinary communication. This quote suggests that trust and communication function as an attractor for wound care communication and help facilitate the evolution of new interdisciplinary communication processes. Trust is acting as a catalyst and the resulting communication is the new behaviour. Participant 3 described some improvements that were contributing to new communication behaviours. "… But yeah, that's great the phone situation… like iPhones… I think this is relatively new too…maybe like five years with the cell." This suggested that the addition of iPhones and smartphones as available tools for communication acted as a catalyst and allowed for new ways of communicating about wounds. Another quote illustrated how patterns and processes used attractors. Participant 1 explained that in regards to communicating with the WOCN, 71 …[I communicate with the WOCN either by] text or phone, I have her cell phone number in mine and she's been really good about responding. 80% of time, she'll answer right then and if not, she'll call back within 15 minutes. So I feel very lucky to have that resource. The participant suggested that having a phone with the functionality to text or call in the moment had facilitated and acted as a catalyst more frequent communication with the WOCN. These quotes suggest that there were attractors present in their experiences with interdisciplinary wound care communication. 4.14.3 Co-Evolution The CAS property of co-evolution is defined as progress in the CAS that occurs with constant tension and balance (Chaffee & McNeill, 2007). Co-evolution showed up in six of the wound care communication categories. One participant discussed the process for how things are escalated among the interdisciplinary team, "I get on them, and we all get on them. And then hopefully they'll reply." This illustrates how the whole interdisciplinary team has evolved together in response to a situation where they need a reply. The tension around not always being able to connect with who they need to connect with in a timely manner has led to this co-evolution which helps move the communication process forward and to achieve the desired outcome for the patient. Participant 11 explained regarding the EHR category, …. So if someone was going out to Fraser Health and being seen every day in the Emergency there we'd have no idea unless someone told us… an improvement is the other health authorities are connected. …but it's been helpful seeing that our clients go other places. This suggests that the whole system across the health authorities has evolved together to help facilitate the interdisciplinary communication process in response to difficulties and concerns 72 that have been raised around knowing the care that is provided external to the community health centre. This change makes it easier for clinicians, even in different health regions, to access some of the information they need to provide care. Despite this improvement the participant still expressed concern that not enough information and detail was available. Participant 6 discussed coordination and illustrated co-evolution, “It’s funny because I don't think there's actually a workflow.... But because I've been here so long, you just kind of know, you figure it out..." They showed how over time practices change and just become familiar. All of these quotes suggest that co-evolution occurs over time to help facilitate wound care communication and the facilitator of the change is a problem that causes tension and the solution is one that works towards balance. 4.14.4 Context and Embeddedness The CAS property of context and embeddedness is explained as a system that resides within and interacts with other systems that influence it (Chaffee & McNeill, 2007). Context and embeddedness showed up in all 15 of the categories identified. The following are some examples of quotes that illustrated how the categories of wound care communication illustrated properties of a CAS. Participant 11 described coordination which illustrated the context in which the wound care communication occurred. "…. But my experience is there's not enough for the level of wound care needs that we have down here. …We just triage, yours is more urgent than yours [one patient’s wound problem is more urgent than another patients’ wound problem]. …." This context was given for Site Two which primarily treats a very vulnerable population that has great difficulty accessing healthcare and can experience many barriers. The context of the wound care communication at the health centre occurs within the larger context of the community that it 73 serves and the systemic socioeconomic issues. The wound care communication process cannot be extracted from the larger community and societal context. Another statement from Participant 11 illustrated how unit culture is an example of context and embeddedness. “And face-to-face, or, I mean, people will email, it just depends on communication style. For me, I much prefer the face-to-face. Yeah. So first of all, I get to know my team…” The unit culture and context resulted in preferences in communication strategies. This individual and site had a clear preference for in person/face-to-face communication. Wound care communication occurred within this unit context which prioritized in person/ face-to-face contact. The category of setting also illustrated context and embeddedness through the following quote from Participant 8, Other people will do things differently to be more formal. Maybe I feel here we're really lucky because we have a lot of people on staff and there's a lot of people around, it'd be different if we were in a different environment … This suggested that because Site One had multiple healthcare disciplines located together in the same building and usually close together on the same floor it facilitated a more informal conversational approach to communication. The setting, physical layout and physical proximity of the team created a context in which wound care communication occurred and facilitated the more informal approach. Participant 3 discussed how written non-electronic communication contributed to context and embeddedness. "… And then we also have like a paper chart for them, and then going into CareConnect. But mostly start with the online, like charting systems that we use..." This provided the other context of the technology and tools that were available and used in the communication process. This larger context showed the hybrid nature of the communication tools available to clinicians. 74 All of the above quotes illustrate how many different contexts were present in the environment in which wound care communication is embedded. Wound care communication cannot be looked at in isolation of the other contexts. 4.14.5 Emergent Behaviour The CAS property of emergent behaviour is explained as new behaviour that is a feature of the CAS represented by constant innovation and creativity (Chaffee & McNeill, 2007). Emergent behaviour was present in twelve of the wound care communication categories. Emergent behaviour was demonstrated by the category of culture. Participant 3 described, …When I've tried to refer to other disciplines it's been met with some resistance... I think in community we're stretched so thin, and there's so many referrals coming in for nursing, for OT, for everyone. It becomes a hassle to refer someone. And so I think … for me it is a frustrating point. The emergent behaviour in this scenario is that due to so many referrals and existing resource issues, people are now reluctant to refer to other professionals. While they are able to refer in the EHR they chose not to. Instead they have a conversation with the professional to confirm if the referral is appropriate and then they will enter this information into the EHR. Participant 6 explained how multiple EHRs also allowed for emergent behaviours, "So every time you go into Pixalere, there is this place that says progress notes. Not many people fill it out, but sometimes I will copy and paste what I wrote in Paris into that progress notes so that the wound care nurse can read it….” This demonstrated how the divergent systems contributed to a new behaviour of charting in two health records to ensure that the information was received by the appropriate person. Participant 1 also demonstrated how the CAS property of emergent behaviours could be seen in faxing. They explained that "based on how little success with 75 phoning I think it's easier just to send the fax and then it's kind of in their hands." While phoning was the communication method of choice, the frustration of not getting a response or answer to the phone call resulted in the clinician changing their communication technique to faxing. This was seen as easier and they felt more secure that the information they were trying to convey had been received. This new behaviour emerged as a result of frustration but was creative in its approach to ensuring there was a physical trail to the communication. Participant 3 showed that the wound care communication category of smartphone could also display the CAS property of emergent behaviours. I think it's very helpful, especially in the community to be able to just send out a text message to somebody and get an immediate response. Sending out a picture to the wound care clinician and getting her input right away is just so amazing…. The provision of the smartphones to clinicians created a mode for people to communicate in the moment while they were in a patient’s home providing care. The camera feature of the smartphone allowed for the emergent behaviour of sending pictures, in time, to the WOCN. The nurse really saw this as an improvement as they could get recommendations for care and implement them without having to go back to the patient at a later date. As outlined above there are many examples of wound care communication categories that illustrate the CAS property of emergent behaviours. The culture, patterns, processes and the introduction of new communication technologies all contribute to emergent behaviours. 4.14.6 Inherent Order The CAS property of inherent order is defined as an order that is maintained in a CAS even without central control (Chaffee & McNeill, 2007). Inherent order showed up in eight of the wound care communication categories. The following quote identifies both the wound care 76 communication category of coordination and the CAS property of inherent order. Participant 6 explained, It's funny because I don't think there's actually a workflow. Nothing that says, ‘do this’. And if not ‘do that, then do that. And then if not, then do that.’ But because I've been here so long, you just kind of know… This example demonstrates how people determine a workflow or process for communication and care coordination without any central guidance or oversight. They learn as they go and they adjust their behaviours based on experience which results in an inherent order. Participant 6 also explained that there was an inherent order to getting the message to their colleagues with a starting point of in person/ face-to-face communication then progressing to messaging or phone calls. I stand up first and look around and if I can't see them… it depends how urgent it is. If it's really urgent that I will text them or call them, okay, right? If it's not that urgent, I will notify them via Paris. … This quote shows that there is nothing formalized to ensure that the communication happens in a specific order. What is interesting is that this same approach was taken by multiple clinicians. This suggests that even without any central control or formal process people approached interdisciplinary wound care communication in the same way demonstrating the presence of an inherent order. 4.14.7 Non-Linearity The CAS property of non-linearity implies that in response to a stimulus a variety of behaviours are possible, and the cause and effect relationship in not directly evident or linear (Chaffee & McNeill, 2007). Non-linearity showed up in seven of the categories. Participant 5 showed how non-linearity was illustrated by wound care communication process. "…No [access 77 to Pixalere]. So if the nurses are on their Pixalere and I can see them looking at something and then I'll go take a look…" This case manager explained that because they did not have access to one of the EHRs, Pixalere, they would ask the nurses who did have access to view the information and images of the wounds. While the case manager did not perform wound care, they needed knowledge of the wound so they could convey the information to the other team members. In an effort to ensure they have the correct information this group came up with a non-linear solution to the problem. Participant 8 showed how EHRs contributed to non-linearity, I think it would be improved if things weren't in different places like if notes weren't in Paris and [Pixalere]. Sometimes people don't look at the progress notes in [Pixalere] and they only go to Paris but then sometimes Paris doesn’t have it so it's kind of like you are double charting in a way. I feel like that's happening a lot and you're just like where do you go to get the proper information… The disjointed nature of the EHRs and the fact that each EHR contains slightly different information results in non-linearity in charting and communicating via electronic health records. 4.14.8 Porous Boundaries The CAS property of porous boundaries is defined as the elements in a CAS that are blurry and porous, allowing exchange and movement between them (Chaffee & McNeill, 2007). Porous boundaries showed up in six of the categories. Participant 5 described a process for wound care communication that showed the multidirectional flow of information from variety of sources. They explained that "… it is usually the home support workers who are doing the bathing who alert me to a new wound…. And then I get the nurse to go in and assess and check." This quote demonstrates that information travels in multiple directions and is not confined to one profession or group. 78 Normally wound care communication would be initiated by the nurses who provide wound care but in this example the home support workers are the ones who are communication to the team about a change in the patient’s condition. This clearly illustrates information exchange and a porous boundary. 4.14.9 Self-Organization The CAS property of self-organization is defined as a process where many local interactions create order without direction from above (Chaffee & McNeill, 2007). Self-organization showed up in nine of the categories. A comment from Participant 5 demonstrated how self-organization appeared in the category of coordination, … home support will communicate with me. Usually, they're the ones that call me first…They'll see the [patient] and then I would find out if there's a nurse involved. I would go talk to the nurse. If there's not a nurse involved and I would talk to the triage nurse about getting … a referral for management… This example shows that the communication can occur in different directions among professionals. There is no guidance provided on when to communicate with whom but the professions self-organize based on patient care needs and communicate information as necessary based on their observations and assessments. Participant 4 showed how self-organization can show up in the category of culture of wound care communication, It depends on the unit. At this unit it's in person, when I’m at other units it might be through Pixalere. But it depends on the clinician style. There are wound clinicians who communicate through Pixalere and then our clinician here communicates more in person. This quote illustrates how each team and site may communicate about wounds differently and that this can be influenced by unit culture and personal preferences. Despite this the team will 79 self-organize and come up with a communication process that works for them without central guidance. Participant 8 explained how physical layout and proximity of the clinic impacted communication which also illustrated the CAS property of self-organization. Other people will do things differently to be more formal. Maybe I feel here we're really lucky because we have a lot of people on staff and there's a lot of people around, it'd be different if we were in a different environment… This suggests that one of the factors that allows self-organization in wound care communication is the fact that there are different professionals physically sharing space and located in close proximity to one another. This facilitates access to other professions and allows for the informal in person/ face-to-face communication that is referenced. 4.14.10 Simple Rules The CAS property of simple rules is defined as the local application of simple rules which can result in broad, complex outcomes (Chaffee & McNeill, 2007). Simple rules showed up in twelve of the categories. Participant 8 discussed some improvements that could be made to Pixalere which related to simple rules. So you're getting [an alert] after [you chart]…well, it would have been nice to know ahead of time, so we could have talked to somebody about it…Because it is a waste of somebody else's time, like the WOCN goes through those and has to look them… The simple rule of how the alerts were set up in the EHR resulted in a conflict with the established documentation workflow, which required documenting care provided after it was completed. The well-intentioned alerts were not helpful as they were received after the nurse had left the patient’s home/ the patient had left the clinic. Therefore, the care could not be adjusted until the next visit at which point the information may no longer be relevant. Participant 3 80 discussed that the way the EHR was set up resulted in the necessity of in person/ face-to-face communication which illustrated simple rules. …But you can't really put it in the computer without talking to someone because you have to put a priority level and so that's why you're sort of getting permission or you're trying to find what priority or what are you going to triage this person at... The simple rule resulted from the way the EHR referral process was designed. It required the input of information that was only known by the person receiving the referral. The person entering the referral would have to guess that information and there was an unease around the potential of entering the information incorrectly and causing a problem. This resulted in a workaround where referrals needed to be preceded by a conversation between the parties to make sure that the correct information was obtained and entered in the system. This simple rule illustrated by wound care communication categories resulted in confusion, longer times to enter referrals and workarounds. 4.14.11 Unpredictability The CAS property of unpredictability is explained as forecasting that is inexact because elements change, behaviour is emerging and activities are nonlinear; the trajectory of a system is unknowable (Chaffee & McNeill, 2007). Unpredictability showed up in eight of the categories. Participant 8 talked about improvements that could be made to the EHRs. The quote illustrates how the current state of the siloed EHRs results in the CAS property of unpredictability. I think it would be improved if things weren't in different places, like if notes weren't in Paris and [Pixalere], sometimes people don't look at the progress notes in [Pixalere] and they only go to Paris but then sometimes Paris doesn’t have it so it's kind of like your double charting in a way …you're just like where do you go to get the proper information… 81 In this example no one knows where to chart as there are two possible places that the information belongs. This results in differing workflows as discussed. Some people will chart in Paris, some will chart in Pixalere and some are nervous that their documentation will not be seen by those who need it so they chose to document in multiple EHRs. This means there is no way to predict where you will consistently find the information needed which leads to unpredictability. Participant 6 demonstrated that in person/ face-to-face, process, messaging and phone call categories illustrate the CAS property of unpredictability. I stand up first and look around and if I can't see them, then I go if they are working? It depends how urgent it is. If it's really urgent that I will text them or call them… If it's not that urgent, I will notify them via Paris. So yeah, or I will just stand up and look and hunt them down. This quote suggests an unpredictable workflow exists that requires multiple strategies to ensure that the communication occurs in a timely manner and that the information that needs to be conveyed is done so and received. Participant 1 described a situation with fax that shows how the CAS property of unpredictability is present, "…failing [someone answering a phone call, I will use] faxing, which is archaic. Based on how little success with phoning I think it's easier just to send the fax and then it's kind of in their hand.” The fact that the clinician is unsure that they are communicating adequately and having the information received leads to varied attempts to convey the message. The unpredictability of the situation results in the clinician resorting to a method of communication they believe is “archaic” in an effort to have some certainty that their message is being received. 82 4.15 Synthesis of CAS Results The categories identified in the qualitative analysis were reflected in all of the CAS properties described by Chaffee and McNeill (2007). The most common CAS properties were context and embeddedness (15 wound care communication categories), simple rules and emergent behaviour (12 wound care communication categories) followed by attractors (11 wound care communication categories). The property of context and embeddedness resonated throughout the analysis. For example, wound care communication itself was a CAS, but that was embedded in the CAS of the health centre, which itself was embedded in the CAS of the organization. If you changed something in any of the complex adaptive systems, it appeared to have an unintended domino effect (i.e., the CAS property of simple rules). For example, if a software engineer changed something in the documentation system (i.e., the alert in Pixalere) without taking workflow into consideration, the system was no longer an effective communication tool. Instead, healthcare providers created workarounds to compensation for the software-workflow mismatch (emergent behaviours). The four properties of adaptable elements, inherent order, self-organization, and co-evolution were present in the dynamic system of wound care communication. While there are rules, policies and procedures to be followed (i.e., simple rules), clinicians strategically navigate these to ensure that they can achieve patient care goals. Things may start as one-off decisions and processes to meet care needs but the unit culture is responsive to changing needs and allows for unspoken processes to emerge (i.e., the CAS property of self-organization and inherent order). Adaptable elements were evident in many of the interviews. The current communication technologies are a large barrier to interdisciplinary wound care communication. Despite this, 83 clinicians are nimble and adaptable to tailor the use of tools/ technologies depending on the urgency, the type of action required, and who they need to communicate with. Even if a technology or tool does not function to support interdisciplinary wound care communication workflows the clinicians will create processes, or workarounds, to achieve the desired effects. Their primary concern is guaranteeing that the information needed by the other parties is received and understood (i.e., they ensure the message is received). They strive to achieve this end goal despite barriers that they encounter. Emergent behaviours varied depending on the different physical layouts of the clinicians’ setting. Being located in close proximity to the interdisciplinary team that they were communicating with led to a preference for face-to-face communication for most messages that they wished to convey among team members. If physical proximity was not available then the clinicians preferred phone calls or text messages (specifically picture messages), where they could get quick responses and confirm the information was received. Email was another option in these circumstances but due to some limitations with certain interdisciplinary team members access to the health organization email there were some barriers to this. 4.16 Summary of Results Several themes were identified: how context shapes interdisciplinary communication, navigation of tools and technologies, and efficiency and trust in face-to-face communication. It became apparent that some key beliefs were shared by the participants. Key beliefs included the desire for one electronic health record, the varying tools and technologies resulted in time spent navigating through the tools and prioritizing communication strategies based on which tools were available, and a preference for face-to-face communication. 84 The categories that emerged were classified using the theoretical lens of CAS. Once mapped it became clear that the categories that made up interdisciplinary wound care communication exemplified many of the properties of a CAS. Each wound care communication category illustrated a minimum of two CAS properties while some showed all eleven CAS properties. This shows that the wound care communication categories exemplify the properties of a CAS, which further suggests that interdisciplinary wound care communication can be a considered a CAS. 85 Chapter 5: Discussion 5.1 Overview of Chapter In this study, ethnographic methods and a CAS framework were used to explore the processes surrounding interdisciplinary wound care communication. While CAS has been studied in some healthcare contexts, to my knowledge, this is the first study that has examined how processes of wound communication were related to the theoretical model of CAS. In this chapter, the results of the CAS analysis are discussed, followed by a discussion of the general themes that emerged from the qualitative analysis. These are followed by a discussion of limitations and implications for nursing research, policy and practice. 5.2 Wound Care Communication as a Complex Adaptive System In Chapter Four the categories of wound care communication were explored to see if they illustrated any of the properties that exist within a CAS as described by Chaffee and McNeill (2007). It was found that wound care communication categories displayed properties of a CAS. In fact, each property of CAS as described by Chaffee and McNeill (2007) could be exemplified by at least six wound care communication categories while others could be exemplified by all fifteen wound care communication categories. This clearly illustrated that the categories identified by participants surrounding wound care communication reflected the properties displayed in a CAS and wound care communication could be considered an example of a CAS (Chaffee & McNeill, 2007). CASs are open systems, operate in conditions outside equilibrium, and the complexity results from patterns of interactions between components (Chaffee & McNeill, 2007; Holden, 2005). This description also works for the processes that surround interdisciplinary wound care 86 communication. The impact that context has on communication processes, the complex navigation that is required of communication tools and the effort that clinicians have to put in to make sure their message is received all align with the descriptions of complex adaptive systems (Benham-Hutchins & Clancy, 2010; Clancy, 2014; Chaffee & McNeill, 2007; Holden, 2005; Notarnicola et al., 2017). Benham-Hutchins and Clancy (2010) discuss healthcare social networks as a hierarchy of embedded CASs. The process of wound care communication is an example of a social network which not only functions as a CAS but is embedded within other complex adaptive systems. As discussed in Chapter Four clinicians are patient focused and they function in a dynamic environment. While there are rules, policies and procedures to be followed, clinicians strategically navigate these to ensure that they can achieve patient care goals. Unit culture allows unspoken processes to develop to meet a shared vision and goals (Gausvik, et al., 2015; Mundt et al., 2016). The role of unit culture and the research done by Gausvik et al. (2016) and Mundt et al. (2016) will be discussed later in this chapter. These unspoken processes and shared vision and goals was a clear example of how the CAS properties of context and embeddedness, simple rules, co-evolution, porous boundaries and self-organization were displayed (Chaffee & McNeill, 2007). It was discovered that communication technologies are a large barrier to interdisciplinary wound care communication. However, clinicians are highly resourceful. Even if a technology or tool did not meet the needs of interdisciplinary wound care communication workflows the clinicians created processes, or workarounds, to achieve the desired effects (Irizarry & Barton, 2013). Their only concern was guaranteeing that the information needed by the other professions was received and understood that closing the loop was considered essential. This clearly 87 illustrated the CAS properties of adaptable elements, attractors, co-evolution, emergent behaviour, inherent order, non-linearity and self-organization (Chaffee & McNeill, 2007). Behaviours varied depending on the different physical layouts of the clinicians’ setting. Being located in close proximity to the interdisciplinary team that they were communicating with led to a preference for face-to-face communication. If physical proximity was not available the clinicians would then utilize phone calls or text messages, specifically picture messages. These tools helped ensure they could get quick responses and confirmed the information was received. This illustrated the CAS properties of adaptable elements, context and embeddedness, emergent behaviours, unpredictability, inherent order and self-organization. (Chaffee & McNeill, 2007). 5.3 Processes of Communication The processes of wound care communication were explored through the interviews with RNs, case managers and the primary care provider (physician). There were certain items that consistently triggered communication between the interdisciplinary team: care coordination, new, changing or worsening wounds, infection, pressure ulcers, equipment or product concerns and dietary concerns. Each of these triggers involved contacting specific members of the team. For example, if the concern was a changing or worsening wound then nursing, the wound ostomy continence nurse or the primary care provider were contacted. However, several participants explained that sometimes communicating and referring outside their professional group could be challenging. They cited workload issues for this challenge. Creswick et al., (2009) looked at communication networks in the context of an emergency department (ED). It was found that 80% of clinicians’ time in ED is spent communicating (Creswick et al., 2009). They explained that the purposes of communication were to provide and coordinate care, similar 88 to what was expressed by the participants of this wound care communication research (Creswick et al., 2009). Social networks were studied through a survey of doctors, nurses, allied health professionals, administrative staff and ward assistants (Creswick et al., 2009). They found that for all of the networks that they looked at, problem-solving, social and medication advice, people were more closely connected to peers in their professional group (Creswick et al., 2009). This supports what was found in this research about wound care communication. It was noted that wound care communication was more common between the same professional group (i.e., nurse to nurse). While it was found that interdisciplinary communication was key to patient care, several participants interviewed for this study mentioned that they would still benefit from more integrated approaches to communication. One example given was that while wound care was interdisciplinary, the monthly wound care rounds were exclusively nursing. The other consistent process that was identified was the method used to communicate and the tool selection. If the individual shared a workspace with the person they were trying to contact then face-to-face communication was used. If the person was not available then a phone call would occur if the issue was deemed urgent. Email and text messaging were then used if the phone call was unsuccessful. If that did not work then the clinician would resort to fax. After all of this was done they would then enter the communication in the EHR. The reluctance to use the EHR as a communication tool beyond documenting care will be discussed later in this chapter. 5.4 Wound Care Communication Culture in the clinical setting was found to consist of the unwritten rules that shaped interdisciplinary wound care communication. The individuals interviewed had a shared understanding of the way things were done but they could not articulate why. Gausvik et al. 89 (2015) talked about how efficient, timely and accurate communication was not only required for quality healthcare but also is strongly linked to job satisfaction. The authors went on to explain that job satisfaction leads to improved retention, recruitment which reflect unit culture (Gausvik, et al., 2015). This aligned with the findings from this study which showed that people really valued the open unit culture that allowed for spontaneous communication among team members. Gausvik et al. (2015) describe that, “a healthy work environment is defined as including a collaborative practice culture, a communication-rich culture, a culture of accountability, expert team members, shared decision making, and recognition of contributions of others.” This was reflected in what was found through the interviews with clinicians for this thesis. The harder time they had communicating with other team members the more frustration they expressed with interdisciplinary communication and the tools available to support it. Lefringhausen et al. (2019) looked culture norms and communication contexts. They explained that “there is increasing acknowledgment by psychologists and interculturalists that the ways in which culture influences people’s behavior are likely to be affected by characteristics of the situation” (Lefringhausen et al., 2019). It was discussed that a closer look at context as influenced by setting and culture is prudent to understanding communication (Lefringhausen et al., 2019). One interesting suggestion was that it isn’t the context that matters it is the individual’s perception of the context (Lefringhausen et al., 2019). This was apparent in the interviews that were conducted for this research. Most clinicians shared a perception of the context that wound care communication was occurring in however, there were a few individuals who worked part-time or casually at different health centres that described their experiences of communication differently than the people who worked full time and exclusively at one site. Mundt et al. (2016) explored primary care team communication networks, team climate, 90 and their association with health outcomes, healthcare utilization and associated costs for patients with diabetes. The researchers concluded that team interconnections and team climate with shared vision or teamwork resulted in better quality of care for patients with diabetes (Mundt et al., 2016). While the authors did not call this “culture or context” their description of team climate aligned with the approach to context and culture taken in this research. Mundt et al. (2016) also found that despite the importance of certain communication processes that an equally important factor was a culture that facilitated teamwork and also had a shared vision for outcomes. This had mitigating factors which resulted in better health outcomes for clients. Physical layout and physical proximity are the other aspect of context that appeared in both the literature and the research findings from this study. Physical layout of the workspace and proximity to interdisciplinary team members was found to influence a preference for in person/ face-to-face communication. People would first look around to see if the person they needed to connect with was physically present. If they were they would talk to them. If they weren’t they would attempt to use other communication tools to connect with them. Creswick et al. (2009) explored communication networks in and emergency department environment. They found that interdisciplinary communication was complex, mostly face-to-face and disjointed (Creswick et al., 2009). While they did not discuss the reason for this finding they did suggest that the close environment in which the professions worked led to this pattern of behaviour (Creswick et al., 2009). There was not much reference to physical layout and proximity in the literature that was reviewed. This subtheme may require some more exploration to understand the role that it plays in interdisciplinary communication. Several participants identified the dream for one EHR. They clearly articulated their concerns about the multiple systems that did not integrate with one another resulting in 91 inconsistent information in each EHR. There seemed to be a resulting reluctance to use the EHR for several reasons including questions about provisioning and a subsequent uncertainty around who had access to the information in the system, duplicate charting concerns, system design not matching workflow and hybrid systems involving paper and electronic documentation, and connectivity issues. This behaviour may have been a result of any number of reasons but requires further exploration. Irizarry and Barton (2013) discuss how the effective use of EHRs is touted as one of the primary solutions to addressing today’s healthcare problems. It is concerning that the EHRs in the health centres are not functioning in the manner that they could to facilitate interdisciplinary communication. Irizarry and Barton (2013) suggest that successful EHR implementation and use depends on five factors: having a long-term plan, anticipating workflow and technology evolution, applying a qualitative and quantitative evaluation method, utilize meaningful user engagement and adapt implementation strategies as needed. It is not clear if these best practices were used when these EHRs were implemented in the health centres but it may be beneficial in future research to look at what strategies were employed and if there are any that could be employed now to improve the usability and uptake of these systems by the clinicians. Mundt et al. (2016) also looked at communications via EHR. Several RNs reported more frequent communication via EHR than face-to-face communication. However, the study found that the number of EHR communications did not impact team climate or lead to better patient outcomes. This is consistent with what was found in this research. There were some clinicians that more frequently used the EHR for communication than face-to-face but this would require more research to understand the impact and what led to this behaviour. Concern about using fax for communication was discussed by several RN participants. They did not understand why they were required to use such an “archaic” technology to 92 communicate what they considered important information. This method was primarily utilized to connect with primary care providers, usually GPs, who were not located in the health centres with the other interdisciplinary team member. In the participants perspective faxing was a last resort and the only benefit was a paper trail. Despite the paper trail they raised concerns about not being able to tell if the intended recipient had in fact received the information they were providing. There were also concerns about security raised. This is consistent with other literature. The United Kingdom (U.K.) government has worked to ban fax machines in the National Health Service (NHS) (U.K. Department of Health and Social Care, 2018). Security and more efficient options through secure emails were cited as reasons to make this move. More research is needed into why we continue to use fax as a communication tool when there are other alternatives out there that have a lower level of risk involved along with an increased ease of use. The majority of participants expressed that if they could find the person they were needing to communicate with, they would rather have an in person/ face-to-face conversation with them over any other method of communication. They explained that the conversations were more efficient and allowed for a better understanding of the care that needed providing to the patient. It was felt that the information provided in face-to-face discussions allowed for a more holistic view to be obtained. This finding is aligned with other literature (Creswick et al., 2009; Gleddie et al., 2018; Lo & Li, 2008; Mundt et al., 2016). Mundt et al. (2016) in their research of team networks and communication about patients with diabetes found that face-to-face interactions between the primary nurse and the primary care provider led to better health outcomes. However, they also found that for every additional team member reporting frequent face-to-face interactions with the primary care provider patient health outcomes started to deteriorate (Mundt et al., 2016). This implied that while face-to-face interactions may have a 93 positive impact on clinical outcomes and may be the preference for care providers there are certain requirements that make them a successful tool. The more people involved in the care of the patient and subsequently in these interactions, the less likely the face-to-face communication will maintain its beneficial effects (Mundt et al., 2016). While patient outcomes were not explored in the research I conducted this suggests that further exploration of face-to-face communication as a tool is required. Creswick et al. (2009) discussed how interdisciplinary communication in the emergency department was complex, mostly face-to-face and disjointed (Creswick et al., 2009). While this was a different setting the finding was similar to what was discovered about interdisciplinary communication in community based wound care communication. Gleddie et al. (2018) looked at nurses’ perceptions of teamwork with physicians in labour and delivery. The authors found that enablers of effective nurse-physician relationships were time, trust, respect, credibility, and social connection (Gleddie et al., 2018). While they did not get into the process of communication or mention face-to-face communication they highlighted the role that trust played (Gleddie et al., 2018). The trust that they found was among peers which did come up in this research but the focus of the finding from this thesis was around trust in the communication tools. This trust in the tools and process needs further investigations. Lo and Lie (2008) highlighted the importance of trust in both the individuals involved in the communication process but also trust in the tools. They suggest that trust in the communication tools available impact the selection of the tool used (Lo & Lie, 2008). Ensuring the message is received emerged as a subtheme as clinicians prioritized communication tools that helped them ensure and have confidence that the information that they were trying to convey was received. This was cited by several participants as a reason why they 94 preferred face-to-face communication. They felt confident when they talked to a colleague that the information they needed to convey about the patient care would be understood and acted on. They had less confidence that if they sent an email, fax or text message that the details of the communication would be received properly. While everyone documented in the EHRs very few people relied on them as the only source of communication about a patient. There were concerns about the accuracy of the clinical contents, accessibility by different professions, conflicts with existing workflow and just a general lack of understanding about system design. Lo and Lie (2008) discussed how despite the rapid development of technology the introduction of new communication tools does not lead to the immediate replacement of old tools. The research by Lo and Lie (2008) offered some explanation as to why people may make the communication tool selections that they do. Lo and Lie (2008) also suggested that for tasks where the communication is unclear or the questions or information that needs to be conveyed is not defined the user tends to select a tool that has high information richness. In contrast when communication is defined and straight forward they chose a communication tool with less information richness (Lo & Lie, 2008). Lo and Lie (2008) suggested that in addition to the type of information that needs to be conveyed the distance of the communication impacts the selection of the communication tool used. They suggested that when people work in close proximity they will chose face-to-face communication regardless of whether the communication task is complex or not since it limits the delay in response time (Lo & Lie, 2008). If the distance is further then they will select the communication tool with more consideration of the information richness provided. Information richness of communication technologies was found to be highest in telephones, followed by instant messenger with webcam, instant messenger with text only, email and then online message boards (Lo & Lie, 2008). This research done by Lo and 95 Lie (2008) aligns closely with the findings of the research in this thesis. The preference that clinicians for certain communication tools in specific situations is explained by this research by Lo and Lie (2008). Raj et al., (2020) explored how health information technologies (HIT) utilized for communication impacted trust among care team members. The authors explained that there are multiple levels involved to trust in a HIT mediated communication: 1) the trust that the documentation will be interpreted correctly and as intended and 2) trust that other clinicians will trust the information that they are inputting into the system (Raj et al., 2020). The trust that clinicians had in the different communication tools became clear in the research conducted in this thesis. The more direct the communication with the peer, the more trust there was that the information was being conveyed properly via the communication tool. This led participants to prioritize face-to-face communication whenever possible, followed by synchronous communication via the telephone. There was also high value and trust that was given to sharing photos. This was explained as the photos functioned as an objective tool that people had confidence in. Texting was used for quick responses to specific questions and was made possible by the provision of smartphones to clinicians. These were seen as an improvement as they made for convenient communication. Some clinicians mentioned that they still referenced and used paper documents for communication but they were not considered very reliable. This aligns with the research by Lo and Li (2008) and Raj et al (2020) but would benefit from further exploration as to why and how these patterns of preference developed. 96 5.5 Limitations Several difficulties were encountered through the course of this research and are discussed in this section. Firstly, the study was being conducted in one health organization in Western Canada. This makes it challenging to transfer results beyond this one specific context. Future research would need to be done in other health organizations and geographical regions to see if the results could be applied more broadly. Further to this, only participants from two community health centres participated in this research. This also impacts the ability to transfer the results. Another limitation of this research was that only RNs, case managers and one primary care provider (physician) were interviewed. This does not give a truly interdisciplinary view of wound care and can only be thought to reflect the perspective of the professions interviewed. Further interviews with other disciplines such as an NP, WOCN, PT, OT and pharmacist would have been beneficial but due to COVID-19 pandemic and time constraints interviews were stopped. The study design had several limitations. The first was the short time frame allocated for data collection. Ethnographic methods and studies often require a long time in the field to achieve an emic perspective (Polit & Beck, 2016). To address this, participants who have plenty of diverse experience in the context of interest were recruited. Participants were only included if they could function as key informants. While this did not create an emic view as described by ethnographers it allowed data saturation on the narrow topic area to be obtained. Due to the narrow focus of the topic being researched, it was sufficient to spend less time in the field, but this resulted in what others may not consider a full emic perspective. 97 This study design was also limited by the selected context of home health, community and primary care. By selecting to focus on these settings it eliminated lots of areas that perform wound care such as emergency departments, urgent care centres, long term care and acute care settings. To keep the methods feasible for the time frame allotted these were excluded intentionally. These areas would be helpful to consider if further research in the future is to be conducted with the same or similar focus. Another limitation incurred by this design, was that one researcher conducted all the interviews and the one observation. While this allowed for consistency in process, this meant that the bias of the researcher could unintentionally impact some of the findings and investigator triangulation was not possible. This was addressed through reflexive journaling and discussion of findings with committee members. While the professional personas created and used to facilitate interviews were very helpful for establishing interviewer credibility and focusing discussions, they may have biased the responses of the participants. The goal was to have the personas validated but they may have shaped some of the responses given. The interviews could be repeated without the personas to see if any different information might have been obtained. 5.6 Implications for Nursing Practice The first implication for nursing practice is that workflow and communication tool design need to account for the complex nature of the healthcare system. This research suggests that interdisciplinary wound care communication is a complex adaptive system that functions within other complex adaptive systems. When decisions are being made about workflows, system design and communication tool introduction, consideration of complex adaptive systems theory may help make decision-making and implementation more successful. For example, when 98 implementing a new or revised EHR it is recommended that the documentation workflow needs to be considered (Irizarry & Barton, 2013). The design currently provides helpful clinical advice when the information is documented. Unfortunately, due to limited accessibility of the system on mobile devices, clinicians only receive this information after the fact when it is no longer of use to inform care. When the EHR is revised there should be decisions made that take into consideration when the charting occurs, the resources available to support the clinicians to chart in the moment and how to best provide clinical tips in a manner that is actually useful to support clinical decision making. This indicates that properties such as context and embeddedness, simple rules, non-linearity and unpredictability should be considered (Chaffee & McNeill, 2007). Lo and Li (2008) offered some explanation of why people may select the communication tools that they do for certain tasks, this involved consideration of information richness, time to response and communication task complexity. This research by Lo and Li (2008) suggested that having more tools and technologies may not be the solution to improve communication. Lo and Li (2008) instead proposed the examination of the goal of communication, review of workflows and then the adaptation of existing systems and tools to match communication needs which could benefit clinician information sharing. Based on this, leaders should consider prioritizing an understanding of workflow and overall clinical goals before implementing alerts to address specific clinical behaviour. There seems to be a deep-rooted preference that emerged for face-to-face communication when physical proximity was available. The research by Lo and Lie (2008) explained why people may prefer face-to-face methods of communication over others when they share space. A recommendation to consider moving forward is to look at where people are located in their work spaces and to have professions who care for the same populations in close proximity to facilitate 99 this communication. The units that have this layout expressed satisfaction with this approach although not all team members are currently located in the same place. Another implication is that the diversity of communication tools available added to the complexity of communication. Each time a clinician needed to communicate with a team member they needed to subconsciously analyze the content that was to be shared, assess for information richness, determine proximity to the intended recipient, determine available tools and make the match to select the communication tool. It became clear that sometimes the selected communication tool did not work as desired and the clinician would have to re-select a new tool and try again. This analysis, prioritization and selection process was time consuming. Frustration emerged when the tool selected did not work as intended. To improve satisfaction with communication processes around wound care this disconnect and process failure needs to be addressed and streamlined. For example, faxes frequently failed and did not send properly. Sometimes there was confirmation of receipt, sometimes there was not. One recommendation is that an effort should be made to move away from fax entirely and switch to secure email. 5.7 Implications for Nursing and Healthcare Policy This research supports some changes to nursing and healthcare policy. Firstly, EHR system access needs to be provisioned appropriately. It became clear that not all professions who needed access to certain EHRs had it. This resulted in workarounds. These workarounds had privacy and security issues associated with them as people were sharing access to systems or logging in and allowing peers to view. Consultation needs to occur with all professions when and EHR is being designed to properly understand workflow and to determine who needs access to the system. 100 Secondly, interoperability of EHRs needs to become mandatory. The frustration expressed around all the different EHRs used in wound care communication was consistent across majority of the professions (RNs and Case Managers) and participants. The only person who did not express this concern was the primary care provider (physician) who only referred to one EHR that was not used by the nurses and case managers. This EHR used by the primary care provider was set up to operate with the other systems already. This disparity between interoperability of the primary care provider EHR and the lack of interoperability of the systems used by the nurses and the case managers needs to be addressed. If the systems can be made to connect for the primary care provider there is no reason that this cannot be done for the other professions. Even better would be the development of one EHR that everyone had access to. Thirdly, there needs to be a policy change to address the use of fax machines. The UK is banning fax machine use in the NHS (U.K. Department of Health and Social Care, 2018). Faxes pose a security risk, add to clinician frustration and are outdated technologies. One policy implication would be at a provincial or federal level to make a move to ban this tool. This would be one less tool to contend with and would streamline the communication process. Secure email and scanning are already available as alternate options. 5.8 Implications for Nursing and Healthcare Research This study sheds some light on the processes of interdisciplinary wound care communication, communication tool use and interdisciplinary wound care communication as an example of a complex adaptive system. Several researchers have previously discussed healthcare and nursing environments as a complex adaptive system but the research on this is still limited in the context of communication (Benham-Hutchins & Clancy, 2010; Clancy, 2014; Chaffee & 101 McNeill, 2007; Holden, 2005; Notarnicola et al., 2017). Further research into complex adaptive systems, healthcare and nursing practices would greatly benefit the field. Additional research into interdisciplinary communication and wound care in other settings and contexts would also be beneficial. 5.9 Summary of Discussion In this chapter a review of the methods and results was completed. Interdisciplinary wound care communication as a complex adaptive system was discussed. The context of wound care communication was looked at in comparison to the literature available on complex adaptive systems. The findings of this research were found to be supported by the literature and showed some evidence that interdisciplinary wound care communication as described by the participants of this study could be considered an example of a complex adaptive system. The processes of communication identified by the participants were compared to what had emerged from the literature and showed some alignment. The themes and subthemes of interdisciplinary communication were also explored. These consisted of: how context shapes interdisciplinary communication (subthemes of culture in the clinical setting and physical layout and proximity), navigating communication tools (subthemes the dream for one electronic health record, keeping current using electronic resources and concern about using fax for communication), efficiency and trust in face-to-face communication (subthemes: ensuring the message is received, synchronous communication via telephone, a picture says a thousand words- the value of photos, smartphones: an improvement for convenient communication, trust in paper documents). When the themes and subthemes were compared to other research that was out there on these topic areas it appeared that there was some overlap with the findings. Several 102 studies emphasized the preference clinicians had for face-to-face communication. Others discussed the frustrations that existed with disjointed EHR systems and incompatibility between these systems and existing workflows. There was also extensive support for the impact that context, perceptions and culture on interdisciplinary communication. The limitations of this study were discussed and some suggestions on how to address these in future research on this topic were offered. Implications of this research were quite widespread and there were some concrete suggestions made for changes that could be made to nursing practice, nursing/ healthcare policy and further nursing and healthcare research. Workflow and complexity need to be considered when implementing new communication tools to help with uptake. Provisioning, interoperability and the discontinuation of fax need to be considered by policy makers to simplify the interdisciplinary communication process. Further research into interdisciplinary communication and complex adaptive systems needs to occur in different contexts to better understand the usefulness of complexity science and complex adaptive systems theory as suitable theoretical model for analyzing nursing and healthcare research. There is potential that this theoretical lens will add to the richness of research being conducted. 103 References Benham-Hutchins, M., & Clancy, T. R. (2010). Social networks as embedded complex adaptive systems. JONA: The Journal of Nursing Administration, 40(9), 352-356. doi:10.1097/NNA.0b013e3181ee42bc Canadian Home Care Association (CHCA) (2016). CHCA on the issues: Wound care. Retrieved November 5, 2018 from http://www.cdnhomecare.ca/content.php?doc=263 Chaffee, M. W., & McNeill, M. M. (2007). A model of nursing as a complex adaptive system. Nursing Outlook, 55(5), 232-241. doi:10.1016/j.outlook.2007.04.003 Chittoria, R. K. (2012). Telemedicine for wound management. Indian Journal of Plastic Surgery: Official Publication of the Association of Plastic Surgeons of India, 45(2), 412-417. doi:10.4103/0970-0358.101330 Clancy, T. R. (2014). It’s all about flow in a complex adaptive system. JONA: The Journal of Nursing Administration, 44(4), 190-193. doi:10.1097/NNA.0000000000000056 Cornforth, A. (2013). Holistic wound assessment in primary care. British Journal of Community Nursing, 18(Sup12), S28-S34. doi:10.12968/bjcn.2013.18.Sup12.S28 Creswick, N., Westbrook, J. I., & Braithwaite, J. (2009). Understanding communication networks in the emergency department. BMC Health Services Research, 9(1), 247-247. doi:10.1186/1472-6963-9-247 Dailey, M. (2005). Interdisciplinary collaboration: Essential for improved wound care outcomes and wound prevention in home care. Home Health Care Management & Practice, 17(3), 213-221. doi:10.1177/1084822304271808 Edwards, H., Finlayson, K., Courtney, M., Graves, N., Gibb, M., & Parker, C. (2013). Health service pathways for patients with chronic leg ulcers: Identifying effective pathways for 104 facilitation of evidence based wound care. BMC Health Services Research, 13(1), 86-86. doi:10.1186/1472-6963-13-86 Friesen, M. R., Hamel, C., & McLeod, R. D. (2013). A mHealth application for chronic wound care: Findings of a user trial. International Journal of Environmental Research and Public Health, 10(11), 6199-6214. doi:10.3390/ijerph10116199 Garrard, J. (2016). Health Sciences Literature Review Made Easy: The Matrix Method. Burlington, Massachusetts: Jones and Bartlett. Gausvik, C., Lautar, A., Miller, L., Pallerla, H., & Schlaudecker, J. (2015). Structured nursing communication on interdisciplinary acute care teams improves perceptions of safety, efficiency, understanding of care plan and teamwork as well as job satisfaction. Journal of Multidisciplinary Healthcare, 33-37. doi:10.2147/JMDH.S72623 Gerrity, E. P. (2005). Care management and wound care: The expanding role of the care manager in the new millennium and opportunities for collaboration and innovation. Home Health Care Management & Practice, 17(3), 175-182. doi:10.1177/1084822304271783 Gleddie, M., Stahlke, S., & Paul, P. (2018). Nurses' perceptions of the dynamics and impacts of teamwork with physicians in labour and delivery. Journal of Interprofessional Care, 1–11. Advance online publication. doi.org/10.1080/13561820.2018.1562422 Holden, L. M. (2005). Complex adaptive systems: Concept analysis. Journal of Advanced Nursing, 52(6), 651-657. doi:10.1111/j.1365-2648.2005.03638.x Irizarry, T., & Barton, A. J. (2013). A sociotechnical approach to successful electronic health record implementation: Five best practices for clinical nurse specialists. Clinical Nurse Specialist, 27(6), 283-285. doi:10.1097/NUR.0b013e3182a872e3 105 Jelnes, R. (2011). Telemedicine in the management of patients with chronic wounds. Journal of Wound Care, 20(4), 187-190. King, B. (2014). Influencing dressing choice and supporting wound management using remote ‘tele-wound care’. British Journal of Community Nursing, 19(Sup6), S24-S31. doi:10.12968/bjcn.2014.19.Sup6.S24 Lefringhausen, K., Spencer-Oatey, H., & Debray, C. (2019). Culture, norms, and the assessment of communication contexts: Multidisciplinary perspectives. Journal of Cross-Cultural Psychology, 50(10), 1098-1111. doi:10.1177/0022022119889162 Lo, S., & Lie, T. (2008). Selection of communication technologies—A perspective based on information richness theory and trust. Technovation, 28(3), 146-153. doi:10.1016/j.technovation.2007.05.017 Lyngstad, M., Grimsmo, A., Hofoss, D., & Hellesø, R. (2014). Home care nurses' experiences with using electronic messaging in their communication with general practitioners. Journal of Clinical Nursing, 23(23), 3424-3433. doi:10.1111/jocn.12590 Lyngstad, M., Hofoss, D., Grimsmo, A., & Hellesø, R. (2015). Predictors for assessing electronic messaging between nurses and general practitioners as a useful tool for communication in home health care services: A cross-sectional study. Journal of Medical Internet Research, 17(2). doi:10.2196/jmir.4056 Miaskiewicz, T., & Luxmoore, C. (2017). The use of data-driven personas to facilitate organizational adoption - A case study. The Design Journal, 20(3), 357-374. doi:10.1080/14606925.2017.1301160 Merriam-Webster (2017). Interdisciplinary. Retrieved March 3, 2017 from https://www.merriam-webster.com/dictionary/interdisciplinary 106 Mundt, M. P., Agneessens, F., Tuan, W., Zakletskaia, L. I., Kamnetz, S. A., & Gilchrist, V. J. (2016). Primary care team communication networks, team climate, quality of care, and medical costs for patients with diabetes: A cross-sectional study. International Journal of Nursing Studies, 58, 1-11. doi:10.1016/j.ijnurstu.2016.01.013 Notarnicola, I., Petrucci, C., De Jesus Barbosa, M. R., Giorgi, F., Stievano, A., Rocco, G., & Lancia, L. (2017). Complex adaptive systems and their relevance for nursing: An evolutionary concept analysis. International Journal of Nursing Practice, 23(3). doi:10.1111/ijn.12522 Polit, D. F. and Beck, C.T. (2016) Nursing Research Generating and Assessing Evidence for Nursing Practice Tenth Edition. Philadelphia: Wolters Kluwer. Raj, M., Platt, J. E., & Wilk, A. S. (2020). Trust in provider care teams and health information technology-mediated communication. The American Journal of Managed Care, 26(1), 23-25. doi:10.37765/ajmc.2020.42141 Santamaria, N., & Kapp, S. (2013). TeleWound care - providing remote wound assessment and treatment in the home care setting: Current status and future directions. Smart Homecare Technology and TeleHealth, 35-41. doi:10.2147/SHTT.S34353 Sikka, N., Carlin, K. N., Pines, J., Pirri, M., Strauss, R., & Rahimi, F. (2012). The use of mobile phones for acute wound care: Attitudes and opinions of emergency department patients. Journal of Health Communication, 17, 37-43. doi:10.1080/10810730.2011.649161 Texas Tech University Health Sciences Centre (2016). Interprofessional Teamwork. Retrieved March 8, 2017 from https://www.ttuhsc.edu/qep/teamwork.aspx 107 U.K. Department of Health and Social Care. (2018, December 9). Health and Social Care Secretary bans fax machines in NHS. Retrieved June 4, 2020 from https://www.gov.uk/government/news/health-and-social-care-secretary-bans-fax-machines-in-nhs Virtual Care Community of Action. (2019, November). Virtual Care in Canada: Snapshots of Innovative Virtual Care. Digital Health in Canada. Retrieved June 4, 2020 from https://digitalhealthcanada.com/publications/whitepaper-virtual-care-in-canada/ Vowden, K., & Vowden, P. (2013). A pilot study on the potential of remote support to enhance wound care for nursing-home patients. Journal of Wound Care, 22(9), 481-488. Wikberg Nilsson, Å., Fältholm, Y., & Abrahamsson, L. (2010). Reframing practice through the use of personas. Reflective Practice, 11(3), 285-298. doi:10.1080/14623943.2010.487376 Ye, J., Zuo, Y., Xie, T., Wu, M., Ni, P., Kang, Y., Yu, X., Sun, X., Huang, Y., & Lu, S. (2016). A telemedicine wound care model using 4G with smart phones or smart glasses: A pilot study. Medicine, 95(31), 1-6. doi:10.1097/MD.0000000000004198 108 Appendices Appendix A: Demographic Survey Demographic Questions 1. What is your clinical profession?  Registered Nurse  Licensed Practical Nurse  Nurse Practitioner/ Physician  Physiotherapist  WOCN  Other 2. How many years have you been a clinician? ________ 3. What is your FTE?  Full Time  Part Time  Casual 4. What is your year of birth? ________ 5. How many years have you been a clinician in this setting/health unit? ________ 6. What degrees do you have? (select all that are true)  Certificate; Field __________________________________________________  Diploma; Field ___________________________________________________  Bachelor’s Degree; Field ____________________________________________  Master’s Degree; Field _____________________________________________  Doctorate; Field ___________________________________________________  Other Degree/Certifications/Relevant education; Field___________________ 7. Sex:  Female  Male  Transgender  Prefer to not Report 109 8. Frequency of computer use outside of work (select one):  Several times/ day  Once/ day  Several times/ week  Several times/ month  Never  Other ___________________ 110 Appendix B: Interview Questions 1. Please describe the process of communication about wound management in your practice. Probes: • Who do you communicate with? • When do you communicate with them? • How do you communicate with them? • How does technology fit in to this communication process? • How often? • Are there differences in communication around acute or chronic wounds? 2. When you need information about your clients’ wound management/ overall health, what is your process for obtaining it? Probes: • Where do you start? • How do you start? • Why do you look for information? • Who do you ask? o Why do you ask? o How do you ask? o When do you ask? • Patient specific information resources? • What resources do you use? o Why? o How? o When? • Is there a way the process could be improved? 3. Who else do you involve in wound management? Probes: • When would you involve these individual(s)? • How do you involve these individual(s)? • Why do you involve these individual(s)? • Who do you refer to? • Why do you refer to them? • How do you refer to them? • What factors are considered in the referral process? • What information do you include in your referral?
Thesis/Dissertation
eng
Nursing
Vancouver : University of British Columbia Library
Attribution-NonCommercial-NoDerivatives 4.0 International
Graduate
Characteristics of complex adaptive systems in technology-mediated wound care communication processes
Text