Building Interactive Communication Tools to Support Interdisciplinary Responsible Innovation

How decisions are made and communication is handled are essential to ensuring a good outcome.In the case of Scardoni v Hawryluck,1 Mrs H was an 81-year-old woman with advanced Alzheimer disease, cardiovascular illness, and septic shock whose family and physician could not agree on goals for care, requiring that a legal decision be made regarding the level of care to be provided. Over time and after much discussion, the multidisciplinary team on the intensive care unit (ICU) reached a consensus that intensive care for Mrs H would not improve her condition. So it was decided that after Mrs H was stepped down to a general medical unit, should an infection or respiratory distress develop, she would not be returned to the ICU. The attending ICU physician informed the family that instead of ICU care, “the hospital would offer her palliative care: painkillers and sedatives to keep her comfortable while her afflictions took their course.”2 In this particular case, the patient’s family challenged the health care team’s recommendations and insisted that their mother be readmitted to the ICU so that aggressive life-sustaining treatment would continue.This case, although Canadian, is relevant to ICU settings throughout North America. The purpose of this discussion is not to provide an in-depth ethical analysis, but rather to use the case of Mrs H to characterize one type of health care situation that clinical ethicists could help facilitate. Medical recommendations such as those involved in the care of Mrs H are made to prevent the “revolving door” patient, who according to ICU teams will receive no medical benefit if returned to the ICU. Decisions not to readmit are euphemistically referred to by some ICU staff as the “one-way ticket out of ICU” or “celestial transfer.” Such language shared between colleagues reflects a coping strategy, a “gallows humor,” intended to manage difficult feelings like sadness, anger, grief, sympathy, or moral distress. Cases like that of Mrs H are of particular concern to critical care nursing. Research has indicated that moral distress, a significant contributing factor to burnout, is encountered by ICU nurses when the care they are providing to a patient is regarded as futile.3It is not uncommon for hospital-based clinical ethicists to receive a request for consultation when disputes regarding similar recommendations for care arise between substitute decision makers and the ICU treatment team. These cases can lead to moral distress because of commonly held opinions among team members that futile treatment is being provided. Although staff can provide many life-sustaining treatments to such a patient, ethical questions often arise during the patient’s stay in the ICU. What ought to happen when an ICU team decides that a patient should be transferred to a general medical unit to receive comfort measures only, with no readmission to the ICU? Although teams discuss the practical questions about what can be done, the ethical questions about what ought to be done are sometimes not as clear. The following discussion explores how clinical ethicists can provide valuable assistance with the kinds of ethical challenges these situations customarily present. Particular emphasis will be placed on working within a process-driven, interdisciplinary framework that maintains a communication-oriented approach to ethical decision making.Clinical ethics is a relatively new field, and the role and purpose of clinical ethicists can vary somewhat according to the particular health care setting. For the purpose of this discussion, the authors describe the knowledge, skills, and activities of clinical ethicists through their review of relevant literature as well as their own training and experiences as staff clinical ethicists at 2 acute care settings in Ontario, Canada.Greater legal clarity or legislative measures to specifically address conflicts that arise over withdrawal or withholding of treatment for terminally ill patients are required, according to at least one legal expert. Current Canadian law, according to this same scholar, leaves doctors, patients and their families in a “grey zone” as to who should have ultimate authority on such decisions.4 The daily reality in most North American ICUs is that this gray zone persists—for better or worse. Although hospitals attempt to provide guidelines for addressing conflicts such as the one involving Mrs H, it is the quality of communication and relationship within the interdisciplinary team and between the treating team and the patient’s family that has a marked influence on decision making.5–7 In most cases similar to this one, consensus about level of care is first achieved by the interdisciplinary team, and a subsequent agreement is reached between the treatment team and the patient’s substitute decision maker and family. However, when agreement cannot be reached because of irreconcilable notions pertaining to what constitutes benefit to the patient and what constitutes harm, the results can be uncertain, stressful, and most unsatisfactory for both the health professionals involved and the patient’s family. This combination of an unfortunate turn of events for the patient, sharing of bad news with family members, and the recommendation for care outside of the ICU is a juncture of decision making at which conflict can occur and ethical challenges are most apparent to members of the interdisciplinary team.8,9Much has been written about the difficulties in communication within the ICU and how this affects patient care. Considerable evidence indicates that communication between the ICU team, patients, and patients’ families can be inadequate, leading to conflict and a possible long-term effect on the patient’s family.6,8,10,11 In one study,8 46% of families who had a loved one die in the ICU reported conflict over decisions to withdraw or withhold life-support measures. These family members also reported conflict over the manner in which staff communicated with or behaved toward them. The authors of that study8 cited family members who felt pressured by staff to “hasten their loved one’s death because they placed a burden on valued resources.” The importance of communication between treatment teams and patients and patients’ families cannot be overstated. In addressing the difficulties and deficiencies that have been identified, 2 experts concluded, “communication with caregivers is consistently identified as the most important and least achieved factor in patient/family satisfaction surveys.”12Intensive care is primarily intended to provide maximum benefit to those patients who are likely to recover from their infirmity or trauma.13 When the interdisciplinary team is not clearly communicating ethical considerations as well as the criteria they are using to determine the effectiveness or success of the treatment plan, patients’ families may develop erroneous expectations that life-sustaining interventions will continue to be offered.6 At the same time as a loved one is receiving ICU care with a grim prognosis, families are struggling to come to terms with impending loss. Family functioning or experience in coping with loss,14 unrealistic expectations regarding health outcome, within a societal context of diverse religious or cultural beliefs, can markedly influence families’ decision making about end-of-life care. Such formidable contributing factors further emphasize that effective communication strategies, as well as an appropriate level of sensitivity, ought to be used in ICUs when dealing with patients’ families.11Team communication, in particular communication between disciplines, also has proven problematic in decisions about end-of-life care in the ICU. Critical care nurses have cited difficulties in communication and decision making within interdisciplinary ICU teams. Ferrand et al15 reported that 75% of the nursing staff who participated believed that “collaboration was inadequate during decision making” despite general agreement that such team collaboration is necessary and desired. In another study,16 about one-third of the ICU nurses who participated felt “excluded by physicians from patient care decisions and felt their exclusion to be a detriment to patient care.”In terms of the burdens carried in making decisions about end-of-life care, some evidence suggests that physicians and nurses experience equal burdens. Physicians experience the burdens associated with having to make these decisions, and nurses feel the burden of having to carry out care decisions made by someone else.17 Given the shared burdens that members of the interdisciplinary team face, as well as the reported difficulties in end-of-life care decision making in the ICU, ensuring effective communication is a key feature of high-quality patient care.7 The following discussion is intended to demonstrate how clinical ethicists can be supportive of such strategies for effective communication and decision making.Medical recommendations like those pertaining to the care of patients such as Mrs H are based on best-practice standards of care and are informed by ethical principles like beneficence, nonmaleficence, and autonomy. Continued life-sustaining support in situations where benefit is in question can be regarded as futile, a concept with inherent ethical challenges. As Weijer et al18 point out, the values inherent in medical futility arguments often confuse treatment considered ineffective and treatment that will be effective but will ultimately result in a controversial outcome such as permanent unconsciousness. A team’s decision to not readmit a patient for ICU care can be an attempt to address futility based on controversial outcomes that the team may perceive as causing more harm for the patient than good. Poignantly stated, “if the welfare of the patient is the whole purpose of providing treatment and if that treatment brings needless suffering, then the whole purpose of medicine is defeated.”19 Although the concept of futility in ICU care is a subject worthy of ethical debate, it will not be the focus of this discussion. Rather, the subject of this discussion is the role of clinical ethicists in helping decision makers address ethical considerations such as futility.The results of inadequate communication, misunderstandings, or disagreements arising from divergent views about what is beneficent and the institutional realities surrounding resource allocation can be seen in the moral distress and subsequent moral residue experienced by both the patient’s family members and the health care staff involved. Moral distress occurs when a person can identify the ethically appropriate course of action, but does not feel able to carry this action forward because of barriers that may include lack of resources, legal limits, institutional obstacles, or imbalances in power, for example. Effects of moral distress on an individual can include feelings of anger, frustration, anxiety, or depression.20 Moral residue can be encountered when “deeply held beliefs, values and principles” are set aside at the expense of one’s personal sense of integrity.21 For families of patients, moral residue can manifest in lifelong memories about difficult health care experiences.The experience of moral distress and moral residue are of particular importance to critical care nursing. Some evidence indicates a relationship between an ICU care nurse’s perception of providing futile care, inadequate communication about the care plan within the interdisciplinary team, and the incidence of moral distress, emotional exhaustion, and burnout.3,16,22 Cases like that of Mrs H can present these kinds of challenges to nurses providing care at the bedside. The discussion also highlights how clinical ethicists can assist interdisciplinary teams in addressing ethical challenges that can lead to moral distress.Finally, the ethical climate within our health care settings is shaped by the organizational values inherent in hospital policies, approaches to handling conflict, allocation of human and material resources, the daily-lived experience of staff providing care, and those to whom care is provided.23,24 Economic constraints, resource allocation difficulties, and staffing shortages contribute to the moral climate of health settings, the moral distress of staff, and burnout among health care providers.25,26In cases such as that of Mrs H, the ethical challenges are not just about treatment requests considered inadvisable but also about scarce resources like ventilator-equipped beds in ICU settings. In the minds of some families, the need for an ICU bed is the primary reason that palliative measures are now being recommended. When conflict surrounds decisions about level of care, it is the bedside ICU nurse who fields the questions, concerns, and emotions expressed by patients’ families.It is through such challenging decision making, in which no agreement is reached, that the moral climate is regrettably defined for all persons with a stake in the decision. However oppressive these disagreements feel to both health care professionals and patients’ family members, most often the disagreements, ironically, do not result from a lack of good intentions on either side of the debate. Rather, these circumstances reflect the complex ethical challenges that are inherent in contemporary health care settings. Clinical ethicists can be an important resource to health care teams, patients, and patients’ families in addressing these difficult challenges.Clinical ethicists who provide consultative services may be requested by the ICU team when conflicts such as the one surrounding the planning of Mrs H’s level of care arise. What are the characteristics, skills, and knowledge that make clinical ethicists a useful resource in helping to address conflict over decisions about level of care for stable but critically ill ICU patients?Clinical ethicists come from a diverse background of training: clinical and academic experiences that include but are not limited to medicine, nursing, social work, theology, philosophy, and anthropology. Most clinical ethicists have advanced academic degrees and/or training in clinical ethics. Despite this diversity in background, clinical ethicists engage in common functions: consultative services, research, education and the development of policies pertaining to patient care and organizational ethics.27–29Clinical ethicists are trained to view ethical problems within an interdisciplinary health care environment whose primary commitment should always be to provide the best patient care possible. Patient care and goals for care are best understood through the wishes, beliefs, and values of the patient and the patient’s family. The approach taken by clinical ethicists in providing consultation is to model interdisciplinary collaboration and effective communication with patients and their families, with the objective of enhancing ethical decision making.28–30In effect, clinical ethicists in cases such as the one involving Mrs H act as facilitators of communication and decision making about goals for care, while directing attention to the ethical considerations underlying such decisions. Generally, clinical ethicists can help clarify differences in the way ethical considerations such as sanctity or quality of life are valued on the basis of religious, personal, or cultural values. Some evidence suggests that ethics consultation generally has been useful in preventing or resolving conflicts, and in reducing the incidence of prolonged controversial treatment.31,32 Current trends in the training and education of clinical ethicists have emphasized skills, knowledge, and expertise better suited to provide ethics support in real time as dilemmas and conflict around decisions related to patient care unfold.28What is particularly important about the approach used by most clinical ethicists is the emphasis placed on fair and just processes for decisions of such importance and consequence in an ICU environment.In cases such as the one involving Mrs H, it is not just what decision ought to be made that is of interest to clinical ethicists, but if and why a particular decision is ethically defensible. If so, to whom is it ethically defensible? How ought discussions and conflicts be managed? These questions raise ethical concerns about justice, fairness, and a reasoned approach to decisions of such consequence. Ethical consideration must also be given to the moral climate, how people feel treated, and the concerns and opinions of key persons with a stake in the decision making, with overarching consideration given to trust in the process used to make such important decisions. Therefore clinical ethicists are as concerned with procedural fairness as they are with outcome when assisting with ethically challenging situations in health care settings.Principal aspects of procedural fairness are as follows: that the process for decision making be as transparent as possible to all involved; that concerns of key persons with a stake in the decision making be considered; that the reasons or rationale behind decisions can be understood and defended; that people responsible for decisions be held accountable; and that in the event disagreement occurs, decisions can be reviewed, taking into account the concerns of those who disagree.33 Process-driven approaches to decision making or to resolving conflict used by clinical ethicists are dependent on using frameworks to guide communication. Such frameworks for communication are not just ethically defensible; they have been shown empirically to be part of good practice standards in ICU settings.6,11,34 Lilly et al35(pS398) found that using a standardized framework for communication resulted in health care providers seeing decision making as a “process rather than as an event”—an attribute consistent with principles for ethical decision making.An example of such a framework to guide communication is described by Lautrette et al,34 who identify such attributes as timeliness, opportunities for the patient’s family to speak, use of appropriate and sensitive language, and ensuring that the setting is private and comfortable. In addition to these attributes, clinical ethicists would include discussion of the values in conflict and ethical obligations that underscore decision making.Frameworks for communication appear well supported in the literature anyway, so what makes the involvement of clinical ethicists of added benefit?Despite advances in implementing communication strategies in many settings, improvement in general is needed in managing communication, enhancing understanding, and meeting needs of ICU patients and their families.6,8,10,11 Furthermore, Sherwin36 believes that communication frameworks and hospital policies can be used coercively, to enforce a particular outcome, if those who lead these discussions or who adhere to policies are not reflecting on personal biases, institutional pressures, and ethical considerations.Clinical ethicists act as facilitators, helping to raise important ethical questions, model effective communication, and model ethical decision making by using teachable moments to heighten the awareness and understanding of the ethical considerations in each case. Within most health care settings, necessary and unavoidable imbalances in power are present between various persons who have a stake in the decision making. Clinical ethicists assist in discussing the values that underlie decisions of such importance, making these transparent to and understood by key involved parties. They model the principles of procedural fairness. Inherently challenging decisions about level of care, as in the case of Mrs H, are often met with challenging feelings and opinions, making fairness and ethical reflection more important than less to involved parties.Clinical ethicists advocate for policies and practices that reduce coercive consequences that can arise when members of the ICU treatment team, patients, or patients’ family members feel overruled or dismissed. In conducting an ethics consultation, the clinical ethicist leads discussions with the interdisciplinary team members about ethical considerations that contribute to moral distress, for example, the conflict in the way benefit and harm associated with a particular therapy or level of care are understood. In most instances, the clinical ethicist must ensure that concerns raised by members of the interdisciplinary team and concerns expressed by patients’ family members are shared and considered. This process is handled in an open and transparent manner. In creating an opportunity through the consultative process for the interdisciplinary team to address concerns, related to both areas of conflict and moral distress, clinical ethicists are also capitalizing on valuable teachable moments in which knowledge about ethics and decision making can be enhanced. As Kälvemark Sporrong et al37(p835) concluded, “Ethical competence is a key factor in preventing or reducing moral distress.”We have found that consultation on an individual case often helps treatment teams identify preventative strategies to reduce or avoid conflict and to engage in more timely discussion about ethics the next time a complex care situation arises. Such measures are necessary in creating a moral climate in which discussion about ethics in daily practice can be supported and thus reducing the effects or incidence of moral distress. The potential exists for all members of the interdisciplinary ICU team, including the most responsible physician, to be so engaged in ethical reflection and decision making on challenging cases. Clinical ethicists model skills of effective communication, ethical reflection, and decision making as well as principles of procedural fairness within the consultative process that they facilitate.We are not suggesting that effective communication, procedural fairness, ethical reflection, and decision making are deficient whenever clinical ethicists are not involved in such cases. In reality, complex and ethically challenging cases occur routinely in ICU settings, most often without the involvement of clinical ethicists. What is being proposed is that clinical ethicists should be seen as a valuable resource for addressing challenging cases in the ICU. Better understanding is needed about the role of clinical ethicists and the kinds of assistance they can provide.In most cases, the ICU team and patient’s family agree on recommendations that comfort measures be provided on a medical intermediate care unit or a palliative care unit for a stable but critically ill patient. However, as in the case of Mrs H, these decisions may be met with considerable emotion from the patient’s family and with differences of opinion about benefit and the appropriate level of care. We think that clinical ethicists can be a valuable resource when challenging cases arise. By providing consultation, clinical ethicists can model effective communication, ethical reflection, and decision making, while following principles of procedural fairness, all of which are key elements to upholding ethics in daily practice and are of particular importance when conflict occurs about level of care in the ICU.The following are practical considerations for critical care nurses:

Although interdisciplinary teams are growing in importance, not much research has been conducted to understand the mechanism of collaboration in interdisciplinary teams. In this paper, I investigate this mechanism by (a) underscoring the importance of cognitive issues in interdisciplinary work and collaborative communication, (b) introducing a possible definition and characteristics of Interdisciplinary IQ(I-IQ), (c) reviewing extant literature related to team cognition to see common features and differences compared to I-IQ, (d) delineating antecedents that lead to I-IQ, and (e) discussing contributions and future directions. By providing three antecedents of I-IQ, this framework will benefit future research in interdisciplinary teamwork by providing the characteristics and mechanisms of their communication.

The pace of scientific advancements in medicine, driven by artificial intelligence as much as by novel biotechnologies, demands an ever-faster update of professional knowledge from physicians and collaboration in interdisciplinary teams. At the same time, the increased heterogeneity of patients' lifeworlds in socially and culturally diverse societies requires healthcare professionals to consider diverging personal and cultural perspectives in their treatment recommendations. Both developments require conveying to students a professional virtue that can be summarised as epistemic humility-a teaching process which, we argue, can and should be supported by novel technologies. By embedding students in realistic scenarios, virtual reality can play a crucial role in teaching medical students a stance of epistemic humility. Such stance implies acknowledging the limitations of one's knowledge as well as taking individual patients' perspectives and experiences seriously. In this sense, epistemic humility can also provide a crucial step towards tackling epistemic injustice and biases in medicine. We discuss how teaching epistemic humility with virtual reality tools can succeed and suggest the development of novel teaching tools that make use of this technology to immersively enable moral growth. Our paper thereby contributes to the emerging field of digital bioethics, calls for more work in the area of experimental bioethics and informs ongoing debates on how medical ethics teaching can prepare future physicians for the challenges of tomorrow's practice of medicine.

Professionals from different disciplinary contexts increasingly collaborate combing design approaches and scientific knowledge for innovative solutions to address complex problems. The processes, methods, and tools are important for interdisciplinary design, especially in situations where participants are from non-design backgrounds in the team. Based on the existing literature on the role of boundary objects for ideation and communication in interdisciplinary or collaborative teams. We construct a research framework for non-designers’ interdisciplinary design with boundary objects and introduce material and verbal boundary objects to facilitate the ideation and communication in the design process. This paper gets insight into a)the effect of boundary objects on the communication of non-designers interdisciplinary team; b) the significance of boundary objects for ideation; c) the performance and experience of non-designers in interdisciplinary design using boundary objects. The data was collected in an interdisciplinary collaborative design workshop in two sessions, in which, 40 non-designer participants in 8 teams were asked to ideate for a future transportation conceptual design project based on their expertise and collaboration. By analyzing the utilization of boundary objects, findings suggest that boundary objects support non-designers to ideate in the design process, however, discover the deficiency. According to the findings, an iteration of the theoretic framework and boundary objects will be carried out to support interdisciplinary collaborative design for non-designers further.KeywordsInterdisciplinary designNon-designersBoundary objects

Background: Multisystem disorders in patients that are difficult to solve in a single-specialty approach are becoming more and more a reality to contemporary clinical medicine. A new paradigm of dealing with this complexity has been the emergence of interdisciplinary collaboration. Purpose: The paper will provide five well-chosen clinical cases analyses to investigate the impact of an organized interdisciplinary team (IDT) collaboration on diagnostic accuracy, therapeutic decision making as well as patient outcomes in various fields of diseases. Methods: The retrospective case-series approach was selected and involved the examination of inpatients treated using formal IDT consultations in three tertiary-care hospitals between January 2022 and December 2023. Cases were sampled to reflect cardio metabolic, neuro-infectious, ophthalmological, musculoskeletal-geriatric, and autoimmune cases. Findings: In all five cases, IDT was improved by delivering a structured management, which resulted in feasible clinical gains achieved, including 30-day readmission prevention, glycaemic control, neurologic, regained ambulation, and remission of an autoimmune disease. Some of the common facilitating factors were shared care plans, joint specialist ward rounds, and goal setting with patients. Some of the barriers experienced included scheduling conflicts, fragmentation of electronic health records, and role ambiguity. Inference: Multi-disciplinary teamwork with a structure is related to optimal clinical outcomes in multisystem disease. Both spread clinical translation and broad clinical translation will be fundamentally dependent on investment in communication infrastructure and formal training in IDT.

Developmental dyslexia is the common term for the neurobiological disorder known as “Specific Learning Disorder in Reading” in the Diagnostic and Statistical Manual 5. It is believed that 14% of students in the United States of America have this diagnosis (Dyslexia Basics - International Dyslexia Association, n.d.). Dyslexia can significantly impact the academic, vocational, social, and emotional aspects of a person’s life, disrupting their meaningful engagement in occupations. Because dyslexia is a complex language disorder with multiple phenotypes and symptoms, no one profession can address all areas of difficulty. Occupational therapists are often brought into interdisciplinary teams in schools to support the writing of students with dyslexia. Historically occupational therapists have worked within a very limited scope, most commonly to address the individual prerequisite components of writing, such as visual motor and perceptual skills, fine motor skills, cognitive and executive function skills, and sensory processing skills (Grajo & Gutman, 2019.) Given the broad range of skills and practice scope that occupational therapists have, and in keeping with the current emphasis on top-down approaches and consideration of how literacy impacts the child's life role as a student, it is time for occupational therapists to consider best practice for occupational therapy interventions in supporting the occupation of transcription for students with dyslexia. Objective A scoping review with narrative synthesis was conducted to ascertain the strategies being used currently to improve the writing of students with dyslexia. The knowledge gained from the review was used to inform the overarching aim of this thesis: To guide occupational therapists and speech-language pathologists working under an interdisciplinary team model in supporting the occupation of transcription for students with dyslexia. Method Articles for this scoping review were identified through a computerized search of five electronic databases accessible by the Otago Polytechnic library: PubMed, ProQuest Central, Taylor and Francis, Cinahl, and ERIC. To ensure current and relevant information was considered, each article's date of publication was within ten years of the current year, 2010 - 2020. The literature search procedure was complimented by manually scanning the reference lists of retrieved articles. This identified two articles outside the inclusion dates. Because these articles were named in multiple reference lists, they were considered relevant and important to current thinking and thus included. Articles were evaluated according to predetermined criteria for inclusion at the title, abstract, and article levels. Seven articles were selected for review. Descriptive content analysis was used to map the current use of strategies and interventions. Results This scoping review identified that the strategy currently used and recommended to improve the writing of students with dyslexia is interdisciplinary team collaboration, including and prioritizing the student's family, individualizing, and providing explicit multi- component interventions. The necessity of understanding the language and interpretations of other professionals in the field in order to be an effective and respected team member was highlighted. The purpose of this review was to use the new knowledge to guide occupational therapists and speech-language pathologists working under an interdisciplinary team model in supporting the occupation of transcription for students with dyslexia. It is very clear from the findings that it is time for occupational therapists to reconsider their current roles and create the opportunity to increase their functional role in literacy. There is plenty of space in this complex field for occupational therapists to upskill and embrace literacy holistically while remaining within their scope of practice.

BackgroundThere are few studies that examine the processes that interdisciplinary teams engage in and how we can design health information systems (HIS) to support those team processes. This was an exploratory study with two purposes: (1) To develop a framework for interdisciplinary team communication based on structures, processes and outcomes that were identified as having occurred during weekly team meetings. (2) To use the framework to guide 'e-teams' HIS design to support interdisciplinary team meeting communication.MethodsAn ethnographic approach was used to collect data on two interdisciplinary teams. Qualitative content analysis was used to analyze the data according to structures, processes and outcomes.ResultsWe present details for team meta-concepts of structures, processes and outcomes and the concepts and sub concepts within each meta-concept. We also provide an exploratory framework for interdisciplinary team communication and describe how the framework can guide HIS design to support 'e-teams'.ConclusionThe structures, processes and outcomes that describe interdisciplinary teams are complex and often occur in a non-linear fashion. Electronic data support, process facilitation and team video conferencing are three HIS tools that can enhance team function.

Over the last decades there is an increasing interest “in digging into” the vast amount of MRI data collected by modern scanners. In neuroradiology, the classic approach of looking at the images of different sequences, assigning qualitatively signal intensities to normal tissues or to disease processes, measuring dimensions and several other metrics, like relaxation times (T1, T2), diffusion tensor imaging scalars (FA, ADC, AD, RD), perfusion (CBV, CBF, MTT) and magnetisation transfer imaging (MTR) continues to represent the fundamentals of our everyday practice. However, the improvement of the MRI technology provides subtle information at a voxel level, undetected even by the most keen, expert neuroradiologic eye, waiting to find its way out. If we really want to take full advantage of our data, we must admit that neuroimaging has become not a “one man’s show” but rather an interdisciplinary team reminiscent of a small orchestra consisting of neuroradiologists, computer scientists, medical physicists and engineers. The first step to a successful performance of such an orchestra is to create a common language, understandable to all parties, to express clearly “what I need to know and why” and “what I can offer and which are the limitations”. This requires continuous education and learning of the basic principles, methods and ideas of the other disciplines. As a conductor, you are not required to play all the organs in the orchestra, but you should be able to coordinate them and evaluate their fine tuning and output. In the United States National Institutes of Health (NIH) Roadmap for Medical Research, it is noted that interdisciplinary team science broadens the scope of investigation into biomedical problems, yields fresh and possibly unexpected insights, and gives rise to new inter-disciplines that are more analytically sophisticated [1]. According to the NIH Roadmap, the traditional divisions within health research can impede the pace of discovery. There are numerous examples of the fruitful fusion of neuroradiology with other disciplines. Engineering for example has recently produced hybrid systems (PET/MRI, PET/CT), with potential to change medical imaging by providing combined anatomical-metabolic image information. Computer science has always been both a loyal servant and a driving force to radiology in all aspects of image reconstruction, visualisation, analysis and storage. Mathematics and informatics along with medical physics and biophysics have been able to provide detailed models of brain anatomy and function and extract information buried in noise or reveal complex relationships, hidden patterns and unexpected trends in the brain data. New fields (radiomics, connectomics) with their own bizarre creatures (textures, graphs, multivariate patterns, independent components) invade and challenge our conceptual framework. We strive to harness the power of the new tools, but we will never succeed alone. We need to reach out for help, to assemble a team that integrates information, techniques, perspectives, concepts, to advance fundamental understanding and solve problems whose solutions are beyond the scope of a single discipline or area of research practice. Working alone is based on a common misconception that math and computers are never wrong, and you only have to buy or download a program and feed it with images to get the correct results. There are many reasons why this is not true. Devil is in the details and you need help from other disciplines to discover him. Never forget that both neuroimaging data and their analysis algorithms, despite their sophistication, remain essentially crude anatomical or physiological models of the human brain, the most complicated object in the known universe. They provide approximations of reality based on various assumptions and, although they are inherently wrong, we use them as extremely useful diagnostic and research tools. Our duty as neuroradiologists is to keep in mind these approximations and assumptions during our assessments. Take for example the tractography maps every modern MRI scanner produces with a few mouse clicks. They are beautiful and impressive 3D representations of the white matter tracts but their production is based on the simplified ellipsoid model of probability for water molecule diffusion and on the streamline algorithm. Both provide a good approximation only in the case of large parallel dense fibers. Additionally, diffusion images have been acquired with specific intensity of the diffusion gradients, which restrict the detection window of the diffusion processes. Add on top of that susceptibility and eddy currents distortions, subject motion, noise effect on quantification, partial volume effects [2] and the initial enthusiasm for the colourful tractography maps will soon be tempered. Every day neuroradiologists make hundreds of decisions impacting the well-being of their patients. Their job becomes increasingly challenging as the growing amount of images increases the workload, slows the reading time and undermines the diagnostic accuracy. New imaging technologies can alleviate the pressure and bring enormous benefits to the patients. They also present new opportunities to expand neuroradiologists’ role as public health providers, but they require a remarkable transition in the working environment. A collaborative team can help them to face the new challenges, establish their pivotal role in the healthcare system, and provide faster, more efficient and more accurate interpretation services. Contrary to the speculations that Artificial Intelligence might one day replace (neuro)radiologists, we believe that the only neuroradiologists whose jobs may be threatened are the ones who refuse to become collaborative interdisciplinary team leaders and embrace the new technologies. According to a popular quote: “We cannot direct the winds, but we can adjust our sails”. It would benefit our careers but more importantly the lives of our patients

Hospice programs rely on interdisciplinary team (IDT) collaboration in the delivery of quality care at the end of life. The hospice philosophy advocates patient autonomy in decision making, and treatment of the patient and family as a unit of care. Including patients and families in IDT meetings regarding their care is a logical corollary of this philosophy. Hospice professionals in one Midwestern US state were interviewed by phone to determine the extent of patient and family involvement in their IDT meetings. A few programs had direct experience with patients and families attending IDT meetings, but attendance was not routine. Better communication was recognized as a potential benefit. The patient's frailty and the burdens of caregiving for the family were noted challenges to participation. Video-mediated communication is offered as a potential solution.

Historically, higher education institutions have been designed with a focus on developing mastery and furthering the body of knowledge within distinct academic disciplines. Unfortunately, this intended design has resulted in a lack of collaboration between academic units and has stifled interdisciplinary research between students and faculty across domains. The Luminosity Lab, located at Arizona State University, is an archetype for a new model of collaborative interdisciplinary research teams. Exceptional students are hand-selected from all areas of the university and come together to fuse youthful spirit, academic prowess, and business acumen—the makings of a 'great group.' Students work together to produce system-level projects that are capable of having a large-scale societal impact. Building upon concepts from systems engineering, the lab employs the use of a view model to analyze current and future systems from various viewpoints (e.g., enterprise, functional, computational, engineering, technology, services, standards). By leveraging the strengths of systems thinking, strategic design, and agile methodologies, our interdisciplinary team is positioned to tackle systemic challenges in domains such as healthcare, energy, education, and global climate. This model of interdisciplinary research was tested at Arizona State University across three academic years with participation from over 100 students, who represented more than 20 academic disciplines. The results have shown successful integration of interdisciplinary expertise to identify unmet needs, design innovative concepts, and develop research-informed solutions. By adopting this approach, higher education institutions can begin to break down the walls that exist between academic units and start to use a holistic view of research and innovation for solving global issues.

Introduction: In partnership with the Ministry of Health (MoH) and the Ministry of Labour and Social Protection (MoLSP), local public authorities, practitioners and civil society, NCD patients, formal and informal carers, Moldova is taking strides to ensure health and social services better meet the needs of vulnerable persons with chronic conditions. This is critical given the multiple crises facing the country and demographic changes (aging, high out-migration). To better integrate care the SDC Healthy Life project has built capacities and undertakes advocacy, including through participatory Policy Round table events, changes in legislative and normative acts, in line with EU succession, while also supporting practical application, interdisciplinary coordination and interventions across the health and social sectors. Methods: The project established a system for continuous support in implementation of integrated community care models for persons with noncommunicable diseases to be better cared for in their own communities. The process includes sectoral training of the Primary Health Teams (managers, family doctors, community nurses), training of the multidisciplinary community teams, support in development and implementation of the Plans for Integration of Community Care Services, practical support and supervision, collection of data and assessment of results. Multidisciplinary teams now apply integrated care that touch prevention, treatment, long-term care, home care, and primary palliative care. Learning from experiences in the social sector (e.g. with vulnerable children) common working tools and procedures are used to assess the needs of NCD patients and involve them along entire intervention process, as well as align eligibility criteria for health and social support, coordination within case management, data exchange, reciprocal referral, and joint follow-up and assessment of results. Results: After a range of introductory activities involving both MoH and MoLSP, all 35 districts of Moldova and 70 community teams have been involved in capacity building activities and supervision towards more integrated care. In the period of 2020-2023 sectorial training was delivered to 1.513 primary health care professionals and intersectoral to 709 members of community teams. The regular support in implementation is ensured for all teams. Additionally, these were supported to develop action plans that are implemented using a cascade principle to new pilot communities. Results from 2022 show that coordination of casework has improved, the roles and responsibilities of each actor are better known, the inefficiencies and duplications have been reduced. However, there are differences between the progresses made according to the level of interest, noting that there is a strong human factor to the issue of case management. Conclusions: Strengthening leadership and capacity of local implementers and promoting team approaches is fundamental. Successful districts have also applied the approach during the pandemic to maintain home visits to NCD patients that were high risk and could not visit health facilities. Further investments need to be made to better train professionals in integrated care principles, teamwork and communication, as well as meaningful collaboration with communities. Institutionalization of the developed training modules and interdisciplinary learning and work also remain pivotal, along with the approval of legal and normative frameworks to support integrated care.

Job satisfaction and retention of healthcare staff remains an ongoing issue in many health systems. Huddles have been endorsed as a mechanism to improve patient safety by improving teamwork, collaboration, and communication in teams. This study aims to synthesises the literature to investigate the impact of huddles on job satisfaction, teamwork, and work engagement in multidisciplinary healthcare teams. Five academic databases were searched to conduct a systematic review of peer-reviewed literature published from January 2000 to January 2020. Articles were included if they (1) featured a daily huddle, were conducted in a healthcare setting, and involved a multidisciplinary team and (2) measured variables including job satisfaction, work engagement, or teamwork. Results were reported in accordance with the systematic synthesis without meta-analysis and preferred reporting items for systematic reviews and meta-analysis guidelines. We identified 445 articles of which 12 met the eligibility criteria and are included in this review. All 12 included studies found a predominantly positive impact on teamwork and job satisfaction. None of the studies discussed or reported evidence of the impact of huddles on work engagement. This review highlights the value of a daily multidisciplinary healthcare team huddle in improving job satisfaction and teamwork for the healthcare staff involved. However, there is a dearth of high-quality, peer-reviewed evidence regarding the direct impact of huddles on job satisfaction, teamwork and in particular on work engagement. Further research-particularly controlled studies on adoption, implementation and outcomes for healthcare team culture-is needed to further assess this intervention.

This paper is a report of a study conducted to refine, shorten and validate the Healthcare Team Vitality Instrument. The Healthcare Team Vitality Instrument was developed to assess team vitality of nurses as well as other licensed and unlicensed personnel working as part of healthcare teams in inpatient hospital units. This instrument was necessary for two reasons. First, other commonly used instruments assess characteristics of Registered Nurses or perceptions about and characteristics of the organizations in which they work, but not these factors in combination with critical factors of interdisciplinary team functioning and collaboration. Second, a short tool for repeated, regular measurement of team vitality was needed to track the impact of changes to improve work environments. Revisions to the Healthcare Team Vitality Instrument occurred in two phases. Phase 1 entailed collecting preliminary data and conducting cognitive interviews to refine the initial items. During Phase 2, the factor structure of the Healthcare Team Vitality Instrument was identified and a brief form developed and validated. Data were collected in 2006 and 2007. Exploratory factor analyses suggested a four-factor solution with the following dimensions: (1) support structures, (2) engagement and empowerment, (3) patient care transitions and (4) team communication. The Healthcare Team Vitality Instrument can contribute both to better management practices and advancing knowledge to promote retention of nurses, and to some extent other healthcare professionals, as well as efforts to transform the acute healthcare work environment.

Abstracts from theCenter to Advance Palliative Care National Seminar Pathways to Quality Palliative Care<i>November 13–15, 2014</i><i>Orlando, Florida</i>

Background: Mycobacterium tuberculosis is the primary causative agent of tuberculous spondylitis (TB spondylitis), a chronic granulomatous inflammatory disease of the spine. Patients with TB spondylitis may have spinal lesions in up to 50% of cases, and 10-45% may also have neurological deficits. We reported a case of severe paraplegia manifesting TB spondylitis in a young adult patient. Case Presentation: A 28-year-old female Javanese Muslim was admitted to Dr. Soetomo General Academic Hospital in Surabaya, Indonesia with back pain, inability to move, and feeling stiff in both legs. During previous therapy, the patient was thought to have spondyloarthropathy. X-ray examination demonstrated T9 to T10 retrolisthesis and T10 corpus lipping. Thoracolumbosacral MRI with contrast revealed that the patient had TB spondylitis. A debridement and hemilaminectomy of T7-8 for fusion with bone segments at T7-8 were performed on the patient. The patient was treated with oral antituberculosis drugs for 10 months and could walk perfectly 8.5 months after the initial treatment. Conclusion: This case demonstrates the complexities of diagnosing TB spondylitis, which necessitates the use of multiple disciplines. Because the clinical manifestations of TB spondylitis differ, various methods, including thoracolumbosacral X-ray and MRI with contrast, are required to confirm the disease. As a result, an interdisciplinary collaborative team is required to achieve optimal patient outcomes and to prevent long-term sequalae.