In 1999, the IOM’s landmark report To Err is Human: Building a Safer Health System, explored the impact of medical errors on clinical outcomes in terms of human lives.1 Importantly, recommendations from that report included establishing interdisciplinary team training and implementing an interdisciplinary, collaborative approach to re-designing complex systems of healthcare delivery. Innovative and inclusive education and training were seen as critical for success because most care is indeed delivered by multidisciplinary, interprofessional teams of people, yet health care training is focused too often on individual responsibilities. In this series, we look at the importance of interprofessional care—and therefore, the continuing education needed to provide that care—in the management of specific disease states.
The Importance of Interprofessional Care in Managing Multiple Sclerosis
Interdisciplinary and interprofessional teamwork is essential in the provision of optimized healthcare.2 Today’s patients have complex health needs and typically require more than one discipline to address issues regarding their health status.3 The division of labor among medical, nursing, pharmacy, and allied health practitioners means that no single professional can ensure delivery of a complete episode of healthcare.2 Interprofessional collaborative practice has been defined as a process which includes communication and decision-making, enabling a synergistic influence of grouped knowledge and skills.3 Collaborative practice happens when multiple health workers from different professional backgrounds work together with patients, families, caregivers and communities to deliver the highest quality of care. It allows health workers to engage any individual whose skills can help achieve local health goals.4
Multiple sclerosis treatment is typically interprofessional – involving medical specialists, specialized nurses, and other paramedical disciplines. Thus, the interprofessional team of health care professionals may include a neurologist, registered nurse specializing in MS, psychologist, physical therapist, occupational therapist, ophthalmologist, rehabilitation specialist, dietician, gastroenterologist, and others. Moreover, as it is largely unpredictable whether or when a specific problem may occur, MS care and counseling should be flexible and personalized.5
Comprehensive, interprofessional care goes beyond the management of disease modifying therapies in MS treatment plans and strives to improve patient outcomes, functionality, and quality of life.6 There is growing interest in the use of lifestyle strategies to support wellness and mitigate disease-related complications in MS, which stems from a growing appreciation of the role of certain comorbidities and lifestyle factors on disease activity, disability, mortality, and overall quality of life.7 Multiple sclerosis affects each patient differently, making a definitive diagnosis and management of symptoms very difficult. Effective symptom management requires an interprofessional team approach. Using the skills and knowledge available from a team of healthcare professionals will help patients navigate the trials and tribulations that follow throughout a life with MS.8
Nurse practitioners (NPs) play an active role in the management of patients with MS via effective monitoring and communication throughout the patient’s treatment regimen and disease course. In the shared decision-making model of MS treatment, NPs ensure that patients understand the implications of their disease-modifying therapies. As patients move through treatments during the course of their disease, the importance of this role increases.9 Delegating parts of the immunotreatment decision-making process to trained nurses has the potential to increase informed choice and participation as well as effectiveness of patient-physician consultations.10
Nurses act as a key element in the process of identification of symptoms.11 Pain, including headaches, lower back pain, neuropathic pain and painful spasms, is a common symptom in people with MS, with a wide prevalence range between 30 and 85%. Pain can significantly interfere with daily activities and employment and affect quality of life.12 Chronic pain in MS is as severe as pain in arthritic conditions and the need for treatment may be underestimated.13 Fatigue in MS is extremely common. It may affect up to 80% of the people with MS, and can be severe in up to 65–70 % of them.14 In clinical practice, MS-related fatigue should be assessed and managed by an interprofessional team involving neurologists, MS nurses, occupational therapists, and physiotherapists.14 Historically, clinicians have recommended less physical activity in order to limit fatigue; however, recent experimental studies suggest that regular exercise provides health benefits with little increase in fatigue. Healthcare providers are encouraged to consider strategies of active listening and careful observation when providing individualized exercise programs for people with MS-related fatigue. In addition, recognition and understanding of the complex nature of fatigue by the interprofessional team might facilitate more positive exercise experiences for this population.15
The promotion of exercise among patients with MS will require resources and strategies that can be readily offered by providers.16 Rehabilitation favorably influences not only symptoms of MS but also functional mobility, activities of daily living, and participation in vocational and social activities. For example, various rehabilitation interventions have been shown to improve balance, walking speed and endurance, aerobic capacity, strength of the extremities, functional independence, and quality of life.6,17–19 Despite unchanging impairment, physical rehabilitation has even shown improvement in disability and had a positive impact on mental components of health-related quality of life perception.20
Implications for rehabilitation anxiety and depression are common in people with MS. Management of mental health needs in people with MS relies on complex decisions made by both people with MS and healthcare professionals.21 As a disease with significant psychosocial challenges, adjustment to these is closely related with effective coping strategies.22 After a diagnosis of immune-mediated diseases like MS, the incidence of psychiatric comorbidity is increased relative to the general population.23 Sexual dysfunction is one of the common symptoms of MS and is often underdiagnosed, especially in women.24
The prevalence of major depression was elevated in persons with MS relative to those without MS and those reporting other conditions. Major depression prevalence in MS for those in the 18- to 45-year age range was high at 25.7%, compared to 8.9% in the general population.25,26 Anxiety disorders are common in patients with MS, with a lifetime prevalence of 35.7%, but are frequently overlooked and under-treated.27 Epidemiological data suggest that the standardized mortality ratio for suicide in MS is approximately twice that of the general population with younger males in the first few years following diagnosis most at risk.28 Mental health and social services play a significant role in developing coping strategies as part of the comprehensive care needs of patients with MS.22
Delivery of interprofessional, collaborative, patient-centered care is key to contemporary healthcare policy. Healthcare settings worldwide are therefore attempting to move away from a traditional organization of care, built around siloes of discipline-based specialization, towards an approach of delivering care through interprofessional teamwork.29,30 When members of the healthcare team understand each other’s professional roles and buy into the need of those roles complementing and depending on each other, the collaboration becomes more effective, thus improving safety and patient outcomes.4
Knowledge of recent clinical trial findings will enhance the delivery of evidence-based care and improve levels of confidence among healthcare providers who treat patients with multiple sclerosis. The collaboration of professionals as an integrated team has shown both disease and quality of life improvement. As these efforts to progress the science of MS management continue, so should the transfer of knowledge and evidence-based clinical practice progress from bench to bedside.
Dr. Pollack is privileged to serve as the Medical Director for AcademicCME, https://academiccme.com/, a joint accredited education provider, where he is able to help develop innovative and engaging multidisciplinary, interprofessional programs aimed at improving patient care. This review of the importance of interprofessional education was initially developed by Michelle Yechout, lead medical writer at AcademicCME.
1. Institute of Medicine (US) Committee on Quality of Health Care in America. To Err Is Human: Building a Safer Health System. (Kohn LT, Corrigan JM, Donaldson MS, eds.). Washington (DC): National Academies Press (US); 2000. http://www.ncbi.nlm.nih.gov/books/NBK225182/. Accessed February 23, 2020.
2. Leggat SG. Effective healthcare teams require effective team members: defining teamwork competencies. BMC Health Serv Res. 2007;7:17. doi:10.1186/1472-6963-7-17
3. Bridges DR, Davidson RA, Odegard PS, Maki IV, Tomkowiak J. Interprofessional collaboration: three best practice models of interprofessional education. Med Educ Online. 2011;16. doi:10.3402/meo.v16i0.6035
4. World Health Organization. Framework for Action on Interprofessional Education & Collaborative Practice.; 2010. http://apps.who.int/iris/bitstream/10665/70185/1/WHO_HRH_HPN_10.3_eng.pdf. Accessed February 26, 2018.
5. Jongen PJ, Sinnige LG, van Geel BM, et al. The interactive web-based program MSmonitor for self-management and multidisciplinary care in multiple sclerosis: concept, content, and pilot results. Patient Prefer Adherence. 2015;9:1741-1750. doi:10.2147/PPA.S93783
6. Sutliff MH, Bennett SE, Bobryk P, et al. Rehabilitation in multiple sclerosis. Neurol Clin Pract. 2016;6(6):475-479. doi:10.1212/CPJ.0000000000000318
7. Moss BP, Rensel MR, Hersh CM. Wellness and the Role of Comorbidities in Multiple Sclerosis. Neurotherapeutics. August 2017. doi:10.1007/s13311-017-0563-6
8. Namaka M, Turcotte D, Leong C, Grossberndt A, Klassen D. Multiple sclerosis: etiology and treatment strategies. Consult Pharm. 2008;23(11):886-896.
9. Roman C, Menning K. Treatment and disease management of multiple sclerosis patients: A review for nurse practitioners. J Am Assoc Nurse Pract. 2017;29(10):629-638. doi:10.1002/2327-6924.12514
10. Rahn AC, Köpke S, Backhus I, et al. Nurse-led immunotreatment DEcision Coaching In people with Multiple Sclerosis (DECIMS) – Feasibility testing, pilot randomised controlled trial and mixed methods process evaluation. Int J Nurs Stud. 2018;78:26-36. doi:10.1016/j.ijnurstu.2017.08.011
11. Fernández-Pablos MA, Costa-Frossard L, García-Hernández C, García-Montes I, Escutia-Roig M, Grupo de enfermeras expertas en el manejo de los síntomas asociados a la espasticidad por EM. [Management of symptoms associated with spasticity in patients with multiple sclerosis]. Enferm Clin. 2016;26(6):367-373. doi:10.1016/j.enfcli.2016.06.009
12. Marck CH, De Livera AM, Weiland TJ, et al. Pain in People with Multiple Sclerosis: Associations with Modifiable Lifestyle Factors, Fatigue, Depression, Anxiety, and Mental Health Quality of Life. Front Neurol. 2017;8. doi:10.3389/fneur.2017.00461
13. Kalia LV, O’Connor PW. Severity of chronic pain and its relationship to quality of life in multiple sclerosis. Mult Scler. 2005;11(3):322-327. doi:10.1191/1352458505ms1168oa
14. Tur C. Fatigue Management in Multiple Sclerosis. Curr Treat Options Neurol. 2016;18(6):26. doi:10.1007/s11940-016-0411-8
15. Smith CM, Hale LA, Olson K, Baxter GD, Schneiders AG. Healthcare provider beliefs about exercise and fatigue in people with multiple sclerosis. J Rehabil Res Dev. 2013;50(5):733-744.
16. Learmonth YC, Adamson BC, Balto JM, et al. Investigating the needs and wants of healthcare providers for promoting exercise in persons with multiple sclerosis: a qualitative study. Disabil Rehabil. 2018;40(18):2172-2180. doi:10.1080/09638288.2017.1327989
17. Nilsagård YE, von Koch LK, Nilsson M, Forsberg AS. Balance exercise program reduced falls in people with multiple sclerosis: a single-group, pretest-posttest trial. Arch Phys Med Rehabil. 2014;95(12):2428-2434. doi:10.1016/j.apmr.2014.06.016
18. Dettmers C, Sulzmann M, Ruchay-Plössl A, Gütler R, Vieten M. Endurance exercise improves walking distance in MS patients with fatigue. Acta Neurol Scand. 2009;120(4):251-257. doi:10.1111/j.1600-0404.2008.01152.x
19. Cattaneo D, Jonsdottir J, Zocchi M, Regola A. Effects of balance exercises on people with multiple sclerosis: a pilot study. Clin Rehabil. 2007;21(9):771-781. doi:10.1177/0269215507077602
20. Solari A, Filippini G, Gasco P, et al. Physical rehabilitation has a positive effect on disability in multiple sclerosis patients. Neurology. 1999;52(1):57-62.
21. Methley A, Campbell S, Cheraghi-Sohi S, Chew-Graham C. Meeting the mental health needs of people with multiple sclerosis: a qualitative study of patients and professionals. Disabil Rehabil. 2017;39(11):1097-1105. doi:10.1080/09638288.2016.1180547
22. Okanli A, Tanriverdi D, Ipek Coban G, Asi Karakaş S. The Relationship Between Psychosocial Adjustment and Coping Strategies Among Patients With Multiple Sclerosis in Turkey. J Am Psychiatr Nurses Assoc. 2017;23(2):113-118. doi:10.1177/1078390316680027
23. Marrie RA, Walld R, Bolton JM, et al. Rising incidence of psychiatric disorders before diagnosis of immune-mediated inflammatory disease. Epidemiol Psychiatr Sci. November 2017:1-10. doi:10.1017/S2045796017000579
24. Bartnik P, Wielgoś A, Kacperczyk J, et al. Sexual dysfunction in female patients with relapsing-remitting multiple sclerosis. Brain Behav. 2017;7(6):e00699. doi:10.1002/brb3.699
25. Patten SB, Beck CA, Williams JVA, Barbui C. Major depression in multiple sclerosis: a population-based perspective. Neurology. 2003;61(11):1524-1527.
26. Kidd T, Carey N, Mold F, et al. A systematic review of the effectiveness of self-management interventions in people with multiple sclerosis at improving depression, anxiety and quality of life. PLoS One. 2017;12(10). doi:10.1371/journal.pone.0185931
27. Korostil M, Feinstein A. Anxiety disorders and their clinical correlates in multiple sclerosis patients. Mult Scler. 2007;13(1):67-72. doi:10.1177/1352458506071161
28. Feinstein A, Pavisian B. Multiple sclerosis and suicide. Mult Scler. 2017;23(7):923-927. doi:10.1177/1352458517702553
29. Interprofessional Education Collaborative. Core Competencies for Interprofessional Collaborative Practice: 2016 Update.; 2016. https://hsc.unm.edu/ipe/resources/ipec-2016-core-competencies.pdf. Accessed February 26, 2018.
30. Liberati EG, Gorli M, Scaratti G. Invisible walls within multidisciplinary teams: Disciplinary boundaries and their effects on integrated care. Soc Sci Med. 2016;150:31-39. doi:10.1016/j.socscimed.2015.12.002