Review
Observation of interprofessional collaborative practice in primary care teams: An integrative literature review

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Abstract

Background

Interprofessional collaboration improves patient care, especially for those patients with complex and/or chronic conditions. Many studies examining collaborative practice in primary care settings have been undertaken, yet identification of essential elements of effective interprofessional collaboration in primary care settings remains obscure.

Objective

To examine the nature of interprofessional collaboration (including interprofessional collaborative practice) and the key influences that lead to successful models of interprofessional practice in primary care teams, as reported in studies using direct observation methods.

Design

Integrative review using Whittemore and Knafl's (2005) five stage framework: problem identification, literature search, data evaluation, data analysis and presentation.

Data sources and review method: Primary research studies meeting the search criteria were accessed from MEDLINE, PsycINFO, Scopus, King's Fund and Informit Health Collection databases, and by hand-searching reference lists. From 2005 to 2013, 105 studies closely examining elements of interprofessional collaboration were identified. Of these, 11 studies were identified which incorporated a range of ‘real time’ direct observation methods where the collaborative practice of health professionals was closely observed.

Results

Constant opportunity for effective, frequent, informal shared communication emerged as the overarching theme and most critical factor in achieving and sustaining effective interprofessional collaboration and interprofessional collaborative practice in this review. Multiple channels for repeated (often brief) informal shared communication were necessary for shared knowledge creation, development of shared goals, and shared clinical decision making. Favourable physical space configuration and ‘having frequent brief time in common’ were key facilitators.

Conclusion

This review highlights the need to look critically at the body of research purported to investigate interprofessional collaboration in primary care settings and suggests the value of using direct observational methods to elucidate this. Direct observation of collaborative practice in everyday work settings holds promise as a method to better understand and articulate the complex phenomena of interprofessional collaboration, yet only a small number of studies to date have attempted to directly observe such practice. Despite methodological challenges, findings suggest that observation data may contribute in a unique way to the teamwork discourse, by identifying elements of interprofessional collaborative practice that are not so obvious to individuals when asked to self-report.

Introduction

Interprofessional collaboration has long been considered an essential principle underpinning effective primary health care (World Health Organisation, 1978), but translation into everyday primary care practice continues to be challenging. Care for those with multiple chronic conditions is fast becoming a dominant health burden for primary care (Grumbach and Bodenheimer, 2004); interprofessional collaboration is essential to best care for such patients and makes best use of finite health professional time and expertise (Wagner, 2000).

Despite growing evidence that interprofessional collaboration can improve patient safety (Proudfoot et al., 2007, Velji et al., 2008), patient satisfaction (Proudfoot et al., 2007), improve health care quality and health outcomes (Strasser et al., 2008), increase job satisfaction (Proudfoot et al., 2007) and result in better staff recruitment and retention (Borrill et al., 2000), interprofessional collaboration has been variably adopted in primary care settings (Xyrichis and Lowton, 2008).

There is also a lack of common understanding about what interprofessional collaboration means in relation to patient care, and whether or not it is the same as teamwork (Nancarrow et al., 2013, Øvretveit, 1996, Way et al., 2000, Xyrichis and Lowton, 2008). Ødegard (2006) acknowledges this lack of understanding and suggests Biggs (1997) and Barr et al. (2005), respectively, provide useful terminology for the terms interprofessional and collaboration which, if taken together provide a definition for interprofessional collaboration. Thus the following definition of interprofessional collaboration is used in this paper: An active and ongoing partnership often between people from diverse backgrounds with distinctive professional cultures and possibly representing different organisations or sectors, who work together to solve problems or provide services. We suggest interprofessional collaboration is the umbrella hierarchy term for two further terms: Interprofessional collaborative practice, a term used to describe the elements of interprofessional collaboration implemented in the practice setting and Teamwork, a term which denotes a deeper level of working together in an interdependent way (Fig. 1).

To date the research literature variously and interchangeably uses the following terms when discussing interprofessional collaboration, interprofessional collaborative practice and teamwork: multidisciplinary; interdisciplinary; multiprofessional; interprofessional; transdisciplinary; teams, and teamwork (Xyrichis and Lowton, 2008), although the spectrum of interprofessional collaboration has been well described (Oandasan et al., 2006). This spectrum ranges from independent patient assessment and treatment with minimal information sharing being necessary (multidisciplinary/professional), through to interdisciplinary/professional working (denoting a deeper level of collaboration), with the term ‘transdisciplinary collaboration’ reserved for the most intense health professional engagement necessary in particularly complex situations (Vyt, 2008).

In talking about interprofessional collaboration some writers distinguish between interdisciplinary teams (professional and non-professional team members) and interprofessional teams (professionals only) (Thylefors et al., 2005), but others do not. The term ‘teamwork’ is sometimes applied to ‘deeper’ (Ravet, 2011) or more ‘focused’ (Reeves et al., 2010) levels of collaboration (Ravet, 2011) which seem to be describing interprofessional collaborative practice. Others (Nancarrow et al., 2013) use the term more broadly. Cohen and Bailey (1997) include the role of social systems by defining a team as:

‘a collection of individuals who are interdependent in their tasks, who share responsibility for outcomes, who see themselves and who are seen by others as an intact social entity embedded in one or more larger social systems and who manage their relationships across organisational boundaries’ (p.239).

Thistlethwaite et al. (2012) notes the term teamwork is neutral and requires an adjective to describe its success or not. Manion et al. (1996) described teams as ‘structural units’ but interprofessional collaboration to be “the way people work together cooperatively and effectively” (Manion et al., 1996, cited in McCallin, 2001, p.422).

There is a concomitant difficulty in articulating the essential characteristics of interprofessional collaboration that are significant in primary care settings. Primary care settings provide the “hub from which patients are guided through the health system” (World Health Organisation, 2008, p.11). Primary care settings differ from secondary care settings in their organisation and day to day service delivery; patient care teams are predominately affected by issues of both location and time. In contrast to secondary settings, health professionals in primary care may or may not be co-located, may or may not formally meet together, and team membership inevitably evolves and changes as patient care extends for many months or years (Safran, 2003). The term ‘primary care team’ is therefore used here to describe health professionals who work together in caring for patients in primary care settings. In practice, the term ‘primary care team’ may denote widely variable membership, forms of information sharing and methods of decision making.

Several comprehensive reviews to date have investigated interdisciplinary practice (McCallin, 2001), interprofessional collaboration (San Martín-Rodríguez et al., 2005, Zwarenstein et al., 2009) and interdisciplinary teamwork (Nancarrow et al., 2013). Reviews pertaining specifically to primary care teams include those conducted by Bélanger and Rodríguez (2008), Dinh (2012), McPherson and McGibbon (2010), Ruddy (2005) and Xyrichis and Lowton (2008). All conclude that interprofessional collaboration is complex. Systemic and organisational factors appear as important as more individual interactional factors (McPherson and McGibbon, 2010). As Xyrichis and Lowton noted in 2008; “whilst much attention has been given in exploring teams’ internal processes, less thought is given to exploring how the wider organisations support and promote their teams” (p.150).

Identification, and then consistent implementation of the essential elements of effective interprofessional collaboration in primary care teams that are significant in practice or are in “the black box” (Zwarenstein and Reeves, 2006, p.51) remain difficult to understand.

In recognising that interprofessional collaboration is a phenomenon that is complex and difficult to measure, we postulated that observational studies (where usual workplace practice and behaviour is directly observed) could hold particular promise in advancing understanding of interprofessional collaboration. Observing people in their natural environments not only avoids biases inherent in self-reported accounts (Mays and Pope, 1995), but also allows researchers to systematically observe and record what participants may be unaware of themselves (Furlong, 2010).

This integrated review was therefore undertaken to identify, explore and critically analyse original research studies, where primary data was collected in relation to primary care teams, and where elements of interprofessional collaboration were clearly identified and examined through direct observation methods. Given the well identified need in previous reviews (McPherson and McGibbon, 2010, Xyrichis and Lowton, 2008), to consider processes, structures and organisational support, we were particularly interested in studies where such elements were robustly identified and verified (e.g. linked to specific processes and/or outcomes) in the primary care setting.

The review ultimately focused on studies where elements of interprofessional collaboration were directly observed in primary care teams, and asked the key research question:

What is the nature of interprofessional collaboration and the key influences that lead to successful models of interprofessional collaboration as reported in studies using direct observation methods?

Section snippets

Design

An integrative review method (Torraco, 2005, Whittemore and Knafl, 2005) was chosen as the most appropriate to investigate the area of enquiry – the nature of interprofessional collaboration in primary care teams. Integrative reviews are considered an appropriate method for reconceptualising an established topic area as the literature broadens and for new, emerging or diverse topics where there is limited research (Torraco, 2005). They allow for the inclusion of research studies using both

Problem identification stage

The initial stage of this review comprised exploring and critically analysing contemporary primary research studies investigating interprofessional collaboration within or involving primary care teams. Because of the problematic terminology, an all-encompassing approach was taken to include as many terms relating to interprofessional collaboration as possible but with a focus on collaboration as it relates to several health professionals working together in primary care teams.

As well as

Literature search stage

A comprehensive search of five bibliographic databases (Ovid MEDLINE, PsycINFO, Scopus, King's Fund and Informit Health Collection) was conducted and included papers published between 1 January 2005 and 7 September 2013. The databases were selected to include medicine, nursing and allied health, psychology, social sciences and health policy subject areas.

Because many different terms have been used to describe interprofessional collaboration, interprofessional collaborative practice and teamwork

Data evaluation stage

All 176 papers meeting the refined study inclusion criteria were read thoroughly and evaluated for topic relevance. This process revealed wide variation in the degree to which interprofessional collaboration was investigated. A ranking system was developed to differentiate between studies which focussed on investigating defined elements of interprofessional collaboration in the research question or objectives (ranked – “high”) compared to those studies where interprofessional collaboration was

Data analysis stage

Each of the 11 studies incorporating observation methods were read critically and study details extracted and summarised (Table 1). Direct ‘real time’ observation of the process of interprofessional collaboration (including interprofessional collaborative practice) was undertaken as part of the study design in each case. All studies also collected a range of other non-observation data (e.g. interview data, review of policy documents). The studies were initially analysed by: authors and

Presentation stage (results)

The overarching theme emerging from this set of studies employing direct observation component(s) was the importance of a multi-level approach to achieve frequent shared informal communication. Described previously as ‘bottom up and top down strategies’ (Hjalmarson et al., 2013), and ‘micro and macro activities’ (Welch et al., 2013), we identify two main sub themes as “Top down organisation” and “Bottom up intrinsic factors”. Within these two main sub-themes, further categories emerged (Table 2

Discussion

This integrative review conducted from 2005 to 2013 identified 11 studies which utilised direct observation data collection and analysis (Mays and Pope, 1995) within their study design. All 11 studies also used non-observation methods. The purpose of the review was to determine the nature of interprofessional collaboration and the key influences that lead to successful models of interprofessional collaborative practice and teamwork as reported in studies using direct observation methods. The 11

Conclusion

This integrative review highlights the need to look critically at the body of research purported to investigate interprofessional collaboration in primary care teams and to focus particularly on those which use more objective methods such as direct observation. Numerous studies have now documented a range of individual and contextual factors influencing collaborative practice. However, inconsistent terminology and reliance on self-report methods have hindered the progression of knowledge about

Conflict of interest

The authors declare that there is no conflict of interest.

Acknowledgements

The authors wish to thank the reference librarians at the Wellington Medical and Health Sciences Library, University of Otago, Wellington for their assistance with bibliographic database searching.

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