First Edition a 2013 Doody’s Core Title and AJN Book of ...

COMPREHENSIVE SYSTEMATIC REVIEW

for ADVANCED PRACTICE NURSING

COMPREHENSIVE SYSTEMATIC REVIEW for ADVANCED PRACTICE NURSING

COM

PREHEN

SIVE SYSTEMATIC REVIEW

for A

DVA

NCED

PRACTICE NU

RSING Cheryl Holly

Susan SalmondMaria Saimbert

E D I T O R S

Cheryl Holly, EdD, RN, ANEF, FNAP • Susan Salmond, EdD, RN, FAAN Maria Saimbert, PharmD, MSN, MLIS, RN

E D I T O R S

Holly · Salm

ond Saim

bert

First Edition a 2013 Doody’s Core Title and AJN Book of the Year Award Winner!

This text provides top-tier guidance for DNP students, graduate faculty, APRNs, and other health care providers on how to use available research for improving patient outcomes and reducing costs. It is the only resource written expressly to meet the objectives of DNP courses. This second edition is completely updated and

features three new approaches—umbrella reviews, mixed-method reviews, and other types of reviews—for seeking, synthesizing, and interpreting available evidence to improve the delivery of patient care. The text also includes two new examples of completed systematic reviews and two completed proposals.

The book presents, clearly and comprehensively, the knowledge and skills necessary to conduct a foundational comprehensive systematic review (CSR). It encompasses the complexities of the entire process, from asking clinical questions to getting the evidence into practice. The text includes question-specific methods and analysis and compares CSR methods, literature reviews, integrated reviews, and meta-studies. It describes how to find and appraise relevant studies, including the non-published “grey” literature and criteria for selecting or excluding studies, and describes how to use the results in practice. Also examined are ways to disemminate findings to benefit clinical practice and support best practices, and how to write a CSR proposal, final report, and a policy brief based on systematic review findings. Plentiful examples, including two completed proposals and two completed systematic reviews, demonstrate every step of the process. An expanded resource chapter that can serve as a toolkit for conducting a systematic review is also provided. The text covers useful software and includes objectives, summary points, end-of-chapter exercises, suggested reading, and references.

NEW TO THE SECOND EDITION:• Three new chapters presenting new systematic review approaches: umbrella reviews, mixed-method

reviews, and other types of reviews including rapid and scoping reviews and reviews of text and opinion

• Two new examples of completed systematic reviews

• Completely updated content throughout

• Detailed information to foster systematic review research question development, efficient literature searches, and management of references

KEY FEATURES:• Delivers the knowledge and skills necessary to conduct a CSR from start to finish

• Serves as the only CSR resource written expressly for the APRN

• Describes useful software for conducting a systematic review

• Provides rich examples including two completed CSRs

• Includes objectives, summary points, end-of-chapter exercises, suggested reading, and references

• Accompanied by a comprehensive toolkit of resources for completing a systematic review

SECOND EDITIONSECOND EDITION

SECOND EDITION

11 W. 42nd Street New York, NY 10036-8002 www.springerpub.com

9 780826 131850

ISBN 978-0-8261-3185-0

Compliments of Springer Publishing Company, LLC

■■ Background

Interprofessional collaborative practice (IPCP) is thought to be key to attaining optimal patient health outcomes. Interprofessional education (IPE) and inter-professional practice (IPP) are interventions designed to improve IPCP and help reach the ultimate goal of better patient health outcomes (Reeves et al., 2011). Yet the relationship between IPCP and patient health outcomes remains poorly understood. The quantitative evidence on this phenomenon has been reviewed many times. Systematic reviews (SRs) have overwhelmingly demonstrated that IPE initiatives lead to improvements in the IPCP educational outcomes of knowledge, attitudes, and beliefs (Lapkin, Levett-Jones, & Gilligan, 2013) and in the IPCP health care outcomes of behaviors, organizational practice, provider and patient satisfaction (Reeves, Perrier, Goldman, Freeth, & Zwarenstein, 2013; Reeves et al., 2008). An SR has also demonstrated that IPP interventions lead to changes in health care outcomes such as length of stay (Merrick Zwarenstein, Goldman, & Reeves, 2009). A scoping review performed by the National Cen-ter for IPP and Education (NCIPE) identified approximately 500 new research studies, including qualitative and quantitative studies, that are related to this topic since the year 2008 (Brandt, Lutfiyya, King, & Chioreso, 2014). However, a search of the Joanna Briggs Institute (JBI) Library of Systematic Reviews and Implementation Reports, the Cochrane Library, and Google Scholar revealed that the qualitative studies on this phenomenon have not been reviewed using SR methods, despite their availability in the literature.

Although the scoping review from the NCIPE included qualitative studies, we believe that a scoping review does not produce the type of high quality pooled evidence needed to guide practice and future research on this important topic, as it does not provide an appraisal of the methodological quality of studies, and it does not synthesize the data from those studies in order to increase the

Interprofessional Collaboration and Health Outcomes: A Systematic Review and Meta-Synthesis

Yuri T. Jadotte, Cheryl Holly, Sabrina M. Chase, Arthur Powell, and Marian Passannante

20

Copyright Springer Publishing Company, LLC

426 VI I . Examples of Systemat ic Rev iews

generalizability or transferability of the results or findings for best practice and future research recommendations (Arksey & O’Malley, 2005; Davis, Drey, & Gould, 2009). It is these added tasks, explicit to SRs, that we sought to accom-plish here, using the JBI method of meta-aggregation (JBI, 2014).

The Institute for Healthcare Improvement (IHI) Triple Aims framework guided the conduct of this review. Promulgated in 2008, this framework pro-poses that there should be a link between any health care delivery models or interventions (such as IPE and IPP) and the patient experience of care, popula-tion health outcomes, and per capita costs. We adopted the NCIPE’s approach (Brandt et al., 2014) in framing this SR, such that only studies from 2008 to the present were sought and, if relevant, included. The objective of this review was to synthesize the best available qualitative evidence on the relationship between IPCP and patient health outcomes. Specifically, this SR asked the following ques-tion: How does IPCP affect patient health outcomes?

■■ Methods

INCLUSION CRITERIA

Types of StudiesThis review considered all qualitative research designs, such as grounded theory, phenomenology, ethnography, action research, and other community-based participatory research methods.

Types of ParticipantsStudies that had any health care stakeholders as participants were included. This could include patients, health care professionals, health care policy adminis-trators, or any other type of individual who normally has a direct involvement in the provision of health care. However, the study sample must have been inter-professional in nature. This means that the participants must have originated from at least two of the health care professions, and they must have been either observed for or have discussed IPCP as an integral component of their partici-pation in the study, or have been engaged in an IPE or IPP activity before or during the study.

Phenomenon of InterestStudies that explored the key phenomenon identified in the research ques-tion were included. Specifically, studies must have explored the experiences, perceptions, views, attitudes, or beliefs of participants regarding how IPCP affects patient health outcomes.

ContextWe included qualitative studies that examined the phenomenon of interest in any health care setting, such as hospitals, clinics, home care, long-term care, and so forth.


20. In terprofess ional Co l laborat ion and Heal th Outcomes 427

FINDING AND ASSESSING STUDIES: SEARCH STRATEGY, STUDY SELECTION, AND METHODOLOGICAL APPRAISAL

A three-step search strategy was implemented. First, a search of MEDLINE and CINAHL (Cumulative Index to Nursing and Allied Health Literature) was done using an initial list of key words, generated from a concept map based on the research question to identify additional key words and index terms that may have been missed during the generation of the initial list of key terms. Second, this broader list of key terms was used to search all the major databases of interest. Finally, the reference lists of studies considered for inclusion were searched for additional potentially relevant studies. To identify IPE/IPP studies consistent with the IHI’s Triple Aim framework, we sought studies published between 2008 and 2014. The initial key words included terms related to socioeconomic status, minority populations, and the urban setting, as we aimed to try to also capture the evidence as it pertains to these factors and their possible influence on the relationship between IPCP and patient health outcomes. Hand searching of relevant specialty-specific journals (i.e., Journal of Interprofessional Care and Journal of Research in Interprofessional Practice and Education) was not war-ranted, as articles from these journals are archived in the major databases. Details on the exact search strategy used for each of the databases are presented in Table 20.1.

Two reviewers screened all identified articles to determine if they met the inclusion criteria (first by title and abstract, and then by examination of the full texts of the articles), and assessed all studies that passed the screening phase for methodological validity, using the JBI critical appraisal checklist for quali-tative studies (JBI, 2014). Studies were included if they met at least half (50%) of the methodological criteria in this critical appraisal tool, which was the threshold established a priori in this review for a decision on inclusion.

SYNTHESIZING THE EVIDENCE: DATA EXTRACTION AND META-SYNTHESIS

Data were extracted from the included studies using the JBI data extraction tools for qualitative studies (JBI, 2014). Extracted data included detailed information on the population (i.e., types of health care professionals, type of health care model), phenomenon of interest, and practice setting/context. Study findings/themes with relevant textual illustrations were extracted from the included qualitative studies for synthesis. We pooled all qualitative findings into a meta-synthesis, using the meta-aggregation approach (JBI, 2014). Data synthesis in this approach is a three-step process involving: extraction of all findings from all included studies with an accompanying illustration and establishing a level of credibility for each finding, development of categories for findings that are sufficiently similar with at least two findings per category, and development of one or more synthesized findings of at least two categories.



TABLE 20.1 DATABASE SEARCH STRATEGIES

MEDLINE Search Strategy and Results September 16, 2014—Updated June 9, 2015

Item Search Terms Results

1 (Interprofessional or IPE or IPP or collaborative practice or interprofessional relations).mp. [mp=title, abstract, original title, name of substance word, subject heading word, key word heading word, protocol supplementary concept word, rare disease supplementary concept word, unique identifier]

45,975

2 (disparities or health disparities or health care disparities or urban or disadvan-taged or socioeconomic or social status or poor or minority or Black or Latino).mp. [mp=title, abstract, original title, name of substance word, subject heading word, key word heading word, protocol supplementary concept word, rare disease supplementary concept word, unique identifier]

683,439

3 (health outcomes or disease or illness or patient health or death or mortality or heart or infarction or stroke or chronic or infection or hospital).mp. [mp=title, abstract, original title, name of substance word, subject heading word, key word heading word, protocol supplementary concept word, rare disease supplementary concept word, unique identifier]

5,906,959

4 1 and 2 and 3 593

5 limit 4 to yr = “2008–Current” 236

CINAHL Search Strategy and Results September 17, 2014—Updated June 9, 2015


S1 TX (Interprofessional or IPE or IPP or collaborative practice or interprofessional relations) AND TX (disparities or health disparities or health care disparities or urban or disadvantaged or socioeconomic or social status or poor or minority or Black or Latino) AND TX (health outcomes or disease or illness or patient health or death or mortality or heart or infarction or stroke or chronic or infection or hospital)

Limiters: Published Date: 20080101-20141231; English Language; Human

Narrow by SubjectMajor: physician attitudes

Narrow by SubjectMajor: nurse–physician relations

Narrow by SubjectMajor: attitude of health personnel

Narrow by SubjectMajor: teamwork

Narrow by SubjectMajor: multidisciplinary care team

Narrow by SubjectMajor: nurse attitudes

Narrow by SubjectMajor: education, interdisciplinary

Narrow by SubjectMajor: collaboration

Narrow by SubjectMajor: interprofessional relations

Search modes: Boolean/Phrase

417

(continued)



■■ Results

DESCRIPTION OF STUDIES

The search yielded an initial number of 1,180 articles. No new articles were iden-tified by searching the citations of papers that met the inclusion criteria. From this final pool of 1,180 papers, 96 duplicates were removed, and the remaining 1,084 studies were screened by title and abstract. A total of 1,006 papers were excluded, leaving 78 papers to be examined via full review of the text of the studies. Ten studies met all inclusion criteria and were subjected to method-ological appraisal. One study was excluded on the basis of poor methodological quality based on the JBI appraisal tool. Therefore, nine qualitative studies were included in this review. See Figure 20.1 for the PRISMA flow chart that docu-ments the search strategy.

METHODOLOGICAL QUALITY

Of the 10 qualitative studies identified, nine met at least half of the method-ological criteria (Adams, Orchard, Houghton, & Ogrin, 2014; Bajnok, Puddester, Macdonald, Archibald, & Kuhl, 2012; Bradley Eilertsen et al., 2009; Chong, Aslani, & Chen, 2013; Eloranta, Welch, Arve, & Routasalo, 2010; Fredheim, Danbolt, Haavet, Kjonsberg, & Lien, 2011; Goldman, Meuser, Rogers, Lawrie, &

Web of Science Search Strategy and Results September 17, 2014—Updated June 9, 2015


S1 TOPIC (Interprofessional or IPE or IPP or collaborative practice or interprofessional relations) AND TOPIC (disparities or health disparities or health care disparities or urban or disadvantaged or socioeconomic or social status or poor or minority or Black or Latino) AND TOPIC (health outcomes or disease or illness or patient health or death or mortality or heart or infarction or stroke or chronic or infection or hospital)

Indexes = SCI-EXPANDED, SSCI, A&HCI Timespan = 2008–2014

349

ProQuest Dissertations and Theses Database Search Strategy and Results September 21, 2014—Updated June 9, 2015


(Interprofessional) AND (disparities or health disparities or health care disparities or urban or disadvantaged or socioeconomic or social status or poor or minority or Black or Latino) AND (health outcomes or disease or illness or patient health or deaths or mortality or heart or infarction or stroke or chronic or infection or hospital)

Additional Limits: Full text; Date: From January 01, 2008 to December 31, 2014; Language English

177

CINAHL, Cumulative Index to Nursing and Allied Health Literature; IPE, interprofessional education; IPP, interprofessional practice.

TABLE 20.1 DATABASE SEARCH STRATEGIES (continued )



Reeves, 2010; Hjalmarson, Ahgren, & Kjölsrud, 2013; Maneze et al., 2014). Most studies used an unspecified qualitative descriptive methodology, except one study that used a grounded theory methodology to conduct a research-based qualitative evaluation of a new program (Bajnok et al., 2012). None of the studies met three of the methodological rigor criteria for qualitative research, which are addressed in questions 1, 6, and 7 of the JBI appraisal tool for qualitative research. Respectively, these criteria address whether the authors’ philosophical perspec-tive is congruent with the study’s methodology, whether there is a statement locating the authors culturally or theoretically, and whether the researchers’ influence on the study is addressed. Unfortunately these are components of qual-itative research studies that are often left out of their published version, as the authors’ attempt to cut down the wording of their manuscripts to meet journal

Records identified throughdatabase searching

(n = 1,180)

Additional records identifiedthrough other sources

(n = 0)

Records after duplicates removed(n = 1,084)

Records screened(n = 1,084)

Iden

tifi

cati

on

Scr

een

ing

Elig

ibili

tyIn

clu

sio

n

Records excluded by titleand abstract (n = 1,006)

Full-text articles excluded,by full review of articles

(n = 68)

Studies excluded byappraisal

(n = 1)

Studies included inmeta-synthesis

(n = 9)

Studies critically appraised(n = 10)

Full-text articles assessedfor eligibility

(n = 78)

FIGURE 20.1PRISMA flow diagram showing results of comprehensive search strategy.



editorial requirements. Table 20.2 lists the results of the critical appraisal for the qualitative studies included in this review. One study was excluded by critical appraisal (M. Zwarenstein, Rice, Gotlib-Conn, Kenaszchuk, & Reeves, 2013).

CHARACTERISTICS OF INCLUDED STUDIES

None of the studies were conducted in the United States. Three studies were done in Canada, two in Australia, two in Norway, one in Finland, and one in Sweden. Participants included a range of health care professionals as well as patients and their family members or caregivers. They were conducted in a vari-ety of clinical settings, including primary care clinics, acute care hospitals,

TABLE 20.2 RESULTS OF THE CRITICAL APPRAISAL OF INCLUDED STUDIES

Qualitative Rigor Criteria

Cong

ruit

y of

Phi

loso

phic

al

Pers

pect

ive

and

Stud

y M

etho

dolo

gy

Cong

ruit

y of

Stu

dy M

etho

dolo

gy a

nd

Rese

arch

Que

stio

n/Ob

ject

ives

Cong

ruit

y of

Stu

dy M

etho

dolo

gy a

nd

Data

Col

lect

ion

Met

hods

Cong

ruit

y of

Stu

dy M

etho

dolo

gy a

nd

Repr

esen

tati

on/A

naly

sis

of D

ata

Cong

ruit

y of

Stu

dy M

etho

dolo

gy a

nd

Inte

rpre

tati

on o

f Re

sult

s

Stat

emen

t Lo

cati

ng t

he R

esea

rche

r Cu

ltur

ally

or

Theo

reti

call

y

Infl

uenc

e of

Res

earc

her

on t

he

Rese

arch

, an

d Vi

ce V

ersa

, Ad

dres

sed

Part

icip

ants

and

The

ir V

oice

s Ad

equa

tely

Rep

rese

nted

Rese

arch

Is

Ethi

cal/

Ther

e Is

Ev

iden

ce o

f Et

hica

l Ap

prov

al

Stud

y Co

nclu

sion

s Fl

ow F

rom

the

An

alys

is o

r In

terp

reta

tion

of

Data

S tudies Q1 Q2 Q3 Q4 Q5 Q6 Q7 Q8 Q9 Q10

Maneze 2014 U Y Y Y Y N N Y Y Y

Bradley 2009 U Y Y Y Y N N Y Y Y

Chong 2013 U Y Y Y Y N N Y Y Y

Goldman et al., 2010

U Y Y Y Y N N Y Y Y

Fredheim et al., 2011

U Y Y Y Y N N Y Y Y

Hjalmarson et al., 2013

U Y Y Y Y N N Y Y Y

Adams 2014 U Y Y Y Y N N Y Y Y

Eloranta 2010 U Y Y Y U N N Y Y Y

Bajnok 2012 U Y Y Y Y N N Y Y Y

Total percentage Yes

0 100 100 100 89 0 0 100 100 100

N, no; U, unclear; Y, yes.



community health centers, and other settings. Table 20.3 provides details on the characteristics of the included studies.

Synthesis of StudiesUsing the nine qualitative studies included in this review, a meta-synthesis was conducted. Findings were considered to be the exact themes stated in the stud-ies by the authors in the results section of the study reports retrieved from the search. Findings were combined into categories based on similarities in con-ceptual meanings embedded in the findings. Two reviewers created the descrip-tions for the categories in this review, as well as the final synthesized finding for this review, by combining the categories into a single cohesive group of declam-atory statements that can be used to provide a response to the central research question and thereby help guide practice. The author findings or themes extracted from each individual study, as well as a diagram illustrating the relationship between these findings and the review categories, are presented in Table 20.3 and Figure 20.2. Meta-aggregation of the included studies generated a single synthesized finding. This overall finding was derived from 64 original study find-ings that were subsequently aggregated into 13 categories. In the following text we present these categories and their descriptions, as well as the overall synthe-sized finding and its description.

Category 1: Role Clarity. Role clarity is a fundamental component and result of effective IPCP. Role clarity consists of the presence of a clear consensus and understanding among health care professionals of their individual and collec-tive responsibilities as well as the skill sets of all health care professionals in the team. It is fostered via experience communicating with health care profession-als from different professions. Role clarity not only enhances effectiveness of patient care via better communication among health care professionals as well as with the patients (such that they always know who to contact for what prob-lem), but it also increases the efficiency of health care systems and can lead to a greater sense of professional meaningfulness and satisfaction. This may require a re-thinking of traditional professional roles and scopes of practice, as well as greater flexibility on the part of all health care professionals.

Category 2: Communication. Communication is an essential component and a result of IPCP. Communication must occur on multiple levels, including among health care professionals as well as with the patients and families for the purpose of clarifying the roles of each team member, and it must involve feedback mechanisms to be sustainable. Interprofessional communication has several important outcomes. It leads to greater role clarity among health care professionals, including greater awareness of the resources that each health professional and parts of the health care system can bring to the table; it helps to minimize professional conflicts and improves the workplace environment, thereby resulting in greater effectiveness in team-based care. It also directly gen-erates greater patient satisfaction with the care received. The absence of effective interprofessional communication results in a lack of continuity (or an increase in fragmentation) and coordination of care.


433

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ore

active

rol

e fo

r th

e ge

nera

l pra

ctitio

ner.

Pro

fess

iona

ls p

erce

ived

the

m

odel

as

bein

g a

valu

able

sup

port

sys

tem

for

long

-ter

m p

lann

ing

of f

ollo

w-u

p ca

re, al

low

ing

pare

nts

to c

olla

bora

te w

ith

the

care

te

am. It

is e

ssen

tial

how

ever

, to

em

phas

ize

the

impo

rtan

ce o

f ha

ving

wel

l-es

tabl

ishe

d ro

utin

es, as

wel

l as

the

use

of a

coo

rdin

a-to

r. Th

is c

an b

e im

port

ant

for

enha

ncin

g co

mm

unic

atio

n be

twee

n pr

ofes

sion

als

and

for

obta

inin

g a

wel

l-fu

nction

ing

colla

bora

tion

(continued

)


434

Stud

yM

etho

ds a

nd

Met

hodo

logy

Part

icip

ants

and

Se

ttin

gsPh

enom

enon

Und

er S

tudy

Auth

ors’

Ove

rall

Con

clus

ions

Cho

ng

(20

13

)In

divi

dual

sem

i-

stru

ctur

ed in

terv

iew

s,

usin

g qu

alit

ativ

e ex

plor

ator

y m

etho

dolo

gy

31

hea

lth

care

pro

vide

rs

from

a r

ange

of

men

tal

heal

th p

rofe

ssio

ns w

orki

ng

in t

he h

ospi

tal o

r pr

imar

y ca

re s

etti

ngs

in A

ustr

alia

To d

escr

ibe

the

perc

epti

ons

of a

ran

ge

of h

ealt

h ca

re p

rovi

ders

on

the

noti

on

of s

hare

d de

cisi

on m

akin

g an

d in

terp

rofe

ssio

nal c

olla

bora

tion

as

part

of

a p

atie

nt-c

ente

red

prac

tice

in

men

tal h

ealt

h

Alt

houg

h he

alth

car

e pr

ovid

ers

ackn

owle

dged

the

impo

rtan

ce o

f in

terp

rofe

ssio

nal c

olla

bora

tion

, on

ly a

min

orit

y di

scus

sed

it w

ithi

n th

e co

ntex

t of

sha

red

deci

sion

mak

ing.

Hea

lth

care

pro

vide

rs

appe

ared

to

have

dif

feri

ng p

erce

ptio

ns o

n th

e le

vel o

f co

nsum

er

invo

lvem

ent

in s

hare

d de

cisi

on m

akin

g. I

nter

prof

essi

onal

rol

es t

o fa

cilit

ate

shar

ed d

ecis

ion

mak

ing

in m

enta

l hea

lth

need

s to

be

ackn

owle

dged

, un

ders

tood

, an

d st

reng

then

ed b

efor

e an

inte

rpro

-fe

ssio

nal a

ppro

ach

to s

hare

d de

cisi

on m

akin

g ca

n be

eff

ecti

vely

im

plem

ente

d

Elo

rant

a (2

01

0)

Focu

s gr

oup,

usi

ng

qual

itat

ive

desc

ript

ive

met

hodo

logy

25

hea

lth

care

sta

ff (

13

H

HW

s, 1

1 H

CN

s, a

nd o

ne

gene

ral p

ract

itio

ner)

, in

clud

ing

24

fem

ales

, w

orki

ng in

hom

e ca

re u

nits

in

Fin

land

; m

ean

age

of 4

3

year

s; m

ean

of 1

1 y

ears

of

elde

r ca

re e

xper

ienc

e

To e

xam

ine

hom

e ca

re u

nit

care

pr

ovid

ers’

per

spec

tive

s of

the

col

lab-

orat

ive

appr

oach

to

hom

e ca

re d

eliv

ery

for

olde

r cl

ient

s

It is

nec

essa

ry t

o de

velo

p m

etho

ds f

or s

hari

ng in

form

atio

n,

part

icul

arly

to

ensu

re t

hat

staf

f m

embe

rs h

ave

acce

ss t

o co

mm

on

pati

ent

info

rmat

ion

reco

rds

that

allo

w a

ll te

am m

embe

rs t

o en

ter

com

men

ts a

nd o

bser

vati

ons

abou

t cl

ient

s. C

are

base

d on

the

cl

ient

’s s

itua

tion

wou

ld m

inim

ize

com

peti

tion

am

ong

staf

f gr

oups

be

caus

e th

ese

grou

ps w

ould

sha

re a

nd c

ontr

ibut

e th

eir

expe

rtis

e to

ach

ievi

ng t

he c

omm

on g

oal o

f se

rvin

g cl

ient

s’ b

est

inte

rest

s

Fred

heim

et

al.

(20

11

)

Focu

s gr

oups

, us

ing

qual

itat

ive

desc

ript

ive

met

hodo

logy

Six

gro

ups

of g

ener

al

prac

titi

oner

s an

d m

enta

l he

alth

wor

kers

(fo

r a

tota

l of

28

per

sons

) se

lect

ed t

o re

pres

ent

the

popu

lati

on

and

infr

astr

uctu

re o

f tw

o re

gion

s in

Nor

way

To in

vest

igat

e st

reng

ths

and

wea

k-ne

sses

in t

oday

’s c

olla

bora

tion

, an

d to

su

gges

t im

prov

emen

ts in

the

inte

rac-

tion

bet

wee

n ge

nera

l pra

ctit

ione

rs a

nd

spec

ializ

ed m

enta

l hea

lth

serv

ice

Coo

rdin

atio

n is

exp

erie

nced

as

impo

rtan

t by

gen

eral

pra

ctit

ione

rs

and

othe

r m

enta

l hea

lth

prof

essi

onal

s in

volv

ed.

Gen

eral

pra

ctit

io-

ners

are

the

gat

ekee

pers

of

spec

ializ

ed c

are,

and

lack

of

colla

bora

tion

see

ms

to c

reat

e pr

oble

ms

for

all h

ealt

h ca

re

prof

essi

onal

s as

wel

l as

the

pati

ent.

Mut

ual k

now

ledg

e an

d m

utua

l acc

essi

bilit

y of

all

heal

th c

are

prof

essi

onal

s is

impo

rtan

t fo

r ef

fect

ive

colla

bora

tion

Gol

dman

et

al.

(20

10

)

Mul

tipl

e ca

se-s

tudy

ap

proa

ch in

volv

ing

sem

i-st

ruct

ured

in

terv

iew

s of

32

hea

lth

care

pro

vide

rs

14

FH

T in

urb

an a

nd r

ural

C

anad

a, in

clud

ing

12

fam

ily

doct

ors,

six

nur

ses,

fiv

e ph

arm

acis

ts,

and

nine

ot

hers

incl

udin

g so

cial

w

orke

rs a

nd d

ieti

cian

s

To e

xam

ine

FHT

mem

bers

’ exp

erie

nces

of

inte

rpro

fess

iona

l col

labo

rati

on a

nd

its

perc

eive

d be

nefit

s

Issu

es s

uch

as r

oles

and

sco

pes

of p

ract

ice,

lead

ersh

ip,

and

spac

e ar

e im

port

ant

to e

ffec

tive

tea

m-b

ased

pri

mar

y ca

re.

This

st

udy

prov

ides

a f

ram

ewor

k fo

r un

ders

tand

ing

diff

eren

t ty

pes

of

inte

rpro

fess

iona

l int

erve

ntio

ns u

sed

to s

uppo

rt in

terp

rofe

ssio

nal

colla

bora

tion

Hja

lmar

son

et a

l. (2

01

3)

Obs

erva

tion

al fi

eld

note

s w

ithi

n a

case

st

udy

23

key

sta

keho

lder

s fr

om

diff

eren

t pr

ofes

sion

s (fi

ve n

urse

s, 1

1 p

hysi

othe

ra-

pist

s, a

nd s

even

occ

upa-

tion

al t

hera

pist

s) w

orki

ng in

ce

ntra

l Sw

eden

To e

xplo

re t

he d

evel

opm

ent

of

inte

rpro

fess

iona

l col

labo

rati

on a

imin

g to

impr

ove

seco

ndar

y pr

even

tion

of

oste

opor

osis

by

stud

ying

thi

s to

pic

expa

nsiv

ely

from

the

per

spec

tive

s of

di

ffer

ent

stak

ehol

ders

A b

alan

ce b

etw

een

bott

om-u

p an

d to

p-do

wn

stru

ctur

es t

rigg

ered

im

prov

emen

ts in

the

dev

elop

men

t of

inte

rpro

fess

iona

l col

labo

ra-

tion

sin

ce h

oriz

onta

l str

uctu

res

gave

the

pro

fess

iona

l fre

edom

to

act

and

enco

urag

ed a

cha

nged

lead

ersh

ip.

The

proc

ess

illus

trat

es

the

forc

es t

hat

are

the

engi

nes

of t

hose

ele

men

ts a

s in

terp

rofe

s-si

onal

mot

ivat

iona

l for

ces

are

crea

ted

thro

ugh

cons

truc

tive

fe

edba

ck f

rom

: in

terp

rofe

ssio

nal i

nter

acti

ons

wit

h sh

ared

pa

tien

t-ce

nter

ed a

ppro

ach,

con

firm

ing

lead

ersh

ip a

nd t

he

deve

lope

d ab

ility

to

reco

gniz

e th

e be

nefit

s of

join

t ac

tion

s

Man

eze

(20

14

)In

divi

dual

inte

rvie

w,

usin

g qu

alit

ativ

e de

scri

ptiv

e m

etho

dlog

y

13

fam

ily m

embe

rs a

nd

pati

ents

wit

h ty

pe 2

di

abet

es a

dmit

ted

to t

he

emer

genc

y de

part

men

t of

a

dist

rict

hos

pita

l ser

ving

a

soci

o-ec

onom

ical

ly

disa

dvan

tage

d po

pula

tion

in

Aus

tral

ia

To e

xplo

re t

he d

iabe

tic

pati

ents

’ ex

peri

ence

of

mul

tidi

scip

linar

y ca

re,

in

part

icul

ar t

heir

per

cept

ions

, pe

rcei

ved

barr

iers

, an

d fa

cilit

ator

s

Pat

ient

s di

d no

t pe

rcei

ve t

heir

dia

bete

s ca

re a

s in

tegr

ated

. Th

eir

care

app

eare

d to

be

diso

rgan

ized

and

fra

gmen

ted.

The

pat

ient

s w

ere

conf

used

and

ove

rwhe

lmed

by

the

proc

esse

s in

volv

ed.

Per

sona

l bio

phys

ical

and

psy

chos

ocia

l iss

ues,

suc

h as

poo

r E

nglis

h la

ngua

ge s

kills

. Tr

ansp

orta

tion

, so

cioe

cono

mic

issu

es a

nd

com

peti

ng p

rior

itie

s of

com

orbi

diti

es,

are

impo

rtan

t ba

rrie

rs f

or

pati

ents

, co

mpo

undi

ng t

heir

dif

ficul

ties

in p

arti

cipa

ting

in t

heir

he

alth

car

e. T

he p

oorl

y co

ordi

nate

d an

d “u

n-in

tegr

ated

” se

rvic

es

mad

e th

ese

barr

iers

eve

n m

ore

chal

leng

ing

FHT,

fam

ily h

ealth

team

s; H

CN

, hom

e ca

re n

urse

s; H

HW

, hom

e he

alth

wor

kers

; IPC

P, in

terp

rofe

ssio

nal c

olla

bora

tive

prac

tice;

IPP,

inte

rpro

fess

iona

l pra

ctic

e; T

IPS,

team

s of i

nter

prof

es-

siona

l sta

ff.

TABL

E 20.

3 CH

ARAC

TERI

STIC

S OF

INCL

UDED

STU

DIES

(con

tinue

d)


435

Stud

yM

etho

ds a

nd

Met

hodo

logy

Part

icip

ants

and

Se

ttin

gsPh

enom

enon

Und

er S

tudy

Auth

ors’

Ove

rall

Con

clus

ions

Cho

ng

(20

13

)In

divi

dual

sem

i-

stru

ctur

ed in

terv

iew

s,

usin

g qu

alit

ativ

e ex

plor

ator

y m

etho

dolo

gy

31

hea

lth

care

pro

vide

rs

from

a r

ange

of

men

tal

heal

th p

rofe

ssio

ns w

orki

ng

in t

he h

ospi

tal o

r pr

imar

y ca

re s

etti

ngs

in A

ustr

alia

To d

escr

ibe

the

perc

epti

ons

of a

ran

ge

of h

ealt

h ca

re p

rovi

ders

on

the

noti

on

of s

hare

d de

cisi

on m

akin

g an

d in

terp

rofe

ssio

nal c

olla

bora

tion

as

part

of

a p

atie

nt-c

ente

red

prac

tice

in

men

tal h

ealt

h

Alt

houg

h he

alth

car

e pr

ovid

ers

ackn

owle

dged

the

impo

rtan

ce o

f in

terp

rofe

ssio

nal c

olla

bora

tion

, on

ly a

min

orit

y di

scus

sed

it w

ithi

n th

e co

ntex

t of

sha

red

deci

sion

mak

ing.

Hea

lth

care

pro

vide

rs

appe

ared

to

have

dif

feri

ng p

erce

ptio

ns o

n th

e le

vel o

f co

nsum

er

invo

lvem

ent

in s

hare

d de

cisi

on m

akin

g. I

nter

prof

essi

onal

rol

es t

o fa

cilit

ate

shar

ed d

ecis

ion

mak

ing

in m

enta

l hea

lth

need

s to

be

ackn

owle

dged

, un

ders

tood

, an

d st

reng

then

ed b

efor

e an

inte

rpro

-fe

ssio

nal a

ppro

ach

to s

hare

d de

cisi

on m

akin

g ca

n be

eff

ecti

vely

im

plem

ente

d

Elo

rant

a (2

01

0)

Focu

s gr

oup,

usi

ng

qual

itat

ive

desc

ript

ive

met

hodo

logy

25

hea

lth

care

sta

ff (

13

H

HW

s, 1

1 H

CN

s, a

nd o

ne

gene

ral p

ract

itio

ner)

, in

clud

ing

24

fem

ales

, w

orki

ng in

hom

e ca

re u

nits

in

Fin

land

; m

ean

age

of 4

3

year

s; m

ean

of 1

1 y

ears

of

elde

r ca

re e

xper

ienc

e

To e

xam

ine

hom

e ca

re u

nit

care

pr

ovid

ers’

per

spec

tive

s of

the

col

lab-

orat

ive

appr

oach

to

hom

e ca

re d

eliv

ery

for

olde

r cl

ient

s

It is

nec

essa

ry t

o de

velo

p m

etho

ds f

or s

hari

ng in

form

atio

n,

part

icul

arly

to

ensu

re t

hat

staf

f m

embe

rs h

ave

acce

ss t

o co

mm

on

pati

ent

info

rmat

ion

reco

rds

that

allo

w a

ll te

am m

embe

rs t

o en

ter

com

men

ts a

nd o

bser

vati

ons

abou

t cl

ient

s. C

are

base

d on

the

cl

ient

’s s

itua

tion

wou

ld m

inim

ize

com

peti

tion

am

ong

staf

f gr

oups

be

caus

e th

ese

grou

ps w

ould

sha

re a

nd c

ontr

ibut

e th

eir

expe

rtis

e to

ach

ievi

ng t

he c

omm

on g

oal o

f se

rvin

g cl

ient

s’ b

est

inte

rest

s

Fred

heim

et

al.

(20

11

)

Focu

s gr

oups

, us

ing

qual

itat

ive

desc

ript

ive

met

hodo

logy

Six

gro

ups

of g

ener

al

prac

titi

oner

s an

d m

enta

l he

alth

wor

kers

(fo

r a

tota

l of

28

per

sons

) se

lect

ed t

o re

pres

ent

the

popu

lati

on

and

infr

astr

uctu

re o

f tw

o re

gion

s in

Nor

way

To in

vest

igat

e st

reng

ths

and

wea

k-ne

sses

in t

oday

’s c

olla

bora

tion

, an

d to

su

gges

t im

prov

emen

ts in

the

inte

rac-

tion

bet

wee

n ge

nera

l pra

ctit

ione

rs a

nd

spec

ializ

ed m

enta

l hea

lth

serv

ice

Coo

rdin

atio

n is

exp

erie

nced

as

impo

rtan

t by

gen

eral

pra

ctit

ione

rs

and

othe

r m

enta

l hea

lth

prof

essi

onal

s in

volv

ed.

Gen

eral

pra

ctit

io-

ners

are

the

gat

ekee

pers

of

spec

ializ

ed c

are,

and

lack

of

colla

bora

tion

see

ms

to c

reat

e pr

oble

ms

for

all h

ealt

h ca

re

prof

essi

onal

s as

wel

l as

the

pati

ent.

Mut

ual k

now

ledg

e an

d m

utua

l acc

essi

bilit

y of

all

heal

th c

are

prof

essi

onal

s is

impo

rtan

t fo

r ef

fect

ive

colla

bora

tion

Gol

dman

et

al.

(20

10

)

Mul

tipl

e ca

se-s

tudy

ap

proa

ch in

volv

ing

sem

i-st

ruct

ured

in

terv

iew

s of

32

hea

lth

care

pro

vide

rs

14

FH

T in

urb

an a

nd r

ural

C

anad

a, in

clud

ing

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ily

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ors,

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ot

hers

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cial

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orke

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ieti

cian

s

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xam

ine

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mem

bers

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erie

nces

of

inte

rpro

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labo

rati

on a

nd

its

perc

eive

d be

nefit

s

Issu

es s

uch

as r

oles

and

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pes

of p

ract

ice,

lead

ersh

ip,

and

spac

e ar

e im

port

ant

to e

ffec

tive

tea

m-b

ased

pri

mar

y ca

re.

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st

udy

prov

ides

a f

ram

ewor

k fo

r un

ders

tand

ing

diff

eren

t ty

pes

of

inte

rpro

fess

iona

l int

erve

ntio

ns u

sed

to s

uppo

rt in

terp

rofe

ssio

nal

colla

bora

tion

Hja

lmar

son

et a

l. (2

01

3)

Obs

erva

tion

al fi

eld

note

s w

ithi

n a

case

st

udy

23

key

sta

keho

lder

s fr

om

diff

eren

t pr

ofes

sion

s (fi

ve n

urse

s, 1

1 p

hysi

othe

ra-

pist

s, a

nd s

even

occ

upa-

tion

al t

hera

pist

s) w

orki

ng in

ce

ntra

l Sw

eden

To e

xplo

re t

he d

evel

opm

ent

of

inte

rpro

fess

iona

l col

labo

rati

on a

imin

g to

impr

ove

seco

ndar

y pr

even

tion

of

oste

opor

osis

by

stud

ying

thi

s to

pic

expa

nsiv

ely

from

the

per

spec

tive

s of

di

ffer

ent

stak

ehol

ders

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alan

ce b

etw

een

bott

om-u

p an

d to

p-do

wn

stru

ctur

es t

rigg

ered

im

prov

emen

ts in

the

dev

elop

men

t of

inte

rpro

fess

iona

l col

labo

ra-

tion

sin

ce h

oriz

onta

l str

uctu

res

gave

the

pro

fess

iona

l fre

edom

to

act

and

enco

urag

ed a

cha

nged

lead

ersh

ip.

The

proc

ess

illus

trat

es

the

forc

es t

hat

are

the

engi

nes

of t

hose

ele

men

ts a

s in

terp

rofe

s-si

onal

mot

ivat

iona

l for

ces

are

crea

ted

thro

ugh

cons

truc

tive

fe

edba

ck f

rom

: in

terp

rofe

ssio

nal i

nter

acti

ons

wit

h sh

ared

pa

tien

t-ce

nter

ed a

ppro

ach,

con

firm

ing

lead

ersh

ip a

nd t

he

deve

lope

d ab

ility

to

reco

gniz

e th

e be

nefit

s of

join

t ac

tion

s

Man

eze

(20

14

)In

divi

dual

inte

rvie

w,

usin

g qu

alit

ativ

e de

scri

ptiv

e m

etho

dlog

y

13

fam

ily m

embe

rs a

nd

pati

ents

wit

h ty

pe 2

di

abet

es a

dmit

ted

to t

he

emer

genc

y de

part

men

t of

a

dist

rict

hos

pita

l ser

ving

a

soci

o-ec

onom

ical

ly

disa

dvan

tage

d po

pula

tion

in

Aus

tral

ia

To e

xplo

re t

he d

iabe

tic

pati

ents

’ ex

peri

ence

of

mul

tidi

scip

linar

y ca

re,

in

part

icul

ar t

heir

per

cept

ions

, pe

rcei

ved

barr

iers

, an

d fa

cilit

ator

s

Pat

ient

s di

d no

t pe

rcei

ve t

heir

dia

bete

s ca

re a

s in

tegr

ated

. Th

eir

care

app

eare

d to

be

diso

rgan

ized

and

fra

gmen

ted.

The

pat

ient

s w

ere

conf

used

and

ove

rwhe

lmed

by

the

proc

esse

s in

volv

ed.

Per

sona

l bio

phys

ical

and

psy

chos

ocia

l iss

ues,

suc

h as

poo

r E

nglis

h la

ngua

ge s

kills

. Tr

ansp

orta

tion

, so

cioe

cono

mic

issu

es a

nd

com

peti

ng p

rior

itie

s of

com

orbi

diti

es,

are

impo

rtan

t ba

rrie

rs f

or

pati

ents

, co

mpo

undi

ng t

heir

dif

ficul

ties

in p

arti

cipa

ting

in t

heir

he

alth

car

e. T

he p

oorl

y co

ordi

nate

d an

d “u

n-in

tegr

ated

” se

rvic

es

mad

e th

ese

barr

iers

eve

n m

ore

chal

leng

ing

FHT,

fam

ily h

ealth

team

s; H

CN

, hom

e ca

re n

urse

s; H

HW

, hom

e he

alth

wor

kers

; IPC

P, in

terp

rofe

ssio

nal c

olla

bora

tive

prac

tice;

IPP,

inte

rpro

fess

iona

l pra

ctic

e; T

IPS,

team

s of i

nter

prof

es-

siona

l sta

ff.


436

Fin

din

gs

Cat

ego

ries

Met

a-S

ynth

esis

Bar

riers

to m

ultid

isci

plin

ary

care

Lack

of c

omm

unic

atio

n am

ong

heal

thpr

ofes

sion

als

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of s

uppo

rt fr

om h

ealth

pro

fess

iona

ls

Vie

ws

of m

ultid

isci

plin

ary

team

car

e

Co

mm

itti

ng

to

co

llab

ora

te f

or

bet

ter

pat

ien

t ca

re

Inte

rpro

fess

iona

l col

labo

rativ

e pr

actic

e co

nsis

ts o

f an

activ

eco

mm

itmen

t by

all h

ealth

car

e pr

ofes

sion

als

to c

omm

unic

atin

gef

fect

ivel

y, w

orki

ng in

team

s, a

nd c

lear

ly u

nder

stan

ding

eac

hot

hers

’ rol

es, f

or th

e co

mm

on p

urpo

se o

f effe

ctiv

ely

and

effic

ient

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chie

ving

opt

imal

pat

ient

car

e. A

ttain

ing

inte

rpro

fess

iona

l col

labo

rativ

e pr

actic

e fir

st a

nd fo

rem

ost

requ

ires

that

hea

lth c

are

prof

essi

onal

s ov

erco

me

pers

onal

bi

ases

abo

ut th

emse

lves

and

eac

h ot

her,

ther

eby

faci

litat

ing

effe

ctiv

e co

llabo

ratio

n-de

pend

ent c

oord

inat

ion

of

cont

inuo

us p

atie

nt c

are.

The

latte

r en

tails

the

impl

emen

tatio

nof

team

-bas

ed p

robl

em-s

olvi

ng a

ppro

ache

s, w

here

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rmat

ion

is s

hare

d sy

stem

atic

ally

, and

a te

am le

ader

is d

edic

ated

to

ensu

ring

that

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utio

ns g

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ated

by

the

team

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forw

ard

with

in th

e co

ntex

t of s

hare

d de

cisi

on m

akin

g am

ong

heal

th c

are

prof

essi

onal

s, th

e pa

tient

s, a

nd th

eir

fam

ilies

. A

chie

vem

ent o

f opt

imal

pat

ient

car

e vi

a in

terp

rofe

ssio

nal

colla

bora

tive

prac

tice

requ

ires

that

the

lack

of m

utua

l ac

cess

ibili

ty o

f hea

lth c

are

prof

essi

onal

s, in

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h tim

e an

dsp

ace,

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l as

the

man

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cial

, eco

nom

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ultu

ral

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iers

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r pa

tient

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ce, a

ll be

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ress

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sim

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sly.

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riers

to p

atie

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are

Ben

efits

of i

nter

prof

essi

onal

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-up

appr

oach

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mitm

ent

FIGU

RE 2

0.2

Synt

hesi

zed

find

ings

.IP

CP,

inte

rpro

fess

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l col

labo

rati

ve p

ract

ice.


437

Inte

rper

sona

l kno

wle

dge

and

com

mun

icat

ion

Co

mm

itti

ng

to

co

llab

ora

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or

bet

ter

pat

ien

t ca

re

Com

mitm

ent

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ly p

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ptio

ns o

f col

labo

rativ

e ca

re

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ease

d tr

ansp

aren

cy a

nd c

ontr

ol

Prid

e

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r of

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st

Wel

l-est

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ines

and

str

uctu

re

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mun

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ion

and

conf

lict r

esol

utio

n

Ear

ly p

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ptio

ns o

f col

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e ca

re

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dbac

k tr

igge

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rofe

ssio

nal m

otiv

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nal

forc

es

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mun

icat

ion

FIGU

RE 2

0.2

Synt

hesi

zed

find

ings

. (co

ntin

ued)


438

Lack

of c

omm

unic

atio

n am

ong

heal

thpr

ofes

sion

als

Per

ceiv

ed le

vel o

f int

erpr

ofes

sion

al c

olla

bora

tion

amon

g he

alth

car

e pr

ovid

ers

Prid

e

Pro

fess

iona

ls w

orki

ng to

geth

er c

anen

hanc

e kn

owle

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Car

er a

s co

ordi

nato

r

Co-

mor

bidi

ties

as b

arrie

rs

Lack

of c

omm

unic

atio

n am

ong

heal

th p

rofe

ssio

nals

Per

ceiv

ed le

vel o

f int

erpr

ofes

sion

al c

olla

bora

tion

amon

g he

alth

car

e pr

ovid

ers

Pro

fess

iona

ls w

orki

ng to

geth

er c

an e

nhan

cekn

owle

dge

Coo

rdin

atio

n-de

pend

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cont

inui

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amili

arity

with

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and

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s

Co

mm

itti

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ora

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or

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ter

pat

ien

t ca

re

FIGU

RE 2

0.2

Synt

hesi

zed

find

ings

. (co

ntin

ued)


439

Inte

rpro

fess

iona

l ini

tiativ

es

Pro

fess

iona

ls w

orki

ng to

geth

er c

an e

nhan

cekn

owle

dge

Effi

cien

cy o

f car

e

Dev

elop

ing

shar

ed v

alue

s an

dpr

even

tive

inno

vatio

ns

Inte

rpro

fess

iona

l ini

tiativ

es

Lack

of s

uppo

rt fr

om h

ealth

prof

essi

onal

s

Pro

fess

iona

ls w

orki

ng to

geth

erca

n en

hanc

e kn

owle

dge

Sha

ring

of in

form

atio

n

Vie

ws

of m

ultid

isci

plin

ary

team

car

e

Info

rmat

ion

shar

ing

Lead

ersh

ip

Man

agem

ent a

nd le

ader

ship

Lead

ersh

ip-d

epen

dent

colla

bora

tion

Co

mm

itti

ng

to

co

llab

ora

te f

or

bet

ter

pat

ien

t ca

re

Wel

l-est

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hed

rout

ines

and

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uctu

re

FIGU

RE 2

0.2

Synt

hesi

zed

find

ings

. (co

ntin

ued)


440

Mut

ual a

cces

sibi

lity

(incl

udin

g am

bula

tory

car

e)

Tim

e an

d sp

ace

Vie

ws

of m

ultid

isci

plin

ary

team

car

e

Mut

ual a

cces

sibi

lity

Cha

nge

Col

legi

al c

onse

nsus

Per

sona

l gro

wth

Pro

fess

iona

ls w

orki

ng to

geth

er c

an e

nhan

cekn

owle

dge

Ove

rcom

ing

pers

onal

bias

es

Ben

efits

of i

nter

prof

essi

onal

car

e

Bet

ter

patie

nt c

are

Com

mun

icat

ion

and

conf

lict r

esol

utio

n

Pat

ient

car

e

Ear

ly p

erce

ptio

ns o

f col

labo

rativ

e ca

re

FIGU

RE 2

0.2

Synt

hesi

zed

find

ings

. (co

ntin

ued)


441

Aw

aren

ess

and

rela

tions

hips

Bet

ter

patie

nt c

are

Com

mun

icat

ion

and

conf

lict r

esol

utio

n

Fee

dbac

k tr

igge

rs in

terp

rofe

ssio

nal m

otiv

atio

nal

forc

es

Inte

rpro

fess

iona

l ini

tiativ

es

Kno

wle

dge

and

skill

s

Pro

fess

iona

ls w

orki

ng to

geth

er c

an e

nhan

cekn

owle

dge

Ret

hink

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ition

al r

oles

and

sco

pes

ofpr

actic

e

Rol

e of

cla

rity

Tea

m r

oles

Lead

ersh

ip

Per

ceiv

ed in

fluen

ce o

f int

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ofes

sion

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llabo

ratio

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red

deci

sion

mak

ing

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hink

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trad

ition

al r

oles

and

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pes

of p

ract

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Sha

red

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ing

Co

mm

itti

ng

to

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llab

ora

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or

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ter

pat

ien

t ca

re

FIGU

RE 2

0.2

Synt

hesi

zed

find

ings

. (co

ntin

ued)


442

Co

mm

itti

ng

to

co

llab

ora

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bet

ter

pat

ien

t ca

re

Ben

efits

of i

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onal

car

e

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ersh

ip

Tea

m g

row

th

Tea

m-b

ased

prob

lem

sol

ving

FIGU

RE 2

0.2

Synt

hesi

zed

find

ings

. (co

ntin

ued)



Category 3: Shared Decision Making. Shared decision making consists of collaborative work to achieve a consensus regarding patient care. It reduces time barriers and minimizes confusion by providing opportunities for patients and health care professionals to ask questions and discuss their concerns prior to the implementation of care. It often requires some health care professionals to relinquish some control over some aspects of their work, but it also entails other health care professionals taking on greater responsibility and accountability for care decisions. Achieving shared decision making in IPCP works concurrently with team-based problem solving and requires the presence of a clear team leader in order to be sustainable.

Category 4: Leadership-Dependent Collaboration. Collaborative practice cannot take place without a team leader who takes responsibility for ensuring team-based problem solving, shared decision making, and effective coordina-tion of care.

Category 5: Team-Based Problem Solving. Team-based problem solving consists of the active participation of different health care professionals in addressing patient issues. Team-based problem solving results in better patient care by fostering a collaborative relationship among health care professionals as well as with patients and families. A clear team leader who is committed to using the results of team-based problem solving in shared decision making is a fun-damental requirement for the success of this approach.

Category 6: Commitment. IPCP is unsustainable without various forms of commitment from all stakeholders in patient care. Commitment consists of clear, irrevocable affirmation of the value of other health care professionals, trust in and appreciation for what each of them brings to the team, and agreement by all team members to practice patient-centered care. It also entails the dedication of adequate resources within health systems to provide effective patient care. A commitment to IPCP facilitates greater efforts toward resolution of professional conflicts, and greater willingness to transfer what is learned in one team to other teams and health care settings, thereby increasing the sustainability of IPCP.

Category 7: Overcoming Personal Biases. Before IPCP can fully take root, health care professionals must learn to overcome their personal biases. These consist of all the perceptions, attitudes, beliefs, and other individual characteris-tics that individuals must overcome in order to work collaboratively. This requires learning to communicate interprofessionally (such as by avoiding discipline spe-cific jargon) and to address conflicting perspectives constructively. Over time, this can lead to substantial personal growth of interprofessional team members.

Category 8: Patient Care. Patient care consists of all the activities that are undertaken by health care professionals as well as patients and their families in order to address the health issue at hand. Effective patient care can include a number of components, including activities to minimize the stress of seeking care and increase patient satisfaction with care. It may or may not be patient-centered, depending on the approach taken by the team.

Category 9: Information Sharing. Information sharing is an integral output of IPCP. It is most effective when it is well supported by structures such as



appropriate information technology. Effective information sharing leads to better patient care with greater continuity by ensuring the transmission of consistent information among health care professionals and with the patients and families.

Category 10: Collaboration-Dependent Continuity of Care. Collaboration-dependent continuity of care is one of the most fundamental mechanisms by which IPCP affects patient health outcomes. Continuity of care consists of the prevention of care fragmentation through various means, including via a system- designated care coordinator, via the patient or a family member acting as a coordinator, or by chance. IPCP works via the first two mechanisms to achieve efficient patient care by ensuring adequate participation of all stakeholders in the processes of care. For example, hospital discharge planning is an important process for providing continuous care that can benefit from IPCP because it is thought to be highly coordination-dependent. Other such processes include the management of multiple chronic conditions, and the successful provision of follow-up and routine care.

Category 11: Efficiency of Care. The efficiency of care is increasingly an important consideration for all health care systems worldwide. Efficiency implies a mutual consideration for effectiveness of interventions as well as their eco-nomic cost and resource use requirements. Achieving the most efficient patient care possible is a multifaceted and challenging process. With regard to IPCP, this may involve improved communication with families to minimize stress, information sharing to reduce incidence of adverse health outcomes, and max-imizing the use of health care professionals’ time through identification of the least costly provider required to competently perform a particular patient care function.

Category 12: Mutual Accessibility. Mutual accessibility is an important requirement for effective interprofessional collaboration. This consists of the availability of health care professionals, both in time and space, to work together in an interprofessional capacity to achieve effective/efficient patient centered care.

Category 13: Barriers to Patient Care. There are many barriers to patient care, which may help to explain the difficulty of IPCP to achieve its stated aims. These barriers include those related to the social, cultural and economic environments or resources of the patient, as well as those that may be embed-ded within multidisciplinary care itself, such as being cared for by multiple health care professionals simultaneously.

Review SynthesisCommitting to Collaborate for Better Patient Care. Interprofessional collab-orative practice consists of an active commitment by all health care profession-als to communicating effectively, working in teams, and clearly understanding each other’s roles for the common purpose of effectively and efficiently achiev-ing optimal patient care. Attaining IPCP first and foremost requires that health care professionals overcome personal biases about themselves and each other,



thereby facilitating effective collaboration-dependent coordination of continu-ous patient care. The latter entails the implementation of team-based problem solving approaches, where information is shared systematically, and a team leader is dedicated to ensuring that solutions generated by the team are carried forward within the context of shared decision making among health care professionals, the patients, and their families. Achievement of optimal patient care via IPCP requires that the lack of mutual accessibility of health care professionals, both in time and space, as well as the many social, economic, and cultural barriers that their patients face, all be addressed simultaneously.

■■ Discussion

Because the conceptual framework of the IHI is the fundamental guide for this study, the time period chosen for the search is a delimitation of this review. Yet given that the construct of IPCP has been around since at least the 1970s, there may be more evidence available on the phenomenon of interest from years prior to 2008. One important limitation is that the original intent of this review was to focus on studies pertaining to socioeconomically disadvantaged contexts. However, only the Maneze et al. (2014) study was done in this context despite the use of a relatively broad search strategy. Finally, the original goal of looking at the relationship between IPCP and patient health outcomes was only par-tially accomplished: None of the studies linked specific patient health outcomes to IPCP. Instead they linked IPCP to patient care outcomes in general. There-fore, rather than producing an empty review without any synthesis of findings, the authors instead relaxed these criteria to include studies done in all contexts and regardless of whether they linked IPCP to specific patient health outcomes. This has allowed the identification of major gaps in the qualitative evidence on the phenomenon of interest.

■■ Summary

The commitment to collaborate is the most important lynchpin in the rela-tionship between IPCP and patient health outcomes. This commitment is required from health care professionals, patients, families, as well as policy makers and health systems, and until this commitment is present, IPCP cannot be expected to change patient health outcomes. Components of this commitment include: attainment of IPCP and related components (i.e., teamwork, communi-cation, role clarity), sharing information, overcoming personal biases, ensuring continuing of care, solving problems in teams and making shared decisions, and addressing the issues of mutual accessibility of health care professionals and the numerous socioeconomic and cultural barriers to care that patients face (JBI Level I evidence for questions of meaningfulness/appropriateness; JBI, 2014).



IMPLICATIONS FOR PRACTICE

Based on currently available evidence, the recommendations for understand-ing the relationship between IPCP and patient care outcomes using the CON-QUAL method receive a Grade of B (“weak”) for making recommendations for practice (JBI, 2014). Health care professionals, policy makers, and other stake-holders in health care should examine the declamatory statements in the syn-thesized finding and strongly consider applying its recommendations in their own context as appropriate and meaningful for their given patient populations. There is currently insufficient evidence of meaningfulness/appropriateness in the relationship between IPCP and patient health outcomes.

IMPLICATIONS FOR RESEARCH

While there is strong qualitative evidence of meaningfulness/appropriateness in the relationship between IPCP and patient care outcomes, there is still a need to conduct qualitative studies on the relationship between IPCP and patient health outcomes. Such studies should explicitly set out to identify specific health care and health-relevant variables that that can be influenced by IPCP, how IPCP relates to those variables, how IPCP and those variables interact to influence patient health outcomes, and what other non-health care/non-health variables are important to consider as confounders in the association between IPCP and patient health outcomes. Future studies should also consider using mixed-methods approaches to overcome the limitations of traditional quantitative or qualitative approaches alone.

■■ References

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