ORIGINAL ARTICLE

Interprofessional collaboration at transition of care: perspectives of child and family health nurses and midwives Kim Psaila, Virginia Schmied, Cathrine Fowler and Sue Kruske

Aims and objectives. To examine collaboration in the provision of universal health services for children and families in Australia from the perspective of midwives and child health and family health nurses. Background. Collaboration is identified as a key concept contributing to families’ smooth transition between maternity and child health services. However, evidence suggests that collaboration between services is often lacking. Few studies have explored how maternity and child health and family health services or professionals collaborate to facilitate a smooth transition. Design. This study reports on data collected in phases 1 and 2 of a three-phase mixed-methods study investigating the feasibility of implementing a national approach to child health and family health services in Australia (Child Health: Researching Universal Services study). Methods. In phase 1, consultations (via discussion groups, focus groups and teleconferences) were held with 45 midwives and 60 child health and family health nurses. Themes identified were used to develop phase 2 surveys. In phase 2, 1098 child health and family health nurses and 655 midwives returned surveys. Results. Midwives and child health and family health nurses reported ‘some collaboration’. Midwives and child health and family health nurses indicated that collaboration was supported by having agreement on common goals and recognising and valuing the contributions of others. Organisational barriers such as poor communication and information transfer processes obstructed relationships. Good collaboration was reported more frequently when working with other professionals (such as allied health professionals) to support families with complex needs. Conclusion. This study provides information on the nature and extent of collaboration from the perspective of midwives and child health and family health nurses providing universal health services for children and families. Relevance to clinical practice. Both professional groups emphasised the impact of service disconnection on families. However, their ability to negotiate professional differences is affected by system constraints and differing perspectives of what constitutes collaboration. Developing the capacity to collaborate is essential to ensure smooth transition of care given ongoing changes to the system.

What does this study contribute to the wider global clinical community?

• This study provides information





on the nature and the extent of collaborative practice from the perspective of midwives and child and family health nurses providing universal health services for children and families. Factors impacting on collaboration between midwives and child and family health nurses include the mode and effectiveness of transfer of client information and tension around professional identity and boundaries. These issues arise particularly during the late antenatal and early post-natal period. Respondents described ‘good collaboration’ in instances when working with other professionals to support families with complex needs, more frequently than when working with families without identified risk.

Authors: Kim Psaila, BHSc, MA, Grad Dip(NEd), PhD Candidate, School of Nursing and Midwifery, University of Western Sydney, Sydney, NSW; Virginia Schmied, BA, MA, PhD, Professor, School of Nursing and Midwifery, Family and Community Health Research Group, University of Western Sydney, Sydney, NSW; Cathrine Fowler, BEd, MEd(Adult), PhD, Tresillian Chair, Child & Family Health Centre for Midwifery, Child & Family Health Faculty of Nursing, Midwifery & Health, University of Technology

Sydney, Sydney, NSW; Sue Kruske, BHSc, PhD, RN, Director, Queensland Centre for Mothers & Babies, The University of Queensland, Brisbane, Qld, Australia Correspondence: Kim Psaila, PhD Candidate, School of Nursing and Midwifery, Building EB Parramatta Campus, University of Western Sydney, Locked Bag 1797, Penrith, NSW 2751, Australia. Telephone: +61 2 96859815. E-mail: [email protected]

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© 2014 John Wiley & Sons Ltd Journal of Clinical Nursing, 24, 160–172, doi: 10.1111/jocn.12635

Original article

Interprofessional collaboration at transition

Key words: child and family health nurses, collaboration, continuity, family health, midwives, transition Accepted for publication: 13 April 2014

Introduction Extensive research supports the importance of the early years for a child’s future potential (Hertzman 2004, Centre for Community Child Health 2007). In response, Australia has committed to a National Agenda for Early Childhood (Centre for Community Child Health 2009). Most recently, the National Framework for Universal Child and Family Health Services (Australian Health Ministers Advisory Council 2011) provides guidance for achieving effective delivery of universal services to children and families. While the framework focuses on the universal health platform, it highlights the importance of providing targeted and specialist services required by families and of effective relationships between service sectors (Australian Health Ministers Advisory Council 2011). Historically, there has been an expectation that health professionals collaborate for the benefit of the consumer (McDonald & Rosier 2011). Today collaboration is emphasised as the solution to reported service gaps and overlaps (COAG 2009b, Moore & Skinner 2010). To date, there is limited information on the level of collaboration between maternity services and child and family health (CFH) services in supporting women, children and families. This study examines collaborative practice in the provision of universal health services for children and families in Australia from the perspective of midwives and CFH nurses.

Background Universal CFH services are provided in Australia within a framework of primary health care (Kuo et al. 2006, Australian Health Ministers Advisory Council 2011) to monitor health and developmental progress during critical periods in children’s lives. Universal CFH services also contribute to broader population health through health promotion and preventive health initiatives such as immunisation programmes, breastfeeding promotion, child safety and parenting support. These services are also ideally situated to identify parental concerns and can provide advice, support and/or appropriate referral for further support through targeted and specialist services (NSW Department of Health 2009, Australian Health Ministers Advisory Council 2011).

© 2014 John Wiley & Sons Ltd Journal of Clinical Nursing, 24, 160–172

The entry point into universal services is usually via publicly funded maternity services that assist/support pregnant women in the antenatal, intrapartum and post-partum period. Following discharge from maternity services, publicly funded community-based CFH nurses provide ongoing services for up to five years of age. Additional services for families are available through private midwives and CFHs, nurses working in pharmacies or private general medical practices (where they can see a doctor or a practice nurse). CFH nursing services continue to offer scheduled universal services at regular intervals until children start school (NSW Department of Health 2008, COAG 2009a), whereas general practitioners (GPs) offer CFH services opportunistically when families present for medical treatment or for immunisation (Jeyendra et al. 2013). This complex mix of maternity and CFH, public and private services in Australia makes the planning and coordination of care across various services challenging (Schmied et al., 2008b; The Allens Consulting Group 2009). Interprofessional and organisational collaboration is important for continuity of care for families across the range of services and health professionals. Government policy describes collaboration at various levels of the health system: organisational, service design and delivery, and professional collaboration (NSW Health 2009, Commonwealth Government 2010). The need for collaboration between professionals and services increases when families experience complicated health and social needs requiring access to several services (McDonald et al. 2009). Despite this demonstrated need, collaboration between services is often lacking (Centre for Community Child Health 2008, Schmied et al. 2011). Although variously defined, collaboration is generally understood to mean the cooperative way in which two or more persons or organisations work together towards a shared goal (Boon et al. 2009, Brown et al. 2011). The use of several interrelated terms to describe working relationships, for example partnership, cooperation, coordination, teamwork and shared care, has added to the confusion (D’Amour et al. 2008). Horwath and Morrison (2007) (Table 1) identified five levels of collaboration between professionals along a continuum, from communication through to integration. This model provides insight into the

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K Psaila et al. Table 1 Collaboration framework Horwath & Morrison 2007 1. Communication: individuals from different disciplines talking together 2. Cooperation: low key joint working on a case-by-case basis 3. Coordination: more formalised joint working, but no sanctions for noncompliance 4. Coalition: joint structures sacrificing some autonomy 5. Integration: organisations merge to create new joint identity

complexity involved for professionals in moving from a lower to higher level of collaboration. This study reports on data from the Child Health: Researching Universal Services (CHoRUS) study, which investigated the feasibility of implementing a national approach to CFH services in Australia. In phase 1 of the CHoRUS study, midwives and CFH nurse participants identified ‘collaboration’ as vital for the smooth transition of families along the continuum of care. Therefore, phase 2 further explored the nature and extent of collaboration between maternity services and community-based CFH services. This study examines collaborative practice in the provision of universal health services for children and families in Australia from the perspective of midwives and CFH nurses.

Method Research design

email. Consultations (via discussion groups, focus groups and teleconferences) were primarily arranged through professional organisations: Maternal, Child & Family Health Nurses Australia, Australian College of Midwives, RACGP, Australian General Practice Network (now Australia Medicare Local Alliance) and Australian Practice Nurse Association. Phase 2 surveys Surveys were distributed to CFH nurses and midwives across Australia via professional networks and at each professional group’s national conference. The CFH nurse survey was available online or in hardcopy from May–October 2011; the midwife survey was available nationally October 2011 to February 2012.

Data collection Phase 1 consultations We held two focus groups via teleconference with midwives and nurses representing their professional associations. One teleconference was held with eight CFH nurses and one with five midwives, and a third focus group was conducted face-to-face with 10 CFH nurses. In addition, we held three consultative discussion groups: one with 42 CFH nurses and one with 40 midwives at two national conferences. Questions were tailored specifically for each professional group (Table 2).

A three-phase, mixed-methods sequential research design was used for the CHoRUS study (Creswell & Plano Clark 2007). Ethical approval was received by the relevant Health Research Ethics Committees with additional approval obtained from area health districts as required. Phase 1 involved consultations (via discussion groups, focus groups and teleconferences) with professional leaders. Subsequently in phase 2, we surveyed midwives and CFH nurses providing direct care to children and families to confirm and clarify themes identified in phase 1. Phase 3 will explore innovations and exemplary models of care. This study presents data on collaboration collected in phases 1 and 2 of the study.

Phase 2 surveys Survey data were collected using the Qualtrics (Qualtrics Labs I 2013) online survey platform. Both surveys were developed by the CHoRUS multidisciplinary research team using the themes identified in an extensive literature review (Schmied et al., 2008a; Schmied et al. 2010), a review of current policy documents from each jurisdiction (Schmied et al. 2011) and themes identified in phase 1. Each survey comprised five sections: (1) demographic data, (2) description of the health service, (3) nature and frequency of services delivered, (4) collaborative working and (5) key barriers and facilitators to perform their role. The survey was adapted for each of the professional groups.

Participants and recruitment

Table 2 Questions tailored specifically for each professional group

Phase 1 consultations A panel of representative leaders from professional groups (midwives, CFH nurses, GPs, practice nurses) was invited to contribute to phase 1. Potential participants were provided with information about the study, the questions to be asked during the consultation and a consent form in advance via

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1. What facilitates the provision of universal child and family health services? 2. What factors obstruct the provision of universal child and family health services? 3. What modifications to existing systems are necessary to enable a comprehensive approach to the delivery of universal health services to children and families?

© 2014 John Wiley & Sons Ltd Journal of Clinical Nursing, 24, 160–172

Original article

Specific items on collaboration in each survey included the following: whom they worked with most closely, the purpose of working with other professionals and the level of collaboration. We also asked respondents to rate collaboration ‘strength’ using several statements about dimensions of organisational and professional collaboration. These were developed from the literature on collaboration (Valentine et al. 2007, D’Amour et al. 2008) and from criteria identified by professionals in phase 1 as being essential for effective collaboration. Content experts from the professional groups on the research team (CFH nurses, midwives, GPs) reviewed each item for content validity. Both surveys were piloted using an external convenience sample generated by the professional groups.

Data analysis Phase 1 data were transcribed verbatim and then analysed in the QSR NVIVO version 9.2 data management program (NVivo qualitative data analysis software; QSR International Pty Ltd. Version 9, 2010, Doncaster, Victoria, Australia). Braun and Clarke’s (2006) six-step process of thematic analysis was used to analyse the transcripts. This required complete familiarisation with all transcripts, which was achieved through repeated readings by the first and second authors. Initially, all ideas and patterns were allocated to as many codes as they fit by the first author. The context of data was upheld by coding inclusively. Memos of additional observations were included against the respective codes. Initially, 49 codes were identified; these were subsequently refined into 21 concept groups. The coding map was then examined for patterns and linkages across the concept groups, highlighting themes within the data. Phase 2 survey data were collected using Qualtrics online survey platform, exported to MS EXCEL for cleaning and transferred to SPSS version 21 (IBM 2012) for analysis. Descriptive statistics were used to analyse numeric responses. Text fields elaborating items were analysed using content analysis. A coding list was developed from the data. Several codes reflected codes identified in phase 1, for example ‘continuity of care’. However, additional in vivo codes were identified, for example ‘referral’. Text responses were then coded into the respective code. If the respondent’s meaning was not readily determined, it was coded to ‘meaning unclear’. Text fields were then analysed using QSR NVIVO version 9.2.

Results In phase 1, 60 CFH nurses were consulted, 42 via discussion groups held at a national conference and an additional © 2014 John Wiley & Sons Ltd Journal of Clinical Nursing, 24, 160–172

Interprofessional collaboration at transition

eight CFH nurses via a teleconference and 10 in a face-toface focus group. Forty-five midwives were also consulted, 40 via two face-to-face focus groups and five via teleconference. In these phase 1 consultations, midwives and CFH nurse participants identified ‘collaboration’ as a key theme contributing to the smooth transition of families along the continuum of care. Therefore, the nature and extent of collaboration between maternity services and communitybased CFH services was explored further in phase 2. Phase 2 surveys were returned by 1098 CFH nurses and 655 midwives. However, the number of responses to individual questions varies due to a direction given to respondents to answer questions based on their current role. In phase 2, the majority of CFH nurse and midwife respondents were female. The mean age of CFH nurse respondents was 512 years, while the mean age of midwives was 483 years (Table 3). The majority of both groups of respondents worked in urban areas. One-quarter of midwives and 40% of CFH nurses had been employed in their field

Interprofessional collaboration at transition of care: perspectives of child and family health nurses and midwives.

To examine collaboration in the provision of universal health services for children and families in Australia from the perspective of midwives and chi...
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