http://informahealthcare.com/jic ISSN: 1356-1820 (print), 1469-9567 (electronic) J Interprof Care, 2015; 29(2): 131–137 ! 2015 Informa UK Ltd. DOI: 10.3109/13561820.2014.955910
ORIGINAL ARTICLE
Using an interprofessional competency framework to examine collaborative practice Shelanne L. Hepp1, Esther Suter1, Karen Jackson1, Siegrid Deutschlander1, Edward Makwarimba2, Jake Jennings3 and Lisa Birmingham3
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1
Alberta Health Services, Workforce Research & Evaluation, Calgary, Alberta, Canada, 2Formerly Alberta Health Services, Calgary, Alberta, Canada, and 3Alberta Health Services, CoACT – Health Professions Strategy & Practice, Calgary, Alberta, Canada
Abstract
Keywords
Healthcare organisations are starting to implement collaborative practice to increase the quality of patient care. However, operationalising and measuring progress towards collaborative practice has proven to be difficult. Various interprofessional competency frameworks have been developed that outline essential collaborative practice competencies for healthcare providers. If these competencies were enacted to their fullest, collaborative practice would be at its best. This article examines collaborative practice in six acute care units across Alberta using the Canadian Interprofessional Health Collaborative (CIHC) competency framework (CIHC, 2010). The framework entails the six competencies of patient-centred care, communication, role clarification, conflict resolution, team functioning and collaborative leadership (CIHC, 2010). We conducted a secondary analysis of interviews with 113 healthcare providers from different professions, which were conducted as part of a quality improvement study. We found positive examples of communication and patient-centred care supported by unit structures and processes (e.g. rapid rounds and collaborative plan of care). Some gaps in collaborative practice were found for role clarification and collaborative leadership. Conflict resolution and team functioning were not well operationalised on these units. Strategies are presented to enhance each competency domain in order to fully enact collaborative practice. Using the CIHC competency framework to examine collaborative practice was useful for identifying strength and areas needing improvement.
Collaborative competence, interviews, interprofessional collaboration, interprofessional practice, qualitative method
Introduction In recent years, increasing evidence has emerged that interprofessional (IP) collaboration improves quality of care and patient outcomes (Berridge, MacKintosh, & Freeth, 2010; Zwarenstein, Goldman, & Reeves, 2009). Healthcare organisations have begun to integrate collaborative practice components into their models of care (Fryers, Young, & Rowland, 2012; Murphy, Alder, MacKenzie, & Rigby, 2010). In 2011, Alberta Health Services (AHS), the provincial health authority in Alberta, Canada, began the Workforce Model Transformation initiative to incorporate collaborative practice as a key component in its future model of care. AHS adopted the definition of collaborative practice by Busing and coworkers as an ‘‘interprofessional process of communication and decision-making that enables the separate and shared knowledge and skills of healthcare providers to synergistically influence the patient care provided’’ (Way, Jones, & Busing, 2000, p. 3). While recognising the importance of collaborative practice, operationalising and measuring progress towards this
Correspondence: Shelanne L. Hepp, Alberta Health Services, Workforce Research & Evaluation, 10301 Southport Lane SW, Calgary, Alberta T2W 1S7, Canada. E-mail: [email protected]
History Received 9 July 2013 Revised 27 June 2014 Accepted 14 August 2014 Published online 10 September 2014
multidimensional concept has proven to be difficult (Reeves, Fox, & Hodges, 2009; Reeves, 2012; Schmitt, 2001; Suter et al., 2009). A popular approach has been to develop a standardised set of IP competencies and train healthcare providers towards achievement of these competencies to facilitate collaborative practice. According to the National Interprofessional Competency Framework developed by the Canadian Interprofessional Health Collaborative (CIHC, 2010), patient/client/family/communitycentred care, communication, role clarification, team functioning, conflict resolution and collaborative leadership are the six key competency domains required for effective collaborative practice. If all six competencies were enacted to their fullest, collaborative practice would be at its best. The use of competency frameworks has been helpful to define professional competence, set consistent standards of practice across settings and identify performance indicators that link to the competencies (Reeves et al., 2009). However, criticisms of using competency frameworks have recently been noted: (1) competencies are generally behaviourbased and often lack integration of values, responsibility, decision-making, problem solving and reflection (Glavin & Maran, 2002; Talbot, 2004); (2) the division of work across settings is not conceptually well understood (Reeves, 2012); and (3) lack of clarity exists about how to robustly measure competency frameworks as there is little evaluation data to inform whether the competencies are being implemented (Reeves, 2012; Schmitt, 2001; Suter et al., 2009).
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This article reports the views of staff about the six competencies and collaborative processes at the six units. The article has three objectives: (1) to describe the current state of collaborative practice on six acute care units in AHS using the CIHC competency framework; (2) identify gaps in collaborative practice; and (3) identify strategies for each competency domain to improve collaborative practice.
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Methodology We conducted a secondary data analysis of qualitative data from a baseline assessment of collaborative practice on six acute care units (surgical and medical) in three Alberta hospitals. Hospitals included one of Canada’s leading clinical, research and teaching hospitals, an inner city hospital providing general and specialised medical and surgical services, and a regional hospital (located in a smaller city) with acute, sub-acute and supportive rehabilitation/ transition beds. At each hospital, staff from one medical and one surgical unit serving adult patients participated in the initiative. These units were selected by AHS leaders to inform implementation of workforce transformation in AHS (i.e. a quality improvement project aimed at implementation of a collaborative model of care). For the primary data collection, one-hour qualitative interviews were conducted with 15–20 staff from each unit with a total of 113 staff members inquiring about their experiences with collaborative practice. The number of interviewees was proportionate to the professional diversity at each unit with a higher representation of nurses (Table I). The semistructured interviews focused on these major areas: model of care, scope of practice, collaboration (specifically, decision-making), patient-centred care, communication, recruitment/retention and leadership. A secondary data analysis is appropriate for several reasons. First, all authors were involved in the original data collection and analysis, which strengthened personal involvement in the data production and context required to undergo the secondary analysis (Long-Sutehall, Sque, & Addington-Hall, 2010). Second, since the primary and secondary analysis converged on the topic of collaboration with many components of the CIHC competency framework addressed, it was fitting to re-analyse our previously collected data (Heaton, 2008; Long-Sutehall et al., 2010). The first author (S. L. H.) extracted statements related specifically to the six CIHC definitions and competency statements of IP collaboration from the detailed reports for each unit report, which formed the overall themes. Subsequently, all authors reviewed, validated and analysed the data extracted for the six competency domains reading the interview transcripts. Table I. Healthcare provider interviewees. Interviewees Nursing (e.g. registered nurse, licensed practical nurse, transition nurse, charge nurse, nurse educator, clinical quality lead, care coordinator and resource nurse) Nursing assistant/healthcare aide Manager Unit clerk, patient registration Other healthcare providers (physiotherapist, occupational therapists social worker, speech language pathologist, spiritual care, pharmacist, dietitians and therapy assistant) Diagnostic imaging, laboratory and X-ray Physician, resident Support services (environmental services, housekeeping, service aide, food services and protection services) Other staff: positions not identified Total
Number 44 8 4 10 30
2 7 5 3 113
Ethical considerations For the secondary data analysis, we did not obtain ethics approval since informed consent was obtained for all interviews in the primary data collection.
Results Examples are presented of current structures and processes as described by clinical and non-clinical staff to illustrate the six competency domains. Staff interviewees also pointed to the strengths and weaknesses of their practice in these domains, and in some cases, they had ideas for improvement. IP communication Generally, interviewees referred to communication as being good (e.g. consistent messaging and formal communication mechanisms) and that everybody is approachable. It was considered important to convey a consistent message to patients rather than ‘‘a whole bunch of people doing things in their little bubble that don’t communicate’’ [Physiotherapist, Unit 6]. They highlighted different types of rounds and charting as the main formal communication mechanisms. Different types of rounds were identified such as IP rounds, discharge rounds, Kardex rounds and/or resident rounds. Rounds varied in length (between 15 and 120 minutes) and purpose. Shorter rounds focused on the daily needs of patients, while longer rounds were used for discharge planning. Besides addressing priority patient needs, staff members also learned about appropriate referrals and roles. IP rounds were primarily attended by nursing, social workers, occupational therapists, physiotherapists, dietitians and pharmacists. It was reported that the charge nurse or nursing team lead may represent the different nursing specialties (e.g. wound care nurse) on some units. The unit manager, bed manager, discharge coordinator or spiritual care coordinator attended on certain units. Physicians generally did not attend IP rounds (with the exception of one unit) resulting in separate communication to keep physicians informed of patients’ status. ðit’s physician drive[n]. So it has to go through the doctor, he writes the order and then the consult is processed. So it, and that’s why, if you don’t have a physician present at Multidisciplinary Rounds, that’s a huge problem because they’re the one driving the whole team. So then you have to take the time after the meeting to fill in the doctors regarding what we discussed in the rounds. So to me it’s essential that they’re present, and they are not at most of the rounds. [Physiotherapist, Unit 6] IP rounds were not always conducted efficiently (e.g. staff arriving late, patients not assessed prior to rounds and lack of clearly written plans for patients) and timing of rounds was at times inconvenient for providers to attend. Other concerns were that not all attendees were treated as equals to offer information and opinions, and lack of accountability for follow through with decisions made during rounds. Regardless of how rounds were conducted, all interviewees stated that it was a useful way to support IP communication: Rounds play a big part of being able to discuss what’s best for the patient and are they able to go back where they from, from the hospital or do we have to look at something else, and then everybody from the team can put their input in whether they have a mobility concern, or nutrition, or swallowing, or different areas. [Dietitian, Unit 3]
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According to interviewees, written documentation among IP team members include progress notes and patient charts kept in different locations (e.g. Kardex, charts, electronic records and discipline-specific binders). Besides leading to duplication, missing information and delays in follow-up, interviewees expressed concern that not everyone reads the information. Many expressed that nurses and other healthcare providers tended to rely on verbal information sharing and that it is rare for them to read the notes: I’m sure we can find a way to condense and have accurate information, but condense it where everybody who needs information can gather it from one page, which I think would be the best result for all of that. [Resource Nurse, Unit 2]
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Patient-centred care The general sense among interviewees was that patient care quality was good; safety standards and patient needs were being met by centering care and decision-making around patients and their families: So I would think that most of the patients’ needs are well met on [unit] although sometimes the nurses sacrifice themselves to obtain that. [Physician, Unit 5] While the safety of patients was not perceived to be compromised, interviewees commented that surgical units tend to discharge patients quickly resulting in rushed post-operative teaching and lack of treatment plans. A recurring sub-theme was a more holistic approach to patient care was needed, as it was believed that patients’ non-surgical issues were not addressed. Another interviewee mentioned that patients could benefit from specific services (e.g. social work) if patients were made aware of the services available to them or if physicians believed in the benefits of that service (e.g. dietary counselling). This was seen as especially important for patients who were without a family doctor. Role clarification Three main sub-themes, highlighting the need for role clarification, emerged from the data: (1) lack of clarity between the roles of registered nurses (RN) and licensed practical nurses (LPNs); (2) scope of practice and utilisation of nursing staff; and (3) lack of understanding of other healthcare provider roles (e.g. physiotherapist and occupational therapist). When discussing nursing scope of practice, some nursing staff agreed that nursing role confusion was the result of increased training and expanded scope of practice of the LPNs over the past few years. Many interviewees delineated the roles of RNs and LPNs around specific tasks (e.g. LPNs give IV medication, but RNs are responsible for central lines and the charge nurse role). However, in many areas, RNs and LPNs were performing similar tasks with lack of differentiation between the two providers. This was reported as leading to role confusion and feelings of frustration for doing tasks that could more appropriately be completed by another provider. Furthermore, RNs were viewed as not working to their full scope of practice: I think maybe the RNs could be working to further scope of practiceðI think back over the years about the bed bathing, the walking, like such a physical job and, and you think about what my training is and what my experience is and what I’m truly paid to do. [Unit Manager/Charge Nurse, Unit 6]
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In addition, others stated that hospital policy was preventing LPNs from working to full scope. It was frequently noted that RNs and LPNs should be spending more time on discharge planning and thinking about the ‘‘bigger picture’’ for patients, while it was suggested that the transition nurse should do the care planning. Interviewees on one unit noted that RNs are encouraged to move away from completing tasks to a focus on a total case management approach to patient care. Lack of understanding between nursing and other healthcare provider roles was also reported. Many nurse interviewees expressed that some of their activities should be the responsibility of another healthcare provider (e.g. physiotherapist) or even housekeeping, as it takes them away from their nursing responsibilities (e.g. discharge planning, treatment planning and patient education). Other interviewees noted overlap in roles between nursing staff and other healthcare providers, resulting in possible duplication in patient education, care planning and mobilisation: I think one of the things is even if you look at all the disciplines in the hospital there is not a lot of knowledge about what everybody’s scope entails ð And I think lots of times if lots of the staff had a better knowledge about what everybody was capable of doing then you could bring the right person in the right time to prevent problems from getting bigger. [Physiotherapist, Unit 6] Other healthcare provider roles were generally reported as fairly clear across units with the exception of role confusion between physiotherapists and occupational therapists, reflected by inappropriate referrals. Team functioning Many nursing interviewees saw teamwork as assisting other nurses with task-oriented patient care, in particular physical activities requiring an extra set of hands. For example, LPNs specifically mentioned that they work closely with healthcare aides to help with baths and heavy lifting. RNs mentioned that they work together to cover each other during breaks. LPNs further commented that they would go to the RN, team lead or the charge nurse to discuss patient concerns if need be. There was agreement that helping each other was important and highly valued and made the workload more manageable. Nurses also spoke positively about teamwork with other healthcare providers. Similarly, these other healthcare provider interviewees had positive comments related to working with nurses, finding them an invaluable source of information, feeling valued by them and attesting to an open relationship: Actually the team works very well together. . . [I]f there’s any questions we make time for each other as a team to kind of collaborate and talk about what we need to talk about. Yeah, they’re actually very approachable. [Social Worker, Unit 1] However, coordinating patient care with other providers was challenging. While some providers are readily available, interviewees acknowledged difficulties in accessing certain providers, in part, due to time of day or day of week (e.g. weekends and evenings) or workload. Many providers stated that a strong atmosphere of teamwork existed on their units. Others voiced that there were times when the team was ‘‘not open to others coming [such as] new staff, casuals’’ [Care Coordinator, Unit 3] and that there is room to improve team functioning. A few staff spoke to
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the lack of respect between providers and how that negatively impacted team functioning: There’s bullying from doctorsð[and]ð nurses, there’s bullying from other departments and I think that’s a huge thing that we deal with every dayð And it makes your life not fun and it interrupts patient care. Andðyou can’t do proper care when you’re upset because someone is attacking you all the time and it does happen everywhere. [Registered Nurse, Unit 4]
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Nursing interviewees from units that had recently introduced a nursing team model of care stated that the model had fostered a deeper sense of shared responsibility and accountability, which in turn increased morale and led staff to feel more empowered. They felt they had permission and were clearer on whom they could reach out to for assistance, and this encouraged stronger and more frequent communication among nursing staff. Collaborative leadership Interviewees described situations suggesting that collaborative leadership at IP rounds was not optimal. For example, it was identified that other healthcare providers were not expected nor encouraged to contribute to discussions on discharge/bed availability. Not having front-line nurses attend IP rounds was seen as a missed opportunity to develop leadership skills in front-line nurses. Concern was voiced with the strong leadership role physicians and charge nurses had and saw it as impeding leadership development in other staff. There was recognition that a ‘‘go-to’’ position was needed at specific points in care (e.g. patient transfer and discharge) to allow patients to flow smoothly through the system. Interviewees also talked about the decision-making authority of official leaders (e.g. charge nurse, physicians and primary nurse). There was acknowledgement that the charge nurse was often responsible for solving problems and making decisions: I think if everything kind of goes through the charge [nurse], when you have that one point of communication it definitely ensure[s] that the information’s sort of at a level where it can be dealt with appropriately and so you know that the communication has happened. [1st Year Medical Resident, Unit 3] However, disadvantages were associated with the charge nurse as the main point of contact – specifically, lacking a complete picture of the patient and disempowerment of the primary nurse. Nursing decision-making about everyday patient care was described as the primary nurse’s (RN or LPN) responsibility. Other healthcare providers also reported having decision-making ability about care related to their individual disciplines. It was clearly articulated by many interviewees that major decisions were made by the physician. Interestingly, one physician noted that the charge nurse needed to be more empowered to make decisions that did not need to be brought to the physician’s attention. Another physician noted that he/she was unclear who had ultimate decision-making responsibility on certain decisions such as transferring patients to another unit. Conflict resolution On the six units, a common source of conflict emerged around the discharge of patients. While some physicians may invite recommendations from staff to inform their decisions, nursing and other healthcare providers expressed some dissatisfaction over physicians’ ultimate decision-making authority for discharges. Other healthcare providers expressed dissatisfaction that the
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results of their professional assessments were ignored, especially when questioning the readiness for discharge of a patient. There seemed to be a lack of objective criteria for discharge or an agreed upon process around negotiating discharge decisions and resolving disagreements. Interviewees mentioned contextual factors that could exacerbate conflict such as high workload, burnout, lack of leadership around coordination of care, disrespect among providers and role blurring.
Discussion Although collaborative practice has been widely embraced in healthcare, operationalising and measuring this multidimensional concept in real life has proven to be difficult. Generally, the literature has focused on knowledge of and attitudes towards collaborative practice, excluding the applied component of how IP competencies are enacted in a practice setting. We used data from interviews with staff discussing their perception of collaboration, roles, communication and staffing in conjunction with the CIHC IP competency framework to examine current state of collaboration on six acute care units. Of the six IP competencies, communication and patientcentred care emerged as strengths. It is not surprising that providers had great awareness of these competency domains because some processes (e.g. rounds, documentation and discharge planning) to support enactment of these competencies were in place. Deficiencies were noted with IP rounds (e.g. not always efficient/informative and not all disciplines attending) and documentation (e.g. duplication), but providers had ideas for possible solutions. Research indicates that rounds conducted with clear goals are key to improving patient flow, communication and coordination of care among healthcare providers, and decreasing length of stay (Geary, Cale, Quinn, & Winchell, 2009). Furthermore, most interviewees knew how patient-centred care should be practiced (e.g. holistic care), were aware of their strengths and shortcomings and identified processes (e.g. integrated care plan and discharge plan) to support this competency. However, time constraints prevented interviewees from delivering holistic care, discharge planning and post-operative teaching. Research suggests that patients’ self-management capabilities and skills are often overestimated and/or not sufficiently addressed, leaving patients unprepared for discharge and without detailed instruction on how to perform simple procedures (e.g. change a wound dressing) (Hesselink et al., 2012). In addition, interviewees had concrete ideas of what they could do to skilfully apply communication (e.g. ensure information communicated at IP rounds flows back to the RNs, LPNs and HCAs) and patient-centred care (e.g. make available basic activities such as walking to patients) competencies and awareness about current gaps and limitations. We uncovered weaknesses with role clarity and collaborative leadership competencies. Although interviewees were aware of role clarity and collaborative leadership issues on the units (e.g. RNs and LPNs were seen as not working to their full scope of practice), providers could not find workable solutions to resolve these issues and identified heavy workload as the largest barrier to working to full scope/role clarity issues. Research suggests that a lack of role clarity and understanding of professional roles can lead to underutilisation of professional expertise (Suter et al., 2009). This may compromise patient outcomes and contribute to excess system utilisation such as preventable 90 day readmission (Besner, 2011). Furthermore, although interviewees could provide instances of where shared leadership was applied (e.g. rapid rounds and patient transfer), leadership centered on decisionmaking by formal leaders such as physicians and charge nurses. Collaborative leadership is needed to ensure that work
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Table II. Select strategies for collaborative practice. Strategies based on the literature and gaps identified by the study Interprofessional communication IP rounds: Issues with IP rounds are that they are not conducted efficiently, often lack clearly written plans for patients and provider representation is not always good. Strategies include the following: Enhance rounds through physician attendance (where appropriate) and strengthen focus on an integrated plan of care (rather than immediate patient needs) (Fryers et al., 2012). Improve rounds by starting as early as possible (before 10 am); spend one minute per patient to discuss the ‘‘plan for the day, plan for the stay’’ (Geary et al., 2009).
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Documentation: Issues with documentation are that notes and charts are kept in different locations, duplication and missing information occurs and that not everyone reads the information. Strategies include the following: Use a Situation-Background-Assessment-Recommendation (SBAR) format to improve shift reporting (Murphy et al., 2010). Create an interprofessional Kardex to reduce duplication and increase the use of documentation for planning (Murphy et al., 2010). Create a patient record shared between physicians and other healthcare providers to improve care, coordinate care, and protect the safety of patients (Canadian Medical Association, 2007). Implement electronic medical records (EMRs) to mitigate disadvantages of paper documentation including missed, and inconsistent information, and time-consuming documentation (Green & Thomas, 2008; Langowski, 2005). Patient-centred care: Issues with patient-centred care are that surgical units often discharge patients quickly, rushed post-operative teaching, and lack of treatment plans. Strategies include the following: Discuss care plan and communicate with patients and families early to improve patient care (Hesselink et al., 2012). Increase amount of direct one-on-one care time with patient and family (time to ask open-ended questions) to improve patient care (Canadian Medical Association, 2007). Incorporate hourly patient care rounding that addresses each patient’s positioning, personal needs, pain, and placement of personal items to improve patient satisfaction (Fryers et al., 2012). Implement white boards for patient information to improve patient safety (Murphy et al., 2010). Implement preadmission classes for surgery patients to prepare patients for surgery and plan for discharge recovery to reduce length of stay (Murphy et al., 2010; Hesselink et al., 2012). Implement a standardised discharge handover protocol for patients and providers, formalised face-to-face discharge consultation and assessments for patients’ level of understanding of information to improve the discharge process, patients’/families’ self-care skills, mitigate patient anxiety, and reduce readmissions (Hesselink et al., 2012). Use pictures, videos and/or storyboards for information exchange with patients and family members to improve patient preparedness, and consistency of patient care (Besner, 2011). Role clarification: Issues with role clarification are lack of delineation between RNs and LPNs, both roles should spend more time on discharge planning, and lack of understanding between nursing and allied health roles. Strategies include the following: Develop clear job descriptions to support providers working to full scope of practice (Canadian Medical Association, 2007; Murphy et al., 2010). Provide ongoing professional development activities (e.g. IP education rounds) that address role optimisation and utilisation of healthcare providers (Murphy et al., 2010; Fryers et al., 2012; Harvey & Priddy, 2011). Facilitate a culture built on quality relationships between healthcare providers (Registered Nurses’ Association of Ontario (RNAO), 2006). Collaborative leadership: Issues with collaborative leadership are allied health is not encouraged to contribute to discussions, front-line nurses are not developing their leadership skills through attendance of IP rounds, and lack of empowerment of the charge nurse. Strategies are as follows: Realign nursing roles to provide leadership opportunities for nursing staff, specifically RNs (Besner, 2011). Support unit managers and other leaders (e.g., transition coordinator, LPN mentor) at the point of care to carry out staff duties/roles (Canadian Medical Association, 2007; Harvey & Priddy, 2011). Team functioning: Issues with team functioning are difficulties coordinating patient care with other providers and accessing certain providers. Strategies are: Implement strategies that focus on the values, beliefs, and behaviours of supportive teams (RNAO, 2006). Implement strategies that support team functioning (e.g., non-hierarchal team structure, democratic working practices) (RNAO, 2006). Allow healthcare providers to be part of formulating unit policies to help ensure that procedures and processes will be adhered to by all participating team members and encourage teamwork (e.g. emergencies, day-to-day functioning and care planning) (RNAO, 2006). Conflict resolution: Issues with conflict resolution are dissatisfaction over physicians’ ultimate decision-making authority for discharges and providers not having an agreed upon process around discharge decisions and resolving disagreements. Strategies are as follows: Establish processes for conflict resolution and problem solving that lead to quality work environments and quality outcomes for patients and clients (RNAO, 2006). Implement structured debriefing after simulated training exercise to improve team competencies and team functioning (Boehler & Schwind, 2012).
environments support providers and foster collaborative partnerships (Disch, Beilman, & Ingbar, 2001; Manojilovich, Barnsteiner, Bolton, Disch, & Saint, 2008). One suggestion for shared leadership was to have all providers attend rounds or have equal input into patient discussions. However, the logistics around gathering all providers on the unit at the same time was not always conducive to promoting shared leadership. While interviewees had concrete ideas of how to improve role clarity (e.g. dedicate a professional practice leader to clarify roles on the unit) and collaborative leadership (e.g. practice team based nursing model of care), they did not have confidence that they could overcome
the barriers identified as prohibiting them from practicing the competencies. Team functioning and conflict resolution emerged as gaps in collaborative practice. Although some awareness existed, interviewees did not understand this competency well and were unaware of potential practices promoting team functioning. Examples of joint problem-solving or shared planning of care were rare. Interviewees’ somewhat simplified notion of teamwork involved assisting each other with task-oriented patient care. Interviewees knew that joint responsibility for actions was required to accomplish goals, but they had difficulties
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coordinating patient care with other providers. This is corroborated by literature (MacNaughton, Chreim, & Bourgeault, 2013; McCallin, 2006) that states team practice continues to be problematic given that professional boundaries are changing and IP coordination across role boundaries is challenging. Furthermore, interviewees across units did not discuss many examples of conflict resolution being practiced. However, contention was noted for situations where hierarchical, decisionmaking was exhibited. Generally, there was lack of awareness around processes to resolve conflict. Interviewees mentioned contextual factors that could exacerbate conflict such as high workload, disrespect among providers and role blurring. Team members must recognise the expertise and functions of others to interact meaningfully, as power struggles, role confusion, lack of respect and autonomy can be barriers to collaboration (Besner, 2011; Beunza, 2013; Keshet, Ben-Arye, & Schiff, 2013; Suter et al., 2009). The findings highlight areas for improvement in each of the six competencies. We propose strategies to enhance collaborative practice and, more specifically, each of the six competencies (see Table II) that have been informed by the literature. The interventions presented are not a comprehensive list but were selected based on the gaps found in collaborative practice from this initiative. The semi-structured nature of qualitative data gathering resulted in vast information about providers’ perceptions of collaborative practice on their units including emerging challenges. However, the limitations of secondary data analysis are well known: data not collected and intended for a specific analysis may fall short of fully representing the social phenomenon under examination. The original interview questions were not constructed based on the definitions and competency statements of the CIHC framework. Although many questions generated sufficient evidence, some competencies were supported with less information (e.g. conflict resolution) than others (e.g. role clarification). In the case of conflict, is likely to be more widespread than occurring between physicians and nursing staff. Furthermore, extracting distinct data to qualify for the secondary analysis may have been difficult for the authors due to the subtle differences between the primary and secondary analysis (Heaton, 1998). While our analysis should be taken with some caution, we are also confident that our conclusions are accurate. We have encountered these weaknesses in collaborative practice at other settings in AHS thus reinforcing the need for the workforce transformation initiative in the first place. Furthermore, some authors have criticised the use of competency frameworks for their reductionist tendency that may reinforce the status quo (Reeves et al., 2009). Competency is a point on a continuum where progression is made from being proficient to being an expert (Talbot, 2004). During this process, analytical skills and intuition are used for decision making and situational understanding, requiring significant experience and reflection of practice (Diwakar, 2002; Glavin & Maran, 2002; Talbot, 2004). Since every individual healthcare professional moves along this continuum towards expertise; defining, assessing and measuring higher order competencies (whether clinical or IP competencies) have been problematic due to their ambiguity and complexity of overlapping domains (Reeves et al., 2009; Talbot, 2004). This may affect the ability of a competency framework to accurately capture the ‘‘level’’ of IP collaboration practiced by a collective group of healthcare providers.
Concluding comments Collaborative competencies play a role in the success of individuals and team members adapting to new models of care.
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Using the CIHC IP competency framework to guide the secondary analysis allowed us to highlight areas of strength as well as gaps and to gain insight into the ‘‘complex interplay between knowledge, skills and behaviors’’ (Reeves et al., 2009). This information is useful when implementing collaborative practice models as it points to areas requiring special attention. It also supports the utility of the CIHC IP competency framework in capturing the essence of IP collaboration (Reeves et al., 2009). As IP competencies have been proven to be difficult to define and measure, this study provides a step forward in identifying competencies in a practical setting. There is still work to be conducted in translating a comprehensive understanding of collaborative practice to frontline providers and decisionmakers. The strategies are intended to make the competencies more tangible by targeting the individual, team and system levels to support the implementation of collaborative models of care.
Acknowledgements The authors would like to acknowledge the extensive contributions of staff and physicians at the six participating units in AHS.
Declaration of interest The authors report no declaration of interest. The authors alone are responsible for the writing and content of this paper. The authors would like to thank the funder, Alberta Health.
References Berridge, E.J., Mackintosh, N., & Freeth, D. (2010). Supporting patient safety: Examining communication within delivery suite teams through contrasting approaches to research observations. Midwifery, 26, 512–519. Besner, J. (2011). Improving the quality of nursing care: The case for collaborative practice. Care, 25, 22–25. Beunza, J.J. (2013). Conflict resolution techniques applied to interprofessional collaborative practice. Journal of Interprofessional Care, 27, 110–112. Boehler, M., & Schwind, C. (2012). Power and conflict and the performance of medical action teams: A commentary. Medical Education, 46, 833–835. Canadian Interprofessional Health Collaborative. (2010). A national Interprofessional competency framework. Retrieved from: http:// www.cihc.ca/files/CIHC_IPCompetencies_Feb1210.pdf. Canadian Medical Association. (2007). Putting patients firstÕ : Patientcentred collaborative care. A discussion paper. Alberta Medical Association. Retrieved from: http://fhs.mcmaster.ca/surgery/documents/CollaborativeCareBackgrounderRevised.pdf. Disch, J., Beilman, G., & Ingbar, D. (2001). Medical directors as partners in creating healthy work environments. AACN Advanced Critical Care, 12, 366–77. Diwakar, V. (2002). Commentary: The baby is thrown out with the bathwater. British Medical Journal, 325, 695–696. Fryers, M., Young, L., & Rowland, P. (2012). Creating and sustaining a collaborative model of care. Healthcare Management Forum, 25, 20–25. Geary, S., Cale, D., Quinn, B., & Winchell, J. (2009). Daily rapid rounds: Decreasing length of stay and improving professional practice. Journal of Nursing Administration, 39, 293–298. Glavin, R.J., & Maran, N.J. (2002). Development and use of scoring systems for assessment of clinical competence. British Journal of Anaesthesia, 88, 329–330. Green, S.D., & Thomas, J.D. (2008). Interdisciplinary collaboration and the electronic medical record. Pediatric Nursing, 34, 225–240. Harvey, A., & Priddy, C. (2011). Collaborative practice: Matching staff skills to patient needs and checking baseline staffing levels. Healthcare Management Forum, 24, 184–187. Heaton, J. (1998). Secondary analysis of qualitative data. Social Research Update, Issue 22, October: University of Surrey. In R.L. Miller & J.D. Brewer (Eds.), The A–Z of social research (pp. 280–285). London: Sage. Heaton, J. (2008). Secondary analysis of qualitative data: An overview. Historical Social Research, 33, 33–45.
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21, 2013 from: http://www.gov.ns.ca/health/MOCINS/docs/MOCINSevaluation-report.pdf. Reeves, S. (2012). The rise and rise of interprofessional competence. Journal of Interprofessional Care, 26, 253–255. Reeves, S., Fox., A., & Hodges, B. (2009). The competency movement in the health professions: Ensuring consistent standards or reproducing conventional domains of practice. Advances in Health Sciences Education, 14, 451–453. Registered Nurses’ Association of Ontario. (2006). Collaborative practice among nursing teams. Toronto, Canada: Registered Nurses’ Association of Ontario. Schmitt, M. (2001). Collaboration improves the quality of care: Methodological challenges and evidence from US health care research. Journal of Interprofessional Care, 15, 47–66. Suter, E., Arndt, J., Arthur, N., Parboosingh, J., Taylor, E., & Deutschlander, S. (2009). Role understanding and effective communication as core competencies for collaborative practice. Journal of Interprofessional Care, 23, 41–51. Talbot, M. (2004). Monkey see, monkey do: A critique of the competency model in graduate medical education. Medical Education, 38, 587–592. Way, D., Jones, L., & Busing, N. (2000). Implementation strategies: Collaboration in primary care: Family doctors & nurse practitioners delivering shared care. Toronto: The Ontario College of Family Physicians. Zwarenstein, M., Goldman, J., & Reeves, S. (2009). Interprofessional collaboration: Effects of practice-based interventions on professional practice and healthcare outcomes (Review). The Cochrane Library, 4, 1–29.
ORIGINAL ARTICLE
Using an interprofessional competency framework to examine collaborative practice Shelanne L. Hepp1, Esther Suter1, Karen Jackson1, Siegrid Deutschlander1, Edward Makwarimba2, Jake Jennings3 and Lisa Birmingham3
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1
Alberta Health Services, Workforce Research & Evaluation, Calgary, Alberta, Canada, 2Formerly Alberta Health Services, Calgary, Alberta, Canada, and 3Alberta Health Services, CoACT – Health Professions Strategy & Practice, Calgary, Alberta, Canada
Abstract
Keywords
Healthcare organisations are starting to implement collaborative practice to increase the quality of patient care. However, operationalising and measuring progress towards collaborative practice has proven to be difficult. Various interprofessional competency frameworks have been developed that outline essential collaborative practice competencies for healthcare providers. If these competencies were enacted to their fullest, collaborative practice would be at its best. This article examines collaborative practice in six acute care units across Alberta using the Canadian Interprofessional Health Collaborative (CIHC) competency framework (CIHC, 2010). The framework entails the six competencies of patient-centred care, communication, role clarification, conflict resolution, team functioning and collaborative leadership (CIHC, 2010). We conducted a secondary analysis of interviews with 113 healthcare providers from different professions, which were conducted as part of a quality improvement study. We found positive examples of communication and patient-centred care supported by unit structures and processes (e.g. rapid rounds and collaborative plan of care). Some gaps in collaborative practice were found for role clarification and collaborative leadership. Conflict resolution and team functioning were not well operationalised on these units. Strategies are presented to enhance each competency domain in order to fully enact collaborative practice. Using the CIHC competency framework to examine collaborative practice was useful for identifying strength and areas needing improvement.
Collaborative competence, interviews, interprofessional collaboration, interprofessional practice, qualitative method
Introduction In recent years, increasing evidence has emerged that interprofessional (IP) collaboration improves quality of care and patient outcomes (Berridge, MacKintosh, & Freeth, 2010; Zwarenstein, Goldman, & Reeves, 2009). Healthcare organisations have begun to integrate collaborative practice components into their models of care (Fryers, Young, & Rowland, 2012; Murphy, Alder, MacKenzie, & Rigby, 2010). In 2011, Alberta Health Services (AHS), the provincial health authority in Alberta, Canada, began the Workforce Model Transformation initiative to incorporate collaborative practice as a key component in its future model of care. AHS adopted the definition of collaborative practice by Busing and coworkers as an ‘‘interprofessional process of communication and decision-making that enables the separate and shared knowledge and skills of healthcare providers to synergistically influence the patient care provided’’ (Way, Jones, & Busing, 2000, p. 3). While recognising the importance of collaborative practice, operationalising and measuring progress towards this
Correspondence: Shelanne L. Hepp, Alberta Health Services, Workforce Research & Evaluation, 10301 Southport Lane SW, Calgary, Alberta T2W 1S7, Canada. E-mail: [email protected]
History Received 9 July 2013 Revised 27 June 2014 Accepted 14 August 2014 Published online 10 September 2014
multidimensional concept has proven to be difficult (Reeves, Fox, & Hodges, 2009; Reeves, 2012; Schmitt, 2001; Suter et al., 2009). A popular approach has been to develop a standardised set of IP competencies and train healthcare providers towards achievement of these competencies to facilitate collaborative practice. According to the National Interprofessional Competency Framework developed by the Canadian Interprofessional Health Collaborative (CIHC, 2010), patient/client/family/communitycentred care, communication, role clarification, team functioning, conflict resolution and collaborative leadership are the six key competency domains required for effective collaborative practice. If all six competencies were enacted to their fullest, collaborative practice would be at its best. The use of competency frameworks has been helpful to define professional competence, set consistent standards of practice across settings and identify performance indicators that link to the competencies (Reeves et al., 2009). However, criticisms of using competency frameworks have recently been noted: (1) competencies are generally behaviourbased and often lack integration of values, responsibility, decision-making, problem solving and reflection (Glavin & Maran, 2002; Talbot, 2004); (2) the division of work across settings is not conceptually well understood (Reeves, 2012); and (3) lack of clarity exists about how to robustly measure competency frameworks as there is little evaluation data to inform whether the competencies are being implemented (Reeves, 2012; Schmitt, 2001; Suter et al., 2009).
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This article reports the views of staff about the six competencies and collaborative processes at the six units. The article has three objectives: (1) to describe the current state of collaborative practice on six acute care units in AHS using the CIHC competency framework; (2) identify gaps in collaborative practice; and (3) identify strategies for each competency domain to improve collaborative practice.
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Methodology We conducted a secondary data analysis of qualitative data from a baseline assessment of collaborative practice on six acute care units (surgical and medical) in three Alberta hospitals. Hospitals included one of Canada’s leading clinical, research and teaching hospitals, an inner city hospital providing general and specialised medical and surgical services, and a regional hospital (located in a smaller city) with acute, sub-acute and supportive rehabilitation/ transition beds. At each hospital, staff from one medical and one surgical unit serving adult patients participated in the initiative. These units were selected by AHS leaders to inform implementation of workforce transformation in AHS (i.e. a quality improvement project aimed at implementation of a collaborative model of care). For the primary data collection, one-hour qualitative interviews were conducted with 15–20 staff from each unit with a total of 113 staff members inquiring about their experiences with collaborative practice. The number of interviewees was proportionate to the professional diversity at each unit with a higher representation of nurses (Table I). The semistructured interviews focused on these major areas: model of care, scope of practice, collaboration (specifically, decision-making), patient-centred care, communication, recruitment/retention and leadership. A secondary data analysis is appropriate for several reasons. First, all authors were involved in the original data collection and analysis, which strengthened personal involvement in the data production and context required to undergo the secondary analysis (Long-Sutehall, Sque, & Addington-Hall, 2010). Second, since the primary and secondary analysis converged on the topic of collaboration with many components of the CIHC competency framework addressed, it was fitting to re-analyse our previously collected data (Heaton, 2008; Long-Sutehall et al., 2010). The first author (S. L. H.) extracted statements related specifically to the six CIHC definitions and competency statements of IP collaboration from the detailed reports for each unit report, which formed the overall themes. Subsequently, all authors reviewed, validated and analysed the data extracted for the six competency domains reading the interview transcripts. Table I. Healthcare provider interviewees. Interviewees Nursing (e.g. registered nurse, licensed practical nurse, transition nurse, charge nurse, nurse educator, clinical quality lead, care coordinator and resource nurse) Nursing assistant/healthcare aide Manager Unit clerk, patient registration Other healthcare providers (physiotherapist, occupational therapists social worker, speech language pathologist, spiritual care, pharmacist, dietitians and therapy assistant) Diagnostic imaging, laboratory and X-ray Physician, resident Support services (environmental services, housekeeping, service aide, food services and protection services) Other staff: positions not identified Total
Number 44 8 4 10 30
2 7 5 3 113
Ethical considerations For the secondary data analysis, we did not obtain ethics approval since informed consent was obtained for all interviews in the primary data collection.
Results Examples are presented of current structures and processes as described by clinical and non-clinical staff to illustrate the six competency domains. Staff interviewees also pointed to the strengths and weaknesses of their practice in these domains, and in some cases, they had ideas for improvement. IP communication Generally, interviewees referred to communication as being good (e.g. consistent messaging and formal communication mechanisms) and that everybody is approachable. It was considered important to convey a consistent message to patients rather than ‘‘a whole bunch of people doing things in their little bubble that don’t communicate’’ [Physiotherapist, Unit 6]. They highlighted different types of rounds and charting as the main formal communication mechanisms. Different types of rounds were identified such as IP rounds, discharge rounds, Kardex rounds and/or resident rounds. Rounds varied in length (between 15 and 120 minutes) and purpose. Shorter rounds focused on the daily needs of patients, while longer rounds were used for discharge planning. Besides addressing priority patient needs, staff members also learned about appropriate referrals and roles. IP rounds were primarily attended by nursing, social workers, occupational therapists, physiotherapists, dietitians and pharmacists. It was reported that the charge nurse or nursing team lead may represent the different nursing specialties (e.g. wound care nurse) on some units. The unit manager, bed manager, discharge coordinator or spiritual care coordinator attended on certain units. Physicians generally did not attend IP rounds (with the exception of one unit) resulting in separate communication to keep physicians informed of patients’ status. ðit’s physician drive[n]. So it has to go through the doctor, he writes the order and then the consult is processed. So it, and that’s why, if you don’t have a physician present at Multidisciplinary Rounds, that’s a huge problem because they’re the one driving the whole team. So then you have to take the time after the meeting to fill in the doctors regarding what we discussed in the rounds. So to me it’s essential that they’re present, and they are not at most of the rounds. [Physiotherapist, Unit 6] IP rounds were not always conducted efficiently (e.g. staff arriving late, patients not assessed prior to rounds and lack of clearly written plans for patients) and timing of rounds was at times inconvenient for providers to attend. Other concerns were that not all attendees were treated as equals to offer information and opinions, and lack of accountability for follow through with decisions made during rounds. Regardless of how rounds were conducted, all interviewees stated that it was a useful way to support IP communication: Rounds play a big part of being able to discuss what’s best for the patient and are they able to go back where they from, from the hospital or do we have to look at something else, and then everybody from the team can put their input in whether they have a mobility concern, or nutrition, or swallowing, or different areas. [Dietitian, Unit 3]
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According to interviewees, written documentation among IP team members include progress notes and patient charts kept in different locations (e.g. Kardex, charts, electronic records and discipline-specific binders). Besides leading to duplication, missing information and delays in follow-up, interviewees expressed concern that not everyone reads the information. Many expressed that nurses and other healthcare providers tended to rely on verbal information sharing and that it is rare for them to read the notes: I’m sure we can find a way to condense and have accurate information, but condense it where everybody who needs information can gather it from one page, which I think would be the best result for all of that. [Resource Nurse, Unit 2]
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Patient-centred care The general sense among interviewees was that patient care quality was good; safety standards and patient needs were being met by centering care and decision-making around patients and their families: So I would think that most of the patients’ needs are well met on [unit] although sometimes the nurses sacrifice themselves to obtain that. [Physician, Unit 5] While the safety of patients was not perceived to be compromised, interviewees commented that surgical units tend to discharge patients quickly resulting in rushed post-operative teaching and lack of treatment plans. A recurring sub-theme was a more holistic approach to patient care was needed, as it was believed that patients’ non-surgical issues were not addressed. Another interviewee mentioned that patients could benefit from specific services (e.g. social work) if patients were made aware of the services available to them or if physicians believed in the benefits of that service (e.g. dietary counselling). This was seen as especially important for patients who were without a family doctor. Role clarification Three main sub-themes, highlighting the need for role clarification, emerged from the data: (1) lack of clarity between the roles of registered nurses (RN) and licensed practical nurses (LPNs); (2) scope of practice and utilisation of nursing staff; and (3) lack of understanding of other healthcare provider roles (e.g. physiotherapist and occupational therapist). When discussing nursing scope of practice, some nursing staff agreed that nursing role confusion was the result of increased training and expanded scope of practice of the LPNs over the past few years. Many interviewees delineated the roles of RNs and LPNs around specific tasks (e.g. LPNs give IV medication, but RNs are responsible for central lines and the charge nurse role). However, in many areas, RNs and LPNs were performing similar tasks with lack of differentiation between the two providers. This was reported as leading to role confusion and feelings of frustration for doing tasks that could more appropriately be completed by another provider. Furthermore, RNs were viewed as not working to their full scope of practice: I think maybe the RNs could be working to further scope of practiceðI think back over the years about the bed bathing, the walking, like such a physical job and, and you think about what my training is and what my experience is and what I’m truly paid to do. [Unit Manager/Charge Nurse, Unit 6]
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In addition, others stated that hospital policy was preventing LPNs from working to full scope. It was frequently noted that RNs and LPNs should be spending more time on discharge planning and thinking about the ‘‘bigger picture’’ for patients, while it was suggested that the transition nurse should do the care planning. Interviewees on one unit noted that RNs are encouraged to move away from completing tasks to a focus on a total case management approach to patient care. Lack of understanding between nursing and other healthcare provider roles was also reported. Many nurse interviewees expressed that some of their activities should be the responsibility of another healthcare provider (e.g. physiotherapist) or even housekeeping, as it takes them away from their nursing responsibilities (e.g. discharge planning, treatment planning and patient education). Other interviewees noted overlap in roles between nursing staff and other healthcare providers, resulting in possible duplication in patient education, care planning and mobilisation: I think one of the things is even if you look at all the disciplines in the hospital there is not a lot of knowledge about what everybody’s scope entails ð And I think lots of times if lots of the staff had a better knowledge about what everybody was capable of doing then you could bring the right person in the right time to prevent problems from getting bigger. [Physiotherapist, Unit 6] Other healthcare provider roles were generally reported as fairly clear across units with the exception of role confusion between physiotherapists and occupational therapists, reflected by inappropriate referrals. Team functioning Many nursing interviewees saw teamwork as assisting other nurses with task-oriented patient care, in particular physical activities requiring an extra set of hands. For example, LPNs specifically mentioned that they work closely with healthcare aides to help with baths and heavy lifting. RNs mentioned that they work together to cover each other during breaks. LPNs further commented that they would go to the RN, team lead or the charge nurse to discuss patient concerns if need be. There was agreement that helping each other was important and highly valued and made the workload more manageable. Nurses also spoke positively about teamwork with other healthcare providers. Similarly, these other healthcare provider interviewees had positive comments related to working with nurses, finding them an invaluable source of information, feeling valued by them and attesting to an open relationship: Actually the team works very well together. . . [I]f there’s any questions we make time for each other as a team to kind of collaborate and talk about what we need to talk about. Yeah, they’re actually very approachable. [Social Worker, Unit 1] However, coordinating patient care with other providers was challenging. While some providers are readily available, interviewees acknowledged difficulties in accessing certain providers, in part, due to time of day or day of week (e.g. weekends and evenings) or workload. Many providers stated that a strong atmosphere of teamwork existed on their units. Others voiced that there were times when the team was ‘‘not open to others coming [such as] new staff, casuals’’ [Care Coordinator, Unit 3] and that there is room to improve team functioning. A few staff spoke to
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the lack of respect between providers and how that negatively impacted team functioning: There’s bullying from doctorsð[and]ð nurses, there’s bullying from other departments and I think that’s a huge thing that we deal with every dayð And it makes your life not fun and it interrupts patient care. Andðyou can’t do proper care when you’re upset because someone is attacking you all the time and it does happen everywhere. [Registered Nurse, Unit 4]
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Nursing interviewees from units that had recently introduced a nursing team model of care stated that the model had fostered a deeper sense of shared responsibility and accountability, which in turn increased morale and led staff to feel more empowered. They felt they had permission and were clearer on whom they could reach out to for assistance, and this encouraged stronger and more frequent communication among nursing staff. Collaborative leadership Interviewees described situations suggesting that collaborative leadership at IP rounds was not optimal. For example, it was identified that other healthcare providers were not expected nor encouraged to contribute to discussions on discharge/bed availability. Not having front-line nurses attend IP rounds was seen as a missed opportunity to develop leadership skills in front-line nurses. Concern was voiced with the strong leadership role physicians and charge nurses had and saw it as impeding leadership development in other staff. There was recognition that a ‘‘go-to’’ position was needed at specific points in care (e.g. patient transfer and discharge) to allow patients to flow smoothly through the system. Interviewees also talked about the decision-making authority of official leaders (e.g. charge nurse, physicians and primary nurse). There was acknowledgement that the charge nurse was often responsible for solving problems and making decisions: I think if everything kind of goes through the charge [nurse], when you have that one point of communication it definitely ensure[s] that the information’s sort of at a level where it can be dealt with appropriately and so you know that the communication has happened. [1st Year Medical Resident, Unit 3] However, disadvantages were associated with the charge nurse as the main point of contact – specifically, lacking a complete picture of the patient and disempowerment of the primary nurse. Nursing decision-making about everyday patient care was described as the primary nurse’s (RN or LPN) responsibility. Other healthcare providers also reported having decision-making ability about care related to their individual disciplines. It was clearly articulated by many interviewees that major decisions were made by the physician. Interestingly, one physician noted that the charge nurse needed to be more empowered to make decisions that did not need to be brought to the physician’s attention. Another physician noted that he/she was unclear who had ultimate decision-making responsibility on certain decisions such as transferring patients to another unit. Conflict resolution On the six units, a common source of conflict emerged around the discharge of patients. While some physicians may invite recommendations from staff to inform their decisions, nursing and other healthcare providers expressed some dissatisfaction over physicians’ ultimate decision-making authority for discharges. Other healthcare providers expressed dissatisfaction that the
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results of their professional assessments were ignored, especially when questioning the readiness for discharge of a patient. There seemed to be a lack of objective criteria for discharge or an agreed upon process around negotiating discharge decisions and resolving disagreements. Interviewees mentioned contextual factors that could exacerbate conflict such as high workload, burnout, lack of leadership around coordination of care, disrespect among providers and role blurring.
Discussion Although collaborative practice has been widely embraced in healthcare, operationalising and measuring this multidimensional concept in real life has proven to be difficult. Generally, the literature has focused on knowledge of and attitudes towards collaborative practice, excluding the applied component of how IP competencies are enacted in a practice setting. We used data from interviews with staff discussing their perception of collaboration, roles, communication and staffing in conjunction with the CIHC IP competency framework to examine current state of collaboration on six acute care units. Of the six IP competencies, communication and patientcentred care emerged as strengths. It is not surprising that providers had great awareness of these competency domains because some processes (e.g. rounds, documentation and discharge planning) to support enactment of these competencies were in place. Deficiencies were noted with IP rounds (e.g. not always efficient/informative and not all disciplines attending) and documentation (e.g. duplication), but providers had ideas for possible solutions. Research indicates that rounds conducted with clear goals are key to improving patient flow, communication and coordination of care among healthcare providers, and decreasing length of stay (Geary, Cale, Quinn, & Winchell, 2009). Furthermore, most interviewees knew how patient-centred care should be practiced (e.g. holistic care), were aware of their strengths and shortcomings and identified processes (e.g. integrated care plan and discharge plan) to support this competency. However, time constraints prevented interviewees from delivering holistic care, discharge planning and post-operative teaching. Research suggests that patients’ self-management capabilities and skills are often overestimated and/or not sufficiently addressed, leaving patients unprepared for discharge and without detailed instruction on how to perform simple procedures (e.g. change a wound dressing) (Hesselink et al., 2012). In addition, interviewees had concrete ideas of what they could do to skilfully apply communication (e.g. ensure information communicated at IP rounds flows back to the RNs, LPNs and HCAs) and patient-centred care (e.g. make available basic activities such as walking to patients) competencies and awareness about current gaps and limitations. We uncovered weaknesses with role clarity and collaborative leadership competencies. Although interviewees were aware of role clarity and collaborative leadership issues on the units (e.g. RNs and LPNs were seen as not working to their full scope of practice), providers could not find workable solutions to resolve these issues and identified heavy workload as the largest barrier to working to full scope/role clarity issues. Research suggests that a lack of role clarity and understanding of professional roles can lead to underutilisation of professional expertise (Suter et al., 2009). This may compromise patient outcomes and contribute to excess system utilisation such as preventable 90 day readmission (Besner, 2011). Furthermore, although interviewees could provide instances of where shared leadership was applied (e.g. rapid rounds and patient transfer), leadership centered on decisionmaking by formal leaders such as physicians and charge nurses. Collaborative leadership is needed to ensure that work
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Table II. Select strategies for collaborative practice. Strategies based on the literature and gaps identified by the study Interprofessional communication IP rounds: Issues with IP rounds are that they are not conducted efficiently, often lack clearly written plans for patients and provider representation is not always good. Strategies include the following: Enhance rounds through physician attendance (where appropriate) and strengthen focus on an integrated plan of care (rather than immediate patient needs) (Fryers et al., 2012). Improve rounds by starting as early as possible (before 10 am); spend one minute per patient to discuss the ‘‘plan for the day, plan for the stay’’ (Geary et al., 2009).
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Documentation: Issues with documentation are that notes and charts are kept in different locations, duplication and missing information occurs and that not everyone reads the information. Strategies include the following: Use a Situation-Background-Assessment-Recommendation (SBAR) format to improve shift reporting (Murphy et al., 2010). Create an interprofessional Kardex to reduce duplication and increase the use of documentation for planning (Murphy et al., 2010). Create a patient record shared between physicians and other healthcare providers to improve care, coordinate care, and protect the safety of patients (Canadian Medical Association, 2007). Implement electronic medical records (EMRs) to mitigate disadvantages of paper documentation including missed, and inconsistent information, and time-consuming documentation (Green & Thomas, 2008; Langowski, 2005). Patient-centred care: Issues with patient-centred care are that surgical units often discharge patients quickly, rushed post-operative teaching, and lack of treatment plans. Strategies include the following: Discuss care plan and communicate with patients and families early to improve patient care (Hesselink et al., 2012). Increase amount of direct one-on-one care time with patient and family (time to ask open-ended questions) to improve patient care (Canadian Medical Association, 2007). Incorporate hourly patient care rounding that addresses each patient’s positioning, personal needs, pain, and placement of personal items to improve patient satisfaction (Fryers et al., 2012). Implement white boards for patient information to improve patient safety (Murphy et al., 2010). Implement preadmission classes for surgery patients to prepare patients for surgery and plan for discharge recovery to reduce length of stay (Murphy et al., 2010; Hesselink et al., 2012). Implement a standardised discharge handover protocol for patients and providers, formalised face-to-face discharge consultation and assessments for patients’ level of understanding of information to improve the discharge process, patients’/families’ self-care skills, mitigate patient anxiety, and reduce readmissions (Hesselink et al., 2012). Use pictures, videos and/or storyboards for information exchange with patients and family members to improve patient preparedness, and consistency of patient care (Besner, 2011). Role clarification: Issues with role clarification are lack of delineation between RNs and LPNs, both roles should spend more time on discharge planning, and lack of understanding between nursing and allied health roles. Strategies include the following: Develop clear job descriptions to support providers working to full scope of practice (Canadian Medical Association, 2007; Murphy et al., 2010). Provide ongoing professional development activities (e.g. IP education rounds) that address role optimisation and utilisation of healthcare providers (Murphy et al., 2010; Fryers et al., 2012; Harvey & Priddy, 2011). Facilitate a culture built on quality relationships between healthcare providers (Registered Nurses’ Association of Ontario (RNAO), 2006). Collaborative leadership: Issues with collaborative leadership are allied health is not encouraged to contribute to discussions, front-line nurses are not developing their leadership skills through attendance of IP rounds, and lack of empowerment of the charge nurse. Strategies are as follows: Realign nursing roles to provide leadership opportunities for nursing staff, specifically RNs (Besner, 2011). Support unit managers and other leaders (e.g., transition coordinator, LPN mentor) at the point of care to carry out staff duties/roles (Canadian Medical Association, 2007; Harvey & Priddy, 2011). Team functioning: Issues with team functioning are difficulties coordinating patient care with other providers and accessing certain providers. Strategies are: Implement strategies that focus on the values, beliefs, and behaviours of supportive teams (RNAO, 2006). Implement strategies that support team functioning (e.g., non-hierarchal team structure, democratic working practices) (RNAO, 2006). Allow healthcare providers to be part of formulating unit policies to help ensure that procedures and processes will be adhered to by all participating team members and encourage teamwork (e.g. emergencies, day-to-day functioning and care planning) (RNAO, 2006). Conflict resolution: Issues with conflict resolution are dissatisfaction over physicians’ ultimate decision-making authority for discharges and providers not having an agreed upon process around discharge decisions and resolving disagreements. Strategies are as follows: Establish processes for conflict resolution and problem solving that lead to quality work environments and quality outcomes for patients and clients (RNAO, 2006). Implement structured debriefing after simulated training exercise to improve team competencies and team functioning (Boehler & Schwind, 2012).
environments support providers and foster collaborative partnerships (Disch, Beilman, & Ingbar, 2001; Manojilovich, Barnsteiner, Bolton, Disch, & Saint, 2008). One suggestion for shared leadership was to have all providers attend rounds or have equal input into patient discussions. However, the logistics around gathering all providers on the unit at the same time was not always conducive to promoting shared leadership. While interviewees had concrete ideas of how to improve role clarity (e.g. dedicate a professional practice leader to clarify roles on the unit) and collaborative leadership (e.g. practice team based nursing model of care), they did not have confidence that they could overcome
the barriers identified as prohibiting them from practicing the competencies. Team functioning and conflict resolution emerged as gaps in collaborative practice. Although some awareness existed, interviewees did not understand this competency well and were unaware of potential practices promoting team functioning. Examples of joint problem-solving or shared planning of care were rare. Interviewees’ somewhat simplified notion of teamwork involved assisting each other with task-oriented patient care. Interviewees knew that joint responsibility for actions was required to accomplish goals, but they had difficulties
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coordinating patient care with other providers. This is corroborated by literature (MacNaughton, Chreim, & Bourgeault, 2013; McCallin, 2006) that states team practice continues to be problematic given that professional boundaries are changing and IP coordination across role boundaries is challenging. Furthermore, interviewees across units did not discuss many examples of conflict resolution being practiced. However, contention was noted for situations where hierarchical, decisionmaking was exhibited. Generally, there was lack of awareness around processes to resolve conflict. Interviewees mentioned contextual factors that could exacerbate conflict such as high workload, disrespect among providers and role blurring. Team members must recognise the expertise and functions of others to interact meaningfully, as power struggles, role confusion, lack of respect and autonomy can be barriers to collaboration (Besner, 2011; Beunza, 2013; Keshet, Ben-Arye, & Schiff, 2013; Suter et al., 2009). The findings highlight areas for improvement in each of the six competencies. We propose strategies to enhance collaborative practice and, more specifically, each of the six competencies (see Table II) that have been informed by the literature. The interventions presented are not a comprehensive list but were selected based on the gaps found in collaborative practice from this initiative. The semi-structured nature of qualitative data gathering resulted in vast information about providers’ perceptions of collaborative practice on their units including emerging challenges. However, the limitations of secondary data analysis are well known: data not collected and intended for a specific analysis may fall short of fully representing the social phenomenon under examination. The original interview questions were not constructed based on the definitions and competency statements of the CIHC framework. Although many questions generated sufficient evidence, some competencies were supported with less information (e.g. conflict resolution) than others (e.g. role clarification). In the case of conflict, is likely to be more widespread than occurring between physicians and nursing staff. Furthermore, extracting distinct data to qualify for the secondary analysis may have been difficult for the authors due to the subtle differences between the primary and secondary analysis (Heaton, 1998). While our analysis should be taken with some caution, we are also confident that our conclusions are accurate. We have encountered these weaknesses in collaborative practice at other settings in AHS thus reinforcing the need for the workforce transformation initiative in the first place. Furthermore, some authors have criticised the use of competency frameworks for their reductionist tendency that may reinforce the status quo (Reeves et al., 2009). Competency is a point on a continuum where progression is made from being proficient to being an expert (Talbot, 2004). During this process, analytical skills and intuition are used for decision making and situational understanding, requiring significant experience and reflection of practice (Diwakar, 2002; Glavin & Maran, 2002; Talbot, 2004). Since every individual healthcare professional moves along this continuum towards expertise; defining, assessing and measuring higher order competencies (whether clinical or IP competencies) have been problematic due to their ambiguity and complexity of overlapping domains (Reeves et al., 2009; Talbot, 2004). This may affect the ability of a competency framework to accurately capture the ‘‘level’’ of IP collaboration practiced by a collective group of healthcare providers.
Concluding comments Collaborative competencies play a role in the success of individuals and team members adapting to new models of care.
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Using the CIHC IP competency framework to guide the secondary analysis allowed us to highlight areas of strength as well as gaps and to gain insight into the ‘‘complex interplay between knowledge, skills and behaviors’’ (Reeves et al., 2009). This information is useful when implementing collaborative practice models as it points to areas requiring special attention. It also supports the utility of the CIHC IP competency framework in capturing the essence of IP collaboration (Reeves et al., 2009). As IP competencies have been proven to be difficult to define and measure, this study provides a step forward in identifying competencies in a practical setting. There is still work to be conducted in translating a comprehensive understanding of collaborative practice to frontline providers and decisionmakers. The strategies are intended to make the competencies more tangible by targeting the individual, team and system levels to support the implementation of collaborative models of care.
Acknowledgements The authors would like to acknowledge the extensive contributions of staff and physicians at the six participating units in AHS.
Declaration of interest The authors report no declaration of interest. The authors alone are responsible for the writing and content of this paper. The authors would like to thank the funder, Alberta Health.
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