Role construction and boundaries in interprofessional primary health care teams: a qualitative study

Exploring healthcare professionals' perceptions of the anesthesia assistant role and its impact on patients and interprofessional collaboration

To practice interprofessional collaboration (IPC), understanding the roles of each profession in the team is key. Anesthesia assistants (AAs) are a relatively new addition to the Canadian healthcare system. As a result, its role in the delivery of anesthesia care can be misunderstood by other healthcare professionals. Using an exploratory multiple case study design, this article explores healthcare professionals' perceptions of the AA role and its impact on patients and IPC. Sixteen semi-structured, in-depth interviews were conducted with a purposive sample of nine healthcare professions from inside and outside the peri-operative care unit in two urban, acute care, university-affiliated teaching research hospitals in Ontario. A thematic analysis of the interview transcripts identified five overarching themes: limited understanding of the AA role, improved patient-centred care, improve IPC and interprofessional education, ongoing challenges, and the future direction for professional growth. Results indicated that despite regular clinical practice collaboration, participants have a limited understanding of AAs in terms of their educational prerequisites, scope of practice, and roles. One reason for this lack of understanding is that there is a high variability of titles and clinical duties for non-physician anesthesia providers. The diverse range of anesthesia services provided by AAs can also become a barrier to the full understanding of their scope of practice and roles. The limited understanding of the AA role was reported as one of AAs' ongoing challenges. It prevents AAs from realising their full scope of practice. Participants suggested that AAs' professional growth should focus on promoting and expanding their role. Understanding other healthcare professionals' perceptions of AAs will assist them to become better ambassadors for their role, and to more effectively promote and practice IPC. Ultimately, this will result in improved interprofessional teamwork to deliver effective and efficient patient care.

Clinical learning environments: place, artefacts and rhythm

CONTEXT

Health care practitioners learn through experience in clinical environments in which supervision is a key component, but how that learning occurs outside the supervision relationship remains largely unknown. This study explores the environmental factors that inform and support workplace learning within a clinical environment.

METHODS

An observational study drawing on ethnographic methods was undertaken in a general medicine ward. Observers paid attention to interactions among staff members that involved potential teaching and learning moments that occurred and were visible in the course of routine work. General purpose thematic analysis of field notes was undertaken.

RESULTS

A total of 376 observations were undertaken and documented. The findings suggest that place (location of interaction), rhythm (regularity of activities occurring in the ward) and artefacts (objects and equipment) were strong influences on the interactions and exchanges that occurred. Each of these themes had inherent tensions that could promote or inhibit engagement and therefore learning opportunities. Although many learning opportunities were available, not all were taken up or recognised by the participants.

CONCLUSIONS

We describe and make explicit how the natural environment of a medical ward and flow of work through patient care contribute to the learning architecture, and how this creates or inhibits opportunities for learning. Awareness of learning opportunities was often tacit and not explicit for either supervisor or learner. We identify strategies through which tensions inherent within space, artefacts and the rhythms of work can be resolved and learning opportunities maximised.

Assessing the facilitators and barriers of interdisciplinary team working in primary care using normalisation process theory: An integrative review

Background

Interdisciplinary team working is of paramount importance in the reform of primary care in order to provide cost-effective and comprehensive care. However, international research shows that it is not routine practice in many healthcare jurisdictions. It is imperative to understand levers and barriers to the implementation process. This review examines interdisciplinary team working in practice, in primary care, from the perspective of service providers and analyses 1 barriers and facilitators to implementation of interdisciplinary teams in primary care and 2 the main research gaps.

Methods and findings

An integrative review following the PRISMA guidelines was conducted. Following a search of 10 international databases, 8,827 titles were screened for relevance and 49 met the criteria. Quality of evidence was appraised using predetermined criteria. Data were analysed following the principles of framework analysis using Normalisation Process Theory (NPT), which has four constructs: sense making, enrolment, enactment, and appraisal. The literature is dominated by a focus on interdisciplinary working between physicians and nurses. There is a dearth of evidence about all NPT constructs apart from enactment. Physicians play a key role in encouraging the enrolment of others in primary care team working and in enabling effective divisions of labour in the team. The experience of interdisciplinary working emerged as a lever for its implementation, particularly where communication and respect were strong between professionals.

Conclusion

A key lever for interdisciplinary team working in primary care is to get professionals working together and to learn from each other in practice. However, the evidence base is limited as it does not reflect the experiences of all primary care professionals and it is primarily about the enactment of team working. We need to know much more about the experiences of the full network of primary care professionals regarding all aspects of implementation work.

Systematic review registration

International Prospective Register of Systematic Reviews PROSPERO 2015: CRD42015019362.

Experiences of nurse practitioners and medical practitioners working in collaborative practice models in primary healthcare in Australia - a multiple case study using mixed methods

Background

In 2010 policy changes were introduced to the Australian healthcare system that granted nurse practitioners access to the public health insurance scheme (Medicare) subject to a collaborative arrangement with a medical practitioner. These changes facilitated nurse practitioner practice in primary healthcare settings. This study investigated the experiences and perceptions of nurse practitioners and medical practitioners who worked together under the new policies and aimed to identify enablers of collaborative practice models.

Methods

A multiple case study of five primary healthcare sites was undertaken, applying mixed methods research. Six nurse practitioners, 13 medical practitioners and three practice managers participated in the study. Data were collected through direct observations, documents and semi-structured interviews as well as questionnaires including validated scales to measure the level of collaboration, satisfaction with collaboration and beliefs in the benefits of collaboration. Thematic analysis was undertaken for qualitative data from interviews, observations and documents, followed by deductive analysis whereby thematic categories were compared to two theoretical models of collaboration. Questionnaire responses were summarised using descriptive statistics.

Results

Using the scale measurements, nurse practitioners and medical practitioners reported high levels of collaboration, were highly satisfied with their collaborative relationship and strongly believed that collaboration benefited the patient. The three themes developed from qualitative data showed a more complex and nuanced picture: 1) Structures such as government policy requirements and local infrastructure disadvantaged nurse practitioners financially and professionally in collaborative practice models; 2) Participants experienced the influence and consequences of individual role enactment through the co-existence of overlapping, complementary, traditional and emerging roles, which blurred perceptions of legal liability and reimbursement for shared patient care; 3) Nurse practitioners’ and medical practitioners’ adjustment to new routines and facilitating the collaborative work relied on the willingness and personal commitment of individuals.

Conclusions

Findings of this study suggest that the willingness of practitioners and their individual relationships partially overcame the effect of system restrictions. However, strategic support from healthcare reform decision-makers is needed to strengthen nurse practitioner positions and ensure the sustainability of collaborative practice models in primary healthcare.

Electronic supplementary material

The online version of this article (doi:10.1186/s12875-016-0503-2) contains supplementary material, which is available to authorized users.

Informational role self-efficacy: a validation in interprofessional collaboration contexts involving healthcare service and project teams

Background

Healthcare professionals perform knowledge-intensive work in very specialized disciplines. Across the professional divide, collaboration becomes increasingly difficult. For effective teamwork and collaboration to occur, it is considered necessary for individuals to believe in their ability to draw on their expertise and provide what others need to perform their job well. To date, however, no instruments exist to measure such a construct.

Methods

A two-study design is used to test the psychometric properties, factor structure and incremental validity of a five-item questionnaire measuring informational role self-efficacy.

Results

Based on parallel analysis and exploratory factor analysis, Study 1 shows a robust and reliable one-dimensional construct. Study 2 cross-validates this factor structure using confirmatory factor analysis. Study 2 also shows that informational role self-efficacy predicts proactive teamwork behaviors over and above goal similarity, interdependence, coordination and intra-team trust.

Conclusions

The instrument can be used in research to assess an individual’s capability beliefs in communicating his/her informational characteristics that are pertinent to the task performance of others. The construct is also shown to have value in team-building exercises.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-016-1382-x) contains supplementary material, which is available to authorized users.

Perceptions of pharmacists' roles in the era of expanding scopes of practice

BACKGROUND

Alberta was the first province in Canada to enact legislative changes to permit expansion of pharmacists' scope of practice, including allowing pharmacists to prescribe. However, such changes to the scope of practice can blur professional boundaries and obscure the roles of pharmacists. Understanding perceptions about the pharmacist's role may provide insight into recent and historical changes in pharmacy practice. This study clarifies perceptions held by pharmacists and other stakeholders concerning the role of the pharmacist in society.

OBJECTIVE

To understand the perceptions of pharmacists, pharmacy students, technicians, other health care professionals, and the public of the pharmacist's role in Alberta.

METHODS

A mixed methods approach was used: focus group sessions (n = 9) and individual interviews (n = 4) of pharmacists and other stakeholders were conducted and analyzed using qualitative-descriptive approach. A web-based survey of Alberta pharmacists (n = 416) explored pharmacists' perceptions of their own roles.

RESULTS

Data analysis revealed the following: participants perceived that the pharmacist's role was transitioning to focus more on patient care; consistency in pharmacist uptake of this new role shaped the public's expectations; pharmacists with expanded scopes of practice were assuming greater responsibility; collaboration and relationships with other health care professionals were essential. The survey confirmed that changes in the roles of pharmacists were primarily related to patient care.

CONCLUSION

Following legislative changes and implementation of a compensation framework for pharmacy services, pharmacists and other stakeholders perceived the pharmacist's role to be shifting toward patient care. Periodic revisiting of pharmacists' roles and professional activities is needed to evaluate changes over time.

Community paramedicine model of care: an observational, ethnographic case study

Background

Community paramedicine programs have emerged throughout North America and beyond in response to demographic changes and health system reform. Our aim was to identify and analyse how community paramedics create and maintain new role boundaries and identities in terms of flexibility and permeability and through this develop and frame a coherent community paramedicine model of care that distinguish the model from other innovations in paramedic service delivery.

Methods

Using an observational ethnographic case study approach, we collected data through interviews, focus groups and field observations. We then applied a combination of thematic analysis techniques and boundary theory to develop a community paramedicine model of care.

Results

A model of care that distinguishes community paramedicine from other paramedic service innovations emerged that follows the mnemonic RESPIGHT: Response to emergencies; Engaging with communities; Situated practice; Primary health care; Integration with health, aged care and social services; Governance and leadership; Higher education; Treatment and transport options.

Conclusions

Community engagement and situated practice distinguish community paramedicine models of care from other paramedicine and out-of-hospital health care models. Successful community paramedicine programs are integrated with health, aged care and social services and benefit from strong governance and paramedic leadership.

Improving paediatric outreach services for urban Aboriginal children through partnerships: views of community-based service providers

BACKGROUND

In Australia, Aboriginal children experience significantly poorer health outcomes compared with non-Aboriginal children. Health policies aimed at improving Aboriginal health outcomes include interventions in the early childhood period. There is a need for government health services to work in partnership with Aboriginal people and other services to achieve the highest level of health possible for Aboriginal children, who often require a range of services to meet complex needs.

AIM

This paper describes the views of service providers on how paediatric outreach services work in partnership with other services, Aboriginal families and the community and how those partnerships could be improved to maximize health outcomes for children.

METHODS

In-depth, semi-structured interviews and focus groups were conducted with managers and service providers over a 6-week period in 2010. The views and suggestions of participants were documented and a thematic analysis was undertaken.

RESULTS AND DISCUSSION

Analysis of two focus groups with seven service providers and five individual interviews with service managers resulted in the identification of four themes: (i) using informal and formal ways of working; (ii) cultivating effective relationships; (iii) demonstrating cultural sensitivity; and (iv) forging strong leadership. Use of formal and informal approaches facilitated effective relationships between service providers and Aboriginal families and communities. Partnerships with the community were founded on a culturally appropriate model of care that recognized a holistic approach to health and wellness. Leadership emerged as an essential component of effective partnerships, cultivating the ethos of the workplace and creating an environment where collaboration is supported.

CONCLUSION

Culturally appropriate child health services, which utilize effective relationships and employ a range of informal and formal collaboration with other services and community members, are well positioned to implement health policy and improve access to services for Aboriginal children with better health outcomes as a result.

Implementation of an electronic health records system within an interprofessional model of care

Implementation of electronic health records (EHR) systems is challenging even in traditional healthcare settings, where administrative and clinical roles and responsibilities are clearly defined. However, even in these traditional settings the conflicting needs of stakeholders can trigger hierarchical decision-making processes that reflect the traditional power structures in healthcare today. These traditional processes are not structured to allow for incorporation of new patient-care models such as patient-centered care and interprofessional teams. New processes for EHR implementation and evaluation will be required as healthcare shifts to a patient-centered model that includes patients, families, multiple agencies, and interprofessional teams in short- and long-term clinical decision-making. This new model will be enabled by healthcare information technology and defined by information flow, workflow, and communication needs. We describe a model in development for the configuration and implementation of an EHR system in an interprofessional, interagency, free-clinic setting. The model uses a formative evaluation process that is rooted in usability to configure the EHR to fully support the needs of the variety of providers working as an interprofessional team. For this model to succeed, it must include informaticists as equal and essential members of the healthcare team.

An integrative review of facilitators and barriers influencing collaboration and teamwork between general practitioners and nurses working in general practice

AIM

To identify facilitators and barriers influencing collaboration and teamwork between general practitioners and nurses working in general (family) practice.

BACKGROUND

Internationally, a shortage of doctors entering and remaining in general practice and an increasing burden of chronic disease has diversified the nurse's role in this setting. Despite a well-established general practice nursing workforce, little attention has been paid to the ways doctors and nurses collaborate in this setting.

DESIGN

Integrative literature review.

DATA SOURCES

CINAHL, Scopus, Web of Life, Cochrane Library, Joanna Briggs Institute Library of Systematic Reviews and Trove (dissertation and theses) were searched for papers published between 2000 and May 2014.

REVIEW METHODS

This review was informed by the approach of Whittemore and Knafl (2005). All included papers were assessed for methodological quality. Findings were extracted, critically examined and grouped into themes.

RESULTS

Eleven papers met the inclusion criteria. Thematic analysis revealed three themes common to the facilitators of and barriers to collaboration and teamwork between GPs in general practice: (1) roles and responsibilities; (2) respect, trust and communication; and (3) hierarchy, education and liability.

CONCLUSION

This integrative review has provided insight into issues around role definition, communication and organizational constraints which influence the way nurses and general practitioners collaborate in a team environment. Future research should investigate in more detail the ways doctors and nurses work together in general practice and the impact of collaboration on nursing leadership and staff retention.

The Mangle of Interprofessional Health Care Teams: A Performative Study Using Forum Theater

The aim of this study was to explore dimensions of relational work in interprofessional health care teams. Practitioners from a variety of disciplines came together to examine teamwork and cocreate knowledge about interprofessionalism using forum theater. Interviews held prior to the workshop to explore teamwork were foundational to structuring the workshop. The forum theater processes offered participants the opportunity to enact and challenge behaviors and attitudes they experienced in health care teams. Throughout the workshop, aspects of professional identity, power, trust, communication, system structures, and motivation were explored. The activities of the workshop were analyzed using Pickering’s theory, identifying three mangle strands found in being a team: organizational influences, accomplishing tasks, and an orientation to care. Performativity was identified as having a bearing on how teams perform and how teamwork is enacted. Practice components were seen as strands within a mangling of human and nonhuman forces that shape team performativity.