Health professionals' experiences and perceptions of challenges of interprofessional collaboration: Socio-cultural influences of IPC.

BACKGROUND: Literature shows that interprofessional collaboration (IPC) is a challenging phenomenon both in theory and practice, and it is affected by socio-cultural contexts in which the health professionals (HPs) play their roles. Considering some evidences on the similarities and differences between eastern and western socio-cultural contexts, this study aims to explore and describe the socio-cultural factors influencing IPC in these two contexts.
MATERIALS AND METHODS: This was a pilot qualitative descriptive study that was conducted in 2012-2013. Data were collected through conducting one-to-one and group interviews as face-to-face and written in terviews (narratives) with purposeful samples of HPs from various disciplines including nurses, medical doctors (MDs) from variety of specialities, social workers, and psychologists from health system in Iran and Germany. Other methods of data collection were taking field notes and reviewing related literature. The qualitative content analyses method was employed to derive the common categories and themes.
RESULTS: Totally 22 participants took part in the study. Moreover, researchers had a 10-day period of field observation in Germany (health systems affiliated with Albert Ludwigs University of Freiburg). Qualitative data analysis revealed three themes and related subthemes. The themes were: (1) Interaction beyond boundaries, (2) motivation to engage in IPC, and (3) readiness to approaching toward IPC.
CONCLUSIONS: The results of the study emphasized that in both eastern and western contexts, organizational, professional, and community socio-cultural textures, mainly in terms of attitudes toward other people, other professions, and IPC, play their role as important factors. We suggest future researches about each of the emerged themes.

INTRODUCTION

Over the past few decades, interprofessional collaboration (IPC) has been identified as a key priority in delivering safe and quality health services.[12] Recent emphasis on holistic client-focused models of care as opposed to an illness-focused perspective has inspired the health professionals (HPs) to adopt interprofessional collaborative models of care. To do this, it is essential for the professionals to learn about how to collaborate successfully.[1]

Nevertheless, it has been emphasized that collaborative practice and teamwork are challenging issues that are often difficult to put into practice.[1] It has been demonstrated that collaboration efforts are affected by various factors that may be supportive or impending to such important processes.[13] Therefore, the researchers have attempted to explore and describe various factors effective in interprofessional collaborative relationships.[45] Some rsearchers have contributed to the understanding of the dynamics of IPC.[1] The results have delineated the human factors, professionals’ attitudes of collaboration and teamwork,[2] and perceptions of organizational factors.[6]

Socio-cultural factors are among the main determinants of successful collaborative efforts.[78] As each collaborative effort takes place in specific socio-cultural context, HPs need to be aware of and learn about the dynamics of their interprofessional collaborative relationships. It is essential for them to alter the traditional patterns of working together.[8] Some reports have identified the socio-cultural factors that may be affecting IPC. The results have emphasized on the importance of supportive culture for teamwork, profession specific culture,[9] team culture including leadership, care philosophy, relationships, and the context of practice.[10] Nevertheless, the related literature is scarce.

As a great attention has been paid to study about similarities and differences between eastern and western socio-cultural contexts,[1112] it would be worthwhile to study the participants’ experiences and perceptions of IPC in two cultural contexts to shed light into the role of socio-cultural factors in IPC initiatives. Therefore, this study aims to explore and describe the socio-cultural factors influencing IPC in two eastern and western contexts.

MATERIALS AND METHODS

This was a pilot qualitative descriptive study[13] that was conducted in 2012–2013. The qualitative method was used in order to explore and categorize the perceptions and experiences as well as the documented data about the socio-cultural factors that affect the professionals’ IPC.[14]

Setting and sample

This study was conducted in the health centers affiliated with Isfahan University of Medical Sciences (IUMS), I. R. Iran and the health systems affiliated with Albert Ludwigs University of Freiburg, Germany. A purposive sampling method[14] was used to recruit data sources. The data were gathered from the three main sources: (1) HPs of various disciplines that were working in the health care settings in Iran and Germany, (2) reviewing of related documents, and (3) written notes about the current state of the health care systems and professional relationships both in Iran and Germany. Sampling adequacy was determined by an agreed level of data saturation.[15]

Data collection

The researchers conducted 13 one-to-one interviews (consisting of 9 face-to-face interviews and 4 written interviews). Moreover, two focus group interviews were conducted that consisted of four and five participants, respectively, in order to discuss some important and challenging issues raised in the previous interviews. Semi-structured interviews with some open-ended leading questions were used that allowed the participants to tell or write their own experiences and perceptions. A sample of leading questions was: “Would you please tell your stories/experiences about how your IPC works and discuss the socio-cultural influential factors that may have worked as facilitating or hindering on your IPC?”

The review of related literature and documents (consisting of any published matter such as articles, formal reports, and the documents presented in the formal websites) was considered as another source of data. The review was done by searching electronic resources as well as by hand searching of library resources. The researchers also took some notes about the current state of the health care systems and professional relationships both in Iran and Germany.

Procedures

This study was approved by the IUMS. Before beginning the interviews, the participants were given an introduction about the study objectives and process. They also signed the informed consent. Afterward, the qualitative interviews were conducted. The participants from Germany were allowed to choose paper-based open-ended semi-structured leading questions to convey their experiences and perceptions. Each interview took approximately 30–60 min. The interviews were tape-recorded and transcribed verbatim. Moreover, the researchers had a 10-day period of field observation in Germany (health systems affiliated with Albert Ludwigs University of Freiburg) and a 6-month period in Iran. The token notes were also reviewed to gain insight of the important units of information that were written as codes.

Data analysis

The general model of conventional qualitative content analysis was adopted to analyze the data, looking for categories of responses and themes about the socio-cultural elements that influence on how nurses collaborate with professionals from other disciplines in the health care settings.[16] Initially, transcripts, written notes (narratives and field notes), and selected documents were reviewed several times to gain a sense of the whole and to identify the words, sentences, and paragraphs as meaningful units that were coded. Then, conceptually similar codes were jointed to make more abstract subcategories. They were classified into the same subcategories that finally were abstracted into categories through a circular reflective process of moving between the whole and parts of the text, codes, subcategories, and categories. Finally, the researchers decided on appropriate labels for themes. The last step was interpretation of the information as a whole, through which a comprehensive understanding was gained.[17]

RESULTS

Totally 22 participants took part in the study. Some socio-demographic characteristics of the participants are presented in Table 1.

Table 1

Socio-demographic characteristics of the study participants

Qualitative data analysis revealed a total of 123 revised codes that were further categorized to three themes and related subthemes [Table 2]. The themes were: Interaction beyond boundaries, motivation to engage in IPC, and readiness to approaching toward IPC. These themes have been discussed with quotations and reviewed evidences.

Table 2

The emerged themes, related subthemes, and sample preliminary codes

Theme 1: Interaction beyond boundaries

In order to expand IPC throughout the health system, professionals must cross the boundaries that are established by sectoral, organizational, as well as professional socio-cultural contexts. This theme consisted of the following four subthemes:

Interprofessional attitudes

Interprofessional attitudes connote the perceptions and views of the professionals about the members of other professions. The study findings showed that some nurses have strong feelings and perceptions about the behaviors of the other professionals that may be influential on the way through which they decide to communicate with the members of other professions. As one of the participants pointed out.

“In my experiences, some of the physicians are not concerned about the people's health. They seem to be members of a market who are trying to gain more and more.” (No. 15, nurse, Iranian).

Some of the participating nurses perceived the poor mutual awareness between HPs as the main cause of poor attitudes against the nurses. Nevertheless, data from German showed up another side of the coin, as the positive attitudes toward the nurses were supported:

“Nurses usually are the professional group with the greatest number. Also, they have the most long-lasting and intensive contact with the patients. They are therefore an extremely important professional group in the hospital….” (No. 6, MD, German).

Insider–outsider approach

As each of the HPs has their specific professional world views, attitudes, and beliefs, they prefer to communicate intra-professionally. Besides, our findings revealed that the professionals are resistant to accept and effectively interact with outsiders.

“Sometimes other professions invade my professional working domain. For example, when a depressed patient mistakenly recourses to a neurologist, he or she must refer the patient to a psychiatrist. But sometimes the neurologist attempts to keep the patient and begin the treatment.” (No. 1, psychiatrist, Iranian).

Western literature also revealed that in some cases, there were some conflicts among HPs that might have originated from different cultural backgrounds. Hall believed that profession-specific cultures can disrupt the interprofessional interactions.[18]

Blurred boundaries

“Blurred boundaries” refers to the overlapped areas of specialties and professional roles that sometimes lead to role ambiguity. This was obvious in both experiences from Iran and Germany:

“Sometimes we don’t know what we should do with these overlapped work areas. Really sometimes I don’t know exactly what my work is.” (No. 4, psychiatrist, Iranian).

Results from German context also revealed the same challenge, as quoted below:

“Problems are … blurred task descriptions … within and between professions.” (No. 8, psychologist, German).

Theme 2: Motivation to engage in IPC

Burnout

Organizational climate in line with high workload has led the HPs to be exhausted. As the study findings showed, it has led both the German and Iranian HPs to routine works instead of IPC:

“In this hospital we have a great patient turnover. When we have such a high work load … we know that the patients have mental health care needs, but we couldn’t do anything.” (No. 12, medical specialist, Iranian)

“Psychosomatic nurses have additional therapeutic tasks … Conducting relation therapy, working with symptom diaries, being responsible for the ward atmosphere.” (No. 16, nurse, German).

Acknowledgment

The study findings emphasized that the acknowledgment of the professionals’ positive behaviors may motivate them to adopt the favorite behaviors more frequently. The Iranian participants pointed out that the poor acknowledgment system has weakened their motivation to engage in IPC initiatives:

“If you get nothing against your endeavour … and if no one acknowledges your positive functions, you will lose your motive to continue your works ….” (No. 4, psychiatrist, Iranian).

This challenge is not limited to the Iranian health care context. It has also been emphasized in the European literature that has identified the poor acknowledgment system.[19]

Problem-oriented approach

Problem-oriented approach refers to a service delivery approach through which the health team members’ professional functions have been directed mainly toward resolving the clients’ health care problems:

“Firstly you need to consider the status of the clients. If you could meet the client's needs or problems, that's ok. But you may need help from other professions to catch the client's partnership. you may feel that the client needs someone else to talk to.” (No. 12, medical specialist, Iranian).

Nevertheless, the study findings showed that focusing on symptom management may lead the professionals fail to engage in an in-depth and meaningful IPC. Our notes from the German context revealed that the HPs mainly discuss clients’ health care issues in their periodically arranged multi-professional team sessions.

Theme 3: Readiness to approaching toward IPC

Readiness is a holistic concept that may consist of individual, organizational, and even national levels. Approaching toward the IPC requires having readiness in various aspects. The following subthemes depict some important areas of such a kind of readiness among nurses and the other HPs.

Knowledge/attitudes about collaboration

To be excellent team members, the HPs should be aware of the processes and benefits of the collaboration and they need to have positive attitudes toward engaging in the IPC practices. It is identified by the participants as an important factor that may facilitate movement toward IPC:

“… Based on my experience, in current health system, the common idea is that if we work together, we will get better results.” (No. 5, nurse, Iranian)

“… Yes, it's the fundament of the daily work in in-patient and day-clinic treatment. In my experience, it is always very fruitful to be in a steady communication between different professions.” (No. 8, psychologist, German).

Person-centered versus professional approach

Person-centered approach refers to the situation in which the HPs’ practices are inspired by personal willingness and motives rather than their professional roles and commitments. The study findings emphasized the critical influence of person-centered approach in hindering of the successful IPC that finally it may lead the health system to conflict:

“Therapist should be in mood of partnership. You know sometimes the therapeutic process becomes difficult and chronic. It's depending on the therapist that how he or she would decide to deal with such condition.” (No. 14, psychiatrist, Iranian).

When the researcher asked the German participant (No. 16) to explain her perception about any restraining forces that she had already experienced in her collaboration with other professions, she mentioned “rivary” as an important factor.

Interpersonal skills

All participants, whether from eastern or western contexts, perceived the interpersonal skills as a main predictor of approaching toward IPC. They also identified the interpersonal gap as a main threat to IPC:

“There are sometimes problems in communication with other professions. We often have this problem with physicians, particularly when the age gap between two individuals is high.” (No. 5, nurse, Iranian).

Another participant from Iran (No. 21, psychiatrist) perceived “poor respect of others’ rights” as an influential factor that leads to poor IPC. Evidences from other contexts have identified social work environment experiences[20] in line with the interpersonal skills as predictors of the IPC.

Professional power

The study findings emphasized the challenge of power inequity among HPs that may lead to IPC gap:

“There is an imbalanced power distribution in the health care system. Always physicians become supported even if they have problems. Finally the nurses, psychologists and social workers are the people who are identified as guilty.” (No. 17, nurse, Iranian)

“…Restraining factors (to the IPC) in my experience is a too strict hierarchy in the hospital which leads to conflicts between the professions.” (No. 6, MD, German).

DISCUSSION

As the other IPC-related literature, the findings reveal that there are several culturally fixed boundaries that hinder information follow-up and communication among the HPs. Interprofessional attitudes/stereotypes, interprofessional mistrust,[21] and ways of thinking and behavior[18] have been identified among the variables that could strengthen the boundaries and hinder the IPC. It is beleived that the interprofessional boundaries are made through a process known as professionalization.[22] Hall[9] pointed out that each health care profession has a different culture which includes values, beliefs, attitudes, customs, and behaviors. These professional cultures contribute to the challenges of effective IPC.[18] Therefore, insight into the different factors which contribute to the culture of the professions can help to improve IPC.

The theme “motivation to engage in IPC” implies another influential factor and another area of IPC challenge as well. The findings showed that sometimes the HPs suffer physically and mentally from the organization- or community-derived factors like overload of responsibilities, task variety, reduced satisfaction in performance,[23] mental fatigue,[24] and poor acknowledgment system,[19] all of which lead the HPs to refrain from engaging in IPC practices. Therefore, it is worthwhile to suggest providing appropriate interprofessional feedback and motivational resources[25] for all HPs, particularly for the nurses who – as our findings showed – are weakened and burned out professionals.

The findings also emphasized on the importance of the HPs’ readiness to approaching toward IPC. Our findings emphasize that the HPs from various professions should be knowledgeable about how to work collaboratively. Moreover, they should have positive attitudes about collaborating with members of other professions. It is emphasized that each profession needs the help of other professions to provide comprehensive care/treatment.[26] Another aspect of the professionals’ readiness is to move from person-centered approach toward professional client-centered interaction. It was pointed out that personal traits always work as an influential factor in the IPC practices.[1820] It is a great challenge of the IPC initiatives because relying only on the personal willingness and motives can make the health system a competition rather than a field of professional, client-centered work.[21] Zwarenstein et al.[27] emphasized on the role of personal motivation, and Weber and Jaekel-Reinhard[28] identified the person–environment misfit as a source of conflict that may negatively affect the collaborative practices. Therefore, it is worthwhile to recommend HPs to work together in partnership, rather than alongside or in competition. It could be achieved through enhancing the professionals’ interpersonal skills. Power issues are also revealed to be an important influential factor that can determine how the nurses and other HPs interact with each other. Equal power distribution can give the professionals a decision-making capacity[19] and autonomy[1923] that are critical to interprofessional teamwork. Nevertheless, based on our findings that have been supported by the relevant literature, unequal power distribution and sometimes discrimination is a great challenge of the current health system.[1922]

Nevertheless, some limitations such as the small number of German participants, limited time of research stay and field observation in the western context and language issues in the western literature search, all may lead to early saturation of the qualitative data and, therefore, may limit the transferability of the findings. Although the study findings have identified some important areas of the socio-cultural factors influencing IPC, it has not been deeply investigated how these factors work in two contexts.

CONCLUSION

The results of the study emphasize that in both eastern and western contexts, organizational, professional, and community socio-cultural contexts, mainly in terms of attitudes toward other people, other professions, and IPC, play their role as important factors. The findings also emphasize on the importance of the HPs’ readiness in various aspects that may facilitate engaging in the IPC practices. Considering the study limitations, mainly the smaller number of German participants, we suggest to conduct future researches about each of the emerged themes separately in the two contexts.