Observation of interprofessional collaborative practice in primary care teams: An integrative literature review.

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Contents lists available at ScienceDirect

International Journal of Nursing Studies journal homepage: www.elsevier.com/ijns

Review

Observation of interprofessional collaborative practice in primary care teams: An integrative literature review Sonya Morgan *, Susan Pullon, Eileen McKinlay Department of Primary Health Care and General Practice, University of Otago, Wellington, New Zealand

A R T I C L E I N F O

A B S T R A C T

Article history: Received 13 August 2014 Received in revised form 26 February 2015 Accepted 10 March 2015

Background: Interprofessional collaboration improves patient care, especially for those patients with complex and/or chronic conditions. Many studies examining collaborative practice in primary care settings have been undertaken, yet identification of essential elements of effective interprofessional collaboration in primary care settings remains obscure. Objective: To examine the nature of interprofessional collaboration (including interprofessional collaborative practice) and the key influences that lead to successful models of interprofessional practice in primary care teams, as reported in studies using direct observation methods. Design: Integrative review using Whittemore and Knafl’s (2005) five stage framework: problem identification, literature search, data evaluation, data analysis and presentation. Data sources and review method: Primary research studies meeting the search criteria were accessed from MEDLINE, PsycINFO, Scopus, King’s Fund and Informit Health Collection databases, and by hand-searching reference lists. From 2005 to 2013, 105 studies closely examining elements of interprofessional collaboration were identified. Of these, 11 studies were identified which incorporated a range of ‘real time’ direct observation methods where the collaborative practice of health professionals was closely observed. Results: Constant opportunity for effective, frequent, informal shared communication emerged as the overarching theme and most critical factor in achieving and sustaining effective interprofessional collaboration and interprofessional collaborative practice in this review. Multiple channels for repeated (often brief) informal shared communication were necessary for shared knowledge creation, development of shared goals, and shared clinical decision making. Favourable physical space configuration and ‘having frequent brief time in common’ were key facilitators. Conclusion: This review highlights the need to look critically at the body of research purported to investigate interprofessional collaboration in primary care settings and suggests the value of using direct observational methods to elucidate this. Direct observation of collaborative practice in everyday work settings holds promise as a method to better understand and articulate the complex phenomena of interprofessional collaboration, yet only a small number of studies to date have attempted to directly observe such practice. Despite methodological challenges, findings suggest that observation data may contribute in a unique way to the teamwork discourse, by identifying elements of interprofessional collaborative practice that are not so obvious to individuals when asked to self-report. ß 2015 Elsevier Ltd. All rights reserved.

Keywords: Integrative review Interprofessional collaboration Multidisciplinary care teams Observational methods Patient care team Primary health care

* Corresponding author at: Department of Primary Health Care and General Practice, University of Otago, Wellington, PO Box, 7343, Wellington South, Wellington 6242, New Zealand. Tel.: +64 4 385 5995. E-mail address: [email protected] (S. Morgan). http://dx.doi.org/10.1016/j.ijnurstu.2015.03.008 0020-7489/ß 2015 Elsevier Ltd. All rights reserved.

Please cite this article in press as: Morgan, S., et al., Observation of interprofessional collaborative practice in primary care teams: An integrative literature review. Int. J. Nurs. Stud. (2015), http://dx.doi.org/10.1016/j.ijnurstu.2015.03.008

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What is already known about the topic? Interprofessional collaboration improves patient care, especially for those patients with complex and/or chronic conditions, but interprofessional collaboration is far from integral to everyday primary care practice. A range of individual and contextual factors influencing collaborative practice in primary care settings have now been documented, yet identification of the essential elements of effective interprofessional collaboration in this setting remains obscure. What this paper adds When studies employing direct observation methods of enquiry are examined, the most critical and tangible element of successful interprofessional collaboration that emerges is the importance of constant opportunity for frequent, shared informal communication, achieved by a multi-level approach including ‘top down organisation’ and ‘bottom up intrinsic factors’. Direct observation of collaborative practice in everyday work settings has the potential to identify elements of interprofessional collaboration that are not so obvious to individuals when asked to self-report, and holds promise as an additional method to better understand and articulate the complex phenomena of interprofessional collaboration and teamwork in primary care. 1. Introduction Interprofessional collaboration has long been considered an essential principle underpinning effective primary health care (World Health Organisation, 1978), but translation into everyday primary care practice continues to be challenging. Care for those with multiple chronic conditions is fast becoming a dominant health burden for primary care (Grumbach and Bodenheimer, 2004); interprofessional collaboration is essential to best care for such patients and makes best use of finite health professional time and expertise (Wagner, 2000). Despite growing evidence that interprofessional collaboration can improve patient safety (Proudfoot et al., 2007; Velji et al., 2008), patient satisfaction (Proudfoot et al., 2007), improve health care quality and health outcomes (Strasser et al., 2008), increase job satisfaction (Proudfoot et al., 2007) and result in better staff recruitment and retention (Borrill et al., 2000), interprofessional collaboration has been variably adopted in primary care settings (Xyrichis and Lowton, 2008). There is also a lack of common understanding about what interprofessional collaboration means in relation to patient care, and whether or not it is the same as teamwork (Nancarrow et al., 2013; Øvretveit, 1996; Way et al., 2000; Xyrichis and Lowton, 2008). Ødegard (2006) acknowledges this lack of understanding and suggests Biggs (1997) and Barr et al. (2005), respectively, provide useful terminology for the terms interprofessional and collaboration which, if taken together provide a definition for interprofessional collaboration. Thus the following definition of interprofessional collaboration is used in this paper: An active and

ongoing partnership often between people from diverse backgrounds with distinctive professional cultures and possibly representing different organisations or sectors, who work together to solve problems or provide services. We suggest interprofessional collaboration is the umbrella hierarchy term for two further terms: Interprofessional collaborative practice, a term used to describe the elements of interprofessional collaboration implemented in the practice setting and Teamwork, a term which denotes a deeper level of working together in an interdependent way (Fig. 1). To date the research literature variously and interchangeably uses the following terms when discussing interprofessional collaboration, interprofessional collaborative practice and teamwork: multidisciplinary; interdisciplinary; multiprofessional; interprofessional; transdisciplinary; teams, and teamwork (Xyrichis and Lowton, 2008), although the spectrum of interprofessional collaboration has been well described (Oandasan et al., 2006). This spectrum ranges from independent patient assessment and treatment with minimal information sharing being necessary (multidisciplinary/professional), through to interdisciplinary/professional working (denoting a deeper level of collaboration), with the term ‘transdisciplinary collaboration’ reserved for the most intense health professional engagement necessary in particularly complex situations (Vyt, 2008). In talking about interprofessional collaboration some writers distinguish between interdisciplinary teams (professional and non-professional team members) and interprofessional teams (professionals only) (Thylefors et al., 2005), but others do not. The term ‘teamwork’ is sometimes applied to ‘deeper’ (Ravet, 2011) or more ‘focused’ (Reeves et al., 2010) levels of collaboration (Ravet, 2011) which seem to be describing interprofessional collaborative practice. Others (Nancarrow et al., 2013) use the term more broadly. Cohen and Bailey (1997) include the role of social systems by defining a team as:

Interprofessional Collaboraon

Interprofessional Collaborave Pracce

Teamwork

Fig. 1. Relationship between Interprofessional Collaboration, Interprofessional Collaborative Practice and Teamwork in the Primary Care context.


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‘a collection of individuals who are interdependent in their tasks, who share responsibility for outcomes, who see themselves and who are seen by others as an intact social entity embedded in one or more larger social systems and who manage their relationships across organisational boundaries’ (p.239). Thistlethwaite et al. (2012) notes the term teamwork is neutral and requires an adjective to describe its success or not. Manion et al. (1996) described teams as ‘structural units’ but interprofessional collaboration to be ‘‘the way people work together cooperatively and effectively’’ (Manion et al., 1996, cited in McCallin, 2001, p.422). There is a concomitant difficulty in articulating the essential characteristics of interprofessional collaboration that are significant in primary care settings. Primary care settings provide the ‘‘hub from which patients are guided through the health system’’ (World Health Organisation, 2008, p.11). Primary care settings differ from secondary care settings in their organisation and day to day service delivery; patient care teams are predominately affected by issues of both location and time. In contrast to secondary settings, health professionals in primary care may or may not be co-located, may or may not formally meet together, and team membership inevitably evolves and changes as patient care extends for many months or years (Safran, 2003). The term ‘primary care team’ is therefore used here to describe health professionals who work together in caring for patients in primary care settings. In practice, the term ‘primary care team’ may denote widely variable membership, forms of information sharing and methods of decision making. Several comprehensive reviews to date have investigated interdisciplinary practice (McCallin, 2001), interprofessional collaboration (San Martıń-Rodrı´guez et al., 2005; Zwarenstein et al., 2009) and interdisciplinary teamwork (Nancarrow et al., 2013). Reviews pertaining specifically to primary care teams include those conducted by Be´langer and Rodrı´guez (2008), Dinh (2012), McPherson and McGibbon (2010), Ruddy (2005) and Xyrichis and Lowton (2008). All conclude that interprofessional collaboration is complex. Systemic and organisational factors appear as important as more individual interactional factors (McPherson and McGibbon, 2010). As Xyrichis and Lowton noted in 2008; ‘‘whilst much attention has been given in exploring teams’ internal processes, less thought is given to exploring how the wider organisations support and promote their teams’’ (p.150). Identification, and then consistent implementation of the essential elements of effective interprofessional collaboration in primary care teams that are significant in practice or are in ‘‘the black box’’ (Zwarenstein and Reeves, 2006, p.51) remain difficult to understand. In recognising that interprofessional collaboration is a phenomenon that is complex and difficult to measure, we postulated that observational studies (where usual workplace practice and behaviour is directly observed) could hold particular promise in advancing understanding of interprofessional collaboration. Observing people in their natural environments not only avoids biases inherent in self-reported accounts (Mays and Pope, 1995), but also

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allows researchers to systematically observe and record what participants may be unaware of themselves (Furlong, 2010). This integrated review was therefore undertaken to identify, explore and critically analyse original research studies, where primary data was collected in relation to primary care teams, and where elements of interprofessional collaboration were clearly identified and examined through direct observation methods. Given the well identified need in previous reviews (McPherson and McGibbon, 2010; Xyrichis and Lowton, 2008), to consider processes, structures and organisational support, we were particularly interested in studies where such elements were robustly identified and verified (e.g. linked to specific processes and/or outcomes) in the primary care setting. The review ultimately focused on studies where elements of interprofessional collaboration were directly observed in primary care teams, and asked the key research question: What is the nature of interprofessional collaboration and the key influences that lead to successful models of interprofessional collaboration as reported in studies using direct observation methods?

2. Design An integrative review method (Torraco, 2005; Whittemore and Knafl, 2005) was chosen as the most appropriate to investigate the area of enquiry – the nature of interprofessional collaboration in primary care teams. Integrative reviews are considered an appropriate method for reconceptualising an established topic area as the literature broadens and for new, emerging or diverse topics where there is limited research (Torraco, 2005). They allow for the inclusion of research studies using both experimental and non-experimental methods (Whittemore and Knafl, 2005) providing a more complete understanding of the phenomenon of concern (Pfaff et al., 2014). The inclusion of studies containing diverse methodologies enables the formation of a broad description of a particular phenomenon and in such a way that ‘‘new frameworks and perspectives on the topic are generated’’ (Torraco, 2005, p.356). This review follows a recognised process of research synthesis (Cooper, 2010) based on Whittemore and Knafl’s (2005) updated five-stage framework for enhancing rigour in integrative reviews: problem identification, literature search, data evaluation, data analysis and presentation (Whittemore and Knafl, 2005). 3. Problem identification stage The initial stage of this review comprised exploring and critically analysing contemporary primary research studies investigating interprofessional collaboration within or involving primary care teams. Because of the problematic terminology, an all-encompassing approach was taken to include as many terms relating to interprofessional collaboration as possible but with a focus on collaboration


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as it relates to several health professionals working together in primary care teams. As well as defining primary care teams we defined an interprofessional team as comprising three or more individual health professionals from at least two health disciplines. This approach eliminated studies describing the work of only two individuals (a dyad), to avoid undue influence from specific one-to-one interpersonal relationships, and to better reflect the group composition of primary care teams. The study period (January 2005–September 2013) chosen provided a contemporary review, exploring research largely conducted since Xyrichis and Lowton (2008) and Be´langer and Rodrı´guez (2008) undertook their reviews. The search output was limited to studies published in English in peer-reviewed sources. Unpublished studies were not sought. In an initial first scan of the literature, it appeared that most studies which met initial inclusion criteria relied solely on self-reported measures of collaboration, with few or no links to defined process criteria or health outcomes. Such self-report methods (i.e. interviews or surveys) can only go so far in their analysis and conclusions, as they force the researcher to rely on second-hand reports of phenomena (Patton, 2002). 4. Literature search stage A comprehensive search of five bibliographic databases (Ovid MEDLINE, PsycINFO, Scopus, King’s Fund and

Informit Health Collection) was conducted and included papers published between 1 January 2005 and 7 September 2013. The databases were selected to include medicine, nursing and allied health, psychology, social sciences and health policy subject areas. Because many different terms have been used to describe interprofessional collaboration, interprofessional collaborative practice and teamwork in the existing literature, we included a range of terms in our search strategy to describe the phenomenon and fully capture all relevant literature. The final search strategy was developed in consultation with a research librarian using MEDLINE Medical Subject Headings and keywords, and adapted as appropriate to each database (Fig. 2). The search was also initially run in CINAHL (Ovid), however due to low relevance of the retrieved citations and the considerable overlap with the MEDLINE database, search output from the full search strategy was discounted, although a simplified cross check CINAHL search was completed towards the end of the study; no further observational studies were identified. Consistent with an integrative review approach, we sought to include all papers reporting relevant primary research studies, experimental and non-experimental. In addition to electronic bibliographic databases, further research was sought using an ancestry approach (Conn et al., 2003). This included hand-searching the references lists of the most relevant studies retrieved and of on-topic readily available review articles (not considered primary research) identified from the database output.

team*.tw.

Collaborat*.tw.

Combined with Boolean operator AND

Combined with Boolean operator AND

Interdisciplinary communicaon Cooperave behaviour Conflict resoluon Negoang Interprofessional conflict Interprofessional communicaon Inter-professional communicaon Interdisciplinary pracce Mulprofessional Mulprofessional pracce Muldisciplinary pracce Co-provision interdependence Communicaon

Combined with Boolean operator AND General pracce Family pracce Office visits Primary care Primary health care Community health services

Interdisciplinary communicaon Cooperave behaviour Conflict resoluon Negoang Interprofessional conflict Interprofessional communicaon Inter-professional communicaon Interdisciplinary pracce Mulprofessional Mulprofessional pracce Muldisciplinary pracce Co-provision interdependence Communicaon

Combined with Boolean operator AND General pracce Family pracce Office visits Primary care Primary health care Community health services

Combined with Boolean operator OR Results limited English language, humans, 1 Jan 2005 - 7 September 2013 Fig. 2. Electronic database search strategy.


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Records idenfied by database search (n=1378)

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Records idenfied by hand search (n=1)

Records aer duplicates removed (n=1229)

Titles/abstracts screened (n=1229)

Titles/abstracts excluded (n=751) -did not meet inclusion criteria

Full-text papers assessed (N=478)

Full-text papers excluded (n=302) -did not meet inclusion criteria, did not invesgate any elements influencing interprofessional collaboraon

Studies invesgated some element(s) of interprofessional collaboraon (n=176)

Papers excluded (n=71) -did not focus on defined elements of interprofessional collaboraon (ranked “low”)

Studies invesgated defined elements of interprofessional collaboraon in research quesons or objecves (ranked “high”) (n=105)

Papers excluded (n=94) -did not include observaon methods

Studies included in integrave review (observaon methods incorporated) (n=11) Fig. 3. Flow diagram of search to inclusion.

4.1. Criteria for considering studies The literature search process is summarised in Fig. 3. The titles and abstracts of all citations retrieved from the search were screened against the study inclusion criteria. Full text was then obtained for titles and abstracts that fulfilled the following inclusion criteria: Research related to interprofessional collaboration/ interprofessional collaborative practice and/or teamwork among health professionals within/or involving primary care; working as part of an interprofessional team of at least three individuals from at least two health disciplines. Original research where primary data collection and analysis was evident. Research related to interprofessional collaboration/ interprofessional collaborative practice and/or teamwork in an interprofessional education context, but only where the learners involved were qualified health professionals engaged in workplace learning.

English language research papers published in peerreviewed journals. Title appeared relevant but no abstract was available. Exclusion criteria – studies were excluded if: They related to interprofessional collaboration/interprofessional collaborative practice and/or teamwork between health professionals and patients. They related to interprofessional collaboration/interprofessional collaborative practice and/or teamwork only between health professionals of the same discipline. They related to interprofessional collaboration/interprofessional collaborative practice and/or teamwork between only two individual health professionals (e.g. an individual doctor and an individual nurse only, or other dyads). They related to interprofessional collaboration/interprofessional collaborative practice and/or teamwork in an interprofessional education context, where the learners involved were either not qualified health


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professionals and/or not specifically engaged in workplace learning. They were reviews, anecdotes, opinion pieces or commentaries and/or not reporting primary data collection and analysis. They were not conducted in or involved with primary care settings. 4.2. Assessment of relevance for inclusion A total of 1229 titles and abstracts from combined search methods were scanned in the screening process (Fig. 3). Authors initially each worked independently, although throughout the screening process, disagreements or uncertainty were resolved by peer-review and/or group consensus. For the purposes of abstract selection, where study titles/abstracts did not specify members of the primary care team, it was assumed until proven otherwise that primary care teams included members of at least two health disciplines, and full text was sought to verify whether the paper met the inclusion criteria. In all, 478 titles/abstracts were retained and full-text obtained, identifying literature relating to the topic of interprofessional collaboration in primary care settings. For the full text review, the scope was further refined to identify studies that described some investigation of elements or factors influencing collaborative practice. Any papers that did not include such elements, or factors influencing interprofessional collaboration or did not meet other study inclusion criteria were excluded. Studies where primary care was clearly peripheral to the study focus were also excluded. 5. Data evaluation stage All 176 papers meeting the refined study inclusion criteria were read thoroughly and evaluated for topic relevance. This process revealed wide variation in the degree to which interprofessional collaboration was investigated. A ranking system was developed to differentiate between studies which focussed on investigating defined elements of interprofessional collaboration in the research question or objectives (ranked – ‘‘high’’) compared to those studies where interprofessional collaboration was mentioned but interprofessional collaborative practice elements were not specifically investigated (ranked – ‘‘low’’). 5.1. Study relevance assessment There were 105 papers which met the study criteria for inclusion as primary research and which ranked ‘‘high’’. These studies, although broad both in terms of content and methodology, all specifically investigated interprofessional collaboration, including interprofessional collaborative practice or teamwork elements in primary care settings. Eleven studies out of the 105 incorporated direct observation of a clinical practice environment in the study design; the remaining 94 studies which used self-report methods were excluded. The 11 studies comprising the final set for review analysis involved the ‘‘systematic, detailed observation of

behaviour and talk: watching and recording what people do and say. . .’’ (Mays and Pope, 1995, p.182). Observational methods can include non-participant observation (including shadowing), participant observation, video/still recording of practice, field-noting or template-recording elements of practice (Walshe et al., 2012). Approaches to direct observation vary according to the role researchers adopt along the continuum of observer to participant (Walshe et al., 2012). For example, ethnography is an observational approach which may incorporate a number of methods. Although traditionally including participant observation (where the researcher immerses themselves as a participant–observer in the field) (Savage, 2000), some studies included in this review have also described nonparticipant observation (including shadowing subjects in the course of their everyday lives), as part of an ethnographic approach (Walshe et al., 2012). 6. Data analysis stage Each of the 11 studies incorporating observation methods were read critically and study details extracted and summarised (Table 1). Direct ‘real time’ observation of the process of interprofessional collaboration (including interprofessional collaborative practice) was undertaken as part of the study design in each case. All studies also collected a range of other non-observation data (e.g. interview data, review of policy documents). The studies were initially analysed by: authors and locality; focus, participants and setting; theoretical framework/study design; data collection methods; analytic framework/ sequence; and stated findings and observational method limitations. No studies were excluded on methodological grounds at this stage of the review. Although individual studies had varying limitations (as noted in Table 1), there are as yet no generally agreed outcome measures for studies of interprofessional collaboration using observational methods; studies in this field of enquiry are as yet exploratory. We therefore took an inclusive approach and considered all studies that clearly described and incorporated an observational element. 6.1. Analysis of study methods Five studies were conducted in different locations in the United Kingdom, four in Canada (two in the same locality with the same research team), one was conducted in Australia and the other in Sweden. All 11 studies had a primary focus on aspects of interprofessional collaboration in primary care teams including: impact of time, physical space and design, impact of system change; influence of organisational boundaries; health professional roles; collective learning in teams, and new knowledge creation. Four studies further identified the study context as a particular area of care: palliative care (Munday et al., 2007); child and youth mental health (Nadeau et al., 2012); chronic kidney disease (Kislov et al., 2012) and osteoporosis (Hjalmarson et al., 2013). All 11 studies reported detailed process findings (influences known or considered to facilitate interprofessional collaboration, interprofessional


Stated findings by the study authors; Reviewers’ assessment of observational limitations

23 individual interviews (hand notes)

Interviews, observation data then incorporated

Findings: Ambiguity surrounds nursing role, degree of trust related to degree of collaboration. Limitations: Analysis draws primarily on interviews, limited observation data reported.

49 h non-participant observation (field logs)

38 individual interviews (audio recorded)

Interview and observation data together from outset

Findings: Informal collective learning effective, essential, but messy. Physical space layout affects shared learning. Pharmacy teams more cohesive than others. Shared learning a relational process. Limitations: Analysis draws primarily on interviews, limited observation data reported.

Case study design, Ethnography

44 h non-participant observation (field notes), observation template used

33 individual interviews, 1 focus group (transcribed)

Observation data generated themes, then interview data incorporated

Focus: IPC across primary and secondary care sites for secondary prevention osteoporosis. Participants: 5+ disciplines: physicians, nurses, directors, occupational therapists, physiotherapists. Setting: 11 sites, IPC across sites.

Longitudinal single case study design

50 meetings/workshops facilitator-participant direct observation (field notes), hours unknown

34 documents reviewed, telephone interviews to access quantitative outcome data

Observation data generated themes, reported separately

Focus: Impact of system change on practice organisation and teamwork. Participants: All general practice staff, 3+ disciplines: GPs, nurses, administrators. Setting: 4 sites, IPC within sites.

Comparative case study design, ethnographic approach

Non-participant direct observation (no recording method specified), hours unknown

unknown number of interviews

No indication as to whether observation data analysed separately

Findings: Physical space and configuration are major influences on IPC. Synchronous and asynchronous sharing of information, both important. Limitations: Observation data embedded within findings, not clearly referenced as a separate data source, although floor diagrams included. Findings: Top down leadership and bottom up shared incentives are both important. Continuous feedback necessary for IPC. Outcome measure – increase in patients investigated for osteoporosis, improved health behaviour. Limitations: none of note. Findings: Roles changed as a result of changes, increased tension around decision making evident. Limitations: Not clear how observation data recorded or managed – embedded within the findings, not referenced as a separate data source.

Study focus, participants and setting

Theoretical framework, design

Observation data

Non-observation data

Akeroyd et al. (2009) Ontario, CA

Focus: Roles of RNs in IP family practices. Participants: 6+ disciplines: FPs, nurses, clinical managers, dietician, occupational therapists, pharmacists. Setting 3 sites, IPC within each site. Focus: Collective learning and change in primary care teams Participants: general practice teams (3+ disciplines: GPs, nurses, administrators), dental practice teams, pharmacy teams. Setting: 10 sites, IPC within each site.

Thematic analysis (Braun and Clarke)

Non-participant observation (field notes), hours unknown

Interpretive epistemology, naturalistic data collection

Gum et al. (2012) Australia

Focus: Implication of health team hub design on IPC. Participants: rural hospitals managed by GPs, 6+ disciplines: GPs, nurses, administrators, paramedics, physiotherapists and ancillary staff. Setting: 3 sites, IPC within each site.

Hjalmarson et al. (2013) Sweden

Huby (2008) Scotland, UK

Bunniss and Kelly (2008) Glasgow, UK

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Analysis framework/ sequence

Data collection

Authors, location



Table 1 Studies included in the review.

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12 interviews (audiorecorded, transcribed), documentary analysis, 8 interviews nonparticipant practices

Observation data and document review analysed separately to interview data, then triangulated. Template and matrix analysis, order not obvious

Findings: Intra organisational professional boundaries are bridged over time to form CoP but interorganisational boundaries tend to obstruct multi-organisational CoP. Knowledge sharing across practices limited. Limitations: Discrete observation findings not reported, but some are provided in supplementary table.

Non-participant direct observation of meetings, practice systems and documents (field notes), hours unknown

45 interviews (audiorecorded, transcribed)

Interview data using matrix analysis, then triangulated with observation data

Participatory research study

Participant direct observation of meetings (no recording method specified), hours unknown

30 interviews, 1 focus group (no recording methods specified)

Interview data thematically analysed, then corroborated at research meetings, by observation data

Ethnographic approach, inductive thematic analysis, constant comparative analysis

139 h non-participant observation (reflective field notes)

37 individual interviews (hand notes/reflections)

Observation data relating to time and space only, then interwoven with interview data

Findings: Outcome measure – 12 month GSF criteria High performing practices (as meeting most GSF criteria) had good concordance of GSF scores with effective IP communication, minimally performing practices did not. Daily maintenance of real time information important. Limitations: Observation data embedded within findings, not clearly referenced as a separate data source. Findings: IPC and partnership challenging in new system. Quality of partnership and collaboration/ collaborative leadership especially crucial in providing care for vulnerable families. Limitations: Not clear how observation data recorded or managed – embedded within the findings, no data referenced. Findings: Quantity and quality of IP communication in primary health care impacted by space and time for informal opportunistic communication. Limitations: Observation data embedded within overall findings, not clearly referenced as a separate data source.


Observation data


Kislov et al. (2012) Manchester, UK

Focus: Effects of intra-and interorganisational boundaries on service improvements within and across primary health care settings, developing CoP, related to chronic kidney disease management. Participants: General practice teams, 3+ disciplines: GPs, nurses, managers/administrators. Setting: 4 sites, IPC within and across sites. Focus: Facilitating primary palliative care – effect of the GSF. Participants: general practice teams, 3+ disciplines: GPs, nurses, administrators. Setting: 15 sites, IPC within sites.

Embedded case study design

20 h non-participant direct observation (field notes)

Comparative case study design

Nadeau et al. (2012) Quebec, CA

Focus: Documenting reform of child and youth mental health services. Participants: Community based health and social service institutions, 7+ disciplines: GPs, nurses, managers, art therapists, psycho-educators, psychologists, social workers. Setting: 3 sites, IPC across sites.

Oandasan et al. (2009) Ontario, CA

Focus: Impact of space and time in IP teamwork in primary care. Participants: family health centres, 12+ disciplines: FPs, nurses, administrators, addiction counsellors, behavioural scientists, dieticians, educators, lab technicians, occupational therapists, pharmacist, physiotherapists, social workers. Setting: 3 sites, IPC within each site.

Munday et al. (2007) Coventry, UK

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Data collection

Authors, location


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Table 1 (Continued )

Quinlan (2009) Saskatchewan, CA

Welch et al. (2013) Lancaster, UK


Focus: Creation and use of new knowledge in primary health care teams. Participants: 4+ disciplines: GPs, nurse practitioners, RNs, managers/ administrators, pharmacists. Setting: 3 sites, IPC within sites. Focus: Clinical and organisational issues for integrative medicine; CAM and orthodox practitioners. Participants: primary care clinics, 3+ disciplines: GPs, ‘clinic staff’, CAM therapists, patients as researchers. Setting: 2 sites, IPC within sites.


Data collection



Observation data


Institutional ethnographic study

Non-participant direct observation – shadowing (field notes + transcribed notes), hours unknown

Document review, unknown number of subsequent interviews (audio-recorded)

Observation data ethnographically analysed (interview data not reported)

Findings: Articulation of ‘informal, every day’ tacit knowledge is prerequisite for new knowledge creation – a social and communicative process. Limitations: none of note.

Action research/ intervention study ethnographic observation

Participant observation (field notes), hours unknown 1 ‘recorded meeting’ (audio-recorded)

Reflective journal, pictures, emails, letters, 2 Interviews (audio-recorded), entry and exit surveys for unknown number GPs, clinic staff and 14 patients.

Interview and observation data analysed together, constant comparative analysis

Findings: Clinical decision making processes change as a result of IPC. Physical space availability affects ability to collaborate. Role clarity and role value affects collaboration. Policy and structure affect ability to collaborate. Macro management issues just as important as micromanagement within clinics. Limitations: Not clear how observation data managed, as embedded within overall findings.

CAM, Complementary and Alternative Medicine; CoP, Communities of Practice; FP, Family Physician; GP, General Practitioner; GSF, Gold Standards Framework; IP, Interprofessional; IPC, Interprofessional Collaboration; RN, Registered Nurse. In the UK/Europe, the term ‘general practitioner’ denotes doctors trained in primary care medicine and based in the community. In Canada/USA, doctors working in a similar role are referred to as ‘family physicians’.

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Authors, location



Table 1 (Continued )

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collaborative practice and team functioning as well as characteristics of well performing teams). Two of the 11 studies went further and also attempted to link process findings with clinical outcome measures in a specific area of care (Hjalmarson et al., 2013; Munday et al., 2007). Case study design (including embedded; longitudinal; comparative) was commonly employed, with most studies investigating interprofessional collaboration within one (or within each of several) sites. Three studies (Hjalmarson et al., 2013; Kislov et al., 2012; Nadeau et al., 2012) also investigated interprofessional collaboration between or across multiple sites or organisations. Ethnographic frameworks were utilised in about half the studies, with non-participant ethnographic approaches to observational data collection most often being described. Participant observation was used in three studies (Hjalmarson et al., 2013; Nadeau et al., 2012; Welch et al., 2013). Approaches to both data collection and analysis were most often referred to as inductive, interpretive and/ or iterative. Direct observation data collection entailed periods of time (often substantial) directly observing formal (e.g. inhouse meetings) and informal health professional activity (e.g. health professional interactions in common areas). Of the five studies that provided specific information, observation time periods ranged from 20 h (Kislov et al., 2012) to 139 h (Oandasan et al., 2009) of direct observation data collection. Recording of direct observation data was undertaken using handwritten field notes in nine of the studies; no recording detail was supplied in the other two studies (Huby, 2008; Nadeau et al., 2012). The non-observation data included interviews, focus groups, reflective journals, document reviews and surveys. Presentation of the interview data was variable; where stated, as few as two interviews (Welch et al., 2013) or as many as 45 interviews (Munday et al., 2007) and/or focus groups were also used as part of the method, most often audio recorded but not necessarily transcribed. Although exact numbers of participants were hard to ascertain in most studies, all included health professionals from at least three disciplinary backgrounds (and sometimes many more). Because the particular focus of interest in this review was on the value or otherwise of direct observation data, close attention was paid not only to the described methods of analysis, but also to the framework and sequence in which the different types of data were collected then analysed. We were interested to see if studies initially analysed and reported direct observation data separately from non-observation data, prior to integration of research results, as recommended by Morse (2010) when different qualitative approaches are used to investigate the phenomena of interest. Furthermore, we wanted to know about the sequence of data collection. We wondered if the studies where observation data was used as the starting point/initial framework differed from those where, in contrast, the initial framework for the analysis was the self-reported or interview/focus group data. In 5 of the 11 studies (Gum et al., 2012; Hjalmarson et al., 2013; Kislov et al., 2012; Oandasan et al., 2009; Quinlan, 2009) it was possible to ascertain that observation data was

initially collected independently from other data, and that the initial analysis stemmed from the observation data. Overall, within the final set of studies, details about data collection (e.g. hours/setting of direct observation, number/duration of interviews, type/discipline and number of participants, number and type of documents reviewed) were often scant, and this lack of data precluded further interpretation. Information about recording methods was also lacking. Field note rigour was rarely mentioned, and no study described video or audio recording of ‘real time’ observation – a recording method potentially allowing more in-depth analysis than is possible using field notes alone (Kevin et al., 2007; Latvala et al., 2000). There was insufficient subsequent detail in any paper to be confident about findings being attributable to the direct observation data independent of non-observation data. Even in the five papers where initial analysis stemmed from observational data, the point at which the process of results integration or triangulation with the interview or other non-observed data was not evident. 6.2. Analysis of study findings Despite study limitations, we recognised that all 11 studies incorporated observation data to varying degrees in their conclusions. Acknowledging this, thematic analysis (Boyatzis, 1998; Braun and Clarke, 2006), well suited to the synthesis of both qualitative and quantitative evidence (Dixon-Woods et al., 2005) was used to organise and categorise the data into themes. Firstly, each author read the results of each study and independently developed a set of common themes. These initial themes were discussed, compared collectively and agreement reached before one author categorised them into a final set of themes and subthemes, which were checked and rechecked. This analytic process provided a summary of findings about what is known from studies incorporating direct observation of interprofessional collaboration in or involving primary care teams in various locales from four countries. 7. Presentation stage (results) The overarching theme emerging from this set of studies employing direct observation component(s) was the importance of a multi-level approach to achieve frequent shared informal communication. Described previously as ‘bottom up and top down strategies’ (Hjalmarson et al., 2013), and ‘micro and macro activities’ (Welch et al., 2013), we identify two main sub themes as ‘‘Top down organisation’’ and ‘‘Bottom up intrinsic factors’’. Within these two main sub-themes, further categories emerged (Table 2) which supported the notion that no one locus alone will ensure the success of interprofessional collaborative practice, particularly the effectiveness of ‘deep’ teamwork; that type of sophisticated teamwork necessary in complex situations to achieve good patient outcomes (Ravet, 2011). 7.1. Top down organisation ‘Top down’ or ‘macro’ factors identified across the studies were predominantly organisational. A number of


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Table 2 Thematic analysis summary. Sub themes

Categories

Subcategories

‘Top down’ organisation Practice policy and structure Organisationally endorsed formal processes Collaborative management and leadership Opportunities for informal communication

Space and time Shared communication methods

‘Bottom up’ intrinsic factors Informal communication Shared knowledge creation Shared clinical decision making

categories relating to facilitating factors were identified: practice policy and structure, organisationally endorsed formal processes, collaborative management and leadership and opportunities for informal communication. The need for explicit policy and structure within a primary care team included the requirement for some formal processes (e.g. regular meetings, written documents) to be in place that allowed time for teamwork, and to help clarify roles and responsibilities (Munday et al., 2007; Welch et al., 2013). Although the type of structure may appropriately vary depending on size (small primary care teams may need different structures to larger teams), management structures needed to be explicitly collaborative, support team development and process, and provide regular feedback on team performance (Hjalmarson et al., 2013; Kislov et al., 2012; Munday et al., 2007; Welch et al., 2013). Several studies also emphasised the need for effective, supportive collaborative leadership – formalised partnerships between staff and between staff and patients (Canadian Interprofessional Health Collaborative, 2010), if this was to be achieved (Hjalmarson et al., 2013; Munday et al., 2007; Nadeau et al., 2012). The importance of creating multiple opportunities for frequent, informal communication to readily occur at different times of the day and week could not be overestimated. Within this category – opportunities for informal communication – sub categories included space and time, shared communication methods. Issues of both space and time emerged as key facilitators (or barriers) to communication (Bunniss and Kelly, 2008; Gum et al., 2012; Oandasan et al., 2009). Not only was the amount of shared physical work space identified as important, but so was the configuration of that space. Spaces needed to allow for several health professionals to gather together and/or pass each other in the course of their work. Colocation of staff so they were visible to each other and within sufficient proximity to frequently but briefly interact to share information was identified as a key promoter of interprofessional collaboration (Bunniss and Kelly, 2008; Gum et al., 2012; Oandasan et al., 2009; Welch et al., 2013). Whether the method of shared communication was synchronous or asynchronous appeared less important than ready access to essential information (most often about patients), and the ability to easily and informally exchange information and ideas, that can quickly build

tacit knowledge about ways of acting and interacting (Quinlan, 2009). At least three studies noted additional asynchronous communication tools. These were found to be particularly useful in primary care teams where part time and full time staff came and went at different times often over days or weeks. The constantly updated shared whiteboard in a common space was a powerful collaborative tool (Gum et al., 2012; Munday et al., 2007); others noted common clinical records (usually electronic) as shared quickly and easily when and where convenient (Gum et al., 2012; Kislov et al., 2012; Munday et al., 2007). 7.2. Bottom up intrinsic factors In contrast, ‘bottom up’ strategies (micro activities) identified across the 11 studies concerned individual attributes as facilitators of interprofessional collaboration. The categories within this sub theme included informal communication, shared knowledge creation, and shared clinical decision making. The ability to informally, briefly but frequently communicate throughout the working day was considered in some studies to be ‘what interprofessional collaboration is’ (Bunniss and Kelly, 2008; Oandasan et al., 2009). As Bunniss and Kelly noted – ‘‘[such] learning does not belong to individual persons, but to the various conversations of which they are a part’’ (McDermott, 1993, cited in Bunniss and Kelly, 2008, p.1192). Shared tacit knowledge creation (including knowledge about teamworking) was identified primarily as a relational and reciprocal process (Bunniss and Kelly, 2008; Quinlan, 2009), occurring and strengthening over time and unusually reliant on informal communication. Shared clinical decision making emerged as the third category within the ‘bottom up’ sub theme; something that was observed and described as only happening when considerable tacit common knowledge had been built up. 8. Discussion This integrative review conducted from 2005 to 2013 identified 11 studies which utilised direct observation data collection and analysis (Mays and Pope, 1995) within their study design. All 11 studies also used non-observation methods. The purpose of the review was to determine the nature of interprofessional collaboration and the key


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influences that lead to successful models of interprofessional collaborative practice and teamwork as reported in studies using direct observation methods. The 11 studies used a range of methods and measures, and reported various level of detail. Thematic analysis of the 11 studies identified two main sub themes – ‘‘top down organisation’’ and ‘‘bottom up intrinsic factors’’. Repeated opportunity for effective, frequent, reciprocal informal communication emerged as the single most important and tangible element of interprofessional collaboration. Furthermore, the ‘bottom up’ intrinsic factors appear to be heavily influenced by the ‘top down’ organisational factors. These factors such as policy, structure, space and time have emerged as key in fostering the informal communication that is so essential for effective shared clinical decision making for best practice patient care. Earlier reviews have also more generally identified the need to consider contextual determinants (McCallin, 2001), and a range of systemic, organisational (top down) and individual (bottom up) factors (Lemieux-Charles and McGuire, 2006; San Martıń-Rodrı´guez et al., 2005), especially in primary care settings (Be´langer and Rodrı´guez, 2008; McPherson and McGibbon, 2010; Xyrichis and Lowton, 2008). To our knowledge, there have been no previous reviews of studies specifically focused on those incorporating direct observation. By searching for, reviewing and synthesising studies that systematically ‘watched and recorded what people do and say’ (Mays and Pope, 1995) in everyday clinical practice settings, we have explored Zwarenstein and Reeves’ (2006) ‘‘black box’’ (p.51) and identified extended knowledge about interprofessional collaboration. We suggest that ‘real time’ direct observation studies hold considerable promise as a way to further knowledge about implementation of interprofessional collaboration, even though observation data is often more difficult and expensive to collect, analyse and integrate than the more usual non-observation data (Morse, 2010). Although standardised collection methods and the sequencing and subsequent integration of observation and other methods have not yet been fully explored and analysis of observation methods not fully described in this context, we argue that ‘real time’ direct observation data nevertheless has the potential to more accurately capture ‘what actually happens’ than non-observed self-report data alone. 8.1. Limitations The review process had some limitations. Despite our best efforts, the definitional challenges described earlier may have precluded finding papers using different terms to describe the phenomena of interest for the review. Restriction of the review to peer-reviewed papers published in English since 2005 may have excluded otherwise eligible direct observation studies in other countries, conducted at an earlier time, or described in unpublished/inaccessible sources. Review findings were limited by the type and quality of information provided about study design, data collection and analysis.

8.2. Further research Nevertheless, ‘real time’ direct observation of day-today clinical workplace practice has the potential to contribute unique information and understanding to the interprofessional collaboration discourse if we are to move beyond problem identification towards articulation of realistic and replicable work models for primary care teams. The nature of collaborative practice is complex, and goes well beyond the elements of personal interprofessional relationships and intrinsic team factors that have been now well captured by numerous interview studies. There are considerable opportunities for more ‘real time’ direct observation studies of interprofessional collaboration to be conducted in primary care. More work is needed to identify meaningful, consistent (and as a consequence, valid and reliable) interprofessional collaboration processes and outcomes that will be helpful to primary care workplaces as measures of success. There is potential for studies to be ‘observation alone’ or part of more complex inquiry, employing more than one data collection and analytic method, meeting Morse’s (2010) criteria for mixed method qualitative studies. Welldesigned studies which not only collect observation data and record it as accurately as possible, but also use that observation data as the primary framework for analysis, hold particular promise for furthering understanding of interprofessional collaboration within clinical workplaces in the community. 9. Conclusion This integrative review highlights the need to look critically at the body of research purported to investigate interprofessional collaboration in primary care teams and to focus particularly on those which use more objective methods such as direct observation. Numerous studies have now documented a range of individual and contextual factors influencing collaborative practice. However, inconsistent terminology and reliance on self-report methods have hindered the progression of knowledge about the essential elements of interprofessional collaboration in primary care teams. Further research should attempt to incorporate a greater range of methods and more clearly report each separately to ensure the different contributions are evident. Nevertheless, by examining studies that have employed direct observation methods, this review shows that the single most important and tangible element of successful interprofessional collaboration is the importance of constant opportunity for frequent, shared informal communication. Despite methodological challenges, we suggest that direct observation data can contribute in a unique way to further developing the evidence base for interprofessional collaboration discourse, by identifying elements of interprofessional collaborative practice that are not necessarily apparent to individuals when asked to self-report. More research incorporating direct observation in everyday work settings is needed to better understand and articulate the complex phenomena of interprofessional collaboration in primary care teams.


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