Transforming maternity care: obstetric partnerships as a policy instrument for integration

Increasing continuity in Dutch maternity care is considered pivotal to improve safety and client-centeredness. Closer collaboration between the historically relatively autonomous professionals and organizations in maternity care is deemed conditional to reach this goal, both by maternity care professionals and policy makers. Governmental policy therefore strives for organizational and financial integration. One of the policy measures has been to stimulate interprofessional and interorganizational collaboration through local obstetric partnerships. This study aimed to gain insight into whether this policy measure supported professionals in reaching the policy aim of increasing integration in the maternity care system. We therefore conducted 73 semistructured interviews with maternity care professionals in the region Northwest Netherlands, from 2014 to 2016. Respondents expressed much willingness to intensify interprofessional and interorganizational collaboration and experienced obstetric partnerships as contributing to this. As such, stimulating integration through obstetric partnerships can be considered a suitable policy measure. However, collaborating within the partnerships simultaneously highlighted deep-rooted dividing structures (organizational, educational, legal, financial) in the maternity care system, especially at the systemic level. These were experienced to hinder collaboration, but difficult for the professionals to influence, as they lacked knowledge, skills, resources and mandate. A lack of clear and timely guidance and support from policy, counterbalancing these barriers, limited partnerships' potential to unify professionals and integrate their services.     

Interprofessional collaboration in the hospital: strategies and meanings

OBJECTIVES: Interprofessional collaboration is widely advocated in health and social care policies. However, existing research provides a relatively poor understanding of how professionals collaborate or the meanings they attach to their collaborative work. This paper aims to contribute to understanding of this activity by providing an in-depth account of interprofessional collaboration on medical wards in a large teaching hospital. METHODS: Ethnographic methods were used, including individual and group interviews with health and social care staff (i.e. doctors, nurses, therapists, social workers; n = 49) and participant observations of ward-based work. RESULTS: The organisation of medical teams, who cared for patients across a number of wards, and the task oriented nature of medical work, limited opportunities for collaboration with other professionals (e.g. nurses, therapists) who were usually based on a single ward. Consequently, collaboration tended to be task-based, terse and formalistic. Staff employed a range of informal and formal communication strategies to overcome these constraints. Professionals also gave contrasting accounts of collaboration: doctors viewed collaboration primarily as an activity involving work with their medical colleagues, whereas other professionals saw it more as an interprofessional activity. CONCLUSIONS: Temporospatial constraints and contrasting notions of 'collaboration' are important factors in shaping the nature of interprofessional collaboration. Policies that promote this activity cannot assume that shared understanding of collaboration exists. They also need to be mindful of the practical constraints that affect collaboration in hospital wards.     

Interprofessional Collaboration in Finnish Residential Child Care: Challenges in Incorporating and Sharing Expertise Between the Child Protection and Health Care Systems

Many children taken into care tend to be in need of psychiatric treatment as well as child protection services, and thus the professional expertise of both systems must be coordinated in their care. However, it is widely known across Europe that collaboration between child protection services and mental health services is not working well and the outcomes for looked-after children are poor. In spite of drastic need for knowledge, interprofessional collaboration between residential workers and mental health practitioners is poorly explored in international research. Most importantly, very little is known about shared expertise in multi-agency teams between these systems. Based on the analysis of interprofessional focus group interviews (eight interviews with 17 practitioners) in Finland, it is claimed that both sides have unrealistic expectations and perceptions of the other professional grouping and its facilities to help high-need children. The study also indicates that the collaboration assumes an equality of status and responsibilities between the professionals that does not always exist amongst residential child care practitioners and mental health professionals. The analysis suggests that the concept of residential child care work itself needs more empirical research to strengthen the interprofessional competencies and enhance child-centred integrated care.     

A comparison of interprofessional perceptions and working relationships among health and social care students: the results of a 3-year intervention

A longitudinal quantitative study in an English faculty of health and social care explored the effects of a pre-qualifying interprofessional curriculum for students from 10 professional programmes. Students on the interprofessional curriculum completed questionnaires containing four attitude scales on entry to the faculty, during their second year and at the end of their final year. At qualification, 581 students (76.9% of those qualifying) completed scales concerning their communication and teamwork skills, their attitudes towards interprofessional learning, their perceptions of interaction between health and social care professionals, and their opinions about their own (inter)professional relationships. Questionnaires were completed at both entry and qualification by 526 students (69.8% of those qualifying), and at all three points by 468 students (61.9% of those qualifying). A comparison group of 250 students (67.6% of those qualifying) on the previous uniprofessional curricula also completed questionnaires at qualification. Students on the interprofessional curriculum showed no significant change in their self-assessment of their communication and teamwork skills between entering the faculty and qualification. However, there was a negative shift in their attitudes to interprofessional learning and interprofessional interaction. Nevertheless, most students were positive about their own professional relationships at qualification. Students with previous experience of higher education were comparatively positive about their communication and teamwork skills, as were female students about interprofessional learning. However, the strongest influence on students' attitudes at qualification appeared to be professional programme. This suggests that interprofessional education does not inhibit the development of profession-specific attitudes. Students who qualified on the interprofessional curriculum were more positive about their own professional relationships than those who qualified on the previous uniprofessional curricula. These data suggest that experiencing an interprofessional curriculum has an effect on students' attitudes at qualification, particularly with regard to their positive perception of their own professional relationships.     

Defining and understanding the relationship between professional identity and interprofessional responsibility: implications for educating health and social care students

This paper is concerned with exploring the relationship between perceptions of professional identities, interprofessional education (IPE) and collaborative practice. It seeks to introduce the concept of interprofessional responsibility as both a shift in the way in which to conceptualise the professional identity of Health and Social Care (H&SC) staff and as a new set of practices that help to inform the way in which students are prepared for collaborative working. The presented research, undertaken as part of a Ph.D. study, is based upon semi-structured interviews (n = 33) with H&SC staff who were recruited from both the United Kingdom (UK) Health Service and UK universities. Drawing upon thematic analysis of the data, the results of the research identified that previous conceptualisations of professional identity aligned to a whole profession do not relate to the way in which professionals perceive their identities. Senior professionals claimed to be more comfortable with their own professional identity, and with working across professional boundaries, than junior colleagues. Academic staff also identified that much IPE currently taught in universities serves the purpose of box-ticking rather than being delivered in meaningful way. It is proposed that the findings have implications for the way in which IPE is currently taught, and that adoption of the proposed concept of ‘interprofessional responsibility’ may help address some of the concerns these findings raise.     

Interprofessional collaboration among junior doctors and nurses in the hospital setting

Medical Education 2011: 45: 478–487 Objectives Evidence suggests that doctors and nurses do not always work collaboratively in health care settings and that this contributes to suboptimal patient care. However, there is little information on interprofessional collaboration (IPC) among new medical and nursing graduates working together for the first time in a multidisciplinary health care team. Our aim was to understand the nature of the interactions, activities and issues affecting these new graduates in order to inform interventions to improve IPC in this context. Methods We interviewed 25 junior doctors and nurses and explored their experiences of working together. Interviews were transcribed, entered into a qualitative analysis software package and data were coded against a theoretical framework for health care team function. Results Although interviewees expressed mutual respect, organisational structures often limited the extent to which they could establish professional relationships. Sharing information and agreeing goals were considered fundamental to good decision making, but the working environment and differing perspectives could make this difficult to achieve. Our data suggest that junior doctors and nurses see themselves as having complementary and non‐competitive roles in patient care. The establishing of an interprofessional team was seen to require leadership, which was not always apparent. Without leadership, new members were not always well oriented to the team. The need to maintain an environment in which open communication could take place was acknowledged as important for patient safety, but there were some barriers to achieving this. Conclusions Our data highlight the professionalism, respect and adaptability of these junior health professionals. We document the types of collaborative activities and tensions relevant in this context and, based on our findings, provide some strategies for improving IPC.     

Unknown makes unloved—A case study on improving integrated health and social care in the Netherlands using a participatory approach

Many initiatives integrating health and social care have been implemented in order to provide adequate care and support to older people living at home. Further development of existing initiatives requires iterative processes of developing, implementing and evaluating improvements to current practice. This case study provides insight into the process of improving an existing integrated care initiative in the Netherlands. Using a participatory approach, researchers and local stakeholders collaborated to develop and implement activities to further improve collaboration between health and social care professionals. Improvement activities included interprofessional meetings focussing on reflection and mutual learning and workplace visits. Researchers evaluated the improvement process, using data triangulation of multiple qualitative and quantitative data sources. According to participating professionals, the improvement activities improved their communication and collaboration by establishing mutual understanding and trust. Enabling factors included the safe and informal setting in which the meetings took place and the personal relationships they developed during the project. Different organisational cultures and interests and a lack of ownership and accountability among managers hindered the improvement process, whereas issues such as staff shortages, time constraints and privacy regulations made it difficult to implement improvements on a larger scale. Still, the participatory approach encouraged the development of partnerships and shared goals on the level of both managers and professionals. This case study highlights that improving communication between professionals is an important first step in improving integrated care. In addition, it shows that a participatory approach, in which improvements are co‐created and tailored to local priorities and needs, can help in the development of shared goals and trust between stakeholders with different perspectives. However, stakeholders' willingness and ability to participate in such an improvement process is challenged by many factors.     

Care managers in rural Japan: Challenges to interprofessional collaboration

Effective interprofessional collaboration for care managers is vital for the care of older people. This study’s aim was to inquire into the obstacles to interprofessional collaboration faced by care managers in rural areas of Japan. Forty-six care managers participated in group discussions and semi-structured interviews, and the qualitative data were analyzed using thematic analysis. Five themes related to obstacles emerged from the analysis regarding relationships with physicians, professional competency, relationships among other professionals, environmental constraints, and relationships with nonprofessionals. Other professionals’ unfamiliarity with the care manager’s role and a lack of mutual understanding, boundaries, and information sharing among medical professionals were also cited as issues.     

Interprofessional training in the context of clinical practice: goals and students' perceptions on clinical education wards

AIMS: This paper describes the context of interprofessional training on clinical education wards (CEWs) and reports students' perceptions of this type of interprofessional and professional training. CONTEXT: A 2-week interprofessional clinical course was designed for medical students in their surgical eighth term, and nursing, occupational therapy and physiotherapy students, all in their sixth term. Clinical tutors were responsible for the patients and also supervised the students. The goals for the students included: to provide the patients with good medical care, nursing and rehabilitation; to develop their own professional roles; to enhance their level of understanding of the other professions; to stress the importance of good communication for teamwork and for patient care; to enhance understanding of the role of the patient, and to become more aware of ethical aspects of health care. MATERIAL AND METHODS: A questionnaire developed by teachers from the 4 educational departments was used. A total of 962 students responded (78%). RESULTS: The CEWs provided the students with good clinical practice in terms of training in their own professions as well in learning more about the other professions. The importance of good communication for teamwork and for patient care was recognised. The quality of supervision and students' perception of their own professional roles were important factors regarding satisfaction with the CEW course. CONCLUSIONS: The CEW course seemed to provide the students with an opportunity to develop their own professional roles and their functions as team members.     

Validating the Readiness for Interprofessional Learning Scale (RIPLS) in the postgraduate context: are health care professionals ready for IPL?

AIMS: This paper describes the process of validating the Readiness for Interprofessional Learning Scale (RIPLS) for use with postgraduate health care professionals. CONTEXT: The RIPLS questionnaire has proved useful in the undergraduate context, enabling tutors to assess the readiness of students to engage in interprofessional learning (IPL). With the drive in the National Health Service (NHS) to deliver health care in interprofessional teams, it seems logical to ask whether postgraduate education should, or could, be delivered successfully in interprofessional contexts. As a preliminary to undertaking an extended IPL project, the researchers tested the validity of the RIPLS tool in the postgraduate health care context. METHOD: A modified version of the RIPLS questionnaire was administered to all general practitioners, nurses, pharmacists and allied health professionals in the Dundee Local Health Care Cooperative (LHCC) (n = 799). A total of 546 staff responded (68%). RESULTS: Three factors, comprising 23 statements, emerged from the statistical analysis of the survey data, namely, teamwork and collaboration, sense of professional identity and patient-centredness. The internal consistency measure was 0.76. Analysis of variance suggested some key differences between the different professions in respect of the factors. CONCLUSIONS: The RIPLS questionnaire was validated for use in the postgraduate context, thus providing researchers with a tool for assessing health professionals' attitudes towards interprofessional learning at practice level, community health partnership level or at a national level of education and training. Significant differences between professional groups should be taken into account in designing any interprofessional learning programme.     

Implementing a national approach to universal child and family health services in Australia: professionals' views of the challenges and opportunities

Australia has a well‐accepted system of universal child and family health (CFH) services. However, government reports and research indicate that these services vary across states and territories, and many children and families do not receive these services. The aim of this paper was to explore professionals' perceptions of the challenges and opportunities in implementing a national approach to universal CFH services across Australia. Qualitative data were collected between July 2010 and April 2011 in the first phase of a three‐phase study designed to investigate the feasibility of implementing a national approach to CFH services in Australia. In total, 161 professionals participated in phase 1 consultations conducted either as discussion groups, teleconferences or through email conversation. Participants came from all Australian states and territories and included 60 CFH nurses, 45 midwives, 15 general practitioners (GPs), 12 practice nurses, 14 allied health professionals, 7 early childhood education specialists, 6 staff from non‐government organisations and 2 Australian government policy advisors. Data were analysed thematically. Participants supported the concept of a universal CFH service, but identified implementation barriers. Key challenges included the absence of a minimum data set and lack of aggregated national data to assist planning and determine outcomes; an inconsistent approach to transfer of information about mothers and newborns from maternity services to CFH nursing services or GPs; poor communication across disciplines and services; issues of access and equity of service delivery; workforce limitations and tensions around role boundaries. Directions for change were identified, including improved electronic data collection and communication systems, reporting of service delivery and outcomes between states and territories, professional collaboration, service co‐location and interprofessional learning and development.     

Validity and reliability of a multiple-group measurement scale for interprofessional collaboration

Background  

Many measurement scales for interprofessional collaboration are developed for one health professional group, typically nurses. Evaluating interprofessional collaborative relationships can benefit from employing a measurement scale suitable for multiple health provider groups, including physicians and other health professionals. To this end, the paper begins development of a new interprofessional collaboration measurement scale designed for use with nurses, physicians, and other professionals practicing in contemporary acute care settings. The paper investigates validity and reliability of data from nurses evaluating interprofessional collaboration of physicians and shows initial results for other rater/target combinations.     

Exploring the perceived effect of an undergraduate multiprofessional educational intervention

CONTEXT: Improved teamwork and greater collaboration between professions are important factors in effective health care. These goals may be achieved by including interprofessional learning in the undergraduate medical curriculum. The Faculty of Medicine at the University of Liverpool organized a pilot two-day multiprofessional course involving all the health care related disciplines. OBJECTIVE: The present study examined the perceived effect of the multiprofessional course on the work practice of these newly qualified health care professionals. METHOD: The views of former students who took part in the pilot course were collected using a semi-structured interview schedule and analysed using a qualitative data analysis software package QSR NU*DIST. RESULTS: Two main themes emerged. These centred around role knowledge and interprofessional attitudes. Data indicated that participants perceived the course to have increased their knowledge of the other professions and that this effect had persisted. Reported benefits to their working practice included facilitating appropriate referrals, increasing professional empathy and awareness of other professionals' skills, raising confidence and heightening awareness of the holistic nature of patient treatment. Participants reported forming negative attitudes towards other professions during their undergraduate education. They believed these had been partly encouraged by course tutors. The pilot course was perceived to have had had little effect on these attitudes. Changes occurred once the newly qualified professionals started work. CONCLUSIONS: The results support the idea that interprofessional educational interventions must be tailored to specific learning goals to be implemented successfully, and that interprofessional education should be prolonged and widespread to have a real impact.     

Improving communication between health professionals and women in maternity care: a structured review

Objective  To review trials of the effectiveness of interventions aimed at improving communication between health professionals and women in maternity care.
Search strategy  The electronic databases Medline, PsycLit, The Cochrane Library, BIDS Science and Social Science Indexes, Cinahl and Embase were searched. Final searches were carried out in April 2000.
Inclusion criteria  Controlled trials of interventions explicitly aimed at improving communication between health professionals and women in maternity care were included. Other trials were included where two reviewers agreed that this was at least part of the aim.
Data extraction and synthesis  95 potentially eligible papers were identified, read by one reviewer and checked against the inclusion criteria. The 11 included trials were read, assessed for quality and summarized in a structured tabular form.
Results  The included trials evaluated interventions to improve the presentation of information about antenatal testing, to promote informed choice in maternity care, woman-held maternity records and computer-based history taking. Four trials in which women were provided with extra information about antenatal testing in a variety of formats suggested that this was valued by women and may reduce anxiety. Communication skills training for midwives and doctors improved their information giving about antenatal tests. The three trials of woman-held maternity records suggested that these increase women's involvement in and control over their care.
Conclusions  The trials identified by this review addressed limited aspects of communication and focused solely on antenatal care. Further research is required in several areas, including trials of communication skills training for health professionals in maternity care and other interventions to improve communication during labour and in the postnatal period.     

Evaluation of an interprofessional continuing professional development initiative in primary health care

INTRODUCTION: Interest in collaborative care approaches and in interprofessional education (IPE) to prepare providers for interprofessional collaboration is increasing and particularly so in the field of primary health care. Although evidence for the effectiveness of IPE is mixed, Barr et al. (2005) have proposed a useful framework for evaluating six levels of IPE outcomes. The Building a Better Tomorrow Initiative (BBTI) was a continuing professional development (CPD) program established to enhance the collaborative competencies of primary health care providers and foster interprofessional collaboration in primary health care settings. This article describes the evaluation design, specific measures, and educational outcomes of the BBTI program using Barr and colleagues' evaluation framework. METHODS: We used a mixed method approach. The evaluation research design was a one-group, pre- to poststudy utilizing a combination of quantitative and qualitative evaluation instruments and methods to collect data for the six levels of the Barr et al. evaluation framework. Evaluation focused especially on the following levels: participant satisfaction (reaction), confidence change (attitudes), performance change, and organizational impact. RESULTS: Participants were very satisfied with the BBTI modules and reported significant increases in their confidence and interprofessional collaborative competencies upon return to their primary health care practice sites. Interviews and focus groups with participants and administrators suggest that the BBTI modules were also effective in promoting and fostering interprofessional collaboration within primary health care settings. DISCUSSION: Results suggest that interprofessional CPD is effective in enhancing understanding of the roles of other professions, fostering respect and positive attitudes toward interprofessional collaboration, developing collaborative competencies, and promoting organizational change.     

The politics of interprofessional working and the struggle for professional autonomy in nursing

This study of interprofessional work relations in a Canadian mental health team examines how nursing deployed different forms of power in order to alter the mental health division of labour, to gain administrative, organizational and content control over its own work, expand its jurisdictional boundaries by expropriating the work of other professionals, and exclude others from encroaching on its old and newly acquired jurisdictions. This is set against the context of nursing's long-standing professional project to consolidate and expand its professional jurisdiction. Using an ethnographic study of a single interprofessional mental health team in a psychiatric hospital in Canada, the paper attempts to understand the politics and paradoxes involved in realizing nursing's professional project and how the politics of professional autonomy and professional dominance are actually conducted through micro-political struggles. The data demonstrates the effects of the political struggles at the organizational and work process levels, particularly in the forms of collaboration that result. Nurses gained substantial autonomy from medical domination and secured practical dominion over the work of non-medical professionals. New forms of interprofessional collaboration were accomplished through both simultaneous and sequential micro-political struggles with psychiatrists and non-medical professionals, and the formation of political alliances and informal agreements. Nursing solidarity at the elite level and substantial effort by the elite nurses and their committed colleagues to mobilize their less enthused members were fundamental to their success. The nurses deployed political (power) strategies and tactics to organize and reorganize themselves and other professionals on multiple levels (politically, organizationally, ideologically, socially and culturally). This study reveals the complexity and robustness of micro-political dynamics in the constitution of professional and collaborative interprofessional work relations.     

From being a nurse to becoming a ‘different’ doctor

Using interpretative phenomenological analysis to make meaning of the experiences of three highly qualified registered nurses who had enrolled in an undergraduate medical programme, this study provides insight into their personal journeys of wanting to become ‘different’ doctors. In so doing, they conceptualised their future selves as adding clinical reasoning and diagnostic skills to the patient-centred caring ethic of their nursing practice, becoming a multi-skilled community member or helping to fix the health care culture. By customising their identities, e.g. by splinting (aligning with their stronger nursing identity), by enriching current nursing practice with newly acquired theory as medical students or by patching a perceived deficiency (i.e. patient-centredness) in medicine, they tailored their identities. Their journeys had, however, not been the natural progression they had anticipated, threatened by perceived and/or real intrinsic (e.g. working as nurses whilst studying medicine) and extrinsic (e.g. interprofessional rivalry) factors. Rather than being accepted as legitimate newcomers to the medical profession, the women sometimes felt like intruders. Some nursing colleagues accused them of desertion. In response, they generally withheld their identities as nurses or medical students, compartmentalising their group membership. This study has highlighted the role of personal (e.g. prior experience; agency; resilience; personality) and contextual factors in ‘becoming’ a doctor. A recommendation emerging from this study is the need for interprofessional learning in the medical curriculum to cultivate a health care culture of collaboration rather than competition. Future research is required in terms of how allied health professionals transition to medicine.     

Characteristics of doctors and nurses as perceived by students entering medical school: implications for shared teaching

INTRODUCTION: Debate continues with respect to when to introduce interprofessional education for maximal potential benefit. One perspective is that interprofessional education should be introduced early in the undergraduate curriculum before students develop stereotyped impressions of other professional groups. However, it may be that students at entry to medical school have already developed these stereotypical impressions. This study examines perceived professional characteristics of doctors and nurses by students entering medical school. METHODOLOGY: Year 1 medical students in 4 consecutive years completed a questionnaire on their perceptions of the characteristics and backgrounds of nurses and doctors and on their attitudes to shared teaching. RESULTS: Year 1 medical students were found to perceive the characteristics of doctors and nurses differently. They considered nurses to be more caring and doctors to be more arrogant. They considered nurses to have lower academic ability, competence and status, although comparable life experience. They were generally very positive about beginning shared learning at an early stage of training. DISCUSSION: Whilst it is encouraging that medical students are positive about shared teaching, it is of concern that they have a poor perception of the academic ability, status in society and professional competence of the nurse at entry to medical school. These perceived impressions, which may reflect societal misconceptions regarding the roles and responsibilities of nurses within a modern health care system, may have an impact on the success of early interprofessional teaching initiatives in undergraduate curricula.     

The struggle to improve patient care in the face of professional boundaries

Professional boundaries make inter-professional communication, collaboration and teamwork more challenging and can jeopardise the provision of safe, high quality patient care. This in-depth interview study conducted in three UK acute hospital organisations in 2003-2004 explored how professional boundaries affected efforts to improve routine practice by acute pain services (small specialist teams set up to drive improvements in postoperative pain management through education, training, standard-setting and audit). The study found that many anaesthetists and to a lesser extent nursing staff saw postoperative pain management as a new and unjustified addition to their professional role. Professional identities and strong fears about the risks of treatments meant that health professionals resisted attempts by the acute pain services to standardise practice and to change medical and nursing roles in relation to postoperative pain management. Efforts by the acute pain services to improve practice were further hindered by inter-professional boundaries (between the medical and nursing professions) and by intra-professional boundaries (within the medical and nursing professions). The inter-professional boundaries led to the acute pain services devoting a substantial part of their time to performing a 'go-between' function between nurses and doctors. The intra-professional boundaries hindered collaborative working among doctors and limited the influence that the acute pain service nurses could have on improving the practice of other nurses. Further work is needed to address the underlying fears that can lead to resistance around role changes and to develop effective strategies to minimise the impact of professional boundaries on patient care.