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Using an interprofessional competency framework to examine collaborative
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Article in Journal of Interprofessional Care · September 2014
DOI: 10.3109/13561820.2014.955910 · Source: PubMed
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ISSN: 1356-1820 (print), 1469-9567 (electronic)
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ORIGINAL ARTICLE
Using an interprofessional competency framework to examine
collaborative practice
Shelanne L. Hepp1, Esther Suter1, Karen Jackson1, Siegrid Deutschlander1, Edward Makwarimba2, Jake Jennings3
and Lisa Birmingham3
1Alberta Health Services, Workforce Research & Evaluation, Calgary, Alberta, Canada, 2Formerly Alberta Health Services, Calgary, Alberta, Canada,
and 3Alberta Health Services, CoACT – Health Professions Strategy & Practice, Calgary, Alberta, Canada
Abstract
Healthcare organisations are starting to implement collaborative practice to increase the
quality of patient care. However, operationalising and measuring progress towards collaborative practice has proven to be difficult. Various interprofessional competency frameworks
have been developed that outline essential collaborative practice competencies for healthcare
providers. If these competencies were enacted to their fullest, collaborative practice would be
at its best. This article examines collaborative practice in six acute care units across Alberta
using the Canadian Interprofessional Health Collaborative (CIHC) competency framework (CIHC,
2010). The framework entails the six competencies of patient-centred care, communication, role
clarification, conflict resolution, team functioning and collaborative leadership (CIHC, 2010). We
conducted a secondary analysis of interviews with 113 healthcare providers from different
professions, which were conducted as part of a quality improvement study. We found positive
examples of communication and patient-centred care supported by unit structures and
processes (e.g. rapid rounds and collaborative plan of care). Some gaps in collaborative practice
were found for role clarification and collaborative leadership. Conflict resolution and team
functioning were not well operationalised on these units. Strategies are presented to enhance
each competency domain in order to fully enact collaborative practice. Using the CIHC
competency framework to examine collaborative practice was useful for identifying strength
and areas needing improvement.
Keywords
Collaborative competence, interviews,
interprofessional collaboration,
interprofessional practice, qualitative
method
History
Received 9 July 2013
Revised 27 June 2014
Accepted 14 August 2014
Published online 10 September 2014
Introduction
In recent years, increasing evidence has emerged that interprofessional (IP) collaboration improves quality of care and patient
outcomes (Berridge, MacKintosh, & Freeth, 2010; Zwarenstein,
Goldman, & Reeves, 2009). Healthcare organisations have begun
to integrate collaborative practice components into their models
of care (Fryers, Young, & Rowland, 2012; Murphy, Alder,
MacKenzie, & Rigby, 2010). In 2011, Alberta Health Services
(AHS), the provincial health authority in Alberta, Canada, began
the Workforce Model Transformation initiative to incorporate
collaborative practice as a key component in its future model
of care. AHS adopted the definition of collaborative practice
by Busing and coworkers as an ‘‘interprofessional process of
communication and decision-making that enables the separate and
shared knowledge and skills of healthcare providers to synergistically influence the patient care provided’’ (Way, Jones, &
Busing, 2000, p. 3).
While recognising the importance of collaborative practice,
operationalising and measuring progress towards this
multidimensional concept has proven to be difficult (Reeves,
Fox, & Hodges, 2009; Reeves, 2012; Schmitt, 2001; Suter et al.,
2009). A popular approach has been to develop a standardised set
of IP competencies and train healthcare providers towards
achievement of these competencies to facilitate collaborative
practice. According to the National Interprofessional Competency
Framework developed by the Canadian Interprofessional Health
Collaborative (CIHC, 2010), patient/client/family/communitycentred care, communication, role clarification, team functioning,
conflict resolution and collaborative leadership are the six key
competency domains required for effective collaborative practice.
If all six competencies were enacted to their fullest, collaborative
practice would be at its best. The use of competency frameworks
has been helpful to define professional competence, set consistent
standards of practice across settings and identify performance
indicators that link to the competencies (Reeves et al., 2009).
However, criticisms of using competency frameworks have
recently been noted: (1) competencies are generally behaviourbased and often lack integration of values, responsibility,
decision-making, problem solving and reflection (Glavin &
Maran, 2002; Talbot, 2004); (2) the division of work across
settings is not conceptually well understood (Reeves, 2012); and
(3) lack of clarity exists about how to robustly measure
competency frameworks as there is little evaluation data to
inform whether the competencies are being implemented (Reeves,
2012; Schmitt, 2001; Suter et al., 2009).
Correspondence: Shelanne L. Hepp, Alberta Health Services, Workforce
Research & Evaluation, 10301 Southport Lane SW, Calgary, Alberta
T2W 1S7, Canada. E-mail: [email protected]
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This article reports the views of staff about the six
competencies and collaborative processes at the six units.
The article has three objectives: (1) to describe the current state
of collaborative practice on six acute care units in AHS using the
CIHC competency framework; (2) identify gaps in collaborative
practice; and (3) identify strategies for each competency domain
to improve collaborative practice.
Methodology
We conducted a secondary data analysis of qualitative data from
a baseline assessment of collaborative practice on six acute care
units (surgical and medical) in three Alberta hospitals. Hospitals
included one of Canada’s leading clinical, research and teaching
hospitals, an inner city hospital providing general and specialised
medical and surgical services, and a regional hospital (located in a
smaller city) with acute, sub-acute and supportive rehabilitation/
transition beds. At each hospital, staff from one medical and one
surgical unit serving adult patients participated in the initiative.
These units were selected by AHS leaders to inform implementation of workforce transformation in AHS (i.e. a quality
improvement project aimed at implementation of a collaborative
model of care). For the primary data collection, one-hour
qualitative interviews were conducted with 15–20 staff from
each unit with a total of 113 staff members inquiring about their
experiences with collaborative practice. The number of interviewees was proportionate to the professional diversity at each
unit with a higher representation of nurses (Table I). The semistructured interviews focused on these major areas: model of care,
scope of practice, collaboration (specifically, decision-making),
patient-centred care, communication, recruitment/retention and
leadership.
A secondary data analysis is appropriate for several reasons.
First, all authors were involved in the original data collection and
analysis, which strengthened personal involvement in the data
production and context required to undergo the secondary analysis
(Long-Sutehall, Sque, & Addington-Hall, 2010). Second, since
the primary and secondary analysis converged on the topic of
collaboration with many components of the CIHC competency
framework addressed, it was fitting to re-analyse our previously
collected data (Heaton, 2008; Long-Sutehall et al., 2010). The
first author (S. L. H.) extracted statements related specifically to
the six CIHC definitions and competency statements of IP
collaboration from the detailed reports for each unit report, which
formed the overall themes. Subsequently, all authors reviewed,
validated and analysed the data extracted for the six competency
domains reading the interview transcripts.
Ethical considerations
For the secondary data analysis, we did not obtain ethics approval
since informed consent was obtained for all interviews in the
primary data collection.
Results
Examples are presented of current structures and processes as
described by clinical and non-clinical staff to illustrate the six
competency domains. Staff interviewees also pointed to the
strengths and weaknesses of their practice in these domains,
and in some cases, they had ideas for improvement.
IP communication
Generally, interviewees referred to communication as being
good (e.g. consistent messaging and formal communication
mechanisms) and that everybody is approachable. It was
considered important to convey a consistent message to patients
rather than ‘‘a whole bunch of people doing things in their
little bubble that don’t communicate’’ [Physiotherapist, Unit 6].
They highlighted different types of rounds and charting as
the main formal communication mechanisms. Different types of
rounds were identified such as IP rounds, discharge rounds,
Kardex rounds and/or resident rounds. Rounds varied in length
(between 15 and 120 minutes) and purpose. Shorter rounds
focused on the daily needs of patients, while longer rounds
were used for discharge planning. Besides addressing priority
patient needs, staff members also learned about appropriate
referrals and roles.
IP rounds were primarily attended by nursing, social workers,
occupational therapists, physiotherapists, dietitians and pharmacists. It was reported that the charge nurse or nursing team lead
may represent the different nursing specialties (e.g. wound care
nurse) on some units. The unit manager, bed manager, discharge
coordinator or spiritual care coordinator attended on certain units.
Physicians generally did not attend IP rounds (with the exception
of one unit) resulting in separate communication to keep
physicians informed of patients’ status.
ðit’s physician drive[n]. So it has to go through the doctor,
he writes the order and then the consult is processed. So it,
and that’s why, if you don’t have a physician present at
Multidisciplinary Rounds, that’s a huge problem because
they’re the one driving the whole team. So then you have to
take the time after the meeting to fill in the doctors regarding
what we discussed in the rounds. So to me it’s essential that
they’re present, and they are not at most of the rounds.
[Physiotherapist, Unit 6]
IP rounds were not always conducted efficiently (e.g. staff
arriving late, patients not assessed prior to rounds and lack of
clearly written plans for patients) and timing of rounds was at
times inconvenient for providers to attend. Other concerns were
that not all attendees were treated as equals to offer information
and opinions, and lack of accountability for follow through with
decisions made during rounds. Regardless of how rounds were
conducted, all interviewees stated that it was a useful way to
support IP communication:
Rounds play a big part of being able to discuss what’s best
for the patient and are they able to go back where they from,
from the hospital or do we have to look at something else, and
then everybody from the team can put their input in whether
they have a mobility concern, or nutrition, or swallowing,
or different areas. [Dietitian, Unit 3]
Table I. Healthcare provider interviewees.
Interviewees Number
Nursing (e.g. registered nurse, licensed practical nurse,
transition nurse, charge nurse, nurse educator, clinical
quality lead, care coordinator and resource nurse)
44
Nursing assistant/healthcare aide 8
Manager 4
Unit clerk, patient registration 10
Other healthcare providers (physiotherapist, occupational
therapists social worker, speech language pathologist,
spiritual care, pharmacist, dietitians and therapy
assistant)
30
Diagnostic imaging, laboratory and X-ray 2
Physician, resident 7
Support services (environmental services, housekeeping,
service aide, food services and protection services)
5
Other staff: positions not identified 3
Total 113
2 S. L. Hepp et al. J Interprof Care, Early Online: 1–7
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According to interviewees, written documentation among IP team
members include progress notes and patient charts kept in
different locations (e.g. Kardex, charts, electronic records and
discipline-specific binders). Besides leading to duplication,
missing information and delays in follow-up, interviewees
expressed concern that not everyone reads the information.
Many expressed that nurses and other healthcare providers tended
to rely on verbal information sharing and that it is rare for them
to read the notes:
I’m sure we can find a way to condense and have accurate
information, but condense it where everybody who needs
information can gather it from one page, which I think would
be the best result for all of that. [Resource Nurse, Unit 2]
Patient-centred care
The general sense among interviewees was that patient care
quality was good; safety standards and patient needs were being
met by centering care and decision-making around patients and
their families:
So I would think that most of the patients’ needs are well met
on [unit] although sometimes the nurses sacrifice themselves
to obtain that. [Physician, Unit 5]
While the safety of patients was not perceived to be compromised,
interviewees commented that surgical units tend to discharge
patients quickly resulting in rushed post-operative teaching
and lack of treatment plans. A recurring sub-theme was a more
holistic approach to patient care was needed, as it was believed
that patients’ non-surgical issues were not addressed. Another
interviewee mentioned that patients could benefit from specific
services (e.g. social work) if patients were made aware of the
services available to them or if physicians believed in the benefits
of that service (e.g. dietary counselling). This was seen as
especially important for patients who were without a family
doctor.
Role clarification
Three main sub-themes, highlighting the need for role clarification, emerged from the data: (1) lack of clarity between the roles
of registered nurses (RN) and licensed practical nurses (LPNs);
(2) scope of practice and utilisation of nursing staff; and (3) lack
of understanding of other healthcare provider roles (e.g. physiotherapist and occupational therapist).
When discussing nursing scope of practice, some nursing staff
agreed that nursing role confusion was the result of increased
training and expanded scope of practice of the LPNs over the past
few years. Many interviewees delineated the roles of RNs and
LPNs around specific tasks (e.g. LPNs give IV medication, but
RNs are responsible for central lines and the charge nurse role).
However, in many areas, RNs and LPNs were performing similar
tasks with lack of differentiation between the two providers. This
was reported as leading to role confusion and feelings of
frustration for doing tasks that could more appropriately be
completed by another provider.
Furthermore, RNs were viewed as not working to their full
scope of practice:
I think maybe the RNs could be working to further scope of
practiceðI think back over the years about the bed bathing, the
walking, like such a physical job and, and you think about
what my training is and what my experience is and what I’m
truly paid to do. [Unit Manager/Charge Nurse, Unit 6]
In addition, others stated that hospital policy was preventing
LPNs from working to full scope. It was frequently noted that
RNs and LPNs should be spending more time on discharge
planning and thinking about the ‘‘bigger picture’’ for patients,
while it was suggested that the transition nurse should do the care
planning. Interviewees on one unit noted that RNs are encouraged
to move away from completing tasks to a focus on a total case
management approach to patient care.
Lack of understanding between nursing and other healthcare
provider roles was also reported. Many nurse interviewees
expressed that some of their activities should be the responsibility
of another healthcare provider (e.g. physiotherapist) or even
housekeeping, as it takes them away from their nursing
responsibilities (e.g. discharge planning, treatment planning and
patient education). Other interviewees noted overlap in roles
between nursing staff and other healthcare providers, resulting in
possible duplication in patient education, care planning and
mobilisation:
I think one of the things is even if you look at all the
disciplines in the hospital there is not a lot of knowledge about
what everybody’s scope entails ð And I think lots of times if
lots of the staff had a better knowledge about what everybody
was capable of doing then you could bring the right person in
the right time to prevent problems from getting bigger.
[Physiotherapist, Unit 6]
Other healthcare provider roles were generally reported as fairly
clear across units with the exception of role confusion between
physiotherapists and occupational therapists, reflected by inappropriate referrals.
Team functioning
Many nursing interviewees saw teamwork as assisting
other nurses with task-oriented patient care, in particular
physical activities requiring an extra set of hands. For example,
LPNs specifically mentioned that they work closely with
healthcare aides to help with baths and heavy lifting. RNs
mentioned that they work together to cover each other during
breaks. LPNs further commented that they would go to the
RN, team lead or the charge nurse to discuss patient concerns
if need be. There was agreement that helping each other was
important and highly valued and made the workload more
manageable.
Nurses also spoke positively about teamwork with
other healthcare providers. Similarly, these other healthcare
provider interviewees had positive comments related to
working with nurses, finding them an invaluable source of
information, feeling valued by them and attesting to an open
relationship:
Actually the team works very well together. . . [I]f there’s
any questions we make time for each other as a team to
kind of collaborate and talk about what we need to talk
about. Yeah, they’re actually very approachable. [Social
Worker, Unit 1]
However, coordinating patient care with other providers was
challenging. While some providers are readily available, interviewees acknowledged difficulties in accessing certain providers,
in part, due to time of day or day of week (e.g. weekends and
evenings) or workload. Many providers stated that a strong
atmosphere of teamwork existed on their units. Others voiced that
there were times when the team was ‘‘not open to others coming
[such as] new staff, casuals’’ [Care Coordinator, Unit 3] and that
there is room to improve team functioning. A few staff spoke to
DOI: 10.3109/13561820.2014.955910 Interprofessional competency framework 3
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the lack of respect between providers and how that negatively
impacted team functioning:
There’s bullying from doctorsð[and]ð nurses, there’s bullying
from other departments and I think that’s a huge thing that
we deal with every dayð And it makes your life not fun and
it interrupts patient care. Andðyou can’t do proper care when
you’re upset because someone is attacking you all the time and
it does happen everywhere. [Registered Nurse, Unit 4]
Nursing interviewees from units that had recently introduced a
nursing team model of care stated that the model had fostered a
deeper sense of shared responsibility and accountability, which in
turn increased morale and led staff to feel more empowered. They
felt they had permission and were clearer on whom they could
reach out to for assistance, and this encouraged stronger and more
frequent communication among nursing staff.
Collaborative leadership
Interviewees described situations suggesting that collaborative
leadership at IP rounds was not optimal. For example, it was
identified that other healthcare providers were not expected nor
encouraged to contribute to discussions on discharge/bed availability. Not having front-line nurses attend IP rounds was seen as
a missed opportunity to develop leadership skills in front-line
nurses. Concern was voiced with the strong leadership role
physicians and charge nurses had and saw it as impeding
leadership development in other staff. There was recognition
that a ‘‘go-to’’ position was needed at specific points in care (e.g.
patient transfer and discharge) to allow patients to flow smoothly
through the system.
Interviewees also talked about the decision-making authority
of official leaders (e.g. charge nurse, physicians and primary
nurse). There was acknowledgement that the charge nurse was
often responsible for solving problems and making decisions:
I think if everything kind of goes through the charge [nurse],
when you have that one point of communication it definitely
ensure[s] that the information’s sort of at a level where it can
be dealt with appropriately and so you know that the
communication has happened. [1st Year Medical Resident,
Unit 3]
However, disadvantages were associated with the charge nurse as
the main point of contact – specifically, lacking a complete
picture of the patient and disempowerment of the primary nurse.
Nursing decision-making about everyday patient care was
described as the primary nurse’s (RN or LPN) responsibility.
Other healthcare providers also reported having decision-making
ability about care related to their individual disciplines.
It was clearly articulated by many interviewees that major
decisions were made by the physician. Interestingly, one physician
noted that the charge nurse needed to be more empowered to
make decisions that did not need to be brought to the physician’s
attention. Another physician noted that he/she was unclear who
had ultimate decision-making responsibility on certain decisions
such as transferring patients to another unit.
Conflict resolution
On the six units, a common source of conflict emerged around
the discharge of patients. While some physicians may invite
recommendations from staff to inform their decisions, nursing and
other healthcare providers expressed some dissatisfaction over
physicians’ ultimate decision-making authority for discharges.
Other healthcare providers expressed dissatisfaction that the
results of their professional assessments were ignored, especially
when questioning the readiness for discharge of a patient. There
seemed to be a lack of objective criteria for discharge or an agreed
upon process around negotiating discharge decisions and resolving disagreements. Interviewees mentioned contextual factors
that could exacerbate conflict such as high workload, burnout,
lack of leadership around coordination of care, disrespect among
providers and role blurring.
Discussion
Although collaborative practice has been widely embraced in
healthcare, operationalising and measuring this multidimensional
concept in real life has proven to be difficult. Generally, the
literature has focused on knowledge of and attitudes towards
collaborative practice, excluding the applied component of how IP
competencies are enacted in a practice setting. We used data from
interviews with staff discussing their perception of collaboration,
roles, communication and staffing in conjunction with the CIHC
IP competency framework to examine current state of collaboration on six acute care units.
Of the six IP competencies, communication and patientcentred care emerged as strengths. It is not surprising that
providers had great awareness of these competency domains
because some processes (e.g. rounds, documentation and discharge planning) to support enactment of these competencies
were in place. Deficiencies were noted with IP rounds (e.g. not
always efficient/informative and not all disciplines attending) and
documentation (e.g. duplication), but providers had ideas for
possible solutions. Research indicates that rounds conducted with
clear goals are key to improving patient flow, communication and
coordination of care among healthcare providers, and decreasing
length of stay (Geary, Cale, Quinn, & Winchell, 2009).
Furthermore, most interviewees knew how patient-centred care
should be practiced (e.g. holistic care), were aware of their
strengths and shortcomings and identified processes (e.g.
integrated care plan and discharge plan) to support this competency. However, time constraints prevented interviewees from
delivering holistic care, discharge planning and post-operative
teaching. Research suggests that patients’ self-management
capabilities and skills are often overestimated and/or not sufficiently addressed, leaving patients unprepared for discharge and
without detailed instruction on how to perform simple procedures
(e.g. change a wound dressing) (Hesselink et al., 2012). In
addition, interviewees had concrete ideas of what they could do to
skilfully apply communication (e.g. ensure information communicated at IP rounds flows back to the RNs, LPNs and HCAs) and
patient-centred care (e.g. make available basic activities such as
walking to patients) competencies and awareness about current
gaps and limitations.
We uncovered weaknesses with role clarity and collaborative
leadership competencies. Although interviewees were aware of
role clarity and collaborative leadership issues on the units (e.g.
RNs and LPNs were seen as not working to their full scope of
practice), providers could not find workable solutions to resolve
these issues and identified heavy workload as the largest barrier to
working to full scope/role clarity issues. Research suggests that a
lack of role clarity and understanding of professional roles can
lead to underutilisation of professional expertise (Suter et al.,
2009). This may compromise patient outcomes and contribute to
excess system utilisation such as preventable 90 day readmission
(Besner, 2011). Furthermore, although interviewees could provide
instances of where shared leadership was applied (e.g. rapid
rounds and patient transfer), leadership centered on decisionmaking by formal leaders such as physicians and charge nurses.
Collaborative leadership is needed to ensure that work
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environments support providers and foster collaborative partnerships (Disch, Beilman, & Ingbar, 2001; Manojilovich,
Barnsteiner, Bolton, Disch, & Saint, 2008). One suggestion for
shared leadership was to have all providers attend rounds or have
equal input into patient discussions. However, the logistics around
gathering all providers on the unit at the same time was not always
conducive to promoting shared leadership. While interviewees
had concrete ideas of how to improve role clarity (e.g. dedicate a
professional practice leader to clarify roles on the unit) and
collaborative leadership (e.g. practice team based nursing model
of care), they did not have confidence that they could overcome
the barriers identified as prohibiting them from practicing the
competencies.
Team functioning and conflict resolution emerged as gaps
in collaborative practice. Although some awareness existed,
interviewees did not understand this competency well and were
unaware of potential practices promoting team functioning.
Examples of joint problem-solving or shared planning of care
were rare. Interviewees’ somewhat simplified notion of teamwork
involved assisting each other with task-oriented patient care.
Interviewees knew that joint responsibility for actions was
required to accomplish goals, but they had difficulties
Table II. Select strategies for collaborative practice.
Strategies based on the literature and gaps identified by the study
Interprofessional communication
IP rounds: Issues with IP rounds are that they are not conducted efficiently, often lack clearly written plans for patients and provider representation is
not always good. Strategies include the following:
Enhance rounds through physician attendance (where appropriate) and strengthen focus on an integrated plan of care (rather than immediate
patient needs) (Fryers et al., 2012).
Improve rounds by starting as early as possible (before 10 am); spend one minute per patient to discuss the ‘‘plan for the day, plan for the stay’’
(Geary et al., 2009).
Documentation: Issues with documentation are that notes and charts are kept in different locations, duplication and missing information occurs and that
not everyone reads the information. Strategies include the following:
Use a Situation-Background-Assessment-Recommendation (SBAR) format to improve shift reporting (Murphy et al., 2010).
Create an interprofessional Kardex to reduce duplication and increase the use of documentation for planning (Murphy et al., 2010).
Create a patient record shared between physicians and other healthcare providers to improve care, coordinate care, and protect the safety of
patients (Canadian Medical Association, 2007).
Implement electronic medical records (EMRs) to mitigate disadvantages of paper documentation including missed, and inconsistent information,
and time-consuming documentation (Green & Thomas, 2008; Langowski, 2005).
Patient-centred care: Issues with patient-centred care are that surgical units often discharge patients quickly, rushed post-operative teaching, and lack of
treatment plans. Strategies include the following:
Discuss care plan and communicate with patients and families early to improve patient care (Hesselink et al., 2012).
Increase amount of direct one-on-one care time with patient and family (time to ask open-ended questions) to improve patient care (Canadian
Medical Association, 2007).
Incorporate hourly patient care rounding that addresses each patient’s positioning, personal needs, pain, and placement of personal items to
improve patient satisfaction (Fryers et al., 2012).
Implement white boards for patient information to improve patient safety (Murphy et al., 2010).
Implement preadmission classes for surgery patients to prepare patients for surgery and plan for discharge recovery to reduce length of stay
(Murphy et al., 2010; Hesselink et al., 2012).
Implement a standardised discharge handover protocol for patients and providers, formalised face-to-face discharge consultation and assessments
for patients’ level of understanding of information to improve the discharge process, patients’/families’ self-care skills, mitigate patient anxiety,
and reduce readmissions (Hesselink et al., 2012).
Use pictures, videos and/or storyboards for information exchange with patients and family members to improve patient preparedness, and
consistency of patient care (Besner, 2011).
Role clarification: Issues with role clarification are lack of delineation between RNs and LPNs, both roles should spend more time on discharge
planning, and lack of understanding between nursing and allied health roles. Strategies include the following:
Develop clear job descriptions to support providers working to full scope of practice (Canadian Medical Association, 2007; Murphy et al., 2010).
Provide ongoing professional development activities (e.g. IP education rounds) that address role optimisation and utilisation of healthcare
providers (Murphy et al., 2010; Fryers et al., 2012; Harvey & Priddy, 2011).
Facilitate a culture built on quality relationships between healthcare providers (Registered Nurses’ Association of Ontario (RNAO), 2006).
Collaborative leadership: Issues with collaborative leadership are allied health is not encouraged to contribute to discussions, front-line nurses are not
developing their leadership skills through attendance of IP rounds, and lack of empowerment of the charge nurse. Strategies are as follows:
Realign nursing roles to provide leadership opportunities for nursing staff, specifically RNs (Besner, 2011).
Support unit managers and other leaders (e.g., transition coordinator, LPN mentor) at the point of care to carry out staff duties/roles (Canadian
Medical Association, 2007; Harvey & Priddy, 2011).
Team functioning: Issues with team functioning are difficulties coordinating patient care with other providers and accessing certain providers.
Strategies are:
Implement strategies that focus on the values, beliefs, and behaviours of supportive teams (RNAO, 2006).
Implement strategies that support team functioning (e.g., non-hierarchal team structure, democratic working practices) (RNAO, 2006).
Allow healthcare providers to be part of formulating unit policies to help ensure that procedures and processes will be adhered to by all
participating team members and encourage teamwork (e.g. emergencies, day-to-day functioning and care planning) (RNAO, 2006).
Conflict resolution: Issues with conflict resolution are dissatisfaction over physicians’ ultimate decision-making authority for discharges and providers
not having an agreed upon process around discharge decisions and resolving disagreements. Strategies are as follows:
Establish processes for conflict resolution and problem solving that lead to quality work environments and quality outcomes for patients and
clients (RNAO, 2006).
Implement structured debriefing after simulated training exercise to improve team competencies and team functioning (Boehler & Schwind,
2012).
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coordinating patient care with other providers. This is corroborated by literature (MacNaughton, Chreim, & Bourgeault, 2013;
McCallin, 2006) that states team practice continues to be
problematic given that professional boundaries are changing and
IP coordination across role boundaries is challenging.
Furthermore, interviewees across units did not discuss many
examples of conflict resolution being practiced. However, contention was noted for situations where hierarchical, decisionmaking was exhibited. Generally, there was lack of awareness
around processes to resolve conflict. Interviewees mentioned
contextual factors that could exacerbate conflict such as high
workload, disrespect among providers and role blurring. Team
members must recognise the expertise and functions of others to
interact meaningfully, as power struggles, role confusion, lack
of respect and autonomy can be barriers to collaboration
(Besner, 2011; Beunza, 2013; Keshet, Ben-Arye, & Schiff,
2013; Suter et al., 2009).
The findings highlight areas for improvement in each of the six
competencies. We propose strategies to enhance collaborative
practice and, more specifically, each of the six competencies
(see Table II) that have been informed by the literature. The
interventions presented are not a comprehensive list but were
selected based on the gaps found in collaborative practice from
this initiative.
The semi-structured nature of qualitative data gathering
resulted in vast information about providers’ perceptions of
collaborative practice on their units including emerging challenges. However, the limitations of secondary data analysis are
well known: data not collected and intended for a specific analysis
may fall short of fully representing the social phenomenon under
examination. The original interview questions were not constructed based on the definitions and competency statements of
the CIHC framework. Although many questions generated
sufficient evidence, some competencies were supported with
less information (e.g. conflict resolution) than others (e.g. role
clarification). In the case of conflict, is likely to be more
widespread than occurring between physicians and nursing staff.
Furthermore, extracting distinct data to qualify for the secondary
analysis may have been difficult for the authors due to the subtle
differences between the primary and secondary analysis (Heaton,
1998). While our analysis should be taken with some caution, we
are also confident that our conclusions are accurate. We have
encountered these weaknesses in collaborative practice at other
settings in AHS thus reinforcing the need for the workforce
transformation initiative in the first place.
Furthermore, some authors have criticised the use of competency frameworks for their reductionist tendency that may
reinforce the status quo (Reeves et al., 2009). Competency is a
point on a continuum where progression is made from being
proficient to being an expert (Talbot, 2004). During this process,
analytical skills and intuition are used for decision making and
situational understanding, requiring significant experience and
reflection of practice (Diwakar, 2002; Glavin & Maran, 2002;
Talbot, 2004). Since every individual healthcare professional
moves along this continuum towards expertise; defining, assessing and measuring higher order competencies (whether clinical or
IP competencies) have been problematic due to their ambiguity
and complexity of overlapping domains (Reeves et al., 2009;
Talbot, 2004). This may affect the ability of a competency
framework to accurately capture the ‘‘level’’ of IP collaboration
practiced by a collective group of healthcare providers.
Concluding comments
Collaborative competencies play a role in the success of
individuals and team members adapting to new models of care.
Using the CIHC IP competency framework to guide the secondary
analysis allowed us to highlight areas of strength as well as gaps
and to gain insight into the ‘‘complex interplay between
knowledge, skills and behaviors’’ (Reeves et al., 2009). This
information is useful when implementing collaborative practice
models as it points to areas requiring special attention. It also
supports the utility of the CIHC IP competency framework in
capturing the essence of IP collaboration (Reeves et al., 2009).
As IP competencies have been proven to be difficult to define
and measure, this study provides a step forward in identifying
competencies in a practical setting. There is still work to be
conducted in translating a comprehensive understanding of
collaborative practice to frontline providers and decisionmakers. The strategies are intended to make the competencies
more tangible by targeting the individual, team and system levels
to support the implementation of collaborative models of care.
Acknowledgements
The authors would like to acknowledge the extensive contributions
of staff and physicians at the six participating units in AHS.
Declaration of interest
The authors report no declaration of interest. The authors alone are
responsible for the writing and content of this paper.
The authors would like to thank the funder, Alberta Health.
References
Berridge, E.J., Mackintosh, N., & Freeth, D. (2010). Supporting patient
safety: Examining communication within delivery suite teams through
contrasting approaches to research observations. Midwifery, 26,
512–519.
Besner, J. (2011). Improving the quality of nursing care: The case for
collaborative practice. Care, 25, 22–25.
Beunza, J.J. (2013). Conflict resolution techniques applied to interprofessional collaborative practice. Journal of Interprofessional Care, 27,
110–112.
Boehler, M., & Schwind, C. (2012). Power and conflict and the
performance of medical action teams: A commentary. Medical
Education, 46, 833–835.
Canadian Interprofessional Health Collaborative. (2010). A national
Interprofessional competency framework. Retrieved from: http://
www.cihc.ca/files/CIHC_IPCompetencies_Feb1210.pdf.
Canadian Medical Association. (2007). Putting patients first: Patientcentred collaborative care. A discussion paper. Alberta Medical
Association. Retrieved from: http://fhs.mcmaster.ca/surgery/documents/CollaborativeCareBackgrounderRevised.pdf.
Disch, J., Beilman, G., & Ingbar, D. (2001). Medical directors as partners
in creating healthy work environments. AACN Advanced Critical Care,
12, 366–77.
Diwakar, V. (2002). Commentary: The baby is thrown out with the
bathwater. British Medical Journal, 325, 695–696.
Fryers, M., Young, L., & Rowland, P. (2012). Creating and sustaining a
collaborative model of care. Healthcare Management Forum, 25,
20–25.
Geary, S., Cale, D., Quinn, B., & Winchell, J. (2009). Daily rapid rounds:
Decreasing length of stay and improving professional practice. Journal
of Nursing Administration, 39, 293–298.
Glavin, R.J., & Maran, N.J. (2002). Development and use of scoring
systems for assessment of clinical competence. British Journal of
Anaesthesia, 88, 329–330.
Green, S.D., & Thomas, J.D. (2008). Interdisciplinary collaboration and
the electronic medical record. Pediatric Nursing, 34, 225–240.
Harvey, A., & Priddy, C. (2011). Collaborative practice: Matching staff
skills to patient needs and checking baseline staffing levels. Healthcare
Management Forum, 24, 184–187.
Heaton, J. (1998). Secondary analysis of qualitative data. Social Research
Update, Issue 22, October: University of Surrey. In R.L. Miller & J.D.
Brewer (Eds.), The A–Z of social research (pp. 280–285). London:
Sage.
Heaton, J. (2008). Secondary analysis of qualitative data: An overview.
Historical Social Research, 33, 33–45.
6 S. L. Hepp et al. J Interprof Care, Early Online: 1–7
J Interprof Care Downloaded from informahealthcare.com by National Library of Medicine on 11/19/14
For personal use only.
Hesselink, G., Flink, M., Olsson, M., Barach P, Dudzik-Urbaniak E,
Orrego C, Toccafondi G, et al. (2012). Are patients discharged with
care? A qualitative study of perceptions and experiences of patients,
family members and care providers. BMJ Quality & Safety, 21,
i39–i49.
Keshet, Y., Ben-Arye, E., & Schiff, E. (2013). The use of boundary
objects to enhance interprofessional collaboration: Integrating complementary medicine in a hospital setting. Sociology of Health &
Illness, 35, 666–681.
Langowski, C. (2005). The times are a changing: Effects of online nursing
documentation systems. Quality Management in Health Care, 14,
121–125.
Long-Sutehall, T., Sque, M., & Addington-Hall, J. (2010). Secondary
analysis of qualitative data: A valuable method for exploring sensitive
issues with an elusive population? Journal of Research in Nursing, 16,
335–344.
MacNaughton, K., Chreim, S., & Bourgeault, I.L. (2013). Role
construction and boundaries in interporfessional primary health care
teams: A qualitative study. BMC Health Services Research, 13, 486.
Manojilovich, M., Barnsteiner, J., Burnes Bolton, L., Disch, J., & Saint, S.
(2008). Nursing practice and work environment issues in the 21st
century: A leadership challenge. Nursing Research, 57, S11–S14.
McCallin, A. (2006). Interdisciplinary teamwork: Labelling is not
enough. Journal of Austalasian Rehabilitation Nurses’ Association,
9, 6–10.
Murphy, G.T., Alder, R., MacKenzie, A., & Rigby, J. (2010). Model of
care initiative in Nova Scotia (MOCINS): Final evaluation report.
Dalhousie University & World Health Organization Collaborating
Centre on Health Workforce Planning & Research. Retrieved January
21, 2013 from: http://www.gov.ns.ca/health/MOCINS/docs/MOCINSevaluation-report.pdf.
Reeves, S. (2012). The rise and rise of interprofessional competence.
Journal of Interprofessional Care, 26, 253–255.
Reeves, S., Fox., A., & Hodges, B. (2009). The competency movement in
the health professions: Ensuring consistent standards or reproducing
conventional domains of practice. Advances in Health Sciences
Education, 14, 451–453.
Registered Nurses’Association of Ontario. (2006). Collaborative practice
among nursing teams. Toronto, Canada: Registered Nurses’
Association of Ontario.
Schmitt, M. (2001). Collaboration improves the quality of care:
Methodological challenges and evidence from US health care research.
Journal of Interprofessional Care, 15, 47–66.
Suter, E., Arndt, J., Arthur, N., Parboosingh, J., Taylor, E., &
Deutschlander, S. (2009). Role understanding and effective communication as core competencies for collaborative practice. Journal of
Interprofessional Care, 23, 41–51.
Talbot, M. (2004). Monkey see, monkey do: A critique of the competency
model in graduate medical education. Medical Education, 38,
587–592.
Way, D., Jones, L., & Busing, N. (2000). Implementation strategies:
Collaboration in primary care: Family doctors & nurse practitioners
delivering shared care. Toronto: The Ontario College of Family
Physicians.
Zwarenstein, M., Goldman, J., & Reeves, S. (2009). Interprofessional
collaboration: Effects of practice-based interventions on professional
practice and healthcare outcomes (Review). The Cochrane Library, 4,
1–29.
DOI: 10.3109/13561820.2014.955910 Interprofessional competency framework 7
J Interprof Care Downloaded from informahealthcare.com by National Library of Medicine on 11/19/14
For personal use only.
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