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COMPREHENSIVE SYSTEMATIC REVIEW
for ADVANCED PRACTICE NURSING
COMPREHENSIVE SYSTEMATIC REVIEW for ADVANCED PRACTICE NURSING
COM
PREHEN
SIVE SYSTEMATIC REVIEW
for A
DVA
NCED
PRACTICE NU
RSING Cheryl Holly
Susan SalmondMaria Saimbert
E D I T O R S
Cheryl Holly, EdD, RN, ANEF, FNAP • Susan Salmond, EdD, RN, FAAN Maria Saimbert, PharmD, MSN, MLIS, RN
E D I T O R S
Holly · Salm
ond Saim
bert
First Edition a 2013 Doody’s Core Title and AJN Book of the Year Award Winner!
This text provides top-tier guidance for DNP students, graduate faculty, APRNs, and other health care providers on how to use available research for improving patient outcomes and reducing costs. It is the only resource written expressly to meet the objectives of DNP courses. This second edition is completely updated and
features three new approaches—umbrella reviews, mixed-method reviews, and other types of reviews—for seeking, synthesizing, and interpreting available evidence to improve the delivery of patient care. The text also includes two new examples of completed systematic reviews and two completed proposals.
The book presents, clearly and comprehensively, the knowledge and skills necessary to conduct a foundational comprehensive systematic review (CSR). It encompasses the complexities of the entire process, from asking clinical questions to getting the evidence into practice. The text includes question-specific methods and analysis and compares CSR methods, literature reviews, integrated reviews, and meta-studies. It describes how to find and appraise relevant studies, including the non-published “grey” literature and criteria for selecting or excluding studies, and describes how to use the results in practice. Also examined are ways to disemminate findings to benefit clinical practice and support best practices, and how to write a CSR proposal, final report, and a policy brief based on systematic review findings. Plentiful examples, including two completed proposals and two completed systematic reviews, demonstrate every step of the process. An expanded resource chapter that can serve as a toolkit for conducting a systematic review is also provided. The text covers useful software and includes objectives, summary points, end-of-chapter exercises, suggested reading, and references.
NEW TO THE SECOND EDITION:• Three new chapters presenting new systematic review approaches: umbrella reviews, mixed-method
reviews, and other types of reviews including rapid and scoping reviews and reviews of text and opinion
• Two new examples of completed systematic reviews
• Completely updated content throughout
• Detailed information to foster systematic review research question development, efficient literature searches, and management of references
KEY FEATURES:• Delivers the knowledge and skills necessary to conduct a CSR from start to finish
• Serves as the only CSR resource written expressly for the APRN
• Describes useful software for conducting a systematic review
• Provides rich examples including two completed CSRs
• Includes objectives, summary points, end-of-chapter exercises, suggested reading, and references
• Accompanied by a comprehensive toolkit of resources for completing a systematic review
SECOND EDITIONSECOND EDITION
SECOND EDITION
11 W. 42nd Street New York, NY 10036-8002 www.springerpub.com
9 780826 131850
ISBN 978-0-8261-3185-0
Compliments of Springer Publishing Company, LLC
■■ Background
Interprofessional collaborative practice (IPCP) is thought to be key to attaining optimal patient health outcomes. Interprofessional education (IPE) and inter-professional practice (IPP) are interventions designed to improve IPCP and help reach the ultimate goal of better patient health outcomes (Reeves et al., 2011). Yet the relationship between IPCP and patient health outcomes remains poorly understood. The quantitative evidence on this phenomenon has been reviewed many times. Systematic reviews (SRs) have overwhelmingly demonstrated that IPE initiatives lead to improvements in the IPCP educational outcomes of knowledge, attitudes, and beliefs (Lapkin, Levett-Jones, & Gilligan, 2013) and in the IPCP health care outcomes of behaviors, organizational practice, provider and patient satisfaction (Reeves, Perrier, Goldman, Freeth, & Zwarenstein, 2013; Reeves et al., 2008). An SR has also demonstrated that IPP interventions lead to changes in health care outcomes such as length of stay (Merrick Zwarenstein, Goldman, & Reeves, 2009). A scoping review performed by the National Cen-ter for IPP and Education (NCIPE) identified approximately 500 new research studies, including qualitative and quantitative studies, that are related to this topic since the year 2008 (Brandt, Lutfiyya, King, & Chioreso, 2014). However, a search of the Joanna Briggs Institute (JBI) Library of Systematic Reviews and Implementation Reports, the Cochrane Library, and Google Scholar revealed that the qualitative studies on this phenomenon have not been reviewed using SR methods, despite their availability in the literature.
Although the scoping review from the NCIPE included qualitative studies, we believe that a scoping review does not produce the type of high quality pooled evidence needed to guide practice and future research on this important topic, as it does not provide an appraisal of the methodological quality of studies, and it does not synthesize the data from those studies in order to increase the
Interprofessional Collaboration and Health Outcomes: A Systematic Review and Meta-Synthesis
Yuri T. Jadotte, Cheryl Holly, Sabrina M. Chase, Arthur Powell, and Marian Passannante
20
Copyright Springer Publishing Company, LLC
426 VI I . Examples of Systemat ic Rev iews
generalizability or transferability of the results or findings for best practice and future research recommendations (Arksey & O’Malley, 2005; Davis, Drey, & Gould, 2009). It is these added tasks, explicit to SRs, that we sought to accom-plish here, using the JBI method of meta-aggregation (JBI, 2014).
The Institute for Healthcare Improvement (IHI) Triple Aims framework guided the conduct of this review. Promulgated in 2008, this framework pro-poses that there should be a link between any health care delivery models or interventions (such as IPE and IPP) and the patient experience of care, popula-tion health outcomes, and per capita costs. We adopted the NCIPE’s approach (Brandt et al., 2014) in framing this SR, such that only studies from 2008 to the present were sought and, if relevant, included. The objective of this review was to synthesize the best available qualitative evidence on the relationship between IPCP and patient health outcomes. Specifically, this SR asked the following ques-tion: How does IPCP affect patient health outcomes?
■■ Methods
INCLUSION CRITERIA
Types of StudiesThis review considered all qualitative research designs, such as grounded theory, phenomenology, ethnography, action research, and other community-based participatory research methods.
Types of ParticipantsStudies that had any health care stakeholders as participants were included. This could include patients, health care professionals, health care policy adminis-trators, or any other type of individual who normally has a direct involvement in the provision of health care. However, the study sample must have been inter-professional in nature. This means that the participants must have originated from at least two of the health care professions, and they must have been either observed for or have discussed IPCP as an integral component of their partici-pation in the study, or have been engaged in an IPE or IPP activity before or during the study.
Phenomenon of InterestStudies that explored the key phenomenon identified in the research ques-tion were included. Specifically, studies must have explored the experiences, perceptions, views, attitudes, or beliefs of participants regarding how IPCP affects patient health outcomes.
ContextWe included qualitative studies that examined the phenomenon of interest in any health care setting, such as hospitals, clinics, home care, long-term care, and so forth.
Copyright Springer Publishing Company, LLC
20. In terprofess ional Co l laborat ion and Heal th Outcomes 427
FINDING AND ASSESSING STUDIES: SEARCH STRATEGY, STUDY SELECTION, AND METHODOLOGICAL APPRAISAL
A three-step search strategy was implemented. First, a search of MEDLINE and CINAHL (Cumulative Index to Nursing and Allied Health Literature) was done using an initial list of key words, generated from a concept map based on the research question to identify additional key words and index terms that may have been missed during the generation of the initial list of key terms. Second, this broader list of key terms was used to search all the major databases of interest. Finally, the reference lists of studies considered for inclusion were searched for additional potentially relevant studies. To identify IPE/IPP studies consistent with the IHI’s Triple Aim framework, we sought studies published between 2008 and 2014. The initial key words included terms related to socioeconomic status, minority populations, and the urban setting, as we aimed to try to also capture the evidence as it pertains to these factors and their possible influence on the relationship between IPCP and patient health outcomes. Hand searching of relevant specialty-specific journals (i.e., Journal of Interprofessional Care and Journal of Research in Interprofessional Practice and Education) was not war-ranted, as articles from these journals are archived in the major databases. Details on the exact search strategy used for each of the databases are presented in Table 20.1.
Two reviewers screened all identified articles to determine if they met the inclusion criteria (first by title and abstract, and then by examination of the full texts of the articles), and assessed all studies that passed the screening phase for methodological validity, using the JBI critical appraisal checklist for quali-tative studies (JBI, 2014). Studies were included if they met at least half (50%) of the methodological criteria in this critical appraisal tool, which was the threshold established a priori in this review for a decision on inclusion.
SYNTHESIZING THE EVIDENCE: DATA EXTRACTION AND META-SYNTHESIS
Data were extracted from the included studies using the JBI data extraction tools for qualitative studies (JBI, 2014). Extracted data included detailed information on the population (i.e., types of health care professionals, type of health care model), phenomenon of interest, and practice setting/context. Study findings/themes with relevant textual illustrations were extracted from the included qualitative studies for synthesis. We pooled all qualitative findings into a meta-synthesis, using the meta-aggregation approach (JBI, 2014). Data synthesis in this approach is a three-step process involving: extraction of all findings from all included studies with an accompanying illustration and establishing a level of credibility for each finding, development of categories for findings that are sufficiently similar with at least two findings per category, and development of one or more synthesized findings of at least two categories.
Copyright Springer Publishing Company, LLC
428 VI I . Examples of Systemat ic Rev iews
TABLE 20.1 DATABASE SEARCH STRATEGIES
MEDLINE Search Strategy and Results September 16, 2014—Updated June 9, 2015
Item Search Terms Results
1 (Interprofessional or IPE or IPP or collaborative practice or interprofessional relations).mp. [mp=title, abstract, original title, name of substance word, subject heading word, key word heading word, protocol supplementary concept word, rare disease supplementary concept word, unique identifier]
45,975
2 (disparities or health disparities or health care disparities or urban or disadvan-taged or socioeconomic or social status or poor or minority or Black or Latino).mp. [mp=title, abstract, original title, name of substance word, subject heading word, key word heading word, protocol supplementary concept word, rare disease supplementary concept word, unique identifier]
683,439
3 (health outcomes or disease or illness or patient health or death or mortality or heart or infarction or stroke or chronic or infection or hospital).mp. [mp=title, abstract, original title, name of substance word, subject heading word, key word heading word, protocol supplementary concept word, rare disease supplementary concept word, unique identifier]
5,906,959
4 1 and 2 and 3 593
5 limit 4 to yr = “2008–Current” 236
CINAHL Search Strategy and Results September 17, 2014—Updated June 9, 2015
Item Search Terms Results
S1 TX (Interprofessional or IPE or IPP or collaborative practice or interprofessional relations) AND TX (disparities or health disparities or health care disparities or urban or disadvantaged or socioeconomic or social status or poor or minority or Black or Latino) AND TX (health outcomes or disease or illness or patient health or death or mortality or heart or infarction or stroke or chronic or infection or hospital)
Limiters: Published Date: 20080101-20141231; English Language; Human
Narrow by SubjectMajor: physician attitudes
Narrow by SubjectMajor: nurse–physician relations
Narrow by SubjectMajor: attitude of health personnel
Narrow by SubjectMajor: teamwork
Narrow by SubjectMajor: multidisciplinary care team
Narrow by SubjectMajor: nurse attitudes
Narrow by SubjectMajor: education, interdisciplinary
Narrow by SubjectMajor: collaboration
Narrow by SubjectMajor: interprofessional relations
Search modes: Boolean/Phrase
417
(continued)
Copyright Springer Publishing Company, LLC
20. In terprofess ional Co l laborat ion and Heal th Outcomes 429
■■ Results
DESCRIPTION OF STUDIES
The search yielded an initial number of 1,180 articles. No new articles were iden-tified by searching the citations of papers that met the inclusion criteria. From this final pool of 1,180 papers, 96 duplicates were removed, and the remaining 1,084 studies were screened by title and abstract. A total of 1,006 papers were excluded, leaving 78 papers to be examined via full review of the text of the studies. Ten studies met all inclusion criteria and were subjected to method-ological appraisal. One study was excluded on the basis of poor methodological quality based on the JBI appraisal tool. Therefore, nine qualitative studies were included in this review. See Figure 20.1 for the PRISMA flow chart that docu-ments the search strategy.
METHODOLOGICAL QUALITY
Of the 10 qualitative studies identified, nine met at least half of the method-ological criteria (Adams, Orchard, Houghton, & Ogrin, 2014; Bajnok, Puddester, Macdonald, Archibald, & Kuhl, 2012; Bradley Eilertsen et al., 2009; Chong, Aslani, & Chen, 2013; Eloranta, Welch, Arve, & Routasalo, 2010; Fredheim, Danbolt, Haavet, Kjonsberg, & Lien, 2011; Goldman, Meuser, Rogers, Lawrie, &
Web of Science Search Strategy and Results September 17, 2014—Updated June 9, 2015
Item Search Terms Results
S1 TOPIC (Interprofessional or IPE or IPP or collaborative practice or interprofessional relations) AND TOPIC (disparities or health disparities or health care disparities or urban or disadvantaged or socioeconomic or social status or poor or minority or Black or Latino) AND TOPIC (health outcomes or disease or illness or patient health or death or mortality or heart or infarction or stroke or chronic or infection or hospital)
Indexes = SCI-EXPANDED, SSCI, A&HCI Timespan = 2008–2014
349
ProQuest Dissertations and Theses Database Search Strategy and Results September 21, 2014—Updated June 9, 2015
Item Search Terms Results
(Interprofessional) AND (disparities or health disparities or health care disparities or urban or disadvantaged or socioeconomic or social status or poor or minority or Black or Latino) AND (health outcomes or disease or illness or patient health or deaths or mortality or heart or infarction or stroke or chronic or infection or hospital)
Additional Limits: Full text; Date: From January 01, 2008 to December 31, 2014; Language English
177
CINAHL, Cumulative Index to Nursing and Allied Health Literature; IPE, interprofessional education; IPP, interprofessional practice.
TABLE 20.1 DATABASE SEARCH STRATEGIES (continued )
Copyright Springer Publishing Company, LLC
430 VI I . Examples of Systemat ic Rev iews
Reeves, 2010; Hjalmarson, Ahgren, & Kjölsrud, 2013; Maneze et al., 2014). Most studies used an unspecified qualitative descriptive methodology, except one study that used a grounded theory methodology to conduct a research-based qualitative evaluation of a new program (Bajnok et al., 2012). None of the studies met three of the methodological rigor criteria for qualitative research, which are addressed in questions 1, 6, and 7 of the JBI appraisal tool for qualitative research. Respectively, these criteria address whether the authors’ philosophical perspec-tive is congruent with the study’s methodology, whether there is a statement locating the authors culturally or theoretically, and whether the researchers’ influence on the study is addressed. Unfortunately these are components of qual-itative research studies that are often left out of their published version, as the authors’ attempt to cut down the wording of their manuscripts to meet journal
Records identified throughdatabase searching
(n = 1,180)
Additional records identifiedthrough other sources
(n = 0)
Records after duplicates removed(n = 1,084)
Records screened(n = 1,084)
Iden
tifi
cati
on
Scr
een
ing
Elig
ibili
tyIn
clu
sio
n
Records excluded by titleand abstract (n = 1,006)
Full-text articles excluded,by full review of articles
(n = 68)
Studies excluded byappraisal
(n = 1)
Studies included inmeta-synthesis
(n = 9)
Studies critically appraised(n = 10)
Full-text articles assessedfor eligibility
(n = 78)
FIGURE 20.1PRISMA flow diagram showing results of comprehensive search strategy.
Copyright Springer Publishing Company, LLC
20. In terprofess ional Co l laborat ion and Heal th Outcomes 431
editorial requirements. Table 20.2 lists the results of the critical appraisal for the qualitative studies included in this review. One study was excluded by critical appraisal (M. Zwarenstein, Rice, Gotlib-Conn, Kenaszchuk, & Reeves, 2013).
CHARACTERISTICS OF INCLUDED STUDIES
None of the studies were conducted in the United States. Three studies were done in Canada, two in Australia, two in Norway, one in Finland, and one in Sweden. Participants included a range of health care professionals as well as patients and their family members or caregivers. They were conducted in a vari-ety of clinical settings, including primary care clinics, acute care hospitals,
TABLE 20.2 RESULTS OF THE CRITICAL APPRAISAL OF INCLUDED STUDIES
Qualitative Rigor Criteria
Cong
ruit
y of
Phi
loso
phic
al
Pers
pect
ive
and
Stud
y M
etho
dolo
gy
Cong
ruit
y of
Stu
dy M
etho
dolo
gy a
nd
Rese
arch
Que
stio
n/Ob
ject
ives
Cong
ruit
y of
Stu
dy M
etho
dolo
gy a
nd
Data
Col
lect
ion
Met
hods
Cong
ruit
y of
Stu
dy M
etho
dolo
gy a
nd
Repr
esen
tati
on/A
naly
sis
of D
ata
Cong
ruit
y of
Stu
dy M
etho
dolo
gy a
nd
Inte
rpre
tati
on o
f Re
sult
s
Stat
emen
t Lo
cati
ng t
he R
esea
rche
r Cu
ltur
ally
or
Theo
reti
call
y
Infl
uenc
e of
Res
earc
her
on t
he
Rese
arch
, an
d Vi
ce V
ersa
, Ad
dres
sed
Part
icip
ants
and
The
ir V
oice
s Ad
equa
tely
Rep
rese
nted
Rese
arch
Is
Ethi
cal/
Ther
e Is
Ev
iden
ce o
f Et
hica
l Ap
prov
al
Stud
y Co
nclu
sion
s Fl
ow F
rom
the
An
alys
is o
r In
terp
reta
tion
of
Data
S tudies Q1 Q2 Q3 Q4 Q5 Q6 Q7 Q8 Q9 Q10
Maneze 2014 U Y Y Y Y N N Y Y Y
Bradley 2009 U Y Y Y Y N N Y Y Y
Chong 2013 U Y Y Y Y N N Y Y Y
Goldman et al., 2010
U Y Y Y Y N N Y Y Y
Fredheim et al., 2011
U Y Y Y Y N N Y Y Y
Hjalmarson et al., 2013
U Y Y Y Y N N Y Y Y
Adams 2014 U Y Y Y Y N N Y Y Y
Eloranta 2010 U Y Y Y U N N Y Y Y
Bajnok 2012 U Y Y Y Y N N Y Y Y
Total percentage Yes
0 100 100 100 89 0 0 100 100 100
N, no; U, unclear; Y, yes.
Copyright Springer Publishing Company, LLC
432 VI I . Examples of Systemat ic Rev iews
community health centers, and other settings. Table 20.3 provides details on the characteristics of the included studies.
Synthesis of StudiesUsing the nine qualitative studies included in this review, a meta-synthesis was conducted. Findings were considered to be the exact themes stated in the stud-ies by the authors in the results section of the study reports retrieved from the search. Findings were combined into categories based on similarities in con-ceptual meanings embedded in the findings. Two reviewers created the descrip-tions for the categories in this review, as well as the final synthesized finding for this review, by combining the categories into a single cohesive group of declam-atory statements that can be used to provide a response to the central research question and thereby help guide practice. The author findings or themes extracted from each individual study, as well as a diagram illustrating the relationship between these findings and the review categories, are presented in Table 20.3 and Figure 20.2. Meta-aggregation of the included studies generated a single synthesized finding. This overall finding was derived from 64 original study find-ings that were subsequently aggregated into 13 categories. In the following text we present these categories and their descriptions, as well as the overall synthe-sized finding and its description.
Category 1: Role Clarity. Role clarity is a fundamental component and result of effective IPCP. Role clarity consists of the presence of a clear consensus and understanding among health care professionals of their individual and collec-tive responsibilities as well as the skill sets of all health care professionals in the team. It is fostered via experience communicating with health care profession-als from different professions. Role clarity not only enhances effectiveness of patient care via better communication among health care professionals as well as with the patients (such that they always know who to contact for what prob-lem), but it also increases the efficiency of health care systems and can lead to a greater sense of professional meaningfulness and satisfaction. This may require a re-thinking of traditional professional roles and scopes of practice, as well as greater flexibility on the part of all health care professionals.
Category 2: Communication. Communication is an essential component and a result of IPCP. Communication must occur on multiple levels, including among health care professionals as well as with the patients and families for the purpose of clarifying the roles of each team member, and it must involve feedback mechanisms to be sustainable. Interprofessional communication has several important outcomes. It leads to greater role clarity among health care professionals, including greater awareness of the resources that each health professional and parts of the health care system can bring to the table; it helps to minimize professional conflicts and improves the workplace environment, thereby resulting in greater effectiveness in team-based care. It also directly gen-erates greater patient satisfaction with the care received. The absence of effective interprofessional communication results in a lack of continuity (or an increase in fragmentation) and coordination of care.
Copyright Springer Publishing Company, LLC
433
TABL
E 20.
3 CH
ARAC
TERI
STIC
S OF
INCL
UDED
STU
DIES
Stud
yM
etho
ds a
nd
Met
hodo
logy
Part
icip
ants
and
Se
ttin
gsPh
enom
enon
Und
er S
tudy
Auth
ors’
Ove
rall
Con
clus
ions
Ada
ms
(20
14
)In
divi
dual
inte
rvie
ws
wit
h pa
rtic
ipan
ts a
t th
ree
tim
e po
ints
, us
ing
qual
itat
ive
desc
ript
ive
met
hodo
logy
11
pra
ctit
ione
rs a
t ur
ban
cent
er in
Can
ada
How
do
com
mun
ity
prac
titi
oner
s ex
peri
ence
the
est
ablis
hmen
t of
an
inte
rpro
fess
iona
l tea
m?
Wha
t ar
e th
e pr
oces
ses
thro
ugh
whi
ch in
divi
dual
co
mm
unit
y-ba
sed
prac
titi
oner
s be
com
e m
embe
rs o
f an
inte
rpro
fess
iona
l tea
m
wit
h a
shar
ed v
isio
n, s
hare
d pu
rpos
e an
d cl
earl
y de
fined
rol
es?
Des
pite
the
bar
rier
s an
d ch
alle
nges
acc
ompa
nyin
g pa
tien
t-
cent
ered
IP
P, p
osit
ive
clin
ical
out
com
es,
and
the
bene
fits
expe
rien
ced
by p
atie
nts
and
prac
titi
oner
s, m
ake
it w
ell w
orth
the
ef
fort
. D
urin
g th
e pr
ojec
t re
port
ed h
ere,
the
res
ults
wer
e ef
fect
ive,
in
expe
nsiv
e tr
eatm
ent
for
a gr
oup
of p
atie
nts
wit
h di
abet
es-
rela
ted
foot
ulc
ers
and
the
joy
they
sha
red
in b
eing
inte
gral
tea
m
mem
bers
. M
ore
inst
itut
iona
l sup
port
s ne
ed t
o be
put
in p
lace
to
faci
litat
e an
d su
ppor
t IP
P in
a v
arie
ty o
f he
alth
car
e se
ttin
gs,
invo
lvin
g a
wid
e va
riet
y of
pra
ctit
ione
rs a
nd p
atie
nts
Baj
nok
(20
12
)Fo
cus
grou
p in
terv
iew
s,
usin
g qu
alit
ativ
e de
scri
ptiv
e m
etho
dolo
gy
Five
tea
ms
of p
hysi
cian
s,
nurs
es,
diet
icia
ns,
audi
olo-
gist
s, a
nd o
ther
hea
lth
care
pr
ofes
sion
als
and
othe
rs
part
icip
atin
g in
the
TIP
S
prog
ram
in C
anad
a
To e
xplo
re w
heth
er in
terp
rofe
ssio
nal
team
dev
elop
men
t fo
r pr
acti
cing
hea
lth
care
pro
fess
iona
ls m
akes
a d
iffe
renc
e in
tea
m f
unct
ioni
ng,
team
mem
ber
sati
sfac
tion
, ab
ility
to
wor
k ef
fect
ivel
y bo
th in
divi
dual
ly a
nd a
s a
team
, an
d im
prov
ed p
atie
nt w
ell-
bein
g
Suc
cess
mea
nt d
iffe
rent
thi
ngs
to e
ach
team
refl
ecti
ng t
he
cont
inuu
m o
f te
am d
evel
opm
ent
from
bui
ldin
g a
safe
, tr
uste
d gr
oup
to b
ecom
ing
lead
ers
of t
eam
dev
elop
men
t fo
r ot
her
inte
rpro
fess
iona
l tea
ms.
Eff
ecti
ve t
eam
wor
k is
cru
cial
to
nurs
es
who
oft
en t
ake
on t
he r
ole
of c
oord
inat
or o
f ca
re o
n a
day-
to-d
ay
basi
s, o
r ar
e in
man
ager
ial r
oles
in in
terp
rofe
ssio
nal c
linic
s or
cl
inic
al p
rogr
am t
eam
s
Bra
dley
(2
00
9)
Focu
s gr
oup
and
indi
vidu
al in
terv
iew
s,
usin
g qu
alit
ativ
e de
scri
ptiv
e m
etho
dolo
gy
23
hea
lth
and
heal
th-r
elat
ed
prof
essi
onal
s w
orki
ng in
the
de
part
men
t of
ped
iatr
ics
at
a un
iver
sity
hos
pita
l in
Nor
way
To e
xplo
re n
on-h
ealt
h an
d he
alth
pr
ofes
sion
als’
vie
ws
of in
terp
rofe
ssio
nal
colla
bora
tion
in g
ener
al
Col
labo
ration
was
con
side
red
sign
ifica
nt f
or p
rofe
ssio
nals
th
emse
lves
and
the
fam
ilies
the
y w
ork
with.
Foc
us g
roup
pa
rtic
ipan
ts s
uppo
rt t
he im
port
ance
of
arra
ngin
g co
llabo
rative
m
eeting
s at
an
early
stag
e of
the
chi
ld’s
illn
ess
and
the
fam
ily’s
cr
isis
. M
any
prof
essi
onal
s, w
orki
ng in
the
chi
ld’s
hom
e co
mm
u-ni
ty, w
ere
alon
e w
ith
the
resp
onsi
bilit
y fo
r fo
llow
-up
care
, bu
t on
ly
a fe
w o
f th
ese
prof
essi
onal
s re
ceiv
ed s
uper
visi
on. M
ore
freq
uent
co
ntac
t w
ith
the
pedi
atric
clin
ic w
as d
esired
, as
wel
l as
a m
ore
active
rol
e fo
r th
e ge
nera
l pra
ctitio
ner.
Pro
fess
iona
ls p
erce
ived
the
m
odel
as
bein
g a
valu
able
sup
port
sys
tem
for
long
-ter
m p
lann
ing
of f
ollo
w-u
p ca
re, al
low
ing
pare
nts
to c
olla
bora
te w
ith
the
care
te
am. It
is e
ssen
tial
how
ever
, to
em
phas
ize
the
impo
rtan
ce o
f ha
ving
wel
l-es
tabl
ishe
d ro
utin
es, as
wel
l as
the
use
of a
coo
rdin
a-to
r. Th
is c
an b
e im
port
ant
for
enha
ncin
g co
mm
unic
atio
n be
twee
n pr
ofes
sion
als
and
for
obta
inin
g a
wel
l-fu
nction
ing
colla
bora
tion
(continued
)
Copyright Springer Publishing Company, LLC
434
Stud
yM
etho
ds a
nd
Met
hodo
logy
Part
icip
ants
and
Se
ttin
gsPh
enom
enon
Und
er S
tudy
Auth
ors’
Ove
rall
Con
clus
ions
Cho
ng
(20
13
)In
divi
dual
sem
i-
stru
ctur
ed in
terv
iew
s,
usin
g qu
alit
ativ
e ex
plor
ator
y m
etho
dolo
gy
31
hea
lth
care
pro
vide
rs
from
a r
ange
of
men
tal
heal
th p
rofe
ssio
ns w
orki
ng
in t
he h
ospi
tal o
r pr
imar
y ca
re s
etti
ngs
in A
ustr
alia
To d
escr
ibe
the
perc
epti
ons
of a
ran
ge
of h
ealt
h ca
re p
rovi
ders
on
the
noti
on
of s
hare
d de
cisi
on m
akin
g an
d in
terp
rofe
ssio
nal c
olla
bora
tion
as
part
of
a p
atie
nt-c
ente
red
prac
tice
in
men
tal h
ealt
h
Alt
houg
h he
alth
car
e pr
ovid
ers
ackn
owle
dged
the
impo
rtan
ce o
f in
terp
rofe
ssio
nal c
olla
bora
tion
, on
ly a
min
orit
y di
scus
sed
it w
ithi
n th
e co
ntex
t of
sha
red
deci
sion
mak
ing.
Hea
lth
care
pro
vide
rs
appe
ared
to
have
dif
feri
ng p
erce
ptio
ns o
n th
e le
vel o
f co
nsum
er
invo
lvem
ent
in s
hare
d de
cisi
on m
akin
g. I
nter
prof
essi
onal
rol
es t
o fa
cilit
ate
shar
ed d
ecis
ion
mak
ing
in m
enta
l hea
lth
need
s to
be
ackn
owle
dged
, un
ders
tood
, an
d st
reng
then
ed b
efor
e an
inte
rpro
-fe
ssio
nal a
ppro
ach
to s
hare
d de
cisi
on m
akin
g ca
n be
eff
ecti
vely
im
plem
ente
d
Elo
rant
a (2
01
0)
Focu
s gr
oup,
usi
ng
qual
itat
ive
desc
ript
ive
met
hodo
logy
25
hea
lth
care
sta
ff (
13
H
HW
s, 1
1 H
CN
s, a
nd o
ne
gene
ral p
ract
itio
ner)
, in
clud
ing
24
fem
ales
, w
orki
ng in
hom
e ca
re u
nits
in
Fin
land
; m
ean
age
of 4
3
year
s; m
ean
of 1
1 y
ears
of
elde
r ca
re e
xper
ienc
e
To e
xam
ine
hom
e ca
re u
nit
care
pr
ovid
ers’
per
spec
tive
s of
the
col
lab-
orat
ive
appr
oach
to
hom
e ca
re d
eliv
ery
for
olde
r cl
ient
s
It is
nec
essa
ry t
o de
velo
p m
etho
ds f
or s
hari
ng in
form
atio
n,
part
icul
arly
to
ensu
re t
hat
staf
f m
embe
rs h
ave
acce
ss t
o co
mm
on
pati
ent
info
rmat
ion
reco
rds
that
allo
w a
ll te
am m
embe
rs t
o en
ter
com
men
ts a
nd o
bser
vati
ons
abou
t cl
ient
s. C
are
base
d on
the
cl
ient
’s s
itua
tion
wou
ld m
inim
ize
com
peti
tion
am
ong
staf
f gr
oups
be
caus
e th
ese
grou
ps w
ould
sha
re a
nd c
ontr
ibut
e th
eir
expe
rtis
e to
ach
ievi
ng t
he c
omm
on g
oal o
f se
rvin
g cl
ient
s’ b
est
inte
rest
s
Fred
heim
et
al.
(20
11
)
Focu
s gr
oups
, us
ing
qual
itat
ive
desc
ript
ive
met
hodo
logy
Six
gro
ups
of g
ener
al
prac
titi
oner
s an
d m
enta
l he
alth
wor
kers
(fo
r a
tota
l of
28
per
sons
) se
lect
ed t
o re
pres
ent
the
popu
lati
on
and
infr
astr
uctu
re o
f tw
o re
gion
s in
Nor
way
To in
vest
igat
e st
reng
ths
and
wea
k-ne
sses
in t
oday
’s c
olla
bora
tion
, an
d to
su
gges
t im
prov
emen
ts in
the
inte
rac-
tion
bet
wee
n ge
nera
l pra
ctit
ione
rs a
nd
spec
ializ
ed m
enta
l hea
lth
serv
ice
Coo
rdin
atio
n is
exp
erie
nced
as
impo
rtan
t by
gen
eral
pra
ctit
ione
rs
and
othe
r m
enta
l hea
lth
prof
essi
onal
s in
volv
ed.
Gen
eral
pra
ctit
io-
ners
are
the
gat
ekee
pers
of
spec
ializ
ed c
are,
and
lack
of
colla
bora
tion
see
ms
to c
reat
e pr
oble
ms
for
all h
ealt
h ca
re
prof
essi
onal
s as
wel
l as
the
pati
ent.
Mut
ual k
now
ledg
e an
d m
utua
l acc
essi
bilit
y of
all
heal
th c
are
prof
essi
onal
s is
impo
rtan
t fo
r ef
fect
ive
colla
bora
tion
Gol
dman
et
al.
(20
10
)
Mul
tipl
e ca
se-s
tudy
ap
proa
ch in
volv
ing
sem
i-st
ruct
ured
in
terv
iew
s of
32
hea
lth
care
pro
vide
rs
14
FH
T in
urb
an a
nd r
ural
C
anad
a, in
clud
ing
12
fam
ily
doct
ors,
six
nur
ses,
fiv
e ph
arm
acis
ts,
and
nine
ot
hers
incl
udin
g so
cial
w
orke
rs a
nd d
ieti
cian
s
To e
xam
ine
FHT
mem
bers
’ exp
erie
nces
of
inte
rpro
fess
iona
l col
labo
rati
on a
nd
its
perc
eive
d be
nefit
s
Issu
es s
uch
as r
oles
and
sco
pes
of p
ract
ice,
lead
ersh
ip,
and
spac
e ar
e im
port
ant
to e
ffec
tive
tea
m-b
ased
pri
mar
y ca
re.
This
st
udy
prov
ides
a f
ram
ewor
k fo
r un
ders
tand
ing
diff
eren
t ty
pes
of
inte
rpro
fess
iona
l int
erve
ntio
ns u
sed
to s
uppo
rt in
terp
rofe
ssio
nal
colla
bora
tion
Hja
lmar
son
et a
l. (2
01
3)
Obs
erva
tion
al fi
eld
note
s w
ithi
n a
case
st
udy
23
key
sta
keho
lder
s fr
om
diff
eren
t pr
ofes
sion
s (fi
ve n
urse
s, 1
1 p
hysi
othe
ra-
pist
s, a
nd s
even
occ
upa-
tion
al t
hera
pist
s) w
orki
ng in
ce
ntra
l Sw
eden
To e
xplo
re t
he d
evel
opm
ent
of
inte
rpro
fess
iona
l col
labo
rati
on a
imin
g to
impr
ove
seco
ndar
y pr
even
tion
of
oste
opor
osis
by
stud
ying
thi
s to
pic
expa
nsiv
ely
from
the
per
spec
tive
s of
di
ffer
ent
stak
ehol
ders
A b
alan
ce b
etw
een
bott
om-u
p an
d to
p-do
wn
stru
ctur
es t
rigg
ered
im
prov
emen
ts in
the
dev
elop
men
t of
inte
rpro
fess
iona
l col
labo
ra-
tion
sin
ce h
oriz
onta
l str
uctu
res
gave
the
pro
fess
iona
l fre
edom
to
act
and
enco
urag
ed a
cha
nged
lead
ersh
ip.
The
proc
ess
illus
trat
es
the
forc
es t
hat
are
the
engi
nes
of t
hose
ele
men
ts a
s in
terp
rofe
s-si
onal
mot
ivat
iona
l for
ces
are
crea
ted
thro
ugh
cons
truc
tive
fe
edba
ck f
rom
: in
terp
rofe
ssio
nal i
nter
acti
ons
wit
h sh
ared
pa
tien
t-ce
nter
ed a
ppro
ach,
con
firm
ing
lead
ersh
ip a
nd t
he
deve
lope
d ab
ility
to
reco
gniz
e th
e be
nefit
s of
join
t ac
tion
s
Man
eze
(20
14
)In
divi
dual
inte
rvie
w,
usin
g qu
alit
ativ
e de
scri
ptiv
e m
etho
dlog
y
13
fam
ily m
embe
rs a
nd
pati
ents
wit
h ty
pe 2
di
abet
es a
dmit
ted
to t
he
emer
genc
y de
part
men
t of
a
dist
rict
hos
pita
l ser
ving
a
soci
o-ec
onom
ical
ly
disa
dvan
tage
d po
pula
tion
in
Aus
tral
ia
To e
xplo
re t
he d
iabe
tic
pati
ents
’ ex
peri
ence
of
mul
tidi
scip
linar
y ca
re,
in
part
icul
ar t
heir
per
cept
ions
, pe
rcei
ved
barr
iers
, an
d fa
cilit
ator
s
Pat
ient
s di
d no
t pe
rcei
ve t
heir
dia
bete
s ca
re a
s in
tegr
ated
. Th
eir
care
app
eare
d to
be
diso
rgan
ized
and
fra
gmen
ted.
The
pat
ient
s w
ere
conf
used
and
ove
rwhe
lmed
by
the
proc
esse
s in
volv
ed.
Per
sona
l bio
phys
ical
and
psy
chos
ocia
l iss
ues,
suc
h as
poo
r E
nglis
h la
ngua
ge s
kills
. Tr
ansp
orta
tion
, so
cioe
cono
mic
issu
es a
nd
com
peti
ng p
rior
itie
s of
com
orbi
diti
es,
are
impo
rtan
t ba
rrie
rs f
or
pati
ents
, co
mpo
undi
ng t
heir
dif
ficul
ties
in p
arti
cipa
ting
in t
heir
he
alth
car
e. T
he p
oorl
y co
ordi
nate
d an
d “u
n-in
tegr
ated
” se
rvic
es
mad
e th
ese
barr
iers
eve
n m
ore
chal
leng
ing
FHT,
fam
ily h
ealth
team
s; H
CN
, hom
e ca
re n
urse
s; H
HW
, hom
e he
alth
wor
kers
; IPC
P, in
terp
rofe
ssio
nal c
olla
bora
tive
prac
tice;
IPP,
inte
rpro
fess
iona
l pra
ctic
e; T
IPS,
team
s of i
nter
prof
es-
siona
l sta
ff.
TABL
E 20.
3 CH
ARAC
TERI
STIC
S OF
INCL
UDED
STU
DIES
(con
tinue
d)
Copyright Springer Publishing Company, LLC
435
Stud
yM
etho
ds a
nd
Met
hodo
logy
Part
icip
ants
and
Se
ttin
gsPh
enom
enon
Und
er S
tudy
Auth
ors’
Ove
rall
Con
clus
ions
Cho
ng
(20
13
)In
divi
dual
sem
i-
stru
ctur
ed in
terv
iew
s,
usin
g qu
alit
ativ
e ex
plor
ator
y m
etho
dolo
gy
31
hea
lth
care
pro
vide
rs
from
a r
ange
of
men
tal
heal
th p
rofe
ssio
ns w
orki
ng
in t
he h
ospi
tal o
r pr
imar
y ca
re s
etti
ngs
in A
ustr
alia
To d
escr
ibe
the
perc
epti
ons
of a
ran
ge
of h
ealt
h ca
re p
rovi
ders
on
the
noti
on
of s
hare
d de
cisi
on m
akin
g an
d in
terp
rofe
ssio
nal c
olla
bora
tion
as
part
of
a p
atie
nt-c
ente
red
prac
tice
in
men
tal h
ealt
h
Alt
houg
h he
alth
car
e pr
ovid
ers
ackn
owle
dged
the
impo
rtan
ce o
f in
terp
rofe
ssio
nal c
olla
bora
tion
, on
ly a
min
orit
y di
scus
sed
it w
ithi
n th
e co
ntex
t of
sha
red
deci
sion
mak
ing.
Hea
lth
care
pro
vide
rs
appe
ared
to
have
dif
feri
ng p
erce
ptio
ns o
n th
e le
vel o
f co
nsum
er
invo
lvem
ent
in s
hare
d de
cisi
on m
akin
g. I
nter
prof
essi
onal
rol
es t
o fa
cilit
ate
shar
ed d
ecis
ion
mak
ing
in m
enta
l hea
lth
need
s to
be
ackn
owle
dged
, un
ders
tood
, an
d st
reng
then
ed b
efor
e an
inte
rpro
-fe
ssio
nal a
ppro
ach
to s
hare
d de
cisi
on m
akin
g ca
n be
eff
ecti
vely
im
plem
ente
d
Elo
rant
a (2
01
0)
Focu
s gr
oup,
usi
ng
qual
itat
ive
desc
ript
ive
met
hodo
logy
25
hea
lth
care
sta
ff (
13
H
HW
s, 1
1 H
CN
s, a
nd o
ne
gene
ral p
ract
itio
ner)
, in
clud
ing
24
fem
ales
, w
orki
ng in
hom
e ca
re u
nits
in
Fin
land
; m
ean
age
of 4
3
year
s; m
ean
of 1
1 y
ears
of
elde
r ca
re e
xper
ienc
e
To e
xam
ine
hom
e ca
re u
nit
care
pr
ovid
ers’
per
spec
tive
s of
the
col
lab-
orat
ive
appr
oach
to
hom
e ca
re d
eliv
ery
for
olde
r cl
ient
s
It is
nec
essa
ry t
o de
velo
p m
etho
ds f
or s
hari
ng in
form
atio
n,
part
icul
arly
to
ensu
re t
hat
staf
f m
embe
rs h
ave
acce
ss t
o co
mm
on
pati
ent
info
rmat
ion
reco
rds
that
allo
w a
ll te
am m
embe
rs t
o en
ter
com
men
ts a
nd o
bser
vati
ons
abou
t cl
ient
s. C
are
base
d on
the
cl
ient
’s s
itua
tion
wou
ld m
inim
ize
com
peti
tion
am
ong
staf
f gr
oups
be
caus
e th
ese
grou
ps w
ould
sha
re a
nd c
ontr
ibut
e th
eir
expe
rtis
e to
ach
ievi
ng t
he c
omm
on g
oal o
f se
rvin
g cl
ient
s’ b
est
inte
rest
s
Fred
heim
et
al.
(20
11
)
Focu
s gr
oups
, us
ing
qual
itat
ive
desc
ript
ive
met
hodo
logy
Six
gro
ups
of g
ener
al
prac
titi
oner
s an
d m
enta
l he
alth
wor
kers
(fo
r a
tota
l of
28
per
sons
) se
lect
ed t
o re
pres
ent
the
popu
lati
on
and
infr
astr
uctu
re o
f tw
o re
gion
s in
Nor
way
To in
vest
igat
e st
reng
ths
and
wea
k-ne
sses
in t
oday
’s c
olla
bora
tion
, an
d to
su
gges
t im
prov
emen
ts in
the
inte
rac-
tion
bet
wee
n ge
nera
l pra
ctit
ione
rs a
nd
spec
ializ
ed m
enta
l hea
lth
serv
ice
Coo
rdin
atio
n is
exp
erie
nced
as
impo
rtan
t by
gen
eral
pra
ctit
ione
rs
and
othe
r m
enta
l hea
lth
prof
essi
onal
s in
volv
ed.
Gen
eral
pra
ctit
io-
ners
are
the
gat
ekee
pers
of
spec
ializ
ed c
are,
and
lack
of
colla
bora
tion
see
ms
to c
reat
e pr
oble
ms
for
all h
ealt
h ca
re
prof
essi
onal
s as
wel
l as
the
pati
ent.
Mut
ual k
now
ledg
e an
d m
utua
l acc
essi
bilit
y of
all
heal
th c
are
prof
essi
onal
s is
impo
rtan
t fo
r ef
fect
ive
colla
bora
tion
Gol
dman
et
al.
(20
10
)
Mul
tipl
e ca
se-s
tudy
ap
proa
ch in
volv
ing
sem
i-st
ruct
ured
in
terv
iew
s of
32
hea
lth
care
pro
vide
rs
14
FH
T in
urb
an a
nd r
ural
C
anad
a, in
clud
ing
12
fam
ily
doct
ors,
six
nur
ses,
fiv
e ph
arm
acis
ts,
and
nine
ot
hers
incl
udin
g so
cial
w
orke
rs a
nd d
ieti
cian
s
To e
xam
ine
FHT
mem
bers
’ exp
erie
nces
of
inte
rpro
fess
iona
l col
labo
rati
on a
nd
its
perc
eive
d be
nefit
s
Issu
es s
uch
as r
oles
and
sco
pes
of p
ract
ice,
lead
ersh
ip,
and
spac
e ar
e im
port
ant
to e
ffec
tive
tea
m-b
ased
pri
mar
y ca
re.
This
st
udy
prov
ides
a f
ram
ewor
k fo
r un
ders
tand
ing
diff
eren
t ty
pes
of
inte
rpro
fess
iona
l int
erve
ntio
ns u
sed
to s
uppo
rt in
terp
rofe
ssio
nal
colla
bora
tion
Hja
lmar
son
et a
l. (2
01
3)
Obs
erva
tion
al fi
eld
note
s w
ithi
n a
case
st
udy
23
key
sta
keho
lder
s fr
om
diff
eren
t pr
ofes
sion
s (fi
ve n
urse
s, 1
1 p
hysi
othe
ra-
pist
s, a
nd s
even
occ
upa-
tion
al t
hera
pist
s) w
orki
ng in
ce
ntra
l Sw
eden
To e
xplo
re t
he d
evel
opm
ent
of
inte
rpro
fess
iona
l col
labo
rati
on a
imin
g to
impr
ove
seco
ndar
y pr
even
tion
of
oste
opor
osis
by
stud
ying
thi
s to
pic
expa
nsiv
ely
from
the
per
spec
tive
s of
di
ffer
ent
stak
ehol
ders
A b
alan
ce b
etw
een
bott
om-u
p an
d to
p-do
wn
stru
ctur
es t
rigg
ered
im
prov
emen
ts in
the
dev
elop
men
t of
inte
rpro
fess
iona
l col
labo
ra-
tion
sin
ce h
oriz
onta
l str
uctu
res
gave
the
pro
fess
iona
l fre
edom
to
act
and
enco
urag
ed a
cha
nged
lead
ersh
ip.
The
proc
ess
illus
trat
es
the
forc
es t
hat
are
the
engi
nes
of t
hose
ele
men
ts a
s in
terp
rofe
s-si
onal
mot
ivat
iona
l for
ces
are
crea
ted
thro
ugh
cons
truc
tive
fe
edba
ck f
rom
: in
terp
rofe
ssio
nal i
nter
acti
ons
wit
h sh
ared
pa
tien
t-ce
nter
ed a
ppro
ach,
con
firm
ing
lead
ersh
ip a
nd t
he
deve
lope
d ab
ility
to
reco
gniz
e th
e be
nefit
s of
join
t ac
tion
s
Man
eze
(20
14
)In
divi
dual
inte
rvie
w,
usin
g qu
alit
ativ
e de
scri
ptiv
e m
etho
dlog
y
13
fam
ily m
embe
rs a
nd
pati
ents
wit
h ty
pe 2
di
abet
es a
dmit
ted
to t
he
emer
genc
y de
part
men
t of
a
dist
rict
hos
pita
l ser
ving
a
soci
o-ec
onom
ical
ly
disa
dvan
tage
d po
pula
tion
in
Aus
tral
ia
To e
xplo
re t
he d
iabe
tic
pati
ents
’ ex
peri
ence
of
mul
tidi
scip
linar
y ca
re,
in
part
icul
ar t
heir
per
cept
ions
, pe
rcei
ved
barr
iers
, an
d fa
cilit
ator
s
Pat
ient
s di
d no
t pe
rcei
ve t
heir
dia
bete
s ca
re a
s in
tegr
ated
. Th
eir
care
app
eare
d to
be
diso
rgan
ized
and
fra
gmen
ted.
The
pat
ient
s w
ere
conf
used
and
ove
rwhe
lmed
by
the
proc
esse
s in
volv
ed.
Per
sona
l bio
phys
ical
and
psy
chos
ocia
l iss
ues,
suc
h as
poo
r E
nglis
h la
ngua
ge s
kills
. Tr
ansp
orta
tion
, so
cioe
cono
mic
issu
es a
nd
com
peti
ng p
rior
itie
s of
com
orbi
diti
es,
are
impo
rtan
t ba
rrie
rs f
or
pati
ents
, co
mpo
undi
ng t
heir
dif
ficul
ties
in p
arti
cipa
ting
in t
heir
he
alth
car
e. T
he p
oorl
y co
ordi
nate
d an
d “u
n-in
tegr
ated
” se
rvic
es
mad
e th
ese
barr
iers
eve
n m
ore
chal
leng
ing
FHT,
fam
ily h
ealth
team
s; H
CN
, hom
e ca
re n
urse
s; H
HW
, hom
e he
alth
wor
kers
; IPC
P, in
terp
rofe
ssio
nal c
olla
bora
tive
prac
tice;
IPP,
inte
rpro
fess
iona
l pra
ctic
e; T
IPS,
team
s of i
nter
prof
es-
siona
l sta
ff.
Copyright Springer Publishing Company, LLC
436
Fin
din
gs
Cat
ego
ries
Met
a-S
ynth
esis
Bar
riers
to m
ultid
isci
plin
ary
care
Lack
of c
omm
unic
atio
n am
ong
heal
thpr
ofes
sion
als
Lack
of s
uppo
rt fr
om h
ealth
pro
fess
iona
ls
Vie
ws
of m
ultid
isci
plin
ary
team
car
e
Co
mm
itti
ng
to
co
llab
ora
te f
or
bet
ter
pat
ien
t ca
re
Inte
rpro
fess
iona
l col
labo
rativ
e pr
actic
e co
nsis
ts o
f an
activ
eco
mm
itmen
t by
all h
ealth
car
e pr
ofes
sion
als
to c
omm
unic
atin
gef
fect
ivel
y, w
orki
ng in
team
s, a
nd c
lear
ly u
nder
stan
ding
eac
hot
hers
’ rol
es, f
or th
e co
mm
on p
urpo
se o
f effe
ctiv
ely
and
effic
ient
ly a
chie
ving
opt
imal
pat
ient
car
e. A
ttain
ing
inte
rpro
fess
iona
l col
labo
rativ
e pr
actic
e fir
st a
nd fo
rem
ost
requ
ires
that
hea
lth c
are
prof
essi
onal
s ov
erco
me
pers
onal
bi
ases
abo
ut th
emse
lves
and
eac
h ot
her,
ther
eby
faci
litat
ing
effe
ctiv
e co
llabo
ratio
n-de
pend
ent c
oord
inat
ion
of
cont
inuo
us p
atie
nt c
are.
The
latte
r en
tails
the
impl
emen
tatio
nof
team
-bas
ed p
robl
em-s
olvi
ng a
ppro
ache
s, w
here
info
rmat
ion
is s
hare
d sy
stem
atic
ally
, and
a te
am le
ader
is d
edic
ated
to
ensu
ring
that
sol
utio
ns g
ener
ated
by
the
team
are
car
ried
forw
ard
with
in th
e co
ntex
t of s
hare
d de
cisi
on m
akin
g am
ong
heal
th c
are
prof
essi
onal
s, th
e pa
tient
s, a
nd th
eir
fam
ilies
. A
chie
vem
ent o
f opt
imal
pat
ient
car
e vi
a in
terp
rofe
ssio
nal
colla
bora
tive
prac
tice
requ
ires
that
the
lack
of m
utua
l ac
cess
ibili
ty o
f hea
lth c
are
prof
essi
onal
s, in
bot
h tim
e an
dsp
ace,
as
wel
l as
the
man
y so
cial
, eco
nom
ic, a
nd c
ultu
ral
barr
iers
that
thei
r pa
tient
s fa
ce, a
ll be
add
ress
ed
sim
ulta
neou
sly.
Bar
riers
to p
atie
nt c
are
Ben
efits
of i
nter
prof
essi
onal
car
e
Bot
tom
-up
appr
oach
Com
mitm
ent
FIGU
RE 2
0.2
Synt
hesi
zed
find
ings
.IP
CP,
inte
rpro
fess
iona
l col
labo
rati
ve p
ract
ice.
Copyright Springer Publishing Company, LLC
437
Inte
rper
sona
l kno
wle
dge
and
com
mun
icat
ion
Co
mm
itti
ng
to
co
llab
ora
te f
or
bet
ter
pat
ien
t ca
re
Com
mitm
ent
Ear
ly p
erce
ptio
ns o
f col
labo
rativ
e ca
re
Incr
ease
d tr
ansp
aren
cy a
nd c
ontr
ol
Prid
e
Tra
nsfe
r of
lear
ning
Tru
st
Wel
l-est
ablis
hed
rout
ines
and
str
uctu
re
Com
mun
icat
ion
and
conf
lict r
esol
utio
n
Ear
ly p
erce
ptio
ns o
f col
labo
rativ
e ca
re
Fee
dbac
k tr
igge
rs in
terp
rofe
ssio
nal m
otiv
atio
nal
forc
es
Com
mun
icat
ion
FIGU
RE 2
0.2
Synt
hesi
zed
find
ings
. (co
ntin
ued)
Copyright Springer Publishing Company, LLC
438
Lack
of c
omm
unic
atio
n am
ong
heal
thpr
ofes
sion
als
Per
ceiv
ed le
vel o
f int
erpr
ofes
sion
al c
olla
bora
tion
amon
g he
alth
car
e pr
ovid
ers
Prid
e
Pro
fess
iona
ls w
orki
ng to
geth
er c
anen
hanc
e kn
owle
dge
Car
er a
s co
ordi
nato
r
Co-
mor
bidi
ties
as b
arrie
rs
Lack
of c
omm
unic
atio
n am
ong
heal
th p
rofe
ssio
nals
Per
ceiv
ed le
vel o
f int
erpr
ofes
sion
al c
olla
bora
tion
amon
g he
alth
car
e pr
ovid
ers
Pro
fess
iona
ls w
orki
ng to
geth
er c
an e
nhan
cekn
owle
dge
Coo
rdin
atio
n-de
pend
ent
cont
inui
ty o
f car
e
Unf
amili
arity
with
exi
stin
g sy
stem
and
reso
urce
s
Co
mm
itti
ng
to
co
llab
ora
te f
or
bet
ter
pat
ien
t ca
re
FIGU
RE 2
0.2
Synt
hesi
zed
find
ings
. (co
ntin
ued)
Copyright Springer Publishing Company, LLC
439
Inte
rpro
fess
iona
l ini
tiativ
es
Pro
fess
iona
ls w
orki
ng to
geth
er c
an e
nhan
cekn
owle
dge
Effi
cien
cy o
f car
e
Dev
elop
ing
shar
ed v
alue
s an
dpr
even
tive
inno
vatio
ns
Inte
rpro
fess
iona
l ini
tiativ
es
Lack
of s
uppo
rt fr
om h
ealth
prof
essi
onal
s
Pro
fess
iona
ls w
orki
ng to
geth
erca
n en
hanc
e kn
owle
dge
Sha
ring
of in
form
atio
n
Vie
ws
of m
ultid
isci
plin
ary
team
car
e
Info
rmat
ion
shar
ing
Lead
ersh
ip
Man
agem
ent a
nd le
ader
ship
Lead
ersh
ip-d
epen
dent
colla
bora
tion
Co
mm
itti
ng
to
co
llab
ora
te f
or
bet
ter
pat
ien
t ca
re
Wel
l-est
ablis
hed
rout
ines
and
str
uctu
re
FIGU
RE 2
0.2
Synt
hesi
zed
find
ings
. (co
ntin
ued)
Copyright Springer Publishing Company, LLC
440
Mut
ual a
cces
sibi
lity
(incl
udin
g am
bula
tory
car
e)
Tim
e an
d sp
ace
Vie
ws
of m
ultid
isci
plin
ary
team
car
e
Mut
ual a
cces
sibi
lity
Cha
nge
Col
legi
al c
onse
nsus
Per
sona
l gro
wth
Pro
fess
iona
ls w
orki
ng to
geth
er c
an e
nhan
cekn
owle
dge
Ove
rcom
ing
pers
onal
bias
es
Ben
efits
of i
nter
prof
essi
onal
car
e
Bet
ter
patie
nt c
are
Com
mun
icat
ion
and
conf
lict r
esol
utio
n
Pat
ient
car
e
Ear
ly p
erce
ptio
ns o
f col
labo
rativ
e ca
re
FIGU
RE 2
0.2
Synt
hesi
zed
find
ings
. (co
ntin
ued)
Copyright Springer Publishing Company, LLC
441
Aw
aren
ess
and
rela
tions
hips
Bet
ter
patie
nt c
are
Com
mun
icat
ion
and
conf
lict r
esol
utio
n
Fee
dbac
k tr
igge
rs in
terp
rofe
ssio
nal m
otiv
atio
nal
forc
es
Inte
rpro
fess
iona
l ini
tiativ
es
Kno
wle
dge
and
skill
s
Pro
fess
iona
ls w
orki
ng to
geth
er c
an e
nhan
cekn
owle
dge
Ret
hink
ing
trad
ition
al r
oles
and
sco
pes
ofpr
actic
e
Rol
e of
cla
rity
Tea
m r
oles
Lead
ersh
ip
Per
ceiv
ed in
fluen
ce o
f int
erpr
ofes
sion
alco
llabo
ratio
n on
sha
red
deci
sion
mak
ing
Ret
hink
ing
trad
ition
al r
oles
and
sco
pes
of p
ract
ice
Sha
red
deci
sion
mak
ing
Co
mm
itti
ng
to
co
llab
ora
te f
or
bet
ter
pat
ien
t ca
re
FIGU
RE 2
0.2
Synt
hesi
zed
find
ings
. (co
ntin
ued)
Copyright Springer Publishing Company, LLC
442
Co
mm
itti
ng
to
co
llab
ora
te f
or
bet
ter
pat
ien
t ca
re
Ben
efits
of i
nter
prof
essi
onal
car
e
Lead
ersh
ip
Tea
m g
row
th
Tea
m-b
ased
prob
lem
sol
ving
FIGU
RE 2
0.2
Synt
hesi
zed
find
ings
. (co
ntin
ued)
Copyright Springer Publishing Company, LLC
20. In terprofess ional Co l laborat ion and Heal th Outcomes 443
Category 3: Shared Decision Making. Shared decision making consists of collaborative work to achieve a consensus regarding patient care. It reduces time barriers and minimizes confusion by providing opportunities for patients and health care professionals to ask questions and discuss their concerns prior to the implementation of care. It often requires some health care professionals to relinquish some control over some aspects of their work, but it also entails other health care professionals taking on greater responsibility and accountability for care decisions. Achieving shared decision making in IPCP works concurrently with team-based problem solving and requires the presence of a clear team leader in order to be sustainable.
Category 4: Leadership-Dependent Collaboration. Collaborative practice cannot take place without a team leader who takes responsibility for ensuring team-based problem solving, shared decision making, and effective coordina-tion of care.
Category 5: Team-Based Problem Solving. Team-based problem solving consists of the active participation of different health care professionals in addressing patient issues. Team-based problem solving results in better patient care by fostering a collaborative relationship among health care professionals as well as with patients and families. A clear team leader who is committed to using the results of team-based problem solving in shared decision making is a fun-damental requirement for the success of this approach.
Category 6: Commitment. IPCP is unsustainable without various forms of commitment from all stakeholders in patient care. Commitment consists of clear, irrevocable affirmation of the value of other health care professionals, trust in and appreciation for what each of them brings to the team, and agreement by all team members to practice patient-centered care. It also entails the dedication of adequate resources within health systems to provide effective patient care. A commitment to IPCP facilitates greater efforts toward resolution of professional conflicts, and greater willingness to transfer what is learned in one team to other teams and health care settings, thereby increasing the sustainability of IPCP.
Category 7: Overcoming Personal Biases. Before IPCP can fully take root, health care professionals must learn to overcome their personal biases. These consist of all the perceptions, attitudes, beliefs, and other individual characteris-tics that individuals must overcome in order to work collaboratively. This requires learning to communicate interprofessionally (such as by avoiding discipline spe-cific jargon) and to address conflicting perspectives constructively. Over time, this can lead to substantial personal growth of interprofessional team members.
Category 8: Patient Care. Patient care consists of all the activities that are undertaken by health care professionals as well as patients and their families in order to address the health issue at hand. Effective patient care can include a number of components, including activities to minimize the stress of seeking care and increase patient satisfaction with care. It may or may not be patient-centered, depending on the approach taken by the team.
Category 9: Information Sharing. Information sharing is an integral output of IPCP. It is most effective when it is well supported by structures such as
Copyright Springer Publishing Company, LLC
444 VI I . Examples of Systemat ic Rev iews
appropriate information technology. Effective information sharing leads to better patient care with greater continuity by ensuring the transmission of consistent information among health care professionals and with the patients and families.
Category 10: Collaboration-Dependent Continuity of Care. Collaboration-dependent continuity of care is one of the most fundamental mechanisms by which IPCP affects patient health outcomes. Continuity of care consists of the prevention of care fragmentation through various means, including via a system- designated care coordinator, via the patient or a family member acting as a coordinator, or by chance. IPCP works via the first two mechanisms to achieve efficient patient care by ensuring adequate participation of all stakeholders in the processes of care. For example, hospital discharge planning is an important process for providing continuous care that can benefit from IPCP because it is thought to be highly coordination-dependent. Other such processes include the management of multiple chronic conditions, and the successful provision of follow-up and routine care.
Category 11: Efficiency of Care. The efficiency of care is increasingly an important consideration for all health care systems worldwide. Efficiency implies a mutual consideration for effectiveness of interventions as well as their eco-nomic cost and resource use requirements. Achieving the most efficient patient care possible is a multifaceted and challenging process. With regard to IPCP, this may involve improved communication with families to minimize stress, information sharing to reduce incidence of adverse health outcomes, and max-imizing the use of health care professionals’ time through identification of the least costly provider required to competently perform a particular patient care function.
Category 12: Mutual Accessibility. Mutual accessibility is an important requirement for effective interprofessional collaboration. This consists of the availability of health care professionals, both in time and space, to work together in an interprofessional capacity to achieve effective/efficient patient centered care.
Category 13: Barriers to Patient Care. There are many barriers to patient care, which may help to explain the difficulty of IPCP to achieve its stated aims. These barriers include those related to the social, cultural and economic environments or resources of the patient, as well as those that may be embed-ded within multidisciplinary care itself, such as being cared for by multiple health care professionals simultaneously.
Review SynthesisCommitting to Collaborate for Better Patient Care. Interprofessional collab-orative practice consists of an active commitment by all health care profession-als to communicating effectively, working in teams, and clearly understanding each other’s roles for the common purpose of effectively and efficiently achiev-ing optimal patient care. Attaining IPCP first and foremost requires that health care professionals overcome personal biases about themselves and each other,
Copyright Springer Publishing Company, LLC
20. In terprofess ional Co l laborat ion and Heal th Outcomes 445
thereby facilitating effective collaboration-dependent coordination of continu-ous patient care. The latter entails the implementation of team-based problem solving approaches, where information is shared systematically, and a team leader is dedicated to ensuring that solutions generated by the team are carried forward within the context of shared decision making among health care professionals, the patients, and their families. Achievement of optimal patient care via IPCP requires that the lack of mutual accessibility of health care professionals, both in time and space, as well as the many social, economic, and cultural barriers that their patients face, all be addressed simultaneously.
■■ Discussion
Because the conceptual framework of the IHI is the fundamental guide for this study, the time period chosen for the search is a delimitation of this review. Yet given that the construct of IPCP has been around since at least the 1970s, there may be more evidence available on the phenomenon of interest from years prior to 2008. One important limitation is that the original intent of this review was to focus on studies pertaining to socioeconomically disadvantaged contexts. However, only the Maneze et al. (2014) study was done in this context despite the use of a relatively broad search strategy. Finally, the original goal of looking at the relationship between IPCP and patient health outcomes was only par-tially accomplished: None of the studies linked specific patient health outcomes to IPCP. Instead they linked IPCP to patient care outcomes in general. There-fore, rather than producing an empty review without any synthesis of findings, the authors instead relaxed these criteria to include studies done in all contexts and regardless of whether they linked IPCP to specific patient health outcomes. This has allowed the identification of major gaps in the qualitative evidence on the phenomenon of interest.
■■ Summary
The commitment to collaborate is the most important lynchpin in the rela-tionship between IPCP and patient health outcomes. This commitment is required from health care professionals, patients, families, as well as policy makers and health systems, and until this commitment is present, IPCP cannot be expected to change patient health outcomes. Components of this commitment include: attainment of IPCP and related components (i.e., teamwork, communi-cation, role clarity), sharing information, overcoming personal biases, ensuring continuing of care, solving problems in teams and making shared decisions, and addressing the issues of mutual accessibility of health care professionals and the numerous socioeconomic and cultural barriers to care that patients face (JBI Level I evidence for questions of meaningfulness/appropriateness; JBI, 2014).
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446 VI I . Examples of Systemat ic Rev iews
IMPLICATIONS FOR PRACTICE
Based on currently available evidence, the recommendations for understand-ing the relationship between IPCP and patient care outcomes using the CON-QUAL method receive a Grade of B (“weak”) for making recommendations for practice (JBI, 2014). Health care professionals, policy makers, and other stake-holders in health care should examine the declamatory statements in the syn-thesized finding and strongly consider applying its recommendations in their own context as appropriate and meaningful for their given patient populations. There is currently insufficient evidence of meaningfulness/appropriateness in the relationship between IPCP and patient health outcomes.
IMPLICATIONS FOR RESEARCH
While there is strong qualitative evidence of meaningfulness/appropriateness in the relationship between IPCP and patient care outcomes, there is still a need to conduct qualitative studies on the relationship between IPCP and patient health outcomes. Such studies should explicitly set out to identify specific health care and health-relevant variables that that can be influenced by IPCP, how IPCP relates to those variables, how IPCP and those variables interact to influence patient health outcomes, and what other non-health care/non-health variables are important to consider as confounders in the association between IPCP and patient health outcomes. Future studies should also consider using mixed-methods approaches to overcome the limitations of traditional quantitative or qualitative approaches alone.
■■ References
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