Interprofessional Collaboration in Health Care
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Interprofessional Collaboration in Health and Social Care is changing the face of service delivery based on government's attraction to this concept. This essay is an attempt to identify and evaluate weaknesses that affect interprofessional working, using a practice based critical incident (see Appendix A). In order to achieve this, a model of critical reflection, a combination of systematic analytical tools (SWOT, PESTEL) and use of relevant theories are adopted to unearth various assumptions and their sources with a view of engaging the application of theory to practice which will consequently improve provision of services to end users in practice with the added benefit of improving interprofessional working.
The various influencing factors identified from the analysis that conflate in the arena of interprofessionalism makes it a very complex, yet desirable concept to embrace and implement for the effective delivery of service within health and social care.
The case for a Model of Critical reflection
Reflection has been defined as "a process of reviewing an experience of practice in order to describe, analyse, evaluate and so inform learning about practice" Reid (1993). Researching various models of critical reflection (Gibbs reflective cycle (1988), Stephenson's framework of reflection (1993), Fook and Askeland (2006) indicated a number of variables which are relevant in the evaluation and reflection on practice situation. For the purpose of this particular case study, I have chosen to reflect on the critical incident described in Appendix A by using Fook's model of critical reflection. This model;
Focuses on identifying underlying assumptions with a specific purpose of fostering improvement in professional practice Fook and Askeland (2006,p),
Highlights power as a critical element of transforming the revealed assumptions with a view to create a positive change in the practice situation.
The concept of power in critical reflection is relevant in the social, cultural, professional and political context with the aim of gaining a sense of personal power therefore more control and choice, through the exposure of dominant assumptions in operation. Fook (2006), Foucault (1983) cited in White et al (2006, p44).
Fook's model enables reflection on awareness and use of power in the course of performing my professional role. Fook also emphasises the place of emotion, communication, dialogue and learning in this model of critical reflection. This is particularly relevant to the practice situation as it led to competence queries in the light of the ensuing reverberation. This model of critical reflection is a valuable tool, enabling better decision-making, improved ability to work with uncertainty and multiple perspectives, resolve dilemmas, recognising the use and power of emotion, and better ability to learn from practice. Fook and Askeland (2006)
My choice of Fook's critical reflection model helps me to take a look at what I do, why I do it, unearthing relevant hidden assumptions influenced by my cultural, social, professional and political beliefs (see PESTEL analysis in Appendix C). It also enables me to reframe myself in view of the revealed assumptions behind my thinking that affects my practice. This model seeks to empower by giving choices and creating new knowledge when the process of reflection is practised. It could also potentially reaffirm personal beliefs that may have been previously separated from professional roles which inadvertently create conflict.
Interprofessional concepts that are apparently relevant to the practice situation are collaboration and communication. The key weaknesses identified were due to lack of communication and failings in collaboration between the pharmacy, social services professions and general practitioner (GP) engaged in the care of the older people in the community.
In order to analyse the practice situation, two analytical tools are adopted namely -
SWOT analysis - considers the strengths and weaknesses in the case and also the opportunity and threats embedded in it. (Appendix B).
PESTEL analysis - This tool relates the situation to its external environmental factors with a view to identifying influences and impacts of the environment.( Appendix C)
The two major areas of weakness focused on are:
The gaps in collaboration between pharmacist, social workers and GPs in the community.
Poor communication between Health and Social Care (HS&C) professionals in the community.
The concept of interprofessional collaboration has been defined as working together with one or more members of the health care team where each makes a unique contribution to achieving a common goal. Each individual contributes from within the limits of his/her scope of practice. Broers et al (2009), College of Nurses Ontario (2008), Makowsky et al (2009). The Health and Social care policy on 'joined up working' Department of Health (DoH 2000) has been regarded as a major document pointing the way to or representing one of the imperatives for the 'modernisation' agenda. Health and Social Care policies has witnessed several changes in the last twenty five years with a shift in focus from institutional to community care with an attendant upsurge in service commissioning, which created an increasing role for primary care. Karban & Smith (2006).
The need for greater collaboration and communication has been highlighted by the recent increase in major enquiries into several aspects of health and social care (Victoria Climbie inquiry report by Laming (2003), Baby P's case). Loxley (1995) asserted that the recognition of health and welfare within society as an interactive, adaptive process without an end becomes the only creative basis for strategies, policies and practices and as such, the ability to collaborate is thus an essential in this interactive process.
The National Service Framework for Older people DoH (2001) clearly demands that the NHS and local authorities work in partnership to promote health ageing and prevent disease in older people. DoH (2001). Various government policies has emphasised partnership and joint working as the main focus to drive improved care to users of health and social care services. DoH (1998a) Partnership in Action (1998b); Working Together (1998c); First class service; quality in the new NHS)
Leathard's(2003) review on McGrath's (1991) study on interprofessional teamwork in Wales found that joint working led to more efficient use of staff, efficient service provision and a more satisfying work environment. Other benefits include the value of knowledge sharing, potential for comprehensively integrated services, efficient use of public funds and the avoidance of duplication and gaps in services. The New NHS-modern and dependable: DoH (1998).
The government's objective is to build a reliable health service where patients have access to high quality services based on identified need, building on integrated care between health and social care where each have equally important roles to play. The White paper (1998) sets out the framework for the partnership, with the intention to remove barriers to effective collaboration in the existing systems and provide new incentives for joint working across agencies.
The role of Pharmacists in interprofessional collaboration.
The pharmacy profession's code of ethics is traditionally based on the medical model of health, where duty of care is to the patient and mainly prescriptive and paternalistic. Naidoo and Wills (2009). There are no strong evidences to support joint working between community pharmacy and other health and social professions despite a strong need for collaboration for the delivery of excellent patient care across the primary and secondary interface. Makowsky et al (2009) review indicates that collaborative working relationships between nurses and physicians have been the focus of several researches, but relatively little work has investigated the integration and nature of collaborative relationships pharmacists have with other health care practitioners. The review stated that most investigations into professional relationship between pharmacy and other healthcare profession has been on physician's satisfaction attitudes or perceptions towards specific aspects of pharmacy practice, pharmacist roles, perceived barriers between physicians and community pharmacists, unmet needs in the medication use process, physician expectations of pharmacist and physician's receptiveness to clinical pharmacists.
'Competencies of the Future Pharmacy workforce' a publication by the Royal Pharmaceutical Society of Great Britain (2003/2004) highlights the need for greater levels of collaboration between pharmacists across all sectors and boundaries as the way forward for relevance within the healthcare workforce. The Pharmacy White paper (year) also emphasised the role of pharmacists in providing services in the present NHS structure and this would necessitate a greater awareness and participatory collaboration with other healthcare professionals.
Barriers to Interprofessional Collaboration
In spite of the laudable and apparently desirable benefits of interprofessional collaboration, in reality there are barriers that limit effectiveness of this concept between health and social care professionals as apparent in my practice situation. Historically, barriers such as professional cultures, different forms of accountabilities between health and social services, political agendas, rigid boundaries, departmental survival existed and still remain to challenge present day twenty-first century health and social care. Hardy et al (1992) cited in Leathard (2003) identified five categories of the challenges facing joint working within health and social care as;
Structural issues such as service fragmentation, gaps in services.
Procedural matters which hinders joint planning through different budgetary planning cycles and procedures.
Financial factors such as different funding mechanisms, administrative and communication costs
Status and legitimacy, for example local responsibilities are based within a democratically elected arena and in contrast, all services are commissioned and centrally run by the NHS.
Professional issues which include problems associated with conflicting views and ideologies about users, professional self-interest, competition for domains, as well as differences between expertise, specialism and skills.
Leathard (2003) noted more barriers such as practitioners isolated with little management support, inequalities in status and salary, differing leadership styles, lack of clarity about roles as damaging to inter professional collaboration.
It has been noted that service users and carers as typified by the examples in the practice situation (see appendix A) often experience frustration and distress in trying to organise the type of care they want or support needed as a carer. This process, involving contact with different agencies and each with different assessment processes, often leave users and carers unclear as to who should be doing what and how it all links together. DoH (1998a)
Joint working has been identified by the DoH (1998) as needed at three levels; strategic planning, service commissioning and service provision. In the practice of pharmacy in the care of the community, service provision must deliver an integrated package that avoids the burden of complex bureaucracy.
Barriers to Joint Working: Communication
Another weakness identified in the SWOT analysis, (see Appendix C) is poor communication. Information sharing in the appropriate context is important in helping to promote informed decision making and aid the provision of user-focused care. On the other hand, incorrect information can destroy or reinforce negative or destructive stereotypes and therefore limit the range of options offered to the user. Hammick et al (2009). Poor communication can be a barrier to effective information sharing in professional practice. The lack of clarity in the process of communication experience in my context can also be down lack of awareness of how the agencies work together. Meads et al (2005) states that poor systems and lack of parity between different professionals can be major risk factors, particularly with regards to effective communication. In the inquiries into the events that led to Victoria Climbie's death in 2000 and the Bristol Royal Infirmary incident, systemic failures that led to poor communications were highlighted.
The issue of communication was further complicated by the fact that I had no prior knowledge of any disability suffered by the patient that would necessitate any form of assessment set out by the Disability Discrimination Act (2004), I assumed that the client's GP would be aware of the process of referral for patients needing support with their medicines as they are usually their first point of call. Carer's expectation was that all service providers talked to each other in a way that gets things done smoothly. Reflecting on what I have learnt on interprofessional collaboration, the situation became clearer as I realised that different organisations have different operating procedures which, despite attempts at collaboration, can still be conflicting.
External influences on the practice situation such as legal factors (see Appendix C) include issues such as patient confidentiality and data protection requirements which make it imperative that proper channels of communication are followed to protect clients' privacy. This raises ethical and legal questions on how much is too much or too little to exchange with other agencies.
I have learnt that the failings in the practice situation described is not a clear cut failing by a single person, but a classic example of how the barriers to interprofessional working can have a direct impact on both the service user and provider.
Systems Approach to Joint Working: A resolve
A systemic approach to collaboration as stated by Payne(1997) in Hammick et al(2009) is relevant to interprofessional practice as it sees individuals as social beings, affected by and influencing others around them, the organisations with which they have contact and the wider society, drawing attention to relationships, structure, processes and interdependence.
The whole systems concept developed by Bertanlanffy (1971) describes the exchange across permeable boundaries between systems and environments. This characteristic of the systems theory is crucial in its application to service organisations, like the NHS and social service. The key elements from the systems theory as concurred to by Loxley(1997) and Willumsen (2008)relevant to understanding collaboration in interprofessional practice is interdependence and interaction, emphasis on management of processes, the recognition of equifinality - the achievement of the same goal from different starting points. Loxley (1997) asserts that it is possible to manage complexity and differences through the recognition and use of common properties which apply to both parts and to a whole when experiences are shared.
For the whole systems approach to work, the right conditions as advocated by Maddock and Morgan (1999) in Leathard (2003) include;
Support for communication between users and frontline staff
Involvement of actively committed staff
Appropriate performance measures supporting change and staff development
Management and practitioners sharing the same agenda on quality and funding issues
A senior management team with a unity of vision.
The benefits of the whole systems approach as shown by the study on delivery of services to older people across health and social care in Brighton and Hove, Sussex Callanan (2001) include; initiatives to identify gaps in services, an improvement in the services provided in the multidisciplinary assessment and review, improved flexibility to meet user's needs and the enabling of small changes which would result in significant improvements in service provision. The whole systems approach with the theorised benefits is not without its limitations. CSIP(Care Service Improvement Partnership) Older People Team cited in the 'whole systems approach' , a document paper by the NHS Wales(2006) concluded that for most places, a whole systems approach is a statement of aspiration rather than a statement of achievement as there are limitations inherent in the approach.
The way forward may be more opportunities for joint learning among health and social care professionals in practice. Integrating joint learning in the whole systems approach to effective collaboration might in some way resolve some of the perceived barriers.
Learning together reflectively will challenge traditional barriers, professional barriers and compartmentalised thinking. Karban and Smith (2006). They argued that a model of critical and reflective practice acquired through learning together will enable future practitioners develop a shared understanding of the world and ways of working together based on creating a shared dialogue within communities of practice that will enhance the experience of service users.
Forming multidisciplinary teams in the care of the community for specific target population may also be effective in closing the gap in collaboration between pharmacy and other health and social care profession.
In order to avoid the reoccurrence of the incident discussed in my practice situation, I will seek to implement the following -
Raise awareness/understanding of referral process among professionals engaged in the management of older people with disability by writing a letter to all agencies concerned.
Organise seminars at local GP meetings with other healthcare professionals involved in the care of older people with the view of clarifying the referral procedures for effective provision of service
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