Facilitators and barriers to interprofessional collaboration among health professionals in primary healthcare centers in Qatar: a qualitative exploration using the “Gears” model | BMC Primary Care

This qualitative focus group study explored facilitators of and barriers to IPC as perceived by health professionals (including GPs, nurses, pharmacists, dentists, and allied health professionals) from various backgrounds in primary healthcare in Qatar using the “Gears” conceptual model. Overall, the majority of health professionals who participated in this study have acknowledged and appreciated the importance of IPC work within their institutions, which is consistent with other published studies [27, 31, 32].

Facilitators

Facilitators under the micro-gear domain focused on healthcare teams. Participants agreed that the diversity of health professionals within the same PHCC is a major facilitator for better collaboration. They also agreed that the presence of different communication channels (e.g. telephones, CERNER, etc.) is another facilitator. Supportive leaders in the team were acknowledged to have a positive influence on attitudes toward IPC. IPE activities were identified as positively influencing attitudes towards toward IPE and IPC. These findings are consistent with those of other studies. There was an agreement among several studies regarding the importance of open communication and various communication strategies and tools in facilitating IPC [33, 34]. For example, Müller et al. [33], in their study where authors interviewed several clinical executive managers, found that participants agreed that multilateral communication is one of the enablers for effective IPC. Facilitators within the individual-gear, includes Individual contextual factors contributing to IPC such as previous exposure to IPC, patient related factors, and characteristics of health professionals. Previous exposure to IPC emerged as a significant facilitator for both health professionals and patients. Communication skills were identified as crucial in supporting exposure to IPC. Participants highlighted the importance of accessible communication methods, such as availability by phone or in person conversations, eliminating roadblocks to IPC. Furthermore, the approachability of health professionals, characterized by their openness to information sharing and their trust and respect for the competency, knowledge, and skills of other health professionals was a key facilitator to IPC.

Regarding the meso-gear facilitators, participants valued the importance of receiving ongoing, and timely feedback based on practice experiences to consolidate learning and minimize recurrence of errors. They advocated for utilizing data from platforms such as Datix; an Incident Reporting System (IRS), which is a valuable resource among all team members involved in patient care. Participants recommend a wider use of such data for learning, in interprofessional team meetings. This aligns with evidence from the literature which suggests that critical to the success of any IRS is the quality of the feedback given to reporters to enable learning, encourage reporting, and give reporters evidence that the information they are providing is being used appropriately [35, 36]. Space and proximity are reported as excellent opportunity for teams to work together and share perspectives in the care for the patient [37]. As new PHCC centers are created to serve the growing needs of Qatar’s population, leaders can benefit from including members of the care teams, in the final design discussions, so that space and proximity can continue to remain optimal and facilitate interprofessional practice and team centered patient care.

The least number of factors were identified under the macro-gears. These relate to governance and regulations, which were considered as a major facilitator for better IPC in the primary healthcare setting in Qatar. The participants in this study had reflected on the existing policy and regulatory facilitators that foster collaborative practice in PHC setting in Qatar, but did not discuss barriers to policies and regulations. The study findings reaffirm the potential role and influence of government policies and regulations in facilitating IPC in primary care settings from the perspective of the health professionals. Additionally, organizational-level policies were also perceived as key facilitators. This aligns with the macro-level factors of the Gears conceptual model, which allows the conceptualization of the intricate relationships between this and the other domains of the model from the perspective of the health professionals. Previous studies have documented the influence of policy and regulation in promoting collaborative practice and IPE. One international review has summarized the global policies and legal factors influencing the behaviors of health professionals towards successful implementation of collaborative practice [38]. These factors largely influence the scope of practice of various health professions and how the different professions work collaboratively, funding mechanisms, and reimbursement systems for health services.

In Qatar, health professions and practices are regulated by the Department of Healthcare Professions under the Ministry of Public Health (MoPH) [39], which is considered a key aspect of professional practice [38]. Although there are no umbrella laws to regulate multiple health professions under a single statute, which is a major drawback to an effective and conducive implementation of collaborative practice in various settings, having a unified regulatory and legal structure has been shown to foster a culture of equity among different health professionals [40]. An important aspect of policy and professional regulation is the scope of practice, which should typically clarify roles and represent specific areas of competence for each particular health profession. Participants indicated the presence of scope of practice for various professions in the State of Qatar. Previous studies and reports have highlighted the importance of restructuring the scope of practice of health professions towards effective IPC and to remove barriers to healthcare provision. This will allow health professionals to practice within the scope of their practices and to the full extent of their professional competence without encroaching other professions’ scope of practice, which will ultimately lead to effective collaborative practice [41, 42]. In addition, funding and reimbursement are macro-level aspects that can significantly impact IPC [40, 43]. In the present study, there was a consensus that these regulatory factors play a key role in facilitating the IPC among the health professionals in primary care settings in Qatar.

Barriers

Barriers pertaining to the healthcare teams, or the micro-gear, are the lack of understanding of other professionals’ scope of practice, and the lack of time. This is not different from what is reported in the literature, where lack of time and poor understanding of other health professionals ‘ roles were considered, besides other barriers, major hinderers for IPC in one review paper that collected multiple articles that studied the enablers and hinderers of IPC [34]. For the individual-gear barriers, health professionals identified that the hierarchy entrenched within the healthcare system contributed a major barrier to collaboration. Within the studied context, GPs are seen as the pinnacle health professional by patients. Therefore, patients are reluctant to provide information to health professionals other than the GP. This ultimately reduces the effectiveness of the healthcare system as the scope of practice of the remainder of the interprofessional team are constrained to meet patient needs. This might limit other health professionals’ roles, and hence they might be less able to exchange care. This idea might go with the concept of the “patient-doctor dyad” that has been reported in the literature, where authors described that one of the hinderers of IPC is the patient’s desire to be mainly seen and examined by GPs, which is often prioritized over collaborative care [44,45,46]. Pharmacists, in this study, described that patients also might ignore pharmacists’ recommendations if it was not aligned with the GPs’ recommendations. While IPC may beget IPC, participants remarked that there was difficulty bringing IPC to life in their PHCC context. Knowledge of IPC must be accompanied by a shift in organizational culture, supported by policies and performance review, led by champions, and guided by exemplars of IPC.

Two subthemes were considered under the meso-factors, which are mainly regarding the information system and the organizational culture. Our results indicate that although a health information system (HIS) is operating within the primary healthcare center (PHCC) system, however, not all members of the team use nor rely on it, to complete their duties in patient care. This fragmentation of data systems poses a threat to team unity and excludes some team members (in this context the pharmacists) from being on the same page as the rest. Efforts to merge all data subunits and enable all team members to access the HIS, can enhance work time efficiency (a micro challenge) that participants reported for pharmacists to require in order to be on the same page as the other care providers in the team and is supported by research which stresses the benefits of a health information system which enables the participation of all staff who are directly concerned with patient care in that setting [47, 48].

In the interest of optimizing patient safety, whilst participants in this study valued the opportunity for a shared HIS to serve as a platform where errors could be recorded, our data indicates that health care team members did not feel safe enough to do so. According to Smiley and colleagues [49] the fear of being fired and subjected to judicial inquiry and prosecution make many nurses conceal errors. This aligns with our participants’ reported concerns about the prevalence of “blame culture” and how this results in individuals feeling personally and professionally vulnerable. Blame culture in health care organizations is mainly associated with the approach used by management when dealing with medical errors and accidents [50, 51]. Efforts to embrace a culture that promotes transparency and accountability, and management approach which as described by Catino [52] relates the causal factors of a given event to the whole organization rather than the individual, are priorities for the PHCC organizational leadership to consider.

Furthermore, hierarchy in privileges, such as varied levels of access to professional development opportunities, threatens team unity, and in turn generates a sense where some professions feel less valued for working in their roles. Educators postulate that if individuals from different professions learn together, they will be able to more effectively work together in teams to achieve desired outcomes [53]. Integrating CPD in interprofessional decision support with quality improvement and patient safety initiatives will likely enhance the uptake and ability to sustain these educational initiatives [54]. For instance, the “Schwartz Center Rounds” in the US and UK provide a forum in which professional and nonprofessional staff across healthcare disciplines can discuss challenging psychosocial and emotional aspects of a patient’s care and the impact of these challenges on the care team. These rounds do not focus solely on decision-making, but attendees report significantly enhanced appreciation of colleagues’ roles and contributions, communication, and teamwork [55]. In this way, the professional learning needs can meet not only the individual profession, but also translate into opportunities for teams to problem solve together and in turn improve safer patient care.

In general, the current study results on facilitators and barriers to IPC align well with those identified by a review study by [34] that summarized the facilitators and barriers for interprofessional care in primary healthcare. Common facilitators in both studies are the lack of time and training for the health professionals, lack of understanding of others’ roles, and poor communication. It is interesting to note that fears relating to professional identity were identified as a hinderer in the review; however, it was not mentioned by any HCP in the current study. This could be due to the proper understanding of the self-role of the HCP in this study. IPC enablers identified by the review were all reported in this study (i.e. communication tools, co-location of HCP, and recognition of other professionals’ roles and contributions).

Strengths and limitations

One strength of this study is the use of the “Gears model” to understand facilitators and barriers at each level within the IPCTs. Identifying the facilitators and barriers at each level of the work environment makes it easier for decision-makers to identify the gaps and the points that need improvement specific for each level, and hence will help implement appropriate, and probably more efficient, interventions suitable for each level to improve IPC within the PHCC settings. The current study included a high diversity of health professionals and did not focus on certain professions, which aligns with what interprofessional work is all about. This study, as mentioned before, is a continuation of a previous quantitative study done on more than 1400 health professionals to assess their attitude toward IPC. Although the previous study showed that health professionals have a positive attitude toward IPC, which was evident by the survey, the current study examined these quantitative findings from a qualitative lens. This provided a clearer insight to ensure a comprehensive understanding of what shapes these perspectives.

Limitations of the study might include the lack of anonymity in focus groups, which might increase the social desirability. Second, although the study included multiple professions, most participants were GPs, pharmacists, or nurses. Moreover, some HCP were not present (e.g. pharmacy technicians, and physiotherapists), which could limit the generalizability of the current study to these professions.