Registered Nurses' Association of Ontario

Nursing Best Practice Guidelines

Conceptual Model for Developing and Sustaining Interprofessional Care

Overview of the Conceptual Model for Developing and Sustaining Interprofessional Care

A model developed by the “RNAO expert panel” based on the National Interprofessional Competency Framework (Canadian Interprofessional Health Collaborative (CIHC), (2010)) and the Registered Nurses’ Association of Ontario Model for Healthy Work Environments for Nurses. In this model exemplary interprofessional care in a healthy work environment is a product of synergy among health-care teams, who demonstrate expertise in its six key domains, which are:
a. Care expertise;
b. Shared power;
c. Collaborative leadership;
d. Optimizing profession, role and scope;
e. Shared decision making; and
f. Effective group functioning.

The six domains are shown surrounded by an outer circle of expected benefits for the health-care team and the organization: a healthy work environment with enhanced quality and improved safety. The domains are supported by competent communication and the three foundational components of the healthy work environment model:
a. Policy, physical, structural;
b. Professional/occupational; and
c. Cognitive/psycho/social/cultural.

The six domains are fundamental for transforming work environments to a collaborative interprofessional environment, while the foundational components support and influence each domain to achieve the goal of exemplary interprofessional care for patients/clients and their support networks.

When interprofessional care has been successfully implemented and sustained, continuous improvement in quality and safety occur on three levels – for patients/clients, for interprofessional providers and for the organization and system.

Care Expertise
Interprofessional care requires collaboration between health-care professionals and patients/clients and their families and circles of care, in order to identify and take advantage of each professional’s care expertise. Specific types of expertise may have to be sought out, depending on a patient’s/client’s needs. Effective use of different types of expertise can be reflected in measures of quality including improved long-term outcomes, quality of life and cost control.

A patient’s/client’s needs are determined by a collaborative interprofessional assessment, to identify what expertise is required. That assessment and the treatment goals and strategies it suggests be individualized for each patient/client and followed by a collaborative and coordinated effort to find the best expert for the patient/client.

At the organizational and system level, policies, practices and structures are in place enabling all health providers to optimize their scope of practice for the benefit of both the patient/client and themselves. To provide optimal expertise, a novice professional is encouraged to draw on the knowledge and support of an expert in the same profession (which speaks to the need for expertise versus the need for competence).

The degree of care expertise needed is dictated by the complexity of a patient’s/client’s needs. The availability of expertise is affected by geographical location and local setting.

Shared Power
Shared power happens when each team member is open to letting others influence patients/clients care regardless of their educational or professional preparation (Orchard, Curran, & Kabene, 2009). Willingness to share power is a commitment to create balanced relationships through democratic practices of leadership, decision making, authority, and responsibility (D’Amour, Ferrada-Videla, San Martin, & Beaulieu, 2005b). Willingness to share power contributes to a healthy work environment where all team members, including the patient/client feel engaged, empowered, respected and validated (SJHC, 2009).

Collaborative Leadership
Collaborative leadership (also called reciprocal or shared leadership) is a people- and relationship-focused approach based on the premise that answers should be found in the collective (the team). According to Michael D. Kocolowski’s 2010 paper, “Shared Leadership: Is it Time for a Change?”, collaborative leadership has several characteristics, including:

■ Reflects shared accountability that addresses power and hierarchy
■ Utilizes structures and processes to advance exemplary care

a. Promoting a collective leadership process based on the belief that at different times and depending on the need, situation, and requirements, different people assume the leadership role and work is assigned based upon the skill requirement.
b. Structuring a learning environment that supports continuous self-development and reflection. The team members are encouraged to learn together and from each other, and to cultivate practices of open-mindedness, mutual trust, constructive feedback and viewing conflict as an opportunity for growth.
c. Supporting relationships that value honesty, mutual respect, expecting the best from others, and the ability to exercise personal choice. Collaborative leadership focuses on facilitating the ability of the team to live those values towards a shared vision that allows people to set common goals and direction.
d. Fostering shared power that implies shared responsibility and accountability for decision making and for learning.
Power is found at the centre of the team rather than at the top of the hierarchy.
e. Practising stewardship and service (rather than focusing on personal power and control) to ensure the interests and needs of others are being served.
f. Valuing diversity and inclusiveness by respecting individual differences, which will result in freedom to learn together and exercising collective ownership.

Optimizing Profession, Role and Scope
Exemplary interprofessional care lets all team members work to their full scope of practice, and takes advantages of the synergies professionals working together can create. The Council of Federations (2012) identified the need for all health-care professionals to work to their full scope of professional capacity, while the National Interprofessional Competency Framework (CIHC, 2010) says practitioners must understand not only their roles but also those of other practitioners on the team. It also says practitioners must be able to articulate their roles, knowledge and skills and use effective listening skills with other team members. The British Columbia Competency Framework for Interprofessional Collaboration (2008) states all practitioners must respect each other’s professional culture and values. The message is that old-fashioned professional “turf ” wars have no place in interprofessional care; rather, overlapping scopes and roles are embraced as an opportunity to collaborate and advance the role of exemplary care for patients/clients and their support network.

Shared Decision Making
Shared decision making gives all team members, including patients/clients, the opportunity to contribute their knowledge and expertise, to arrive collaboratively at an optimal goal (Orchard et al., 2009). It requires respectful and trusting relationships among providers and between them and the patient/client. For shared decision making to work, everyone must recognize and respect each others’ knowledge and expertise, regardless of occupation and formal position (Grinspun, 2007). Everyone must also accept that each team member has both the right and ultimate responsibility to share knowledge to contribute toward a patient’s/client’s plan of care (Orchard et al., 2009). Shared decision making also means, importantly, that each team member must be willing to accept responsibility for decisions.

Shared decision making is not appropriate in every situation. For example, in an emergency such as a code blue, a patient’s/client’s life depends on the person running the code, making decisions and directing the team quickly and decisively. However, where decisions are shared, all team members can participate in a review of their responses after an emergency is over. There are other situations in health care where some team members do not get to offer input. In those situations, transparency around decision making is very important. Team members can continue to feel valued and respected if they know in advance which decisions are shared and which are not. Collaboration is a continuum, from least collaborative, where team members are told what is happening without any opportunity for input, to most collaborative, in which teams can expect to co-create outcomes with maximum opportunity for input (D’Amour, Goulet, Labadie, Martín-Rodriguez & Pineault, 2008).

Shared decision making does not mean everything must be decided unanimously. Decisions may be made by one or more people, or by team consensus. What is important is that each member of the team, including the patient/client, has an appropriate opportunity to influence the plan of care (Edwards, Davies & Edwards, 2009). Quaschning, Korner, and Wirtz, (2013) suggest shared decision making is important to optimize patients’/clients’ participation and enhance
a high quality of care.

Effective Group Function
A health-care system that supports effective teamwork can improve the quality of patients/clients care, enhance patients/clients safety, and reduce workload issues that cause burnout among professionals (Oandasan & Reeves, 2005). We have adapted our definition of effective team functioning in interprofessional care from Ivy Oandasan and Scott Reeves (2005), who describe it as the successful interaction or relationship of an interprofessional health- care team who work interdependently to provide care for patients/clients. In the National Interprofessional Competency Framework (Canadian Interprofessional Health Collaborative (CIHC), (2010)), effective team functioning is one of the six competency domains, and its key competency is that “learners/practitioners understand the principles of team dynamics and group processes to enable effective interprofessional team collaboration” (p.11). The Conceptual Model for Developing and Sustaining Interprofessional Health Care uses the word group in the domains, rather than team, to draw attention to the importance of group process development and maintenance (see Figure 2).

To function effectively, interprofessional team members are expected to work collaboratively to formulate, implement and evaluate care and assess, practice and reflect on whether the group processes they have used were effective (CIHC, 2010, Oandasan et al., 2006).

In 2011, Adamson examined the empathy between members of interprofessional teams within a hospital environment.

Findings from the study found interprofessional empathy was an important part of the relationships among interprofessional team members. Six themes emerged as critical to the development of effective and highly empathetic teams:
1. Engaging in conscious interactions;
2. Using dialogic communication;
3. Understanding each other’s roles;
4. Appreciating personality differences;
5. Taking perspective; and
6. Nurturing the collective spirit.

The evidence also found accessibility, team building, overlapping scopes of practice, teachable moments, perception of workload, empathetic leadership, non-hierarchical work relationships and job security provided the necessary organizational supports to promote and sustain positive interprofessional relationships (Adamson, 2011).

Competent Communication
Competent communication – openness, honesty, respect for each other’s opinions and effective communication skills – is part of all domains of interprofessional practice (Humphreys & Pountney, 2006). Team communication goals are achieved by sharing and responding to information in a timely manner, actively listening to other points of view, communicating clearly and succinctly, (Shaw, de Lusignan, & Rowlands, 2005) and using established processes and tools for sharing information (Mulkins, Eng, & Verhoef, 2005). Effective communication enhances interprofessional relationships and therefore patients/ clients care and other work-related activities. Competent communication helps develop and sustain leadership and actively engages members of the team while demonstrating respect and professionalism (RNAO, 2007c).