A qualitative study

Abstract

Interprofessional collaboration (IPC) in primary healthcare is important because each patient's health needs are complex, and one health professional can't meet all of the patient's needs.1 However, IPC isn't usually an option because individual work is perceived to be easier, although it may not optimally meet the needs of the patient. Previous studies have described IPC in Indonesian healthcare settings. One study that used mixed methods identified perceptions of IPC among practitioners in the Depok area.2 A qualitative research study in South Sulawesi found that IPC was being practiced in the management of nutrition problems.3 Other studies have identified the factors influencing IPC in East Java and East Nusa Tenggara.4,5 The purpose of this study is to use a phenomenologic design to evaluate healthcare professionals' experience with IPC and to answer the research question: What are the processes for, barriers to, and expectations of IPC in family health services? The family health program in Indonesia's primary healthcare is an essential program of the public health center that has been supported since 2016 by the policy of the Minister of Health to improve health coverage. It uses a cross program and sector collaboration approach; however, it doesn't yet include a collaboration guideline. Method This research uses a descriptive phenomenologic approach. The researcher described the research process to the person in charge of the family health program during an in-person meeting and then, during an online meeting, explained it to members of the family health team who were potential participants at three health centers in East Jakarta. The inclusion criterion for this study was that the health workers (nurses, physicians, midwives) had to have worked as a team for at least 6 months. The person in charge of the family health program recruited potential participants and distributed the G form link. The researcher had created the G form, which contained an explanation of the research process and a section for willingness or unwillingness to participate. When a potential participant voluntarily agreed to participate, a researcher contacted them via WhatsApp and asked about an appropriate time and method for the interview. A researcher conducted semi-structured in-depth interviews via video call, using guidelines that focused on the processes, barriers, and expectations of collaborative practice (See Table 1). Almost all of the interviews took place in the participants' offices; a few took place in their homes. The interviews lasted for 34 to 100 minutes; they were recorded and stored on a laptop. Table 1: - Interview questions General question: Could you tell us about the team's experiences in interprofessional collaboration in implementing the family health program? Specific questions: How did the team carry out interprofessional collaboration? How was the process? What were the barriers? What were your hopes for the continuation of the collaboration process? Researchers used Colaizzi's seven stages for data analysis.6 The data are considered valid because the study was carried out according to the criteria of credibility, dependability, confirmability, and transferability. This study received ethical approval from the Research Ethics Committee, Faculty of Nursing, Universitas Indonesia, number SK-284/UN2.D1.2.1/2020ETHICS. Results Of the 53 potential participants who voluntarily stated a willingness to participate, 35 participants agreed to the time and method of interview via video. The other 18 potential participants didn't state a clear time to be interviewed. Saturation occurred with the 22nd participant. These 22 participants consisted of 5 nurses, 11 physicians, and 6 midwives, all 27 to 35 years old, with team experience ranging from 1 to 5 years (see Table 2). Through these interviews, researchers found four themes that describe the experiences of the healthcare workers using IPC. Table 2: - Demographics data for participants (N = 22) Characteristics Categories Frequency Percentage (%) Profession Doctor 11 50 Nurse 5 22.7 Midwife 6 27.3 Total 22 100 Sex Female 20 90.9 Male 2 0.1 Total 22 100 Age (years) <30 10 45.5 ≥ 30 12 54.5 Mean/Total Mean = 29.6 22 100 Experience (years) < 6 22 100 ≥ 6 0 0 Mean/Total Mean = 3.8 22 100 Theme 1: Perception of collaboration The participants associated collaboration mostly with activities in which they worked together. Some participants emphasized responsibility carried out according to the duties, roles, and functions of each profession; others focused on helping each other complete team tasks. Four participants indicated that tasks were completed by a competent professional with appropriate responsibility. Five participants perceived that collaboration meant duties were carried out together to achieve the objectives of these projects. Participant statements included: “...according to our respective tasks... I [a doctor] do the anamnesis and inquiry... nurses do physical examination; midwives perform other assessment if there is a pregnant woman.” (P.9) “Teamwork...the nurse...has the role of...physical examination; ...midwives...are very needed...so that pregnant women...everyone is healthy...until the time to give birth; ... physicians also have the roles [of]...prescribing medicine...[and] establishing [a] diagnosis...everyone has their own role but are interrelated and [indeed] need and complement each other.” (P.19) “We work as a team... work together...I involve all, so everyone participates in the activity.” (P.13) Therefore, collaboration is perceived as two or more different processes aimed at completing team tasks. Theme 2: Teamwork mechanism Most participants mentioned that teamwork was implemented through a series of coordinated activities that not only involved the health team and the health center leader, but also community leaders, informal health workers, and families. Participant 13 said: “Coordinating with the head of the health center, with my team ... with other health center [village level] ... coordinating with the sub-district health center because ... they are the ones I have to report every month...cross-sectoral coordination... to informal community leaders, informal care workers.” These coordinated activities included task orientation, program socialization, preparation, data collection, initial interventions, dissemination of data collection results, follow-up interventions, evaluation, and dissemination of implementation and evaluation results. Each stage reflected coordination and communication among teams and with related programs and sectors. Personal perceptions and the health center system were found to be barriers to teamwork. Theme 3: Internal and external barriers Some participants noted that selfishness was the major internal barrier, whereas limited support was said to be the major external barrier to working as a team. Selfish behavior was shown in several ways: not communicating, not handling input well, reluctance to help with the main task, and individualism. Participants described this behavior as: “...not being open to talk about, from their attitude...not being open or not talking... Their attitude is unpleasant ...” (P.9) “The kind of attitude are the most stubborn, egoist ...” (P.13) “... he/she didn't want to go down [carrying out home visit or health services outside the building]... For various reasons it is not going down” (P.19) “Big egos. Even though we work as a team...stubborn...and individualist.” (P.20) These characteristics contributed to a negative view of IPC. Misperceptions of the program and limited health personnel were the major causes of a lack of support from the health center system. Participants mentioned that other health personnel didn't think that family services were mandatory for the health center. Participants also said that if a team manages one program, this makes the workload fall disproportionately to the health workers in other programs. Specific comments included: “Because the tasks are different...the team...like, one task can be done by many people.” (P.10) “Many people don't know about it (family health program) ...they only know that we just go down the field and collect data...not familiar with our roles.” (P.21) “They (other health workers) think that our program (family health) is not an essential program for the health center...” (P.9) “...family health program is a program of the Head of Department...the assumption is that when a Head of Department changes, the regulation will also change...” (P.21) Members of the team were also given additional tasks in both individual and community services. These additional tasks prevented the team from performing their main tasks, as stated by the participants: “... (It) disturbed because ... double job... not purely [doing one main job] ... I [am] responsible to [the] community program and health promotion too...” (P.13) “Limited human resources...while there are lots of programs ...lots of activities... it's written in the decree as family health team [tasks], but in reality, it's not like that...” (P.20) “What the health center lacks of [health staff] ...we can't promise [that we can do] home visits.” (P1) “...sometimes there's a shortage of staff to do indoor activities...so those who went down [to] the field [weren't] a complete [team]...” (P.10) These barriers to IPC implementation prompted questions about its sustainability. How can teams become dynamic and tough? What can teams do to make themselves stronger? How should this program be integrated and socialized? Theme 4: Expectations for a dynamic and tough team, team strengthening, and program integration and socialization Participants mentioned that a dynamic and tough team was needed to sustain IPC in family services because they faced challenges related to the personal characteristics of team members and having so many different client needs. Many participants mentioned that the team required each member to be strong mentally and physically, handle various needs, and respond quickly to meet patients' needs. Participants said: “We really have to back each other up, keep [each] other mentally and physically strong.” (P.18) “We have to handle [many needs]...similar to [an] octopus [with many] tentacles, it can do anything.” (P.19) The team's ability to deal with these demands can be fostered by providing training and education to build various skills, so the team can become stronger and more resilient. These requirements also highlighted the need for self-development to strengthen the team's capacity. Some participants mentioned that training was needed for self-development, both in the context of clinical skills and teamwork skills: “Training about teamwork or leadership...seems necessary to improve our skills...” (P.19) “.. training for skills...in the field...we have to rack our brains. We really want to...have our own ... tools...” (P.21) Team members' experience of IPC along with their additional assignments generated expectations related to program management in the form of program integration and socialization. The purpose of the family service team is that the family is the smallest unit in society and public health services should include family health. Participants expected that there would be program integration in terms of data and management. Some participants said that data from the families became necessary for all programs, which would require integration of the data collection and utilization system. Participants also hoped that management of the public health service would be integrated with family services, along with the integration of teams and activities. They stated: “By collecting data...it can be useful for other health programs...between the data and the existing programs should be connected.” (P.10) “...the data should have been integrated from the health center database for all program chief[s]......[I] want everyone to know too...” (P1) “We can collaborate on almost all activities...almost all public health programs have family program member[s] who go down...also helping the health center performing outdoors activities...” (P.13) “Public health programs really need the family health team. Because the family health team has the data...” (P.10) Integration doesn't mean fusing into one but getting to know one another and supporting each other to help achieve the goals of the institution. This requires program socialization, as mentioned by the participants: “Socialization about the program...to the health center staff...should be increased...with one specific name that people know.” (P.9) “... [increase] socialization that we are truly official, staff from the health center...” (P4) Getting to know each other promotes mutual respect and has an impact on the strength of the organization as a program entity. Discussion Exploring experience of IPC practices in family services at the three health centers in East Jakarta resulted in interrelated themes. Perception of collaboration. The nurses, physicians, and midwives who participated in this study perceived IPC as a process of cooperation to complete team tasks. Coordination is used if the professional authority says that it's needed. IPC is used with the terms “multidisciplinary and interdisciplinary.”7 In a multidisciplinary approach to patient care, practitioners and nurses each carried out specific tasks to provide comprehensive services; in an interdisciplinary approach, practitioners and nurses worked together to provide effective care.7 Results of a literature review indicated that cooperation is relevant to an interdisciplinary approach. Teamwork mechanism. To organize a family health service, the teamwork mechanism involved nine steps: task orientation, program socialization, preparation, data collection, initial interventions, dissemination of data collection results, follow-up interventions, evaluation, and dissemination of implementation and evaluation results. This teamwork process is in line with the mandate of Program Indonesia Sehat Pendekatan Keluarga (PISPK), Family Approach Program, initiated by the Ministry of Health, which includes the following six activities: data collection; creating and managing databases; analyzing the data, formulating interventions, and developing plans; carrying out home visits; carrying out health services inside and outside the building; and implementing an information and reporting system.8 Internal and external barriers. In the practice of teamwork, the challenges for practitioners include the adjustment to collaborative work, which depends on the willingness and commitment of members.9 Selfish attitudes can occur because the healthcare professionals are used to working alone and aren't ready to work together. Being responsible for more than one program can also be a hinderance for collaborative work because additional tasks can prohibit team members from carrying out the main task of providing family services. The root of this problem is that there aren't enough health workers to adequately support the number of programs. Another barrier is the perception that the family services program isn't mandatory, so it's not a priority. Conflicts centered on professional disputes are also obstacles to IPC and usually occur due to a lack of understanding of the role of the profession.10 This is in line with one study that says that IPC requires management support, which includes the number and quality of health workers, as well as regulations.3 Expectations for dynamic and tough teams, team strengthening, and program integration and socialization. The complexity of family and community needs demands that the teams be physically and mentally strong and that they can master skills and adapt to the needs of their environments. When two professions collaborate, support is needed for the negotiation of space, place, and rules.11 The team's expectations illustrate that self-preparation is needed to adapt to teamwork and that this transition involves their families and the community. Collaboration and the complexities of family and community needs also demand that the team master leadership and professional clinical skills. Important factors for successful collaboration are trust, respect, and competence in each profession.12 Factors influencing IPC related to treatment plans were patient, professional, interpersonal, organizational, and external factors.13 The expectations for strengthening teams in this study are in accordance with the identified personal and professional factors.13 Expectations for program integration were fulfilled because the team identified program overlaps. The focus of the teamwork is on family-based services, and Program Indonesia Sehat Pendekatan Keluarga is also carried out with a family approach. It's hoped that program integration can be an alternative to overlapping programs. Expectations for program integration are in accordance with the definition of integrated services from the perspective of policy makers and organized management, which focuses on the alignment of policies and management systems applied at the service level.14 Integrated services have implications for the provider and the profession. For providers, integrated services mean that there needs to be a multidisciplinary system that unifies services for clients, so common treatment goals can be achieved. For the profession, integrated services mean that professionals from different healthcare areas work together to provide services. Misperceptions of other staff members regarding the characteristics of family health services have triggered hopes for socialization of legal aspects of the program. Unfortunately, the program isn't a priority because it's not considered to be essential, and there's less personal responsibility because one program is managed by three professions. To ensure IPC in the public health sector, the different roles must be understood.15 Another important principle of implementing effective IPC is understanding each other's perspectives. The limitation of this study was the unequal number and the discrepancy in educational background of participants, that is, physicians, nurses, and midwives; the experiences as a team of less than 6 years; and the relatively young age of the participants. Implications and conclusion Nurse leaders need to be aware that the effective application of IPC practices must be based on the correct understanding of the role of each discipline, organization of mechanisms and processes, and support for implementation. The process of IPC is perceived as an activity of cooperation, oriented to the completion of tasks. Teamwork is carried out for task completion but doesn't necessarily indicate IPC. The main barriers to IPC are self-interest and limited support. When participating in IPC, team members' expectations included having a dynamic and tough team, developing team members' qualities and skills to build a stronger team, integrating programs, and promoting socialization among the different programs. Creating IPC implementation guidelines can be a solution for improving service practices.