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Addressing power dynamics in interprofessional health care teams

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Abstract

The balance of power among interprofessional healthcare teams influences their effectiveness. In this study, the researcher assessed the factors that influence power dynamics in interprofessional healthcare teams and the approaches they can use to address these dynamics. The study was based on a quantitative analysis of a total of 11 studies. The study’s outcome regarding the factors influencing power dynamics in interprofessional healthcare teams indicates that there are five groups of factors associated with these dynamics: team-related factors (unbalanced allocation of space and time and respect for medical hierarchy), role allocation-related factors (lack of recognition, lack of delineation of duties, lack of confidence in the skills and competencies of others), communication-related factors (nature and tone of communication, receptivity, and responsiveness), trust and respect, and individual-related factors (teamwork skills and positive team attitude). The researcher also noted that the strategies that can be adopted to address the factors associated with power imbalance include a collaborative approach, an open-door policy, direct communication, education and mentoring, and a merit-based approach when assigning leadership roles to team members.

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... A strong facilitator of IPC that was mentioned in the majority of included reviews and across all types of collaboration is co-location. This is not a surprise, as it has often been cited as a key enabler of collaborative work in the literature [65][66][67], by not only facilitating communication but also reducing power imbalances between professionals [68]. ...
... Actually, compliance with the medical hierarchy could result in power imbalances in collaborative teams [72], and lead to non-inclusive decision-making processes, poor communication and coordination issues [73]. Unfortunately, issues related to professional identity are difficult to address because they are often rooted in power struggles [68]. In fact, some authors have attempted to develop and conceptualize an interprofessional identity that could replace the existing identities of each professional group involved in IPC [74,75]. ...
... Thus, efforts could target flexibility and shared leadership between professionals [78]. In the long term, however, the most promising option seems to rely on education, and more particularly on mentoring [68]. ...
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Introduction: Interprofessional collaboration (IPC) is becoming more widespread in primary care due to the increasing complex needs of patients. However, its implementation can be challenging. We aimed to identify barriers and facilitators of IPC in primary care settings. Methods: An overview of reviews was carried out. Nine databases were searched, and two independent reviewers took part in review selection, data extraction and quality assessment. A thematic synthesis was carried out to highlight the main barriers and facilitators, according to the type of IPC and their level of intervention (system, organizational, inter-individual and individual). Results: Twenty-nine reviews were included, classified according to six types of IPC: IPC in primary care (large scope) (n = 11), primary care physician (PCP)-nurse in primary care (n = 2), PCP-specialty care provider (n = 3), PCP-pharmacist (n = 2), PCP-mental health care provider (n = 6), and intersectoral collaboration (n = 5). Most barriers and facilitators were reported at the organizational and inter-individual levels. Main barriers referred to lack of time and training, lack of clear roles, fears relating to professional identity and poor communication. Principal facilitators included tools to improve communication, co-location and recognition of other professionals' skills and contribution. Conclusions: The range of barriers and facilitators highlighted in this overview goes beyond specific local contexts and can prove useful for the development of tools or guidelines for successful implementation of IPC in primary care.
... Enacting implementation strategies without a focus on equity could allow disparities to emerge in both implementation and clinical outcomes (80). Although it is important for clinical champions to be well-networked and hold influence within their organizations, power within organizations can replicate hierarchies or systems of power and privilege reflected in society more broadly (63,81). Perceptions of core clinical champion characteristics, such as trust/respect, communication, and leadership are influenced by socio-cultural positionality, including, but not limited to, race/racism, gender/sexism, and ability/ableism (82). ...
... Power imbalance and hierarchies present in both healthcare teams and organizations can have negative impacts on implementation. Power imbalances that plague healthcare organizations include those related to communication (i.e., receptivity and responsiveness from leadership), trust and respect, as well as role allocation (i.e., lack of recognition or delineation of duties) (81). For clinical champions, imbalances related to communication may impede collaboration and educating peers about the EBP, which may reduce their overall effectiveness. ...
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Background The clinical champion approach is a highly utilized implementation strategy used to mitigate barriers and improve outcomes of implementation efforts. Clinical champions are particularly effective at addressing provider-level barriers and promoting provider-behavior change. Yet, the specific causal pathways that explain how clinical champions impact provider behavior change have not been well-explicated. The current paper applies behavior change models to develop potential causal pathway mechanisms. Methods The proposed mechanisms are informed by previous literature involving clinical champions and empirically supported behavior change models. These models are applied to link specific attributes to different stages of behavior change and barriers for providers. Results Two unique pathway mechanisms were developed, one that explicates how providers develop intention to use EBPs, while the other explicates how providers transition to EBP use and sustainment. Clinical champions may promote intention development through behavioral modeling and peer buy-in. In contrast, champions promote behavioral enactment through skill building and peer mentorship. Conclusion Clinical champions likely play a critical role in reducing provider implementation barriers for providers across various phases of behavior change. The proposed pathways provide potential explanations for how clinical champions promote provider behavior change. Future research should prioritize empirically testing causal pathway mechanisms.
... The composition of the panel was designed to include clinical, administrative, and front-line care delivery and care recipient perspectives. Deliberately recruiting a minority of physicians, equal in number to pharmacists and family caregivers, and fewer than nurses, was intended to mitigate the inherent power differential that can arise in interprofessional activities that include physicians [13]. The intention of having more than one family caregiver was to increase the weight of the family's voice in the deliberation process relative to the clinicians' voice. ...
... Throughout our process, the research team was sensitive to the historical imbalances of academic-participant collaborations [29], hierarchical imbalances arising from combining healthcare professionals and lay persons to the same team, and interprofessional power imbalances deeply ingrained in healthcare systems [13]. Within the UK context our design process might be labelled as 'co-production' of research [30,31], with egalitarian participation and voice being the goal throughout the research design process from beginning (i.e. the research question) to end, we describe our process as collaborative [30], with the role of the stakeholders being two-fold: adding valuable knowledge and skills to the research process, and providing experiential information about the hospice environment in which the study would be implemented and research findings will be used [32]. ...
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... Power dynamics or power disparity are considered to be significant contributing factors. [16] This interpretation holds that bullying arises directly out of the positional dominance/power that traditional hierarchal systems confer. Nurses are sometimes dominated and exploited by senior nurses, physicians, and individuals from other multidisciplinary teams. ...
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Nurses are the backbone of healthcare organizations. However, as frontline workers, nurses are regularly exposed to perilous conditions and workplace harassment, with a few or no avenues to report or seek adequate support. This causes frustration and stress among nurses and can eventually lead to compromised patient care. This also contributes to workplace bullying, which results in a toxic and stressful work environment. This problem is a global health and safety issue due to its highly negative impact on both individuals and organizations. Recent studies indicate that the COVID 19 pandemic has significantly increased incidents of workplace bullying against nurses. Several contributing factors have been highlighted, when considering the underlying causes of workplace bullying against nurses, including power disparity, organizational attributes, and the image of nurses, as portrayed in the media. Because the pandemic has brought the challenge of creating a safe work environment for nurses to the fore, now more than ever, healthcare organizations need to take bold actions to protect nurses. Nursing management needs to implement bullying prevention interventions that provide nurses with a safe work environment. Using empirical and theoretical literature as its basis, this paper aims to discuss workplace bullying against nurses and consider how this problem has been impacted by the COVID 19 pandemic. This paper recommends the application of a Socio Ecological Model (SEM), which provides evidence-based interventions intended to reduce workplace bullying against nurses.
... Nurses are described throughout the literature as historically subordinate to and dominated by doctors (Dyson, 2017;Keddy et al., 1986). This "steep hierarchical gradient" (Green et al., 2017, p. 450) perceives doctors as superior to nurses (Okpala, 2021). In practice, nurses may feel intimidated by doctors and 3 SDG5 seeks to "[a]chieve gender equality and empower all women and girls." ...
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Significant global events in recent years have had a substantial impact on the nursing profession. The COVID‐19 pandemic, climate change, and systemic racism are a few of the many complex issues that create a landscape of disruption and uncertainty in healthcare. With the aims of protecting both people and the planet, the United Nations’ Sustainable Development Goals offer a road map to combat these global concerns, yet require more widespread consideration as a way forward. Education on the Sustainable Development Goals is recognised as a key aspect for healthcare professionals to take action towards achieving the targets of the goals. For student nurses, the undergraduate curriculum offers an opportunity to enculturate future nurses on the important role they play in the global agenda to transform our world. Brazilian pedagogue Paulo Freire's theoretical approach to education, critical pedagogy, espouses transformation with conscientization, dialogue and liberation, which may create a paradigm shift toward global action. This discussion paper seeks to provide an argument for embedding the Sustainable Development Goals into nursing curricula using the philosophies of Freire's critical pedagogy. It will argue that a critical approach to education is required to create the transformation needed for student nurses to be educated on the Sustainable Development Goals.
... It may be more productive to recognize power as something diffuse that shifts as collaborators assert their power by adopting a variety of adversarial and collaborative stances to create alliances around issues of importance to their organizational priorities. Occupational therapy training, research, and practice remain embedded in the hierarchical power structures of the health care system (Green et al., 2017;Okpala, 2020); thus, disability studies-informed CBPR researchers must critically examine their implicit biases and understand how these inform the execution of CBPR. ...
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In order to succeed in today's health care environment, interprofessional teams are essential. The terms "multidisciplinary care" and "interdisciplinary care" have been replaced by the more contemporary term "interprofessional practice and education" (IPE), which occurs when individuals "from two or more professions learn about, from and with each other to enable effective collaboration and improve health outcomes." This commentary discusses new models of care, team members who contribute to IPE, and incentives and challenges. ©2016 by the North Carolina Institute of Medicine and The Duke Endowment. All rights reserved.
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To identify facilitators and barriers influencing collaboration and teamwork between general practitioners and nurses working in general (family) practice. Internationally, a shortage of doctors entering and remaining in general practice and an increasing burden of chronic disease has diversified the nurse's role in this setting. Despite a well-established general practice nursing workforce, little attention has been paid to the ways doctors and nurses collaborate in this setting. Integrative literature review. CINAHL, Scopus, Web of Life, Cochrane Library, Joanna Briggs Institute Library of Systematic Reviews and Trove (dissertation and theses) were searched for papers published between 2000 and May 2014. This review was informed by the approach of Whittemore and Knafl (2005). All included papers were assessed for methodological quality. Findings were extracted, critically examined and grouped into themes. Eleven papers met the inclusion criteria. Thematic analysis revealed three themes common to the facilitators of and barriers to collaboration and teamwork between GPs in general practice: (1) roles and responsibilities; (2) respect, trust and communication; and (3) hierarchy, education and liability. This integrative review has provided insight into issues around role definition, communication and organizational constraints which influence the way nurses and general practitioners collaborate in a team environment. Future research should investigate in more detail the ways doctors and nurses work together in general practice and the impact of collaboration on nursing leadership and staff retention. © 2015 John Wiley & Sons Ltd.
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Background: There is emerging consensus that enhanced inter-professional teamwork is necessary for the effective and efficient delivery of primary care, but there is less practical information specific to primary care available to guide practices on how to better work as teams. Objective: The purpose of this study was to describe how primary care practices have overcome challenges to providing team-based primary care and the implications for care delivery and policy. Approach: Practices for this qualitative study were selected from those recognized as patient-centered medical homes (PCMHs) via the most recent National Committee for Quality Assurance PCMH tool, which included a domain on practice teamwork. Participants: Sixty-three respondents, ranging from physicians to front-desk staff, were interviewed from May through December of 2013. Practice respondents came from 27 primary care practices ranging in size, type, geography, and population served. Key results: Practices emphasizing teamwork overcame common challenges through the incremental delegation of non-clinical tasks away from physicians. The roles of medical assistants and nurses are expanding to include template-guided information collection from patients prior to the physician office visit as well as many other tasks. The inclusion of staff input in care workflow redesign and the use of data to demonstrate how team care process changes improved patient care were helpful in gaining staff buy-in. Team "huddles" guided by pre-visit planning were reported to assist in role delegation, consistency of information collected from patients, and structured communication among team members. Nurse care managers were found to be important team members in working with patients and their physicians on care plan design and execution. Most practices had not participated in formal teamwork training, but respondents expressed a desire for training for key team members, particularly if they could access it on-site (e.g., via practice coaches or the Internet). Conclusions: Participants who adopted new forms of delegation and care processes using teamwork approaches, and who were supported with resources, system support, and data feedback, reported improved provider satisfaction and productivity. There appears to be a need for more on-site teamwork training.
Article
AimThis study explores the current state of collaboration and communication between nurses and general practitioners in nursing homes, as well as needs and expectations of nursing home residents and their families. Finally, we aim to develop a new model of collaboration and communication.Background Rising numbers of residents in nursing homes present a challenge for general practice and nursing in most Western countries. In Germany, general practitioners visit their patients in nursing homes, where nurses work in shifts. This leads to a big variety of contacts with regard to persons involved and ways of communication.DesignQualitative multicentre study.Methods Study part 1 explores needs and problems in interprofessional collaboration in interviews with nursing home residents and their relatives, general practitioners and nurses. Simultaneously, general practitioners' visits in nursing homes are observed directly. In study part 2, general practitioners and nurses will discuss findings from study part 1 in focus groups, aiming to develop strategies for the improvement of shortcomings in a participatory way. Based on the results, experts will contribute to the emerging model of collaboration and communication in a multi-professional workshop. Finally, this model will be tested in a small feasibility study. The German Federal Ministry of Education and Research approved funding in March 2011.DiscussionThe study is expected to uncover deficits and opportunities in interprofessional collaboration in nursing homes. It provides deeper understanding of the concepts of all involved person groups and adds important clues for the interaction between professionals and older people in this setting.
Article
Abstract Increased emphasis on team care has accelerated interprofessional education (IPE) of health professionals. The health mentors program (HMP) is a required, longitudinal, interprofessional curriculum for all matriculating students from medicine, nursing, occupational therapy, physical therapy, pharmacy, and couple and family therapy. Volunteer lay health mentors serve as educators. Student teams complete four modules over 2 years. A mixed-methods approach has been employed since program inception, evaluating 2911 students enrolled in HMP from 2007 to 2013. Program impact on 577 students enrolled from 2009-2011 is reported. Two interprofessional scales were employed to measure attitudes toward IPE and attitudes toward interprofessional practice. Focus groups and reflection papers provide qualitative data. Students enter professional training with very positive attitudes toward IPE, which are maintained over 2 years. Students demonstrated significantly improved attitudes toward team care, which were not different across programs. Qualitative data suggested limited tolerance for logistic challenges posed by IPE, but strongly support that students achieved the major program goals of understanding the roles of colleagues and understanding the perspective of patients. Ongoing longitudinal evaluation will further elucidate the impact on future practice and patient outcomes.
Article
Abstract Interprofessional teamwork has become an integral feature of healthcare delivery in a wide range of conditions and services in many countries. Many assumptions are made in healthcare literature and policy about how interprofessional teams function and about the outcomes of interprofessional teamwork. Realist synthesis is an approach to reviewing research evidence on complex interventions which seeks to explore these assumptions. It does this by unpacking the mechanisms of an intervention, exploring the contexts which trigger or deactivate them and connecting these contexts and mechanisms to their subsequent outcomes. This is the second in a series of four papers reporting a realist synthesis of interprofessional teamworking. The paper discusses four of the 13 mechanisms identified in the synthesis: collaboration and coordination; pooling of resources; individual learning; and role blurring. These mechanisms together capture the day-to-day functioning of teams and the dependence of that on members' understanding each others' skills and knowledge and learning from them. This synthesis found empirical evidence to support all four mechanisms, which tentatively suggests that collaboration, pooling, learning, and role blurring are all underlying processes of interprofessional teamwork. However, the supporting evidence for individual learning was relatively weak, therefore there may be assumptions made about learning within healthcare literature and policy that are not founded upon strong empirical evidence. There is a need for more robust research on individual learning to further understand its relationship with interprofessional teamworking in healthcare.
Article
This study aims to describe how senior nursing students viewed the clinical learning environment and matured their professional identity through interprofessional learning in a student-led hospital 'ward'. Undergraduate nursing and medical student teams participated in a trial of ward-based interprofessional clinical learning, managing patients over 2weeks in a rehabilitation ward. Qualitative and quantitative program evaluation was conducted using exit student focus groups and a satisfaction survey. Twenty-three nursing and medical students in three placement rounds provided positive feedback. Five main themes emerged describing their engagement in 'trying on' a professional role: 'experiencing independence and autonomy'; 'seeing clearly what nursing's all about'; 'altered images of other professions'; 'ways of communicating and collaborating' and 'becoming a functioning team'. Ward-based interprofessional clinical placements offer senior students authentic ideal clinical experiences. We consider this essential learning for future interprofessional collaboration which should be included in senior nursing students' education.
Article
AimTo investigate health care improvement team coaching activities from the perspectives of coachees, coaches and unit leaders in two national improvement collaboratives. Background Despite numerous methods to improve health care, inconsistencies in success have been attributed to factors that include unengaged staff, absence of supportive improvement resources and organisational inertia. Methods Mixed methods sequential exploratory study design, including quantitative and qualitative data from interprofessional improvement teams who received team coaching. The coachees (n=382), coaches (n=9) and leaders (n=30) completed three different data collection tools identifying coaching actions perceived to support improvement activities. ResultsCoachees, coaches and unit leaders in both collaboratives reported generally positive perceptions about team coaching. Four categories of coaching actions were perceived to support improvement work: context, relationships, helping and technical support. Conclusions All participants agreed that regardless of who the coach is, emphasis should include the four categories of team coaching actions. Implications for nursing managementLeaders should reflect on their efforts to support improvement teams and consider the four categories of team coaching actions. A structured team coaching model that offers needed encouragement to keep the team energized, seems to support health care improvement.
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The healthcare system is plagued with increasing cost and poor quality outcomes. A major contributing factor for these issues is that outdated leadership practices, such as leader-centricity, linear thinking, and poor readiness for innovation, are being used in healthcare organizations. Complexity leadership theory provides a new framework with which healthcare leaders may practice leadership. Complexity leadership theory conceptualizes leadership as a continual process that stems from collaboration, complex systems thinking, and innovation mindsets. Compared to transactional and transformational leadership concepts, complexity leadership practices hold promise to improve cost and quality in health care.
Article
Since the publication of its reports, Health professions education: A bridge to quality (2003) and To err is human: Building a safer health system (2000), the Institute of Medicine has continued to emphasize interprofessional education (IPE), founded on quality improvement and informatics, as a better way to prepare healthcare professionals for practice. As this trend continues, healthcare education will need to implement administrative and educational processes that encourage different professions to collaborate and share resources. With greater numbers of students enrolled in health professional programs, combined with ethical imperatives for learning and reduced access to quality clinical experiences, medical and nursing education increasingly rely on simulation education to implement interdisciplinary patient safety initiatives. In this article, the authors describe one approach, based on the Core Competencies for Interprofessional Collaborative Practice released by the Interprofessional Education Collaborative (2011) • Interprofessional Education Collaborative Expert Panel Core competencies for interprofessional collaborative practice. Interprofessional Education Collaborative, Washington, DC 2011 • Google Scholar , toward providing IPE to an audience of diverse healthcare professionals in academia and clinical practice. This approach combines professional standards with the authors’ practical experience serving on a key operations committee, comprising members from a school of medicine, a school of nursing, and a large healthcare system, to design and implement a new state-of-the-art simulation center and its IPE-centered curriculum.
Article
Interprofessional practice implies that health professionals are able to contribute patient care in a collaborative environment. In this paper, it is argued that in a hospital the nurses' station is a form of symbolic power. The term could be reframed as a "health team hub," which fosters a place for communication and interprofessional working. Studies have found that design of the Nurses' Station can impact on the walking distance of hospital staff, privacy for patients and staff, jeopardize patient confidentiality and access to resources. However, no studies have explored the implications of nurses' station design on interprofessional practice. A multi-site collective case study of three rural hospitals in South Australia explored the collaborative working culture of each hospital. Of the cultural concepts being studied, the physical design of nurses' stations and the general physical environment were found to have a major influence on an effective collaborative practice. Communication barriers were related to poor design, lack of space, frequent interruptions and a lack of privacy; the name "nurses' station" denotes the space as the primary domain of nurses rather than a workspace for the healthcare team. Immersive work spaces could encourage all members of the healthcare team to communicate more readily with one another to promote interprofessional collaboration.