As illustrated in Figure 8, four primary sub-themes related to enablers of IPW emerged from the qualitative data. These were effective communication; established teams; IPPL for qualified professions, and shared processes and policies. As secondary sub-themes of effective communication, a further four enablers emerged: planned communication, unplanned communication, proximity,
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Enablers of IPW
Effective Communication
and electronic communication. The remainder of this section explains each of these themes.
Effective communication
Effective communication was one of the commonest enablers mentioned in the interviews, with twenty participants highlighting a range of different factors which they perceived enabled effective communication. As this was such a large primary sub-theme, it was sub-divided into a further four secondary sub-themes: planned communication, unplanned communication, proximity, and electronic communication.
Figure 8. Thematic map of the enablers of IPW
Established Teams
IPPL for Qualified Professions Shared Processes and Policies Proximity Planned Communication Electronic Communication Unplanned Communication
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Planned communication
Regular planned meetings such as multidisciplinary meetings, safety debriefings and structured short meetings which occurred on a regular basis, were highlighted in 13 of the interviews as an enabler of IPW. These were perceived as being of particular value where multiple professions came together on a regular basis to discuss and review plans of care following input from different professions. For many participants, these meetings were a reminder of their shared goal of delivering effective care and the value of having input from different professions:
“I think the most important thing I see in them [the multi-disciplinary team meetings] is, ‘look we are all in this together, look there is a potential problem here, c’mon, let's get a wee grip, let's get talking about now’… we can all try our best to control it [the potential problem].” (Adult Nurse, community, interview 12)
One social worker discussed the value of structured formal meetings in maintaining communication between different professions and also as a means of preventing issues from occurring at a later stage which could be attributed to lack of communication. However, this social worker also perceived that there was the potential for these structured meetings to become devalued and not regularly attended, as other work priorities took precedence:
“I think they are worthwhile, I’m a big fan of them. They seem to bear a lot of fruit, so, but it is a kind of work that is, it could fall into the category of preventative, prophylactic type work that it’s the kind of stuff that prevents other stuff going on but often goes on the wayside if you have got a lot of other things on and then you don’t have time for that.” (Social Worker, local authority, interview 22)
Unplanned communication
Whereas planned communication was perceived as an enabler of IPW, for the ability to maintain structured lines of communication between professions, informal and ad hoc instances of communication also emerged as a common theme within the interviews. Fourteen health care and social work professionals highlighted that unplanned communication was as an enabler of IPW. Furthermore, where planned
109 and unplanned communication occurred, these were viewed as complementary to each other. The sub-theme of unplanned communication seemed to be quite closely linked to the secondary sub-theme of proximity. Some of the participants pointed out that opportunistic discussions and informal referrals often occurred “in the passing” in the corridor, during breaks in the staff room, or a brief conversation over the telephone:
“We do have informal information from the OTs as well, just kind of ad hoc, they’ll phone up and say ‘So and so came down, they managed to do so and so…’ Yeah, that works as well.” (Mental Health Nurse, community, interview 10)
Proximity
Close proximity between professions was a recurrent theme, with just over half of the participants, mainly from the community setting, highlighting that close physical proximity to other professions enabled IPW. Phrases such “around the corner”, “just along the corridor” or “just up the stairs” defined this as a short distance between professions, either in the same building or within the same department. As previously discussed, proximity seemed to further encourage unplanned communication between professions:
“It literally is, just upstairs and they’ll come down and speak to us about patients too, if there is someone I have been in with and I am just a bit worried about, I tend to pop in just to check and I can go and speak to them about that...” (GP, community, interview 2)
With close proximity, there seemed to be a sense that professions felt that others were more approachable, and as a result, were more likely to engage in unplanned and ad hoc conversations:
“They’ve [nurses] got to know me and hopefully they feel that they can approach me because we know each other quite well, that does help.” (Consultant, community, interview 1)
Although the theme of proximity seemed to be more evident within the interviews undertaken within the community setting, proximity was also perceived as an enabler
110 to IPW where professions highlighted that they worked in close proximity within the acute setting,
“I think geography has a lot to do with it. I think if we were a team that had their main base somewhere else in the hospital, just came in, saw patients and went away, we wouldn’t have the same level of multidisciplinary working.” (Physiotherapist, acute, interview 16)
Working in close proximity to different professions was also perceived to affect professional relationships and their identity as a team. For some, this proximity was more than just coming in and out of each other’s space; there was sense that the team were more readily available to help each other and took a shared approach to troubleshooting problems as they arose:
“It’s a much closer working relationship, so when you come along and say ‘I’ve got a real problem, I need your help now’, I say, ‘Ok, what is it we need to do’?... you work together and you can solve problems together.” (GP, community, interview 3)
Shared working spaces and social spaces such as open plan offices and staff rooms were perceived as an enabler of IPW. Many participants stated that the opportunity to share a staff room with their colleagues from other professions provided a social area to chat informally and to informally discuss work issues. These shared spaces seemed to encourage positive interprofessional working relationships:
“Just from a social point of view, everyone gets together in the coffee room, we all meet and we discuss things…we’ll often discuss cases over coffee with people we are not quite sure what to do with.” (GP, community, interview 2) Although IPW was perceived to be enabled within the closer proximity of an open plan office, shared by more than one profession, as highlighted by one social worker and one district nurse, there were also challenges related to working in such close proximity in an open plan area. Noise levels were felt to impact on work and concentration levels, and overhearing other professions conversations were distracting. However, as illustrated in the following two quotes, these negative points seemed to be outweighed by the value of being able to get to know other members
111 of the team on a more personal level, and as an opportunity to answer queries more quickly than if professions were located in different departments:
“We are now in open plan which with it brings all its issues, but in reality, what has been good and I can see what has been good about that is, that I now know who the criminal justice workers look like. I know what they look…and for that we are becoming real people to each other….it comes down to person, being a person first and then being a professional second or you know if somebody has a baby or somebody has a grandchild.” (Social worker, local authority, interview 21)
“And you know, you just hear things and you think, ‘Oh I know that.’ That sort of thing happens, you know, quite quickly.” (Occupational therapist, community, interview 13)
Electronic communication
Electronic communication included systems such as email, online referral systems and electronic records which were used to document any information related to care provided to service users. In all of the interviews, participants pointed out that these systems were increasingly used in health and social care. For some of the participants, they were perceived as enabling effective communication, particularly within the community setting. Electronic records were maintained for service users which could be then accessed by other professions. It seemed to be perceived as an effective means of keeping other professions updated on any changes or interventions in treatment or care:
“It’s actually much better if we put an [electronic record] entry in and we will certainly do that now if we are taking a sample that the GPs haven’t asked us for.” (District Nurse, community, interview 5)
This system was also seen as an effective way of alerting colleagues to non-urgent issues and was sometimes viewed as a more effective alternative to email communication. This was found to be particularly effective where colleagues needed to be contacted during a clinic. An instant messaging facility was perceived as a quicker and more direct way to get the information to their colleague, allowing their colleague to respond at a convenient time:
112 “If they [GPs] are busy with patients we’ll put it on their computer as a triage of what we’re wanting them to do and what we’re wanting them to say and then quite often they, if they’ve seen that, they’ll come through and seek us out and speak to us.” (District Nurse, community, interview 7)
Emails were highlighted as an effective way of communicating non-urgent information to other professions, such as non-urgent referrals between professions in health care, and between professions from health care and social work. It was also identified as a way of updating other professions within the same department and particularly to ensure that communication was maintained in the instance of a colleague’s absence from a face to face meeting.
“Sometimes for different reasons, one or two members may not be able to attend, they are still involved closely with patient care and they will still be kept up to speed with meeting notes…They [other health care professionals] are very diligent to make sure that the team is aware of what they are wanting to add. He [the chair of the meeting] will give an update by email.” (Learning Disabilities Nurse, acute, interview 14)
Established teams
In 13 of the interviews, it was identified that teams of mixed professions had worked together for a long period of time. The terms “established teams” and “strong teams” were used frequently during these interviews. Particularly within the community setting, it was noted by participants that established teams had good knowledge of their service users. This was felt to be invaluable for providing effective care, and for ensuring continuity in care delivery, where input from multiple professions was required. As evidenced by the following quote, this knowledge was also useful when conflict within the team was sometimes apparent. There was a sense that this conflict was more tolerable and accepted within teams that identified themselves as being well established:
“They work out how your character works, you work out how their character works. You realise where there can be areas of conflict. You know how to steer around those areas of conflict…..” (GP, community, interview 3)
113 With established teams, came awareness and understanding of roles and responsibilities, appreciation and mutual respect of each other. Participants provided examples of their colleagues from other professions knocking on their door to seek advice or to get a second opinion. This was particularly evident with established teams within the community settings:
“All the GPs would come to us [the District Nurses] and ask for advice or what could we do and how quickly we could do it or what [would we] suggest or what if they feel any areas that they are not comfortable in that they know any of us have got any expertise in…we honestly do have total professional respect for each other and it’s both ways.” (District Nurse, community, interview 6)
Two participants discussed actively ensuring that roles and responsibilities were clear. Within these interviews, there were interesting contrasting reasons for why conscious efforts were made to ensure this understanding. As discussed by one participant who worked within a mental health setting, there was sense that roles and responsibilities were made explicit to ensure the safety of staff and service users, and in particular, new members of staff working within a specialised area:
“Me personally, I think there’s clear understanding and if we have a new member of staff on the ward and they weren’t sure what somebody’s role was, there would always be one of the other nurses that would be able to explain what the role of the person is. I think it’s probably the type of patients that we have, being a forensic setting, we do make sure that everybody is aware of each other’s roles.” (Mental Health Nurse, community, interview 11)
In contrast, for the other participant, working within the context of obstetrics in an acute setting, there was a perceived need for a clear delineation of the roles and responsibilities of midwives. This participant highlighted that this strategy ensured protection of their workload and prevented some of the doctors “offloading” some of their responsibilities on to midwives.
Interprofessional practice learning for qualified professions
Seven participants emphasised that being involved in joint training with other professions enabled IPW. Those that worked within community settings referred to protected learning time; that is, ring fenced, in-service time for professions to attend
114 staff training sessions. Joint training was valued as a way improving interprofessional working relationships because it helped with developing an awareness of roles and responsibilities. In the main, such training activities appeared to be interprofessional in their delivery, as informal group discussions and “the conflab” which was described, implied interaction during their learning. This opportunity for informal discussion was felt to be of particular value:
“You will get professionals, you know, with a degree of humour, slagging each other off and then being actually able the say ‘well, the psychologist did that because x, y and z’, so being able to get together in a less formal environment and talk about the different roles do is really very helpful… it just felt like a really nice environment to demystify what each other did without any particular sensitivities and because we were from different areas as well.” (Clinical Psychologist, acute and community, interview 18)
This training was also felt to contribute to enable ongoing IPW after the event, as described by the following quotes from two participants working with the community setting and the local authority. These participants utilised the training sessions to build a network of professions that they felt they would be able to contact in the future if their input was required. This networking was facilitated by the exchange of emails before or after correspondence related to staff training:
“There are occasions where you go to these training and you think, ‘oh that’s that person and oh I will phone them’ … you are no longer just a name on a bit of paper or a person at the end of the phone.” (Social Worker, local authority, interview 21)
“Networking really helps, you know putting a name to a face and actually knowing what they do because we all work in our own little silos and until you actually need somebody, you don’t know what you need them for, you don’t know what’s there.” (Health Visitor, community, interview 8)
Shared processes and policies
This theme was related to systems and policies shared by different professions within health care and also between health care and social work, and was highlighted as an enabler of IPW on six of the interviews. The Getting It Right for
115 Every Child (GIRFEC) national framework for the implementation of the Children and Young People (Scotland) Act (2014), was referred to as an example of a policy which guided health care and social work professionals’ practice in the community, acute and local authority settings. These participants stressed that GIRFEC encouraged a coordinated approach between health, social care and other agencies, such as education and police. In doing so, this shared policy was perceived as making an important contribution to enabling IPW:
“I feel that this breaking down barriers and finding that teachers, social workers, nurses are all doing aspects of the job that are very similar and especially now with GIRFEC we’ve all got very, you know we are all protecting children and you’ve just got slightly different roles in that. The more we communicate and understand each other roles, and we are all using the same paperwork and format now, then that can only be a good thing.” (Health Visitor, community, interview 8)
Other examples of shared processes included shared documentation, information boards used by more than one profession to document key details about service users, and routine multi-disciplinary meetings and safety briefings. These shared processes were viewed as enablers of IPW.