Accreditation as a lever for change in the development of the collaborative practitioner in the Australian health system
Fiona Kent
A E , Lynda Cardiff B , Bronwyn Clark B F , Julie Gustavs C , Brian Jolly D , Josephine Maundu B , Glenys Wilkinson B and Sarah Meiklejohn A *
A
B
C
D
E
F
Abstract
Patient expectations in the Australian healthcare system are for coordinated, collaborative practice. There is a need for education institutions, health services, accreditation authorities, and consumers to work together to achieve this goal. As part of a larger body of work, we sought to understand how these stakeholders contribute to the development of collaborative healthcare practice.
Nineteen focus groups were conducted in 2022 with 84 participants consisting of education providers (n = 62), consumers (n = 10), representatives from the Health Profession’s Education Standing Group (n = 8), and health service practitioners (n = 4). Framework analysis was initially undertaken to understand facilitators of, and barriers to, collaborative practice and learning. In a secondary analysis, the themes were re-organised according to the Bolman and Deal domains of organisational practice, to make explicit the structural, human resource, political, and symbolic factors deemed useful for re-imaging a process for learning about and incentivising collaborative practice.
There are multiple factors across healthcare settings that both facilitate and challenge the development of collaborative practice. Co-location of professions and participation in formal interprofessional processes such as team meetings and handovers facilitated learning collaborative practice, although traditional cultures which perpetuate siloed models of healthcare, power differentials between the professions, funding structures, and information sharing limited opportunities. The ‘value’ of collaborative practice was facilitated through both consistent curriculum messages throughout health professional courses and positive role modelling.
Education institutions, health service practitioners, accreditation authorities, and consumers can work together to facilitate the development of collaborative practice through attention to policy and processes, curriculum activities, student participation, health service activities and practice, and resource allocation.
Keywords: accreditation, collaborative practice, education providers, health professions education, health service, interprofessional education, interprofessional learning, workplace learning.
Introduction
Since 2010, the World Health Organization and others have advocated for integration of health and education sectors to achieve development of collaborative and comprehensive patient-centred practice.1,2 Interprofessional collaborative practice has been described as ‘when multiple health workers from different professional backgrounds work together with patients, families, carers and communities to deliver the highest quality of care’.2 Some progress has been made toward this goal in Australia with the recent development of an Interprofessional Collaborative Practice Statement of Intent by the Australian Health Practitioner Regulation Agency.3 This statement has extended earlier work in two important ways: first to emphasise the importance in addressing racism and discrimination in workplaces, and second to include patients as an integral and active member of the interprofessional team.4 Other important foundational work in Australia included the Securing an Interprofessional Future project which emphasised the importance of system leadership and advice, collective standards, support for education providers, and development and dissemination of knowledge.5
Despite these advances, stakeholders report ongoing challenges implementing interprofessional learning opportunities. Skilled collaborative practitioners demonstrate open communication, understanding of other health professional roles, team working, and mutual trust and respect.6 However, the Australian healthcare system is large, diverse, and complex, so enactment (and learning) of collaborative practice across all settings is influenced by a combination of structures and processes, politics, people, and values.7,8 One key challenge has been a lack of a national framework for interprofessional education (IPE), without which education providers have innovated within their individual institutions, resulting in much variation.4 The authors call for a reform of Australian standards, echoed by researchers internationally who have called for accreditation authorities to set standards for interprofessional learning.9,10
Objective
Using Bolman and Deal’s frames,11 we sought to explore systemic and organisational factors that contribute to the development of collaborative practice, to inform future work of education providers, accreditation authorities, and health services. This study was positioned within a larger body of research which explored the role of accreditation authorities in developing collaborative practice.12
Setting
Health professional education straddles both universities and health services and is provided across settings, including public, private, and the community. This research focuses on learning at the pre-registration level, where higher education and accreditation authorities can influence the curriculum. University-based IPE, although important, was not the focus of the study which sought to further understand opportunities and challenges in the workplace. Postgraduate and continuing professional development learning opportunities, although equally important in the learning trajectory toward collaborative practice, were deemed beyond the scope of this research.
Methods
Study design
A constructivist qualitative research design was selected to value the perspective of multiple stakeholders invested in development of interprofessional collaborative practice-ready graduates. Constructivism acknowledges there may be multiple and at times conflicting realities.13 Focus groups were selected as the preferred method for gathering perspectives from a range of stakeholders through interaction and dialogue.14
The research questions asked:
Participants and recruitment
Recruitment methods differed for each stakeholder group: education providers via accreditation authorities, consumers via the Consumers Health Forum and Health Care Consumers Australia, and currently practising practitioners via professional organisations, state government health service leaders, and stakeholder networks. Eligibility criteria were developed for each stakeholder group. Health profession education providers were recruited across the breadth of health professions represented in Australia. Consumers were recruited from national consumer advocacy groups who are trained and positioned to provide opinions from the broader perspective of Australian consumers. Potential participants submitted an online expression of interest form, after which explanatory statements and consent forms were distributed. Eligibility criteria, demographic data, and preferred focus group session times and dates were embedded within expression of interest forms.
Data collection
Semi-structured focus groups were conducted over Zoom by four members of the research team (FK, LC, JG, JM) in 2022. Focus groups were conducted separately with each stakeholder group to tailor language. Where possible, education providers were grouped according to their health profession (e.g. medicine). Focus groups commenced with a description of research aims and questions, introduction to a shared definition of collaborative practice, followed by semi-structured questions. Audio recordings were transcribed verbatim using a transcription service and corrected, included from one to eight participants, and ranged in length from 45 to 105 min. Last minute changes to practitioner availability reduced the number of participants to one on two occasions due to their busy health service roles.
Data analysis
Framework analysis was undertaken in the stages described by Ritchie and Spencer.15 Familiarisation was undertaken first, whereby the entire research team read and inductively coded three diverse transcripts and then met to determine the approach to coding. The first research question was inductively coded for any factors that may contribute to the development of collaborative practice; the second research question was initially deductively coded using the domains suggested by the Canadian Interprofessional Health Education Accreditation Standards Guide to focus on the domains available for consideration by accreditation authorities.16 Indexing was then undertaken by one researcher (SM), who coded all transcripts using Nvivo® software, with frequent meetings with the research team. Charting, mapping, and modification of themes and domains was undertaken by the research team through the duration of analysis. Themes from both questions were organised using Bolman and Deal’s organisational frame to more clearly communicate findings.11
Bolman and Deal propose four domains to systematically analyse the ways in which a complex change can be designed and implemented across organisation functions: structural, human resources, political, and symbolic.11 Structural factors include the roles and responsibilities of key players, the importance of clear organisational structures and governance, policies, tasks and resource allocation, and technology. Human resource factors consider how staff are recruited, engaged, trained, treated, and valued. Political factors recognise finite resources, finances and power to direct ways of working. Symbolic factors focus on organisational culture, customs, and narratives as they give us insight into ‘how we do things around here’ to reimagine a more collaborative health system of the future.11
Research team and reflexivity
The research team hold professional backgrounds in medicine, nutrition and dietetics, pharmacy, physiotherapy, and education. Educational research PhDs are held by SM, BJ, LC, JG, and FK, while BC, BJ, GW, JG, and JM hold professional leadership and accreditation roles. Varied perspectives contributed to the depth of discussion regarding interpretation of data, which contributed to the decision to conduct a secondary analysis using the Bolman and Deal's framework.11
Outcomes
Nineteen focus groups were conducted from October to November 2022 with 84 participants, consisting of education providers (n = 62), consumers (n = 10), representation from Universities Australia drawn from the Health Profession’s Education Standing Group (n = 8), and practitioners (n = 4). Education providers self-identified across 19 health professions, with some representing a health program other than their own professional background. Professions and educational courses represented were: Aboriginal and Torres Strait Islander Health Practice, chiropractic, dental, dietetics, medicine, medicine radiation practice, nursing and midwifery, optometry, osteopathy, occupational therapy, paramedicine, pharmacy, physiotherapy, podiatry, psychology, and speech pathology.
Participants identified factors within healthcare systems that may enable or inhibit fostering learning about collaborative practice. Participants also identified mechanisms through which education providers, accreditors, and healthcare practitioners could collaborate to facilitate development of collaborative practice within health professions program graduates. Multiple levels of influence were described: university or faculty, education program, student engagement, health service, and commitment of resources. Key themes related to each of the research questions, under the domains described by Bolman and Deal, are summarised below.
Structural factors
Co-location of health professionals in clinical, ward, or office settings facilitated collaborative working and opportunities for student learning. Shared meetings, handovers, and interprofessional case management structures also facilitated collaborative working. Opportunities for formal and informal dialogue were deemed useful. Dedicated IPE roles were also proposed as useful to facilitate learning opportunities:
[referencing clinical settings] I’m not sure that we are providing them enough exposure to allied health, pharmacists, physios, and how they actually link into the patient’s journey. (Educator 2)
our students would report of…their collaboration…early morning rounds or…early morning team meetings. Those are probably the ones that they found most useful. (Educator 4)
Accreditation authorities could seek evidence of compliance with accreditation standards which facilitated interprofessional learning opportunities at the structural level, such as co-location of health profession students in clinical settings and participation in collaborative tasks:
there needs to be a shared set of competencies across all health professionals that are recognised as important to provide optimal patient-centered care…. not only the supervisors are incorporating those competencies when they are trying to progress students or mark interns and then accreditation groups are looking for those [also]. (Practitioner 64)
Human resource factors
Lack of human resources was consistently identified as a challenge. Facilitator training was proposed for effective delivery of interprofessional programs, and interprofessional staff socialisation across programs further assisted:
we’ve only got, two dedicated staff across the whole faculty to do this. (Educator 81)
important things like interprofessional education get pushed to the side…without that real leadership of IPE to say this is really important and that continual drive, it does get pushed by the wayside. (Educator 49)
Explicit work-integrated learning education opportunities supported skill development in workplaces, such as shadowing others, attending handovers, or case conferences:
I’ve always encouraged them to spend formal time with each of the disciplines sitting down, finding out what their role is…perhaps sitting in on consultations or going on home visits to look through the lens of…the other practitioner. (Educator 3)
Accreditation authorities could seek evidence of interprofessional learning at the education program level. A curriculum that had been co-designed with consumers was described as a useful facilitator of collaborative practice. Constructive alignment of interprofessional activities to intended learning outcomes, and embedding student activities throughout health programs, including workplace activities, was deemed preferable. Authentic assessment of collaborative practice could further signify the importance of the competencies.
Political factors
Presence of perceived hierarchies within healthcare teams and historical ways of working within professional silos reduced opportunities for learning collaborative practice:
there was a lot of animosity between doctors and pharmacists and nurses and pharmacists. What really helped collaborative practice in that hospital was when they moved to satellite pharmacies and actually put [pharmacists] on wards, that made a profound difference in terms of the ability to collaborate and work in teams. (Educator 28)
Accreditation authorities could contribute to this agenda through seeking evidence of dedicated policies or processes supporting interprofessional learning:
Our structures and our systems don’t enable us to do that. And that’s partly related to power…. our systems and our funding and all of those sorts of things just don’t enable us to do this. Unless we actually really critique the whole systems and what’s going to actually enable us to achieve that, then we’re not going to get there. (Educator 66)
Symbolic factors
Consistent curriculum messages throughout training supported development of collaborative practice. A shared interprofessional framework was proposed as a useful symbolic method of uniting stakeholders on the aspiration and language of collaborative practice:
What we’ve found is having that consistent approach from all the way through…let’s say with the shared framework…so knowing the competencies and knowing the approach, so that those students have it and they’re aware of it, obviously teachers are aware of it as well. And then that goes through to when they go on placement in the hospital and health service, the staff also have access to the same training that their students did. (Educator 82)
Value clinical supervisors placed on working with others could positively or negatively impact on collaborative learning opportunities. Perception of interprofessional curriculum as an optional ‘add on’ resulted in reduced integration or prioritisation of interprofessional learning opportunities. By contrast, role modelling of effective collaborative practice was deemed useful for learning. Some education providers assumed all students were exposed to interprofessional learning experiences during clinical placements, which may or may not be occurring:
…all of our educators here….work really well together too…[students] learn to treat a patient together as they will be treating them clinically…and we demonstrate by how we work together. (Educator 47)
Accreditation authorities could seek documentary evidence of interprofessional frameworks or guidelines, positive role modelling, or co-design of interprofessional curriculum between health services and higher education institutions.
Discussion
Collaborative practice positively influences patient outcomes;17 however, there are structural reasons why health systems pose a barrier to both learning and enacting collaborative practice.18 In Australia, collaborative practice is challenged by different models of service provision, organisational structures, funding and management systems, and geographical considerations.18,19 Our findings highlighted that these structural and system factors impacted upon opportunities available for learning about collaborative practice in workplaces, given the need for both positive modelling and experiential practice.
Education providers, health services, and accreditation authorities share a vested interest in development of well-prepared graduates. Successful development of collaborative practice requires both clear messaging of the ‘value’ of collaboration and appropriate learning opportunities to achieve this goal. There is a need for a cultural shift toward consistent messaging across professions, campuses, and work-integrated learning settings about the importance of collaborative practice. Siloed approaches to professional practice and the presence of professional hierarchies that remain across some settings were viewed as counterproductive. Therefore, regardless of increased IPE programs within campus-based teaching, if clinical placements failed to offer collaborative workplace learning opportunities, desired graduate learning outcomes may not be achieved.20
Accreditation authorities play a significant role in shaping education programs. Individual professions must meet their respective interprofessional accreditation standards; however, diverse accreditation standards can create barriers to implementation.4,20 Accreditation authorities should identify multiple experiential and social activities that can be considered valid methods of contributing to developing collaborative practice skills,21 rather than a narrow focus on attendance at formal IPE activities. Useful factors to audit may include: policies, leadership, a continuum of formal and informal learning opportunities across health courses, authentic assessment, and resourcing. The Canadian accreditation guidance documents, although not entirely applicable to the Australian setting, provide useful prompts for seeking evidence of interprofessional learning.16 Finally, assessment of collaborative practice competency was described as important, although the complexity and barriers to achieving this aspiration have been previously well described.22
Limitations
Despite the large total recruitment pool, educators and accreditors dominate the response pool. We sought to recruit more practitioners; however, due to workforce pressures, many were unable to commit to the research once recruited. Broader health practitioner perspectives would better inform ways of increasing interprofessional learning opportunities facilitated within clinical settings.
Conclusion
Accreditation authorities, education institutions, practitioners, and consumers need to work together to facilitate development of collaborative practice through attention to policy and processes, curriculum activities, student participation, health service activities, and resource allocation. Implementation of IPE, in isolation, is insufficient to achieve the aspiration of collaborative practice. Formal opportunities for students to work collaboratively, coupled with identification and encouragement of informal opportunities in the workplace are recommended.
Data availability
The data that support this study cannot be publicly shared due to ethical or privacy reasons and may be shared upon reasonable request to the corresponding author if appropriate.
Declaration of funding
This research was funded by the Australian Pharmacy Council and Australian Medical Council.
Acknowledgements
The authors acknowledge the contributions of the Health Professions Accreditation Collaborative Forum Interprofessional Education Working Group for their contributions to this research.
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