Participants were asked to define collaborative practice and then to develop narratives about their life and their experiences leading up to their successful engagement in collaborative models of practice. Several themes emerged as important for engaging in collaborative practice, including childhood experiences; societal expectations; influential people, role models, or mentors; positive exposure to collaborative environments; and negative experience in non-collaborative environments. Some challenges emerged as well.
Perspectives on collaborative practice
Participants highlighted key attitudes and skills they considered to be elements of collaboration (). Attitudes included maintaining an open mind, valuing other professions, having an awareness of power differentials, enjoying working with people, being patient-centred, and believing in lifelong learning. The following quotation links the ideas of working together for the benefit of the patient (being patient-centred), being open to discovery and surprise, and being respectful:
Key attitudes, skills, and personal qualities
There’s so little chance that any one person’s going to be able to discover what’s going to work. It’s sort of by definition it has to be a group of people working on behalf of the patient doing that process of discovery. So collaboration for me is about discovery and surprise and experimenting and improvising on behalf of what a person [or a] patient needs or I guess what the team members need, and the foundations of that are probably respectful, trusting relationships.
Participants emphasized that it is unnecessary or even impossible to eliminate power differences; however, it is important to recognize them:
I think that we can’t shift some of the power relationships that exist, … but we’ve got to acknowledge that they exist. … People who are not hung up on themselves holding the power are much more likely to work more comfortably in a collaborative environment. Not that they won’t be leaders, not that they won’t have authority in some situations (maybe all the time), but they’re not needing that for their self-identity.
A positive attitude toward lifelong learning was also emphasized: “I’m always open to learning something new. I think being a generalist is very helpful because I am used to thinking about knowledge as broad and my only having pieces of it.”
Key skills included listening, learning from each other, team decision making, communication, establishing trust, and acting respectfully:
Collaborative practice requires mutual trust and respect, sufficient knowledge of each other to, in fact, trust in the skills of the other. That doesn’t necessarily mean you had that knowledge before; it means that you create that knowledge exchange very early on in the practice setting, so you can get on with the business [at hand], which is solving the problem for the patient.
Participants described key personal qualities that defined collaborative practice, such as introspection or self-reflection, humility, and confidence. One participant said about the notion that any single practitioner’s self-reflection might lead to appropriate humility, “… Underline that, put it in bold that the self-awareness it’s … the humility, the learned humility.” At the same time, self-confidence was also noted as an important quality:
Being confident enough in your own skills, to be able to be in partnership with other people, I think you have to bring something to the table, but [be] humble enough to recognize that there may be someone else at any one time that’s better able to do something than you.
Influences on the choice to practise collaboratively
All participants began the interview by describing their childhood experiences, in small prairie towns, large Canadian cities, and cities in England. Being open and tolerant, seeking justice and fairness, positioning oneself within a broader global perspective, supporting inclusive friendships, being honest, and encouraging critical questioning were values participants described learning as children:
- “People of all colours and nationalities coming to the house.”
- “I think growing up I had a very keen sense of justice and injustice.”
- “But in point of fact, open debate and the valuing of opinion and shared decision-making was very much a part of my childhood.”
As the quotes above demonstrate, most of the participants described being raised in families that were fairly liberal, open, and tolerant. This could have shaped attitudes and choices they made as adults, for example, their definitions of collaborative practitioners as respecting and valuing others.
Participants described themselves as being very involved in their communities as children, whether they were faith communities, clubs, sports teams, music, or drama: “[W]e were always part of clubs, you know. Brownies and Guides and those sorts of things, and so that sort of participation was really sort of valued and encouraged, [as was] working in groups.”
Some described themselves in early childhood as being able to easily move between groups: “I was sort of betwixt and between a lot of different groups, so I could . . . find my way into a lot of groupings without being the centre of any of them but could easily move among them. …”
This exposure to teams and groups could have helped to prepare these participants for group collaboration in their professional lives. The childhood feeling of being “betwixt and between” was connected later in this participant’s story with listening skills, being open to learning from others, and humility: “I always felt I had so much more to learn, so that I feel that everybody can teach me something and I’m never sure how much I can teach others. … I’m not sure if that’s related to … that part that I never fit or never felt that I fit in throughout my childhood.” Participants connected the liberal values and community involvement experienced in early childhood to later engagement in collaborative models of care.
Participants described how social norms influenced their career path. Guidance counselors actively discouraged young women from pursuing careers in medicine. As a result, some participants followed alternative health career trajectories: “[A]s a young woman in the ‘60s, early ‘70s, … you didn’t, shouldn’t really look into medicine. That’s too hard to get into and it would not be that great of a career for a young woman.”
Influential people, role models, and mentors
All of the participants described people who had been important role models or mentors in their choice of career: “Well, [X] is the leader, the medical leader of the Chronic Pain Team. I should name him because there’s no question in my mind that he really showed me what mutual respect and regard really looks like in a health care team.”
Positive exposure to collaborative environments
The importance of positive exposure to collaborative environments was emphasized. Participants described a range of contexts in which they were first introduced to collaborative models of care, including community health centres (CHCs), a kibbutz, rural practice settings, palliative care, a chronic pain team, problem-based learning, and the North American Primary Care Research Group (NAPCRG): “It was a street-front clinic, and I was just blown away by the teamwork and what everybody else could contribute to caring for these complex patient situations and family situations that they were dealing with there.”
Negative experience in non-collaborative environments
Also influential in participants’ decisions to practise collaboratively were the negative experiences they had, even in practice settings where (ostensibly) there were health care teams. Some described personal abuse by supervisors; many described a sense of professional isolation and a devaluing of certain professions.
Emotionally abusive supervisors
If I look at my whole spectrum of team experience and what’s influenced some of my decisions and, you know, passion for interprofessional practice, it’s some of the negative ones [that] have influenced me as much as the positive ones, and one that sort of stands out in my mind was being in a team conference and with the physician and the OT and the nurse and a patient had come in and had been complaining, complained bitterly of pain and accusing me of not acknowledging her pain; … the patient left and the physician turned to me and said, “Well what were you thinking? How come you didn’t treat her pain or what, what’s going on here?” I opened my mouth here to say what I thought and he yelled at me and said “I don’t give a f**k what you thought!”... It’s funny how you remember these things. … I can remember it to this day because it was so totally inappropriate and that would be sort of the very low end of my horrible, horrible team experiences. … But it really influenced me to think people shouldn’t have to work in those environments and people shouldn’t have those kinds of communications with each other and it’s really important to have respectful communication.
Professional isolation and silos
Many participants had experienced traditional solo practice models in the past, which left them feeling isolated, unable to connect with other professionals to meet the needs of patients, and ultimately, unsatisfied: “When I came there, it was much more a traditional silo. There was a nurse and a doctor on every team; …we didn’t talk to one another and there was very little give and take, and I was very unsatisfied with that.”
Devaluing of certain professions
Some participants described feeling devalued and humiliated as students in inter-professional settings, because of the hierarchy between professions:
OT students were the lowest rung on the ladder, in the orthopedic training environment particularly, and the specialists would come into rounds. The medical students would be sitting in the front row; you would greet them; you wouldn’t greet anybody else. The physio students would make the tea and the OT students would hold the x-rays up to the x-ray box. The fact that there were perfectly good clips on the x-ray box had nothing to do with anything.
Others noted that attempts to develop collaborative practice were hampered by the hierarchy:
[One physician practised] pseudo-engagement of the community, but [was] really pretty patriarchal in his approach. So I learned from that; I watched that as a participant observer. I watched how hard it is when you’ve all got the right language, but in fact you [act] in a way that doesn’t allow for participation.
Through negative experiences with rigid hierarchical models of care, participants learned the value of encouraging genuine participation from all team members.
Benefits of, and challenges to, collaborative practice
Benefits of engaging in collaborative practice
Participants described the benefits of practising in a collaborative model as including improved patient care, support and shared responsibility leading to less isolation and burnout, increased work satisfaction, and enjoyment of interacting with and learning from others:
I think that it’s very, very difficult to try and do everything for the patient. … But if you can share some of the responsibility, the evidence is really clear that you provide better care; it’s just more possible to do. [In my past work] I was involved with sexual assault, sexual abuse work, family violence, which is really difficult work. It saps your energy; it takes everything out; it doesn’t give you much back. But if you’re working with other people, you can do it. I’ve seen this, I’ve seen people burnt out; you burn out because you get used up. Collaborative practice protects you from being used up.
Challenges to collaborative practice
The main challenges are conflicts over power and turf and the time required to communicate in a collaborative model. Collaborative environments can become the arena in which conflicts over power are played out. Power struggles often emerge during decision making:
I think that choosing to work in a collaborative situation or framework [does] not fit with somebody who has an issue with power. … If that is an issue and they have trouble with sharing this power or the decision making, then they would not be drawn [to] or comfortable [with] or … able to even survive in that kind of situation without creating a lot of conflict.
Sometimes, the struggle to carve out a space for one’s professional turf, advocating for one’s profession, is at odds with the nature of collaborative practice: “[B]eing in a female-dominated career that was very much in its developmental stages, we were very much advocating for the profession, which in some ways was in conflict with being collaborative.”
Collaborative models of practice do take more time. Team members must be committed to the belief that the patient benefits resulting from collaboration are worth the extra time involved: “I think often there is a perception that it does take longer, and that’s when you see people kind of rolling their eyes about the team meetings and having to be involved in those sorts of decisions. I think that’s a deterrent for some.”
Transferring the collaborative style to other relationships and settings
Participants described how they manifest a collaborative approach in other roles beyond practitioner, including administration, research, and teaching:
- “[W]hen I’m in an administrative role, can I also look at fostering relationships with colleagues using those same values?”
- “[T]o do that as an educator, by definition, I need to have other disciplines involved with me and learn from other disciplines in my own educational practice. So from the start of my involvement in teaching medical students, I’ve been partners with other disciplines.”
In addition, participants described applying the same values and principles in their families: “I’ve approached my kids essentially in the same way, in childrearing. … I was real clear about when I was the leader in that team, but still my children were raised in that sort of environment where their ideas mattered, their thoughts mattered, … a willing sharing of power and influence.”