Patients’ perspectives on interprofessional collaboration between health care professionals during hospitalization: a qualitative systematic review

Abstract

Objective: 

The objective of this review was to gain a better understanding of the interprofessional collaboration between health care professionals from the patients’ point of view during hospitalisation; the influence of interprofessional collaboration on patient care, safety, and well-being; and patients’ perspectives of their role in the interprofessional collaboration process.

Introduction: 

Interprofessional collaboration is a key factor in improving patient health care outcomes and safety through better communication between health care professionals, better teamwork, and better care coordination. However, implementing interprofessional collaboration in the clinical setting can prove complex. Patients are increasingly interested in becoming partners within the health care system. They have the potential to contribute to their own safety and to observe professionals during the care process, thus gaining a better understanding of the interprofessional collaboration process and facilitating changes in the behavior of health care professionals.

Inclusion criteria: 

This review considered qualitative research and mixed-method studies. Participants were hospitalized patients. Studies were included when they explored i) patients’ perceptions of interprofessional collaboration, ii) the influence of interprofessional collaboration on patients’ care, safety, or well-being, or iii) patients’ perceptions of their own role in interprofessional collaboration. Qualitative studies focusing only on the care process or families’ points of view were excluded.

Methods: 

Searches of six databases including MEDLINE, CINAHL, Embase, Web of Science, PsycINFO, and Sociological Abstract, limited to English, French, and German were conducted from March 2017 to June 2018. Assessment of methodological quality of studies was performed using the JBI Qualitative Assessment and Review Instrument. Data were extracted using the standardized data extraction tool from JBI. Data synthesis following the JBI approach of meta-aggregation was performed. The level of confidence for each synthesized finding was established based on ConQual.

Results: 

A total of 22 studies were included, which resulted in 89 findings and 24 categories. Eight synthesized findings were generated: patients’ perceptions of interprofessional collaboration based on personal experiences and observations; patients’ experiences with effective or ineffective interprofessional communication; patients’ experience with power imbalance and paternalistic attitudes; patients’ perceptions of key factors for a confident relationship with the interprofessional health care team; patients’ need for comprehension of discussions between health care professionals; patients’ perceptions of their role in an interprofessional health care team; patients’ perceptions of opportunities for empowerment in interprofessional health care teams; and patients’ need for humanizing care from interprofessional health care teams. The level of confidence of synthesized findings varied from low to moderate according to ConQual.

Conclusions: 

This systematic review synthesized the perspectives of hospitalized patients regarding interprofessional collaboration and their perceived role in collaborative practices. Hospitalized patients observe interprofessional collaboration, either directly or indirectly, and the way interprofessional collaboration is performed may impact both their care and their well-being. However, little evidence has been found regarding the impact of interprofessional collaboration on patient safety. Patients’ perspectives on their perceived role is not unanimous; some patients want to play an active role in the collaborative process, whereas others prefer to trust the health care professionals’ expertise. Health care professionals should consider patients’ preferences and act accordingly regarding both the collaborative process and the inclusion of the patients in collaborative practices.

1 Summary of Findings

2 Introduction

Recommendations for the implementation of interprofessional collaboration (IPC) have increased since the publication of the seminal report “To Err Is Human” by the Institute of Medicine (IOM) in 1999,¹ highlighting negative patient outcomes and death due to errors and failures in the health care system. Interprofessional collaboration occurs when multiple health workers from different professional backgrounds provide comprehensive services by working with patients, their families, carers, and communities to deliver the highest quality of care.² However, two decades after the IOM report, patients are not yet safe in hospital, with 42.7 million adverse events, most of them avoidable, from 421 million hospitalizations each year worldwide.³ This induces a global cost of US$42 billion and leads to a negative psychological impact on patients and their families, and a loss of trust in health care professionals and the health care system.³ Switzerland is no exception to these safety issues, with a report by the Swiss Scientific Advisory Board estimating that 10% of hospitalized patients have been aware of errors committed during their hospitalization.⁴

A majority of errors across all types of industries are due to poor communication and lack of collaboration.^5,6 In the health care system, up to 70% of errors leading to adverse events are due to a breakdown in communication, ineffective communication, and disruptive behavior between nurses and physicians.^5,7,8 Organizations such as the IOM and World Health Organization (WHO) have recognized the importance of IPC as a key factor to ensure optimal patient outcomes and safety through better team coordination and communication.^2,9 A study conducted by Aiken and colleagues¹⁰ echoes these results, showing that an improved work environment, including doctor–nurse relationships and interprofessional decision-making, among other factors, have been positively associated with improved patient satisfaction, quality of care, and safety. Interprofessional collaboration has the potential to enhance professional practice,¹¹ patients’ quality of life,¹² health care professionals’ satisfaction,¹³ and job retention.¹⁴ Some systematic reviews associate IPC with better patient assessment and management, better comprehension of the patient's condition, improved care delivery,¹⁵ and reduced mortality.¹⁶ However, despite the existing body of knowledge concerning the possible positive outcomes of IPC, it remains a complex process to implement in the clinical setting¹⁷ due to power imbalances between health care professionals,¹⁸ divergent comprehensions of IPC, or different backgrounds and professional interests.¹⁹ Furthermore, the concept or models of IPC has always been explored from health care professionals’ perspective.^20,21 Health care professionals need to better understand effective or ineffective IPC processes and develop awareness that their actions matter to the patient.²²

In previous decades, health care policies have been more interested in including patients’ points of view. Patients have proved to be legitimate and active observers concerning the process around their care, including safety issues.^23,24 Despite patients generally feeling safe, up to 40% of them report being concerned with safety issues at some point during their hospitalization.²³ Patients who have faced safety issues generally relate them to a lack of team coordination.¹⁰ Patients are recognized for their active participation²⁵ and their value as partners²⁶ and/or collaborators.²⁷ This is supported by the Canadian Interprofessional Health Collaborative,²⁷ which has provided a patient-centered definition of IPC, describing it as a process that maintains working relationships between health care professionals, patients, and patients’ families, aiming for optimal patient outcomes. However, little is known about patients’ preferences in terms of inclusion in the collaborative process²⁸ and their knowledge of IPC. Some studies reported that patients are not willing to accept professionals as unique experts and solely responsible for determining their future.^7,29 In another qualitative study, patients expressed a desire to be part of the team, but without giving any detail about their specific role.³⁰ Concrete results on patients’ participation in collaborative practices concern mostly the process of decision-making,^17,31 which is only one part of IPC. Pullon et al.³⁰ found that patients appreciate observing effective IPC and having direct contact with the health care team. According to the authors,³⁰ IPC can be effective only if it is visible to the patients. The same authors found that despite appreciating effective IPC, patients were unaware of each professional's role within the team.³⁰ They considered the physicians as the unique leaders of the team.

There is a gap between appreciating effective IPC and being ready to or given the opportunity to become involved in the process. Some authors contend that patient participation in collaborative practices might be a utopia³² or a health professional's fantasy.¹⁷ Neither patients nor health care professionals seem ready to engage in collaboration for variable reasons.²⁸ On the one hand, patients may not have the necessary resources or understanding of IPC to take part in collaborative practices or in the decision-making process. On the other hand, the health care professionals may hold beliefs about the patient's role in the health care team that impede effective patient-centered IPC.³¹ Some authors maintain that the patient's perspective should be a key component of any health care quality improvement strategy.³³ For any concept that is relevant for practice, such as IPC, patients’ perspectives and expectations need to be considered.³⁴ Patients’ accounts may help health care professionals to overcome their barriers regarding IPC in hospital settings, thus reducing disruptive behaviors that lead to adverse events. Health care professionals may then be able to tailor their interventions to provide optimal health care to patients. If the health care system and/or health care professionals intend to include patients in collaborative processes, a better understanding of how hospitalized patients comprehend IPC and how they perceive their role in the collaborative process are needed. Hence, this review addressed the perspectives of adult and pediatric patients about IPC during hospitalization.

A preliminary search was conducted in the JBI Database of Systematic Reviews and Implementation Reports, PROSPERO, the Cochrane Database of Systematic Review, PubMed, and CINAHL, and no review (published or in progress) on this topic was currently available.

3 Review objective

The objective of this review was to examine the available evidence on IPC from patients’ perspectives, specifically i) IPC in adult or pediatric wards during hospitalization; ii) the influence of IPC on patient care, safety, and well-being in adult or pediatric wards during hospitalization; and iii) patients’ roles in the IPC process in adult or pediatric wards during hospitalization.

4 Inclusion criteria

4.1 Participants

This review considered studies including any adult and/or pediatric (≤18 years of age) hospitalized patient, regardless of diagnoses.

4.2 Phenomena of interest

Studies were considered for inclusion if they focused on patients’ perceptions and perspectives of, and experiences with, the IPC process. Studies exploring perspectives on IPC and/or its influence on the care, safety, and well-being of patients hospitalized in adult and pediatric wards – and/or patients’ perspective on their role in the IPC process – were identified and retrieved.

4.3 Context

This review considered studies conducted in any cultural or geographical context, including patients hospitalized in adult or pediatric wards.

4.4 Types of studies

This review considered qualitative evidence including, but not limited to, methodology such as phenomenology, grounded theory, ethnography, action research, and feminist research. During the building of the search strategy, the reviewers and librarian decided to specify and add mixed-method research, which included quantitative and qualitative data, in order to ensure the identification of these studies.

5 Methods

This systematic review was conducted in accordance with JBI methodology for systematic reviews of qualitative evidence.³⁵ An a priori protocol³⁶ was registered in PROSPERO (CRD42017077224).³⁶

5.1 Search strategy

The search strategy aimed to find both published and unpublished studies. A three-step search strategy was utilized in this review. An initial limited search of MEDLINE and CINAHL was undertaken followed by analysis of the text words contained in the title and abstract, and of the index terms used to describe an article. A second search using all identified keywords and index terms was undertaken across all included databases, with a scientific librarian specialized in systematic reviews. The librarian matched the keywords, MeSH terms, and thesaurus results related to the concepts of IPC, patients’ perspectives, and acute health care settings in each database. To identify the keywords, MeSH terms, and thesaurus results, a search in relevant articles was first conducted, followed by a test of the words in each database. The full search strategies are provided in Appendix I. Finally, the reference lists of included articles were hand searched for additional studies. The search was limited to English, German, and French publications or translations, from 1980 to 2018. The date limitation was motivated by the beginning of discussions on IPC and person-centeredness with the IOM-report “To Err Is Human” from the year 2000.¹ The reviewers and the librarian chose to search from 1980 onward to include early reflections on the involvement of patients or consumers in the health system before 2000.^37-40

5.1.1 Information sources

The following databases were searched: MEDLINE (Ovid), CINAHL Complete (EBSCO), Embase (Embase), Web of Science (Clarivate Analytics), PsycINFO (OvidSP), and Sociological Abstracts (ProQuest). The sources for unpublished studies included Dart-Europe and ProQuest Dissertations and Theses A&I. An updated search from the end of 2017 to mid-2018 was also conducted.

5.2 Study selection

Following the search, all identified citations were collated and uploaded into EndNote X9 (Clarivate Analytics, PA, USA) and Rayyan (Qatar Computing Research Institute, Doha, Qatar) and duplicates removed. Titles and abstracts were screened by two independent reviewers for assessment against the inclusion criteria for the review (JC, AD). Potentially relevant studies were retrieved in full and imported into the JBI System for the Unified Management, Assessment and Review of Information 2017 (JBI SUMARI; JBI, Adelaide, Australia). Full-text studies that did not meet the inclusion criteria were excluded; reasons for their exclusion are provided in Appendix II. Any disagreements that arose between the reviewers (JC, AD) were resolved through discussion or with a third reviewer (BP).

5.3 Assessment of methodological quality

Qualitative papers were assessed by three independent reviewers (BP, AD, SD) for methodological quality prior to inclusion in the review using the standardized JBI Qualitative Assessment and Review Instrument.⁴¹ The three reviewers are experienced nurses and academics. A consultation with a fourth reviewer (JC) to resolve any disagreements was available as a contingency but was not required. There was debate and discussion about the decisions concerning the evaluation of the methodological quality of studies. The critical appraisal focused mainly on the following aspects: philosophical position; study methodology and method; data collection and analysis; and possible influence of the researcher on the study, ethics, participants’ voices, and conclusion. Before undergoing the appraisal, a cut-off point of a minimum of five “yes” responses to the 10 questions was established as a requirement for inclusion. This decision was based on an evaluation of the five first included studies by three reviewers (BP, SD, AD). Nevertheless, the participant's voice through their illustrations was an essential prerequisite for inclusion and an eliminatory criterion.

5.4 Data extraction

Qualitative data were extracted from papers using the standardized data extraction tool from JBI.⁴¹ Data extraction concerned specific details such as the methodology, method for data collection and analysis, phenomena of interest, research setting, geographical and cultural context, data on participants, and authors’ study conclusions. Data extraction was performed by one reviewer (SD) and checked by a second reviewer (AD).

5.5 Data synthesis

Data synthesis of the analytic texts from qualitative research included a three-step process: extracting findings, grouping findings into categories, and grouping categories into synthesized findings following the JBI meta-aggregative approach, regardless of the study methodology.

More specifically, qualitative findings were grouped based on similar meanings, descriptive or conceptual similarities using the JBI meta-aggregative approach. This involved the aggregation or synthesis of similar findings together to generate a set of statements. The findings were rated according to their level of credibility (i.e. unequivocal, credible, unsupported).

Unequivocal (U) relates to evidence beyond reasonable doubt, which may include findings that are matter of fact, directly reported/observed, and not open to challenge. Credible (C) findings are plausible in light of data and theoretical framework, although they are derived from the authors’ interpretations. They can be logically inferred from the data. Because the findings are interpretive, they can be challenged. The findings are labeled as not supported (NS) when they cannot be supported by the data.

Once labeled, the findings were categorized based on similarity in meaning of ideas or concepts. These categories were then subject to a meta-aggregation to produce a single comprehensive set of synthesized findings to be used as a basis for evidence-based practice. Three reviewers performed the data synthesis (SD, BP, AD). Each reviewer individually read the initial 100 findings to determine their credibility compared to the patients’ verbatim illustrations. The group subsequently discussed the credibility of the findings attributed by each reviewer. Based on the group discussion, the reviewers reached a consensus for each finding. The reviewers then grouped the unequivocal and credible findings into categories. Four meetings were necessary to reach a consensus on the classification of the findings and the naming of the categories. Another set of four meetings was required to synthesize the findings.

5.6 Assessing confidence in the findings

The final synthesized findings were graded according to the JBI ConQual approach for establishing the level of confidence in the output of qualitative research synthesis and presented in the ConQual Summary of Findings.⁴² The ConQual Summary of Findings includes the major elements of the review and details how the ConQual score was developed. Each synthesized finding from the review is presented, along with the type of research informing it, scores for dependability and credibility, and the overall ConQual score. Credibility evaluates whether there is congruency between the author's interpretation and the original source data.⁴³ According to Guba,⁴⁴ the concept of dependability is related to the consistency of findings. Dependability is established if the research process is logical (i.e. the methods are suitable to answer the research question and are in line with the chosen methodology), traceable, and clearly documented.⁴² The level of confidence provides the assessment of evidence produced from qualitative systematic review.

6 Results

6.1 Study inclusion

The structured search strategy was implemented from June 2017 to June 2018 (Appendix I). The results of the database searches were imported from EndNote X9 to Rayyan for title and abstract screening. Studies were retrieved for full-text review in EndNote X9 library for screening. A total of 11,369 papers were identified through electronic databases (Figure 1).⁴⁵ After duplicates removed and records screened, 107 full-text studies were included for eligibility assessment based on the inclusion criteria (e.g. participants, context, phenomena of interest, type of studies). After study selection and critical appraisal, 22 studies^46-67 were included, of which two papers were derived from the same authors and based on the same gathered data. For the current systematic review, these two papers were considered as two different studies because not all of the findings were presented in one paper. Both papers presented complementary data relevant for the objectives of this review. Across these 22 studies, all of them were qualitative studies,^46-51,54-67 one was a master thesis,⁵³ and one was a doctoral thesis.⁵² As the phenomenon of interest was on the patient's perspective, only primary sources with patients’ voices adequately represented were selected.

Figure 1: Search results and study selection and inclusion process⁴⁵

6.2 Methodological quality

The included studies were deemed to be of moderate to high methodological quality with scores of 6/10,^63,64 7/10,^58-60,62 8/10,^{46-51,54-57,61,66,67} 9/10,^52,65 and 10/10⁵³ based on the 10 questions of the JBI critical appraisal tool. All included studies were of qualitative design; however, four of them did not offer explicit statements on the design.^59,62-64 The aims, objectives, and data collection method were congruent with a qualitative study design, thus, the reviewers could infer the qualitative nature of the design and respond affirmatively to Q1, Q2, Q3, Q4, and Q5. Aside from Q6 concerning the researcher's cultural or theoretical background (18%) and Q7 concerning the influence of the researcher on the research, and vice-versa (14%), the authors of the included studies responded adequately to the remaining questions with a high rate. All the included studies responded to Q8 concerning the illustration of the participant's voice, which was an eliminatory question. Three studies that did not address Q8 and one study that did not reach the minimum five “yes” responses to the 10 questions were excluded (Appendix III).

Table 1: Critical appraisal of eligible studies

6.3 Characteristics of included studies

Among the 22 qualitative studies, most of the authors defined their methodology and/or their method (i.e. grounded theory,⁵² action research,⁵³ naturalistic approach,^66,67 phenomenology,^51,56,60 ethnographic approach,^57,65 or critical discourse method)^46,47,55. Some authors^{48-50,54,58,61} defined their research in the frame of a qualitative design without further detail on the methodology. Four other studies did not provide any indication concerning the design.^59,62-64 Data were collected via interviews with open-ended questions,^46,47 interviews with open-ended questions and focus group,⁶¹ in-depth interviews,⁵⁹ in-depth interviews and focus group,⁵² semi-structured interviews and observations,^57,63,67 semi-structured interviews and focus group,^48,53,54,58 and semi-structured interviews.^{49-51,55,56,60,62,64-66} Data were analyzed through critical discourse,^46,47 realist synthesis,⁵⁵ concept mapping,⁶⁰ constant comparative,^{49,51,52,54,59,61,65} content analysis,^50,53,58,67 and thematic analysis,.^{48,56,57,62-64,66} Data collection occurred in different health care settings such as palliative care,⁵⁹ geriatric,^57,67 obstetrics,⁵⁶ mental health,^60,67 pediatric,^49,63 oncology,^50,61,64 rehabilitation,^{51-53,55,57,60,65} and acute care units (e.g. neurology, dialysis, surgery, medicine, intensive care unit, emergency department).^{46-48,54,55,58,62,63,66} The most represented countries in this review were the United Kingdom^{48,51,55,57,59,61,64,65} and the United States.^{49,52,54,60,63,66} Studies were also conducted in Canada,^50,53 Australia,^58,62 New Zealand,⁵⁶ and Europe (e.g. Norway,^46,47 the Netherlands).⁶⁷ The majority of participants of the included studies were adults (n = 389). Only two of the studies included exclusively pediatric participants (n = 36).^49,63 One study included pediatric and adult patients but reported the illustration of the adult patients only.⁶⁵ The age range varied from 19 to 98 years for adult participants and from seven to 18 years for pediatric participants in the included studies. For one study, the age of adult participants was not available despite a correspondence with the first author of the article.⁶⁷ More characteristics about the included studies are described in Appendix IV.

6.4 Review findings

From the 22 qualitative primary research studies included in the review, 100 findings were extracted, with the majority of these findings graded as “unequivocal” (n = 76), some graded as “credible” (n = 13), and some graded as not supported (n = 11) (Appendix V). The findings graded as “not supported” were not included in the meta-aggregation because these findings were unsupported by the data. Once retained, the 89 findings were grouped based on their similarity in meaning, ideas, or concept into 24 categories named by the reviewers. The naming of these categories was based on the similarities of meaning, ideas, or concepts of the findings generated by the patients’ illustrations. These 24 categories were merged to produce eight synthesized findings.

6.4.1 Categories and synthesized findings

A summary of 24 categories with an example illustration for each rated finding is presented in Table 2    . The illustrations are available in Appendix V.

Table 2: Summary of categories with findings and illustrations

Table 2 (Continued): Summary of categories with findings and illustrations

Table 2 (Continued): Summary of categories with findings and illustrations

Table 2 (Continued): Summary of categories with findings and illustrations

Table 2 (Continued): Summary of categories with findings and illustrations

A synthesized finding consists of at least two categories. To constitute a synthesized finding, categories had to have similar meaning or illustrate a similar concept or idea. The eight synthesized findings include the following: patients’ perceptions of IPC based on personal experiences and observations; patients’ experiences with effective or ineffective interprofessional communication; patients’ experience with power imbalance and paternalistic attitudes; patients’ perceptions of key factors for a confident relationship with the interprofessional health care team; patients’ need for comprehension of (interprofessional) discussions between health care professionals; patients’ perceptions of their role in an interprofessional health care team; patients’ perceptions of opportunities for empowerment in interprofessional health care teams; and patients’ need for humanizing care within an interprofessional health care team.

Synthesized finding 1: Patients’ perceptions of IPC based on personal experiences and observations

This synthesized finding was derived from 18 findings merged into four categories (Table 3). These findings and categories were similar in the ways in which the patients described the interactions between different health care professionals at their bedside. Patients’ observations of IPC took place when health care professionals discussed and worked closely together while the patients observed this. Patients perceived and interpreted these interactions between the health care professionals as effective or less effective. Their perceptions, observations, and interpretations depended on aspects of communication, information sharing, the number of health care professionals interacting together, shared understanding of patients’ conditions, and shared goals, as well as the health care professionals’ work conditions. The perceived effectiveness of the interprofessional interactions depended strongly on the way the different health care professionals communicated one with another:

“From my experience, they all seemed really in step with each other. They were all very friendly with each other. They seemed to communicate really well, knew each other very well”.^54(p.701)

Table 3: Synthesized finding 1

The number of professionals communicating together was found to be an important factor for collaborative work and information exchange. For some patients, a large number of professionals interacting and communicating effectively together was perceived as an advantage:

“I was most impressed. They [Dr and transdisciplinary team] came in together several times. They were very thorough and showed wonderful co-operation. We felt we were getting exactly what the doctor wanted.”^58(p.29)

A team with many health care professionals was perceived by patients to be more effective when discussing and working together on their health care issues.^49,55,58,62 A big team can be an efficient gain of time and work.⁴⁹ The patients felt, according to their observations, that the more health care professionals who took care of them, the more their health would improve.^49,62

“If there are more experts taking care of my diabetes like it is in the hospital and they do things on a big scale, then my diabetes will improve.”^62(p.22)

As such, some patients were very comfortable with the interprofessional team and valued them when they observed effective communication and information. Patients also observed interactions between the health care professionals that they perceived as ineffective, leading to ineffective IPC. This happened when patients observed a power struggle or conflict between health care professionals.^56,61 According to patients, time and workload were also two factors related to ineffective collaboration. These patients expressed that health care professionals were not able to do a good job because they were overwhelmed.⁶⁰ Some patients could neither observe nor infer the existence of an interprofessional team meeting and discussing their health status or health condition. These patients expressed being confused about the role and/or the function of each health care professional because they were not properly informed.^55,61 Other patients made assumptions, based on their observations, that health care professionals worked in parallel rather than together:

“I just assumed that these links exist, but I didn’t know they existed formally, and I don’t think we were ever told as patients that there is an MDT (multidisciplinary team) team discussion.”^{61(Table 1)}

Some patients gave recommendations for an improved and effective IPC process.^54,61,65 There was a suggestion for having a leader within the interprofessional care team, someone who could be the key person (i.e. a supervisor or a reference person to improve the team functioning). Interestingly, some patients made reference to the doctors when talking about the health care team, giving indication that these professionals occupy a specific role in the team.^49,63,64 Interprofessional communication was a critical aspect of the IPC process. Patients suggested certain means of communication, such as using the same communication tool (e.g. computer) to obtain complete information on patients.⁵⁴

Synthesized finding 2: Patients’ experiences with effective or ineffective interprofessional communication

The second synthesized finding was derived from six findings merged into two categories (Table 4). This synthesized finding revealed that patients experience effective or ineffective interprofessional communication during their hospitalization, and both types of communication have an influence on their well-being and trust in health care professionals. According to the patients’ illustrations, effective communication included an efficient, open, and equitable communication:

“There was… um a real sort of clarity and consistency… most of the time I’m talking to [Specialist Registrar]… if I get some sort of more like day to day things, that's not being addressed then maybe I go to [Specialist Nurse] and at the end of the day you know, on the whole big scale sort of you know guiding my care was [Consultant Haematologist]… there was a clear chain of command…” (51-year-old man).^64(p.7)

Table 4: Synthesized finding 2

Patients reported that effective communication minimized their uncertainty towards their care plan (e.g. concerning surgery) or the role of individual members of the patients’ health care team.^50,55,64 They expressed being reassured when health care professionals were aware of their health care issues.⁵⁴ One patient observed that nurses shared information or discussed cases with physicians and students outside the patient's room.⁵⁰ This observation was interpreted by the patient that the nurses, physicians, and students worked as a team with effective functioning. Some patients assumed a lack of communication between health care professionals when they had little or no knowledge about the patients’ health condition⁵³ or were not aware of decisions made with other health care professionals.⁵⁴

Synthesized finding 3: Patients’ experience with power imbalance and paternalistic attitudes

This synthesized finding was derived from 18 findings merged into five categories (Table 5). Patients indicated that they sometimes lost control of their condition in hospital. Patients felt they had no other choice than to comply with the interprofessional health care team's orders and/or decisions, and to act passively.^50,63 For the patients, the health care professional team held the power against the patients’ lack of knowledge or expertise.^46,47,53 Some patients compared this to a loss of freedom. Patients reported that some health care professionals adopted a paternalistic attitude or imparted information without adaptation to the patients or without taking into account the patients’ knowledge. These patients thought that the less information they received about their condition, the more they felt out of control.⁵³

“As long as I know what it is that has happened, is happening, or is going to happen, I’m in control of myself. It's when I’m being dangled at the end of that string without being given any specific information, I never did appreciate it, no.”^53(p.87)

Table 5: Synthesized finding 3

The power imbalance was visible in the patients’ illustrations and in the findings when the patients described a lack of integration of their experiences by the interprofessional team. One patient felt that some medical errors could have been avoided if the patients were more informed and/or listened to.^61,63

“Like the heparin shot, I wish I would have known I was going to get that this morning, I would have told her… and they were like well, it was a mistake, he wasn’t supposed to get it.”^63(p.10)

Some patients felt disappointed when not listened to by the health care professionals regarding their health status.⁶³ Missed opportunities in shared decision-making generated by health care professionals was another aspect of power imbalances that patients had to face. The patients expressed that they had not been able to challenge the decisions that the interprofessional team made for them and did not get the opportunity to participate in the decisions.^46,47

“Well, I don’t know actually if the decisions, if I have decisions that other people are making for me I can’t compete on it. You see, you can’t say no, no, no, you’re not doing that. But you see if it was decisions that belong to you… I couldn’t do it.”^57(p.62)

Synthesized finding 4: Patients’ perceptions of key factors for a confident relationship with the interprofessional health care team

This synthesized finding was derived from seven findings grouped into two categories (Table 6). This synthesized finding highlighted several factors that were perceived by the patients as contributing to their reliance on the interprofessional health care team. Patients felt they could trust the expertise of and decisions made by the interprofessional team. Patients were convinced that health care professionals had sufficient expertise and experience to do the best in their interest.^53,57,64 Conversely, when patients assessed a lack of knowledge, their relationship with health care professionals could be undermined. Loss of trust can result when patients perceive a lack of professional expertise or knowledge with respect to the health condition.^53,60

“Especially in the area of cerebral palsy… That's mighty scary and to double that fear, the medical professional doesn’t know what to do with us…. What do we believe? Who do we believe?”^60(p.1110)

Table 6: Synthesized finding 4

Synthesized finding 5: Patients’ need for comprehension of discussions between health care professionals

The fifth synthesized finding was derived from 14 findings merged into four categories (Table 7). Patients claimed the need to understand the content of interprofessional communication. First, patients were convinced that health care professionals should stop using medical jargon when talking to them.⁵² Patients would then better understand their health care condition and have improved communication with health care professionals. Second, not understanding the discussion between health care professionals was a source of anxiety and fear for patients.⁴⁹ A lack of comprehension might either lead the patients to feel uncomfortable or to feel they were being a nuisance during interprofessional meetings or discussions.^49,61 For patients, the relationship with health care professionals depended on effective and frequent communication.⁶⁶ Hardly any communication or its absence led to frustration and sub-optimal quality of care for the patients.

“I was taught about diabetes by the nurses when I was diagnosed but I could not remember what she taught me, it was one session when I was in the hospital. So many health people visited me, I don’t know who.”^62(p.22)

Table 7: Synthesized finding 5

Other patients did not appreciate being provided with a large amount of information, being questioned in the presence of the whole team, or finding themselves in the middle of a discussion among health care professionals.⁶²

Synthesized finding 6: Patients’ perceptions of their role in an interprofessional health care team

The sixth synthesized finding was derived from eight findings formed into two categories (Table 8)

Table 8: Synthesized finding 6

According to patients, the health care professionals’ responses to their needs and concerns depended on the patients’ own attitude and behavior. Some patients indicated that a positive and discrete attitude might help to win more favorable attitudes and behaviors from health care professionals.⁵³ On the other hand, some patients conceived their role and responsibilities as active participation in their care and in decision-making.⁶³ Learning and gathering information by themselves was part of this attitude.⁵² These findings identified two types of patients: those playing a more passive role who were content to be on the receiving end of health care professionals’ decisions, and those actively participating, willing, and struggling to play an important role.

“I think it is a combination, but I do feel it depends on the individual. You really need to make the staff aware of the fact that you want to be informed. I don’t think that you should have to just dig for all of your information… but on the other hand, if you don’t ask you might never find out.”^52(p.108)

Synthesized finding 7: Patients’ perceptions of opportunities for empowerment in interprofessional health care teams

This synthesized finding was derived from 11 findings merged into three categories (Table 9). Both patients and health care professionals could promote patients’ empowerment. The findings highlighted contributing factors to greater patient empowerment. These included being involved, being a member of the team, and being given choices or opportunities. From the patients’ perspectives, health care professionals remained key and decisive actors in the care process and/or in shared decision-making.^61,64 Patients felt they could only participate in collaboration if health care professionals allowed it. For some patients, health care professionals had to consider patients as team members⁵² or give them the opportunity to do so.⁶¹ Some of those patients defined the opportunities as having multiple choices and options for treatment, having complete information, and having enough time to think about the choices and make decisions.

“I’m not taking the drug to which I am entitled; I chose not to take it, at the moment, anyway. I don’t want the side effects, and I discussed it with the oncologist and the surgeon and the radiologist…they gave me that choice.”^61(p.90)

Table 9: Synthesized finding 7

Some of the patients stated they needed to have control over the decisions.^51,52,61 Effective communication and collaboration between the health care professionals and the patients enhanced and allowed empowerment to occur.

Synthesized finding 8: Patients’ need for humanizing care within an interprofessional health care team

The eighth synthesized finding was derived from seven findings forming two categories (Table 10). Patients expressed the need to be considered and treated as a person and not as a number or as an object by interprofessional teams.⁴⁷

“They treat you like a person. They respected me. They asked me what my goals and expectations are and seemed to care if I was tired.”^52(p.80)

Table 10: Synthesized finding 8

In certain cases, patients felt ignored, neglected, and not listened to by the interprofessional team during hospitalization.⁵³ Patients illustrated a lack of humanized care when describing themselves as “a piece of furniture,”⁴⁷ “specimens,”⁴⁹ or “a pill chaser”⁶³ for health care professionals. Patients valued when the health care professionals took time to provide them with information. Conversely, patients expected at least one member of the interprofessional care team to take time for them and provide them with the necessary information. They did not appreciate running after each health care professional to obtain missing information on their health status.⁵⁰

“It took time before I asked the question [about when I was going to die] and I feared the answer. But I was not told (…) what my life expectancy was. I did not know if I was buying myself a few more years (…) because we don’t know how long I am going to take it [the treatment] (…) what is next? (…) what are the signs that it [the cancer] is coming back or not coming back?”^50(p.34)

7 Discussion

This review examined the available evidence on IPC from the patients’ perspective in order to gain an understanding of IPC; its influence on patients’ care, safety, and well-being; and the role of the patients in the collaborative process. Data on the influence of IPC on patient safety were limited, but patients’ accounts indicated that they had full confidence in health care professionals’ decisions and expertise. This may support the finding of Guijarro et al.²³ showing that patients generally feel safe in hospital.

The most propitious moments for patients’ observations were during ward rounds, medical meetings, or during the process of decision-making. Patients understood IPC in terms of coordination, communication, and relationships between health care professionals. The IPC process was visible to some patients and less to other. Thus, hospitalized patients have the same concerns as patients in other health care settings (e.g. primary care or community care).^30,68 Interprofessional collaboration is not always visible to patients, but when it was visible and effective, patients were reassured and satisfied.^50,64 The patients in the primary care setting reported appreciating “regular contact” with the health care team, effective coordination, and information sharing among the members of the health care team.³⁰ This was supported by another study that was conducted in various hospitals in different European countries, associating a positive working relationship of health care professionals with patient satisfaction and quality of care.¹⁰ When not visible, IPC was not necessarily perceived or assessed as ineffective. This is in contrast with Pullon's conclusion,³⁰ which found that IPC was more effective when visible to patients. The findings of this review showed that patients tried to find indicators to assess effectiveness of IPC (e.g. care process, care coordination, information sharing, knowledge of health care professionals about patients’ health condition, and/or communication between the health care professionals). If these indicators were positively assessed, patients assumed that effective IPC was the foundation of an effective care process.^49,52 When suboptimal, patients assumed IPC was ineffective due to lack of communication, lack of time, or work overload. Ineffective IPC (i.e. ineffective care coordination, ineffective interprofessional communication) may cause patients fear, stress, or frustration. Guijarro et al.²³ found that patients associated adverse events with a lack of team coordination, making them afraid, threatened, or feeling loss of control.

When IPC is visible, patients are attentive to the following indicators: interprofessional communication, relationships between the health care professionals,^{49,54-56,59,61} and the coordination of care.^54,60 Patients stressed the importance of communication and relationships between the health care professionals, reinforcing that these are determinants of successful IPC.²¹ The way in which health care professionals communicate and work together can enhance or impede effective collaboration and team functioning. Simply acting as a group at the patient's bedside was not enough to appear as an effective interprofessional team. Health care professionals needed to introduce their functions and roles to patients, otherwise the patients felt confused or intimidated about the number of health care professionals or their roles. Interestingly, some patients considered that a health care team should have a leader or a reference person to coordinate the team.⁶⁵ Some patients named the physician when referring to the whole team^49,63,64 or defined effective collaboration as perceiving that the whole team was following the medical advice.⁹ Other patients observed conflicts⁵⁶ or power issues between physicians and other health care professionals.⁶¹ These accounts from adult patients are in line with the findings of Holyoake⁶⁹ whose pediatric participants reported that physicians were in charge. Holyoake's findings⁶⁹ and the findings of this systematic review differ in that nurses are not necessarily perceived as being positioned hierarchically lower than the physicians.⁶⁸ However, viewing the physicians as leading the interprofessional team and referring to the physicians while designating the whole team indicates the hierarchical position patients assign to the physicians.

Patients’ perspectives concerning their perceived role was not unanimous. Some patients wanted to play an active role in the decision-making process and in their goal setting. This resonates with Bakker's²⁹ findings, which reported that patients do not want health care professionals to be the unique holders of knowledge and expertise. Despite the patients’ willingness to play an active role, health care professionals did not necessarily integrate patients in the care process or in the collaborative process.³² Longtin et al.³¹ identified health care professionals’ characteristics (i.e. their beliefs, attitudes, and behaviors) that facilitate or impede them from including patients in decision-making or in the care process. The patients’ preferences and characteristics are also important to consider³¹; for example, the findings of the present systematic review highlighted that some patients expressed their reticence to participate in important decisions or team meetings due to their perceived lack of expertise.

Different points are thus highlighted: hospital-based health care teams can only adopt a patient-centered view of IPC if patients and health care professionals change their beliefs, attitudes, and behavior toward the patients’ role within an interprofessional health care team. Patients need to know that they can be part of the team. They need to be informed and involved in interprofessional practices such as decision-making and goal setting. Health care professionals need to evaluate systematically the degree to which patients want to take part in collaborative moments. A patient-centered IPC, or partnership with patients in hospital settings, cannot take place if patients and health care professionals remain in an asymmetric relationship. On the other hand, power imbalances due to knowledge and expertise differences between patients and health care professionals are inevitable. Thus, health care professionals need to work in an interprofessional and collaborative fashion while providing patients the opportunity to feel part of the team, adapting their language depending on with whom they are speaking. Integrating patients as health care team members needs to be balanced and personalized according to patients’ preferences.

Humanized care constituted another aspect of care pointed out by the participants. This did not constitute the initial focus of this review; however, this aspect was retained as patients described it in the context of IPC. Humanized care was viewed to be the responsibility of each health care professional and the whole team. A humanized approach of care was sometimes lacking. This indicates that IPC must be more than risk- and safety-oriented. Otherwise, patients may feel they are a separate entity handled by others. Patients need to feel that they are at the center and part of the interprofessional health care team. In other words, patients’ care should not be seen as a fragmented process, sometimes explored under the lens of quality and sometimes under the perspective of interprofessionality or humanized care. Care should be holistic. This might find resonance in a person-centered IPC; however, further investigations are needed to correlate interprofessional care with more personalized, humanized, and optimized care.

7.1 Strengths and limitations

This systematic literature review provides an overview of the perception of hospitalized patients and their understanding of IPC based on their direct or indirect observations of and experiences with IPC. The participants related IPC to a complementary and humanized aspect of care.

Based on the JBI critical appraisal tool, the methodological quality of the included studies was high, and most of the studies were recent. The confidence of the synthesized findings was low to moderate based on the ConQual approach.

However, not all studies were conducted in the hospital setting, which made some findings difficult to evaluate. Numerous discussions and verifications were necessary to determine the exact context of the finding. Findings illustrating the perspectives and experiences of patients outside the hospital setting were excluded.

Some patients discussed the health care team in terms of “the doctors.” The reviewers had to thoroughly consider the context of the study and examine the patients’ accounts in order to determine whether they were talking about an interprofessional team, an intraprofessional team, or individual health care providers.

The studies did not all focus on the three objectives of the present systematic review; therefore, the number of findings in some articles was limited to one.⁶⁶

Another limitation was related to the geographical setting of the studies. Most of the studies were conducted in English-speaking countries. The health care system and context of these countries might be different from some other countries; patients’ literacy may vary due to a different health care policy. The concept of “patient-partner” was launched and developed in North America²⁶ and the United Kingdom.³¹ Patient partnership and involvement might be more encouraged in those countries; thus, patients may have a more active approach toward their health care. In English-speaking countries, patients may also be more active due to technological innovation, enhancing their access to health care information and to more person-centered health care policies.³² Hospitalized patients may be less active as they are in an environment they do not fully control and where the health care professionals are more powerful in number and in knowledge. However, this would require further studies comparing hospitalized patients’ characteristics, attitudes, and behaviors toward their health care in European and English-speaking countries.

8 Conclusions

Despite a low to moderate ConQual grade due to a mix of unequivocal and credible findings, the findings of this qualitative systematic review, derived from studies of high-to-moderate methodological quality, highlighted hospitalized patients’ unique perspectives of IPC. These findings are in line with and support the recommendations of organizations such as the World Health Organization and the Institute of Medicine, which encourage optimized interprofessional teamwork, coordination, communication, and patient-centered care.^2,3,9 In addition, these findings provide a complementary understanding of IPC from the point of view of patients, and the role that patients assume or wish to assume in IPC.

The patients have observed aspects of IPC (e.g. the relationship between health care professionals, interprofessional communication, coordination, information sharing), which have been defined as critical concepts by researchers in health care literature.^21,70-72 Patients appreciate observing effective IPC; however, not all patients are necessarily willing and able to participate in collaborative practices or processes, such as decision-making, discussions about the choice of treatments, goal setting, ward rounds, interdisciplinary meetings or interdisciplinary discussions at the bedside of the patients. It is difficult to anticipate patients’ preferences concerning collaborative practices. For this reason, it is important to evaluate the preference of each patient individually and to work accordingly. Some aspects should be systematically applied in order to be visible as an interprofessional team and to be effective at the patient's bedside or when performing IPC in the presence of the patient. The following propositions would allow patients to participate in the interprofessional communication held at their bedside: the interprofessional team should introduce the function of each professional to the patient, avoid medical jargon if discussions take place at the patient's bedside, tailor the amount of information provided to the patient at one time, and allow the patient enough time to make a decision, if he or she is willing to participate in decision-making.

8.1 Recommendations for practice

The accounts of the participants and the findings of the 22 included studies gave indications for some recommendations. Interprofessional collaboration is a process that is directly or indirectly assessed. When IPC is not visible to patients, they seek indicators to assess it through information exchange or care coordination. Interprofessional collaboration may influence patients’ care, experience, and participation to some extent. This means that the actions and behaviors of the health care professionals, as a team and toward the patients, influence the way the patients perceive IPC, their care, and their role in an interprofessional health care team within a hospital ward. Some patients need to be actively involved in the collaborative process, whereas others prefer to receive care without taking an active part in the decisions, assigning their confidence to the expertise of the health care professionals. Thus, health care professionals should consider patients’ preferences individually and facilitate their comprehension of the collaborative process. The following recommendations have been graded B according to the moderate to low level of ConQual grade of the synthesized findings.⁴¹ The recommendations are in line with the opinions and recommendations of authors and experts who have covered the topics related to person-centered approaches,^26,31,32,73 patient participation, or patients as partners models, which are proximate concepts of patient-centered IPC. The following recommendations are made for health care professionals:

• Health care professionals should introduce themselves and their respective roles to the patients in order to i) avoid any confusion concerning the role or the function of the professional, and ii) avoid patients feeling intimidated by the presence of a large number of professionals at their bedside. (Grade B)
• Health care professionals should adopt effective interprofessional communication (clear, respectful, without jargon) and ensure care coordination in order to avoid stressful situations as reported by the patients (feeling uncertainty about decisions, feeling out of place during interprofessional encounters, not understanding the shared information). (Grade B)
• ∘ The interprofessional discussions held at the bedside of the patients should be adapted to patients’ understanding, avoiding medical terms the patients do not understand; the communication should be tailored to the patients’ levels of knowledge and expertise.
• ∘ The interprofessional relationships should enhance a trustful and respectful atmosphere between the health care professionals.
• Health care professionals should systematically assess the expectations of patients regarding the amount and the type of information they want to receive. (Grade B)
• Health care professionals should assess patients’ preferences regarding their participation in interprofessional meetings, goal setting, discharge planning, or decision-making process. (Grade B)
• Health care professionals should recognize and valorize patients’ experiences and give them the opportunity and space to take part in their health care–related discussions. (Grade B)
• Health care professionals should adopt a patient-centered approach of IPC and care process, in which every health care professional values the patient as a person at every stage of the hospital stay. (Grade B)

For some patients, it is important to observe a leader in the team, while others prefer to know that the health care professionals are complementary (i.e. that there are no power relationships between the health care professionals).

8.2 Recommendations for research

Most of the findings of this qualitative systematic review are derived from English-speaking studies. Thus, the transferability of the results might be limited in countries with a different health care policy, where patient partnership and/or participation in health care processes or collaborative processes are not widely practiced, such as in European countries. Patient participation in collaborative process depends on a set of factors: social norms,³¹ health care policies, and interactional structure.⁷⁴ A deeper understanding of Swiss social norms related to patient participation in collaborative processes, patient characteristics, and patient preferences is needed. Little is known about whether health care professionals consider these factors when deciding how to include patients, and whether patients’ perspectives have an impact on interprofessional processes. The following recommendation is proposed for future research:

• Additional explorative qualitative studies and mixed-method studies combining interviews with the main health care stakeholders (i.e. patients, health care professionals, and the general public) to help gain a local and European view of IPC and the implication on patients’ perspectives and preferences.

Additional observations of collaborative moments at patients’ bedsides or during medical meetings, discharge planning, or goal setting would help to highlight successful collaborative processes and help health care professionals to adapt these behaviors.

9 Acknowledgments

The co-investigators of the parent study: Professor Dr. Brigitte Liebig, Professor Dr. Med. Jean-Pierre Pfammatter, and the scientific committee of the University of Applied Sciences and Arts Western Switzerland (HES-SO). This review contributes to the PhD of author AD.

10 Funding

The University of Applied Sciences and Arts Western Switzerland (HES-SO) partly funded this qualitative systematic review. The university played no role in the content development of this review.