Best Practice Guidelines

DECEMBER 2013

Developing and Sustaining

Interprofessional Health Care:
Optimizing patient, organizational and system outcomes
Disclaimer
These guidelines are not binding for nurses or the organizations that employ them. The use of these guidelines
should be flexible based on individual needs and local circumstances. They neither constitute a liability nor
discharge from liability. While every effort has been made to ensure the accuracy of the contents at the time of
publication, neither the authors nor the Registered Nurses’ Association of Ontario (RNAO) give any guarantee as
to the accuracy of the information contained in them nor accept any liability, with respect to loss, damage, injury
or expense arising from any such errors or omission in the contents of this work.

Copyright
With the exception of those portions of this document for which a specific prohibition or limitation against
copying appears, the balance of this document may be produced, reproduced and published in its entirety,
without modification, in any form, including in electronic form, for educational or non-commercial purposes.
Should any adaptation of the material be required for any reason, written permission from the Registered Nurses’
Association of Ontario must be obtained.

The appropriate credit or citation must appear on all copied materials, as follows:

Registered Nurses’ Association of Ontario (2013). Developing and Sustaining Interprofessional Health Care:
Optimizing patients/clients, organizational, and system outcomes. Toronto, Canada: Registered Nurses’ Association
of Ontario.

This program is funded by the Ministry of Health and Long-Term Care.

Contact Information
Registered Nurses’ Association of Ontario
Healthy Work Environments Best Practice Guidelines Project
158 Pearl Street, Toronto, Ontario M5H 1L3

Website: www.rnao.ca/bpg
Developing and Sustaining
Interprofessional Health Care:
Optimizing patient, organizational and system outcomes
 Developing and Sustaining Interprofessional Health Care: Optimizing patient, organizational and system outcomes

Greetings from Doris Grinspun,

Chief Executive Officer, Registered Nurses’ Association of Ontario
It is with great pleasure that the Registered Nurses’ Association (RNAO) of Ontario
releases this guideline, Developing and Sustaining Interprofessional Health Care:
Optimizing patients/clients, organizational and system outcomes.

This is one in a series of best practice guidelines on healthy work environments

developed by RNAO for the health-care community. The aim of these guidelines is
to provide the best available evidence to support the creation of healthy and thriving
work environments. These guidelines, when applied, will serve to support the
excellence in service that health-care professionals are committed to delivering in
their day-to-day practice. RNAO is delighted to provide you with this key resource.

We offer our endless gratitude to the many individuals and organizations who are
making our vision for healthy work environment best practice guidelines a reality: the Government of Ontario for
recognizing RNAO’s ability to lead the program and providing generous funding; Dr. Irmajean Bajnok, Director,
RNAO International Affairs and Best Practice Guidelines Programs, for her expertise and leadership in advancing the
production of these guidelines; my co-chair Dr. Joshua Tepper and co-advisor Dr. Craig Jones for the many hours of
critical deliberations, Development Panel co-chairs Dr. Stewart Kennedy and Dr. Rani Srivastava – for their superb
stewardship, commitment and, above all, exquisite expertise. Endless thanks also to Program Manager Althea Stewart-Pyne
who provided leadership to the process and worked intensely to see that this guideline move from concept to reality.
Very special thanks to the best practice guideline’s panel – we respect and value your expertise and volunteer work.
To all, we could not have done this without you!

The nursing community and other health-professional partners – committed to, and passionate about excellence in
clinical care and healthy work environments – have provided knowledge and countless hours essential to the creation,
evaluation and revision of each guideline. Employers have responded enthusiastically by nominating Best Practice
Champions, becoming Best Practice Spotlight Organizations®, implementation and evaluating the guidelines and
working towards a culture of evidence-based practice.

Creating healthy work environments is both an individual and collective responsibility. Successful uptake of these
guidelines requires a concerted effort by governments, administrators, clinical staff and others, partnering together to
create evidence-based practice cultures. We ask that you share this guideline with members of your team. There is much
we can learn from one another.

Together, we can ensure that nurses and all health-care providers contribute to building healthy work environments.
This is central to ensuring quality patient care. Let’s make health-care providers and the people they serve the real
winners of this important effort!

Doris Grinspun, RN, MSN, PhD, LLD (Hon), O. ONT.

Chief Executive Officer
Registered Nurses’ Association of Ontario

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Table of Contents
How to Use this Document . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

Purpose and Scope . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

Guiding Principles and Assumptions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

Summary of Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

Types of Evidence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

BACKGROUND
Advisory Committee Members . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

Development Panel Members . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

RNAO Best Practice Guideline Program Team . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

Stakeholder Acknowledgement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

Background to the Healthy Work Environments Best Practice Guidelines Project . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

Organizing Framework for the Healthy Work Environments Best Practice Guidelines Project . . . . . . . . . . . . . . . . . . . . 18

Background Context of the Guideline . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

Overview of the Conceptual Model for Developing and Sustaining Interprofessional Care . . . . . . . . . . . . . . . . . . . . . 23

External/System Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28

Organizational Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
R E C O M M E N D AT I O N S

Individual/Team Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42

Research Gaps and Future Implications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47

Implementation Strategies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48

Evaluation & Monitoring of Guideline. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49

Process for Reviewing and Updating the Healthy Work Environments Best Practice Guidelines . . . . . . . . . . . . . . . . . . 52

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References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
REFERENCES

Appendix A: Glossary of Terms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63

Appendix B: Guideline Development Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66

Appendix C: Process for Systematic Review/Search Strategy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67

APPENDICES

Appendix D: Enablers and Barriers to Interprofessional Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71

Appendix E: Example of Team Charter . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83

Appendix F: Interprofessional Competency Framework Self-Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86

Appendix G: Description of the Toolkit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94

Appendix H: Charter Statements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95

ENDORSEMENTS

Ontario Association of Social Workers (OASW) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96

Ontario Society of Occupational Therapists (OSOT) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97

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How to Use this Document

BACKGROUND
This healthy work environmentG best practice guideline (BPG) is an evidence-based document that focuses on developing
and sustaining interprofessionalG health care. It contains much valuable information, but is not intended to be read
and applied all at once. We recommend you review and reflect on the document and implement the guidelines as
appropriate for your organization at a particular time. The following approach may be helpful:

1. Study the Healthy Work Environments Organizing Framework: Developing and Sustaining Interprofessional
Health Care was built on the Healthy Work Environments Organizing Framework, which was created to help users
understand relationships among key factors in the workplace. Understanding the framework is critical to using the
guideline effectively. We suggest you start your work with the guideline by reading and reflecting on the framework.

2. Identify a focus: Once you have studied the framework, we suggest identifying an area you believe needs attention
to create a supportive environment for interprofessional health care.

3. Read the recommendations and the summary of research for your focus: Each major element of the model offers
a number of evidence-based recommendations. The recommendations are statements of what nursesG, organizations,
and systems do, or how they behave, to provide a supportive, violence-free work environment for nurses. and other
health-care providers. The literature supporting each recommendation is summarized briefly. We believe you will
find it helpful to read the summaries to understand the “why” of the recommendations.

4. Focus on the recommendations or desired behaviour most appropriate for you and your current situation:
Our recommendations are not meant to be applied as rules. Rather, they are tools to assist individuals, organizations
and systems developing and sustaining interprofessional health care. In some cases there is a lot of information to
consider. You will want to explore ideas and identify behaviours that need to be analyzed and perhaps strengthened
for your situation.

5. Start planning: When you have selected a small number of recommendations and behaviours to work on, consider
strategies to implement them. Make a tentative plan for what you might actually do to address the issues you are
focusing on. If you need more information, you might wish to consult some of the material cited in the references.

6. Discuss the plan with others: Take time to get input on your plan from people it might effect, or whose engagement
will be critical to success, and from trusted advisors, who will give you honest and helpful feedback on your ideas.
This is an important phase for developing and sustaining interprofessional health care.

7. Revise your plan and get started: It is important to keep gathering feedback and adjusting your plan in response to
it as you implement recommendations from this guideline. Developing and sustaining interprofessional health care
is a lifelong quest; enjoy the journey.

* Throughout this document, terms marked with the superscript symbol G (G) can be found in the
Glossary of Terms (Appendix A).

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Purpose and Scope

BACKGROUND

Purpose:
This best practice guideline, Developing and Sustaining Interprofessional Health Care: Optimizing patients/clients,
organizational, and system outcomes is intended to foster healthy work environments. The focus in developing this
guideline was identifying attributes of interprofessional careG that will optimize quality outcomes for patients/
clientsG, providers, teamsG, the organization and the system.

Scope:
This guideline identifies best practices to enable, enhance and sustain teamworkG and interprofessional collaboration,
and to enhance positive outcomes for patients/clients, systems and organizations. It is based on the best available
evidenceG; where evidence was limited, the recommendations were based on the consensus of expert opinionG.

Target Audience:
The target audience includes nurses and health-care professionals in all roles and practice settings, including
interprofessional team members; non-nursing administrators at the unit, organizational and system level; clinical
nurses; students; educators; researchers; policy makers and governments; professional organizations, employers,
labour groups; and federal, provincial and territorial standard-setting bodies.

Guiding Principles and Assumptions

1. More effective teams produce better outcomes
2. Collaborative teams are more effective than individual health-care providers
3. Patients/clients are an integral part of interprofessional teams
4. The total expertise of team members is greater than the sum of its parts and produces better outcomes
5. Services are holistic and coordinated across the full spectrum of providers
6. The reward of improved patient/client outcomes is the best incentive for high-functioning interprofessional teams
7. There are ingrained power and status differentials that are discussed by the team to support effective team
functioning
8. The power differential between health-care providers and between patients/clients needs to be acknowledged
and addressed through policies
9. Financial frameworks and incentives advance interprofessional team-based health services

See Appendix A for a glossary of terms. See Appendices B and C for the guideline development process and process
for systematic reviewG/search of the literature.

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Summary of Recommendations

BACKGROUND
We have organized these recommendations according to the key concepts of the Healthy Work Environments
Framework:
■ System-based recommendations
■ Organizational recommendations
■ Individual/Team recommendations

System-Based Recommendations
1.0 System-wide partnerships
1.1 Leaders of key agencies (governments, academic institutions, regulatory bodies, professional associations,
and practice-based organizations) collaborate to make interprofessional care a collective strategic priority.
1.2 Agencies in the health-care system strategically align interprofessional care with their other initiatives for
healthy work environments.
1.3 Interprofessional care partnerships across organizations agree on an evidence-based approach to planning,
implementation, and evaluation for joint activities.

2.0 Power and hierarchy in systems

2.1 Show willingness to acknowledge and share power across organizational boundaries by:
a. Talking about power: be open to constructive and courageous conversations that examine inequities,
privilege and power differentials;
b. Building a collaborative inter-organizational environment by recognizing and understanding your power
and its influence on others around you;
c. Creating balanced power relationships through sharing leadership, decision making, authority and
responsibility;
d. Including diverse voices in collaborative decision making;
e. Sharing knowledge with each other, not withholding or hoarding information; and
f. Creating safe collaborative spaces where everyone feels welcome.

3.0 Academic organizations

3.1 Academic organizations build interprofessional care knowledge and competenciesG into their curricula.
3.2 Academic organizations prepare students to work in interprofessional teams by:
a. Instilling values, skills and professional role socialization that will support interprofessional care;
b. Developing, implementing and evaluating education models that foster interprofessional values and skills;
and
c. Enhancing educational and clinical opportunities for health professions to study and learn together.

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4.0 Research recommendations

4.1 Researchers partner with decision makers to conduct research examining the impact of interprofessional care
BACKGROUND

teams on both patient/client outcomes and on health-care teamsG.

4.2 Health research granting agencies develop and maintain a focus on Interprofessional care research
priority areas.
4.3 Researchers use knowledge translation strategies to encourage action on research findings by funders,
government, professional associations and regulatory bodies, as well as by unions, health-care organizations,
educational institutions, study participants and other stakeholders.

5.0 Professional associations, regulatory bodies and unions

5.1 Professional associations, regulatory bodies and unions can support interprofessional care by:
a. Including it in legislation and policies for their members;
b. Working together to develop joint competencies and standards for interprofessional care;
c. Working
 together to add interprofessional care principles to approval standards for education programs;
and
d. Including interprofessional care as a competency for licensure.

6.0 AccreditationG organizations

6.1 Accrediting bodies for organizations and education programs develop standards and performance indicators
for interprofessional care.

7.0 Government
7.1 Governments can support the culture required for interprofessional care by:
a. Making interprofessional care a priority, and evaluating its impact; and
b. Providing health-care organizations with the fiscal resources required to develop, implement and evaluate
interprofessional care.

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Organizational Recommendations

BACKGROUND
8.0 Power and hierarchy in organizations
8.1 Organizations must acknowledge the impact of power and hierarchy by:
Identifying imbalances of power and making changes to equalize power and build mutually supportive, safe
interprofessional workplaces.
8.2 Organizations need to engage and develop leaders at every level, including among their point-of-care health
professionals, for successful interprofessional care.
Strategies for doing that include:
a. Developing interprofessional care champions/role models in different professions and programs; and
b. Offering leadership courses to introduce the concepts and competencies of interprofessional care and its
management.

9.0 Operational supports

9.1 Organizations promote interprofessional care by developing a culture that expects collaboration and creates
the operational supports it will need to succeed by:
a. Establishing human resources plans that allow dedicated time and coverage for staff to participate in
interprofessional activities e.g. team development, a team charter (see Appendix E, H) and effective
communication;
b. Designing buildings, spaces, programs and care pathways to accommodate and encourage interprofessional
care; and
c. Considering shared spaces for patients/clients and team members to enhance opportunities for
communication and innovation.

10.0 Competent communication

10.1 Organizations can support interprofessional care through enhanced communication by:
a. Establishing effective communication processes and tools to support collaboration and communication in
teams, professions, with patients/clients and across programs and organizations;
b. Standardizing documentation and encouraging information sharing;
c. Adopting strategies to tackle issues such as “turf ” protection and disrespectful communication; and
d. Creating a culture that promotes regular formal and informal communication among team members with
team rounds and care conferences.

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Individual/Team Recommendations
BACKGROUND

11.0 Supporting interprofessional team and care delivery

11.1 All health-care professionals, as well as volunteers and students, demonstrate their commitment to the
principles of interprofessional care by:
a. Practising and collaborating with colleagues, patients/clients and families in a way that fosters respect, trust
and understanding;
b. Understanding their roles and expertise, reflecting on their practice, being confident in their own abilities,
and expertise, knowing the standards and boundaries of their practice and recognizing when it’s time to turn
to other team members; and
c. Developing communication and conflict-management skills.

12.0 Power and hierarchy in teams

12.1 Team members demonstrate their willingness to share power by:
a. Building a collaborative environment through recognizing and understanding power and its influence on
everyone involved;
b. Creating balanced power relationships through shared leadership, decision making, authority, and
responsibility;
c. Including diverse voices for decision making;
d. Sharing knowledge with each other, openly; and
e. Working collaboratively with patients/clients and their families to plan and deliver care.

13.0 Interprofessional education

13.1 Individuals develop skill and competency in precepting, mentoring and facilitating interprofessional learning.

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Types of Evidence

BACKGROUND
EVIDENCE RATING TYPE OF EVIDENCE

A Evidence obtained from controlled studies, meta-analysesG

A1 Systematic Review

B Evidence obtained from descriptive correlational studiesG

C Evidence obtained from qualitative researchG

D Evidence obtained from expert opinion

D1 Integrative ReviewsG

D2 Critical ReviewsG

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Advisory Committee Members

BACKGROUND

Doris Grinspun, RN, MSN, PhD, LLD (hons), Joshua Tepper, MD, FCFP, MPH, MBA
O.ONT. Vice President, Education
Chief Executive Officer Sunnybrook Health Sciences Centre
Registered Nurses’ Association of Ontario

Craig Jones, MD
Director
Vermont Blueprint for Health

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Development Panel Members

BACKGROUND
Rani Srivastava, RN, PhD Danielle Lubbers, BScN
Panel Co-chair University of Windsor, Thames Nursing Society
Chief of Nursing & Professional Practice Windsor, Ontario
Centre for Addiction and Mental Health
Toronto, Ontario Patti McGillicuddy, MSW, RSW
Director, Professional Practice, Health Professions
Stewart Kennedy, MD, CCFP, MHA University Health Network
Panel Co-chair, Past president Toronto, Ontario
Ontario Medical Association
Toronto, Ontario Charmaine McPherson, RN, PhD
Associate Professor
Salma Debs-Ivall, RN, MScN School of Nursing
Manager, TOH Models of Nursing & Interprofessional St. Francis Xavier University
Patients/clients Care, The Ottawa Hospital Antigonish, Nova Scotia
Ottawa, Ontario
Sheri Oliver, RPN
Laurie Goodman, RN, BA, MHScN Manager, Education Initiatives
Advanced Practice Nurse/Educator, Registered Practical Nurses Association of Ontario
Toronto Regional Wound Healing Clinic Toronto, Ontario
Dermatology Office of Dr. R. Gary Sibbald
Mississauga, Ontario Hazel Sebastian, MA, MSW, RSW
Psychogeriatric Resource Consultant
Scott Graney, MSW, RSW St. Michael’s Hospital
Professional Practice Leader, Social Work Toronto, Ontario
St. Joseph’s Health Centre
Toronto, Ontario Gary Sibbald, MD, FRCPC, ABIM, DABD, Med
Professor Public Health, Medicine
Rozanna Haynes, RN Dalla Lana School of Public Health
Professional Practice Specialist University of Toronto
Ontario Nurses’ Association Toronto, Ontario
Toronto, Ontario
Judy Smith, RN, BScN, MEd(DE), ENC(C)
Bonny Jung, PhD, BSc(OT) Geriatric Emergency Management Nurse (GEM)
Assistant Professor and Director of Program for Mackenzie Richmond Hill Hospital
Interprofessional Practice, Education and Research Richmond Hill, Ontario
(PIPER)
McMaster University, Hamilton, Ontario Eric Li, MA, BSc. Pharm.
Manager, Pharmacy Practice
Kathleen Klaasen, RN, MN, GNC(C) Ontario Pharmacists’ Association
Chief Executive Officer Toronto, Ontario
Saul and Claribel Simkin Centre
Winnipeg, Manitoba

Declarations of interest and confidentiality were made by all members of the Guideline Development Panel.
Further details are available from the Registered Nurses’ Association of Ontario.

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Registered Nurses’ Association of Ontario

Best Practice Guideline Program Team
BACKGROUND

Althea Stewart-Pyne, RN, BN, MHSC Erica D’Souza, BSc, GC, DipHlthProm
Program Manager Project Coordinator
Registered Nurses’ Association of Ontario Registered Nurses’ Association of Ontario
Toronto, Ontario Toronto, Ontario

Patti Hogg, BA (Hons) Alice Yang, BBA

Project Coordinator Project Coordinator
Registered Nurses’ Association of Ontario Registered Nurses’ Association of Ontario
Toronto, Ontario Toronto, Ontario

Marian Luctkar-Flude, RN, MScN Kim English, RN, BScN, MN

Research Assistant Research Assistant

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Stakeholder Acknowledgement

BACKGROUND
The Registered Nurses’ Association of Ontario wishes to acknowledge the following for their contribution in
reviewing this nursing best practice guideline and providing valuable feedback:

Marta Crawford, RN, BN, MN Jennifer Harrison, RRT, BSc (Hons), BEd (Adult)
Manitoba Health, Manitoba Professional Practice Advisor
College of Respiratory Therapists of Ontario
Ruby Grymonpre, Pharm D, FCSHP Toronto, Ontario
Professor and IPE Coordinator
University of Manitoba John Dick
Winnipeg, MB Peer Support
Ontario Shores Centre for Mental Health Sciences
Maria Casas, RN, GNC(C) Whitby, Ontario
Director of Care
St. Joseph’s Villa Ivan Silver, MD Ed
Sudbury, Ontario Vice President, Education
Centre for Addiction and Mental Health
Val Johnston-Warren, RN, BScN, MN Toronto, Ontario
Clinical Nurse Specialist
Grand River Hospital, Freeport site Kelly Stadelbauer, RN, BScN, MBA
Specialized Mental Health Executive Director
Kitchener, Ontario Association of Ontario, Midwives
Toronto, Ontario
Dawn Burnett, PT, PhD
Director Jane Paterson, MSW, RSW
Academic Health Council – Champlain Region Director Interprofessional Practice
Ottawa, Ontario Centre for Addition and Mental Health
Toronto, Ontario
Samantha Peck, Hon BA
Program Coordinator Lily Spnajevic, RN, BScN, MN, GNC(C), CRN
Family Councils’ Program, Self-Help Resource Centre Advanced Practice Nurse Geriatrics-Medicine
Toronto, Ontario Joseph Brant Memorial Hospital
Burlington, Ontario
Sheila Driscoll, RN, BHA
Nursing Consultant Ivy Oandasan, MD, CCFP, MHSc, FCFP
Ministry of Health and Long-Term Care Associate Professor and Clinician Investigator
Barrie, Ontario Department of Family and Community Medicine,
University of Toronto
Julie Lapointe, PhD, OT(C), OT. Reg. (Ont.) Associate Director, Academic Family Medicine,
Research Analyst / Fellow College of Family Physicians of Canada
Canadian Association of Occupational Therapists Toronto, Ontario
Ottawa, Ontario

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Background to the Healthy Work Environments

Best Practice Guidelines Project
BACKGROUND

Nurses are essential for achieving and sustaining affordable access to high-quality, timely health care for Canadians.
Work environments that maximize health and well-being are essential for good nursing and the best patients/
clients and organizational outcomes: those two realities are the drivers behind the Healthy Work Environment
Best Practice Guideline Project.

What do we mean when we speak of a healthy work environment? It’s one which recognizes nurses’ professionalism
and their ability to work autonomously and to lead. Healthy work environments are safe, collaborative and diverse,
and offer reasonable workloads. But a healthy workplace is not easy to create, and there are many pressures – from
rising costs and calls for increased productivity, to the growing demands of an aging population – that can
undermine it.

The idea of developing and widely distributing a guide for creating healthy work environments was first proposed
in Ensuring the Care Will Be There: Report on Nursing Recruitment and Retention in Ontario (RNAO, 2000, submitted to
the Ontario Ministry of Health and Long-Term Care [MOHLTC] in 2000 and approved by the Joint Provincial Nursing Committee [JPNC]). What has
evolved from that, the Healthy Work Environments Best Practice GuidelinesG Project, is based on needs identified
by the JPNC and the Canadian Nursing Advisory Committee (CNAC, 2002).

The work began in July of 2003, when the Registered Nurses’ Association of Ontario (RNAO), with funding from
MOHLTC, began a partnership with Health Canada’s Office of Nursing Policy to develop best-practice guidelines
for creating healthy work environments for nurses. From the beginning, we were committed to creating evidence-
based guidelines, to ensure the best possible outcomes for nurses, their patients/clients, organizations and the
system as a whole.

We found plenty of evidence on the relationship between nurses, work environments, patients/clients outcomes
and organizational and system performance (Dugan et al., 1996; Estabrooks, Midodzi, Cummings, Ricker, & Giovannetti, 2005;
Lundstrom, Pugliese, Bartley, Cox, & Guither, 2002). A number of studies have shown strong links between nurse staffing and
adverse patients/clients outcomes (ANA, 2000; Blegen & Vaughn, 1998; Cho, Ketefian, Barkauskas, & Smith, 2003; Kovner & Gergen, 1998;
Needleman & Buerhaus, 2003; Needleman, Buerhaus, Mattke, Stewart, & Zelevinsky, 2002; Person et al., 2004; Sasichay-Akkadechanunt, Scalzi, &
Jawad, 2003; Sovie & Jawad, 2001; Tourangeau, Giovannetti, Tu, & Wood, 2002; Yang, 2003) . Evidence shows that healthy work
environments yield financial benefits to organizations in terms of reductions in absenteeism, lost productivity,
organizational health-care costs and costs arising from adverse patients/clients outcomes (Aldana, 2001).

Other reports and articles have documented the challenges of recruiting and retaining a healthy nursing workforce
(CFNU 2011; Bauman et al., 2001). Some have suggested the nursing shortage is a result of unhealthy work environments
(Dunleavy, Shamian, & Thomson, 2003; Grinspun, 2000; Grinspun, 2002; Shindul-Rothschild, Berry, & Long-Middleton, 1996). Strategies to
enhance nurses’ workplaces are needed to repair the damage of a decade of relentless restructuring and downsizing.

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Achieving healthy work environments for nurses requires transformational change, with interventions that target
underlying workplace and organizational factors (Lowe, 2004). We have developed these guidelines to bring about

BACKGROUND
that change. Implementing them will make a difference for nurses, their patients/clients and the organizations and
communities in which they practice. We anticipate that a focus on creating healthy work environments will benefit
not only nurses but other members of health-care teams as well. We also believe that best practice guidelines can
be successfully implemented only where there are adequate planning processes, resources, organizational and
administrative supports, and appropriate facilitation.

A healthy work environment is…

...a practice setting that maximizes the health and well-being of nurses, quality patients/clients
outcomes, and organizational performance and societal outcomes.

THE PROJECT HAS PRODUCED NINE HEALTHY WORK ENVIRONMENTS BEST PRACTICE GUIDELINES
■ Collaborative Practice Among Nursing Teams

■ Developing and Sustaining Effective Staffing and Workload Practices

■ Developing and Sustaining Nursing Leadership

■ Embracing Cultural Diversity in Health Care: Developing Cultural Competence

■ Professionalism in Nursing

■ Workplace Health, Safety and Well-being of the Nurse

■ Preventing and Managing Violence against Nurses in the Workplace

■ Preventing and Mitigating Nurse Fatigue in Health Care

■ Mitigating and Managing Conflict in Health-care Teams

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 Developing and Sustaining Interprofessional Health Care: Optimizing patient, organizational and system outcomes

Organizing Framework for the Healthy Work

Environments Best Practice Guidelines Project
BACKGROUND

Figure 1. Conceptual Model for Healthy Work Environments for Nurses – Components, Factors & Outcomesi-iii

Physical/Structural Policy Components

al Policy Factors
Extern

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O

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Components Macro Level

A healthy work environment for nurses is complex and multidimensional, comprised of numerous components and
relationships among the components. A comprehensive model is needed to guide the development, implementation
and evaluation of a systematic approach to enhancing the work environment of nurses. Healthy work environments
for nurses are defined as practice settings that maximize the health and well-being of the nurse, quality patients/clients
outcomes, organizational performance and societal outcomes.

The Conceptual Model for Healthy Work Environments for Nurses presents the healthy workplace as a product of
the interdependence among individual (micro level), organizational (meso level) and external (macro level) system
determinants as shown in Figure 1 the three outer circles. At the core of the circles are the expected beneficiaries of
healthy work environments for nurses, patients/clients, organizations and systems, and society as a whole, including
healthier communities. The lines within the model are dotted to indicate the synergistic interactions among all levels
and components of the model.

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 Developing and Sustaining Interprofessional Health Care: Optimizing patient, organizational and system outcomes

The model suggests that functioning within the individual micro level is mediated and influenced by interactions
between the individual and his/her environment. Thus, interventions to promote healthy work environments must

BACKGROUND
be aimed at multiple levels and components of the system. Similarly, interventions must influence not only the factors
within the system and the interactions among these factors but also influence the system itself.

The assumptions underlying the model are as follows:

■ healthy work environments are essential for quality, safe patients/clients care;
■ the model is applicable to all practice settings and all domains of nursing;
■ individual, organizational and external system level factors are the determinants of healthy work environments
for nurses;
■ factors at all three levels impact the health and well-being of
nurses, quality patients/clients outcomes, organizational
and system performance, and societal outcomes either individually or through synergistic interactions;
■ at each level, there are physical/structural policy components, cognitive/psycho/social/cultural components and
professional/occupational components; and
■ the professional/occupational factors are unique to each profession, while the remaining factors are generic for all
professions/occupations.

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 Developing and Sustaining Interprofessional Health Care: Optimizing patient, organizational and system outcomes

Physical/Structural Policy Components

BACKGROUND

Figure 1A. Physical/Structural Policy Components ■ Atthe individual level, the Physical Work Demand Factors
include the requirements of the work which necessitate
al Policy Factors
Extern physical capabilities and effort on the part of the individual.
schedules and shifts, heavy lifting, exposure to hazardous
ational Physical Fact
aniz ors
Org and infectious substances, and threats to personal safety.
Work Demand Fa
cal cto
ysi ■ Atthe organizational level, the Organizational Physical
Ph

rs

Nurse/ Factors include the physical characteristics and the physical

Patient/Client
Organizational environment of the organization and also the organizational
Societal
Outcomes structures and processes created to respond to the physical
demands of the work. Included among these factors are
staffing practices, flexible, and self-scheduling, access to
functioning lifting equipment, occupational health and safety
policies, and security personnel.

■ Atthe system or external level, the External Policy Factors

include health-care delivery models, funding, and legislative,
trade, economic and political frameworks (e.g., migration
policies, health system reform) external to the organization.

Cognitive/Psycho/Socio-Cultural Components
Figure 1B. Cognitive/Psycho/Socio-Cultural Components ■ Atthe individual level, the Cognitive and Psycho-social Work
Demand Factors include the requirements of the work which
necessitate cognitive, psychological and social capabilities
and effort (e.g., clinical knowledge, effective coping skills, and
communication skills) on the part of the individual. Included
among these factors are clinical complexity, job security, team
relationships, emotional demands, role clarity, and role strain.
Nurse/
Patient/Client
Social Work D

Organizational ■ At the organizational level, the Organizational Social Factors

Cogniti
Organiza

Societal
are related to organizational climate, culture, and values.
Externa

Outcomes
v e an
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yc Included among these factors are organizational stability,

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relations and a culture of continuous learning and support.

ra

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to
rs
■ Atthe system level, the External Socio-Cultural Factors
include consumer trends, changing care preferences, changing
roles of the family, diversity of the population and providers,
and changing demographics – all of which influence how
organizations and individuals operate.

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 Developing and Sustaining Interprofessional Health Care: Optimizing patient, organizational and system outcomes

Professional/Occupational Components

BACKGROUND
Figure 1C. Professional/Occupational Components ■ At the individual level, the Individual Nurse Factors include
the personal attributes and/or acquired skills and knowledge
of the nurse which determine how she/he responds to the
physical, cognitive and psycho-social demands of work.
Included among these factors are commitment to patients/
clients care, the organization and the profession; personal
values and ethics; reflective practice; resilience, adaptability
Nurse/

ational Factors
Patient/Client and self confidence; and family work/life balance.
tors

Factors
Organizational
ac

Societal
At the organizational level, the Organizational/Professional/
rse F

■
Outcomes
tional
ccup
Nu

du
Occupational Factors are characteristic of the nature and role
al

upa
O

ivi
al /

In d
of the professional/occupation. Included among these factors
Occ
ion

fe
ss

al /

ro
on

n al P are the scope of practice, level of autonomy and control over

ssi

er
Ext ro
fe

lP practice, and intradisciplinary relationships.

terna
Ex

■ At the system or external level, the External Professional/

Occupational Factors include policies and regulations at the
provincial/territorial, national and international level which
influence health and social policy and role socialization
within and across disciplines and domains.

i Adapted from DeJoy, D.M. & Southern, D.J. (1993). An Integrative perspective on work-site health promotion.
Journal of Medicine, 35(12): December, 1221-1230; modified by Lashinger, MacDonald and Shamian (2001); and further modified by Griffin,
El-Jardali, Tucker, Grinspun, Bajnok, & Shamian (2003)

ii Baumann, A., O’Brien-Pallas, L., Armstrong-Stassen, M., Blythe, J., Bourbonnais, R., Cameron, S., Irvine Doran D., et al. (2001, June). Commitment
and care: The benefits of a healthy workplace for nurses, their patients/clients, and the system. Ottawa, Canada: Canadian Health Services
Research Foundation and The Challenge Foundation.

iii O’Brien-Pallas, L., & Baumann, A. (1992). Quality of nursing worklife issues: A unifying framework. Canadian Journal of Nursing Administation,
5(2):12-16.

v Green, L.W., Richard, L. and Potvin, L. (1996). Ecological foundation of health promotion. American Journal of Health Promotion, 10(4): March/
April, 270-281.

iv Hancock, T. (2000). The Healthy Communities vs. “Health”. Canadian Health Care Management, 100(2), 21-23.

vii Grinspun, D. (2010). The Social Construction of Nursing Caring. (Doctoral Dissertation, York University).

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Background Context of the Guideline on

Developing and Sustaining Interprofessional
BACKGROUND

Health Care: Optimizing Patient,

Organizational and System Outcomes
A work environment is healthy for nurses when it maximizes their health and well-being, as well as quality
patients/clients outcomes and the organization’s performance. Effective interprofessional teamwork is part
of a healthy work environment.

The Government of Canada, seeking to improve health care, assembled a working group of the provincial and
territorial first ministers in 2012. This group was asked to integrate best practices for three priority areas: clinical
practice guidelines, team-based health-care delivery models and health human resource management initiatives.
Their report, From Innovation to Action (First Ministers’ Health Care Innovation Working Group, 2013) highlighted the importance
of team-based care delivery, using competencies developed collaboratively by health professionals.

Interprofessional care – comprehensive health services provided by multiple caregiversG working collaboratively
– is important in all health-care settings to enhance health outcomes and patients/clients experiences, reduce costs
and improve the work environment for all providers (First Ministers’ Health Care Innovation Working Group, 2013).

Despite the range of professionals involved, interprofessional care is not restricted to hospitals. It can be delivered
in a variety of settings, sometimes, thanks to technological advances, by team members in multiple locations,
which may be across town or hundreds of kilometers apart. Interprofessional teams work with patients/clients as
they move across health-care sectors, whether that’s from long term care to acute care, or in the community or at
home. That’s why good communication is a core competency of interprofessional teams. Patients/clients and their
families’ support networks are also integral to interprofessional care. The focus of this best practice guideline is to
help you develop your role on your interprofessional team.

Interprofessional care was a response to a variety of changes, including increasingly complex patients/clients,
limited resources, shifting demographics and changing laws, priorities and mandates. A number of regulated
professions, including nurse practitioners, occupational therapists, pharmacists, dieticians and physician assistants,
have initiated changes in scopes of practice and diversification of their skills to foster collaborative interprofessional
practice and care.

Interprofessional care is the provision of comprehensive health services to patients/clients by multiple

health caregivers who work collaboratively to deliver quality care within and across settings.
(From Innovation to Action: The First Report of the Health Care Innovation Working Group, Council of the Federation,2012, p.14)

This guideline aligns with the first ministers’ team-based care priority, which encourages health professionals to
work to their full professional scope to better meet patient/client and community needs in a safe, competent, and
cost-efficient manner (From Innovation to Action, 2012).

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Figure 2. Conceptual Model for Developing and Sustaining Interprofessional Health Care

BACKGROUND
Conceptual Model for Developing and Sustaining Interprofessional Health Care*

Healty Work Environment

Competent Communication
Policy/Physical/ • Is clear, focused, transparent and respectful Cognitive/Psycho/
• Constructively manages conflict
Structural • Maintains and enhances the relationship Social/Cultural
Components Components
Care Expertise
• Patient/client are full participants in their own care
• Encompasses specific contributions and
collective knowledge and dictated by the
complexity of the patient/client needs
• Greater complexity may dictate
Effective Group Functioning a need for coordination of
specialized expertise
• Group members assess, practice and Shared Power
reflect upon effective group processes • Creating balanced power relationships
• Collaborate together to formulate, • Leveraging opportunities for all team

Professional/
implement and evaluate care
• Intentionally engage to formulate Goal: members to contribute
• Contributes to healthy work environment Professional/
implement and evaluate care Exemplary Interprofessional
Occupational Care for Patients/Clients and Occupational
Components Shared Decision Making their Support Network Collaborative Leadership Components
• Develop structures and processes
to support shared decision making • Reflects shared accountability that
• Reflect the priorities addresses power and hierachy
• Communicate and implement with • Utilizes structures and processes
respect of the context and the Optmizing to advance exemplary care
contribution of each team
member within and across
Profession/Role/Scope
the team of care • Demonstrate knowledge application
of own profession/scope
• Exploring and integrating roles of others
• Optimizing interface to result in
enhanced care

Cognitive/Psycho/ Policy/Physical/
Social/Cultural Structural
Components Components

Quality & Safety Continuous

Improvement/Enhancement

*Adapted from the National Competency Framework and the RNAO Model for Healthy Work Environments for Nurses

Overview of the Conceptual Model for

Developing and Sustaining Interprofessional Care
Figure 2 presents a model developed by the “RNAO expert panel” based on the National Interprofessional
Competency Framework (Canadian Interprofessional Health Collaborative (CIHC), (2010)) and the Registered Nurses’ Association
of Ontario Model for Healthy Work Environments for Nurses. In this model exemplary interprofessional care in a
healthy work environment is a product of synergy among health-care teams, who demonstrate expertise in its six
key domains, which are:
a. Care expertise;
b. Shared power;
c. Collaborative leadership;
d. Optimizing profession, role and scope;
e. Shared decision making; and
f. Effective group functioning.

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The six domains are shown surrounded by an outer circle of expected benefits for the health-care team and the
organization: a healthy work environment with enhanced quality and improved safety. The domains are supported
BACKGROUND

by competent communication and the three foundational components of the healthy work environment model:
a. Policy, physical, structural;
b. Professional/occupational; and
c. Cognitive/psycho/social/cultural.

The six domains are fundamental for transforming work environments to a collaborative interprofessional
environment, while the foundational components support and influence each domain to achieve the goal of
exemplary interprofessional care for patients/clients and their support networks.

When interprofessional care has been successfully implemented and sustained, continuous improvement in
quality and safety occur on three levels – for patients/clients, for interprofessional providers and for the organization
and system.

Care Expertise
Interprofessional care requires collaboration between health-care professionals and patients/clients and their families
and circles of careG, in order to identify and take advantage of each professional’s care expertise. Specific types
of expertise may have to be sought out, depending on a patient’s/client’s needs. Effective use of different types of
expertise can be reflected in measures of quality including improved long-term outcomes, quality of life and cost
control.

A patient’s/client’s needs are determined by a collaborative interprofessional assessment, to identify what expertise is
required. That assessment and the treatment goals and strategies it suggests be individualized for each patient/client
and followed by a collaborative and coordinated effort to find the best expert for the patient/client.

At the organizational and system level, policies, practices and structures are in place enabling all health providers
to optimize their scope of practice for the benefit of both the patient/client and themselves. To provide optimal
expertise, a novice professional is encouraged to draw on the knowledge and support of an expert in the same
profession (which speaks to the need for expertise versus the need for competenceG).

The degree of care expertise needed is dictated by the complexity of a patient’s/client’s needs. The availability of
expertise is affected by geographical location and local setting.

Shared Power
Shared power happens when each team member is open to letting others influence patients/clients care regardless
of their educational or professional preparation (Orchard, Curran, & Kabene, 2009). Willingness to share power is a
commitment to create balanced relationships through democratic practices of leadership, decision making, authority,
and responsibility (D’Amour, Ferrada-Videla, San Martin, & Beaulieu, 2005b). Willingness to share power contributes to a healthy
work environment where all team members, including the patient/client feel engaged, empowered, respected and
validated (SJHC, 2009).

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Collaborative Leadership

BACKGROUND
Collaborative leadership (also called reciprocal or shared leadership) is a people- and relationship-focused approach
based on the premise that answers should be found in the collective (the team). According to Michael D. Kocolowski’s
2010 paper, “Shared Leadership: Is it Time for a Change?”, collaborative leadership has several characteristics, including:

COLLABORATIVE LEADERSHIP
■ Reflects shared accountability that addresses power and hierarchy

■ Utilizes structures and processes to advance exemplary care

a. Promoting a collective leadership process based on the belief that at different times and depending on the need,
situation, and requirements, different people assume the leadership role and work is assigned based upon the skill
requirement.
b. Structuring a learning environment that supports continuous self-development and reflection. The team members
are encouraged to learn together and from each other, and to cultivate practices of open-mindedness, mutual trust,
constructive feedback and viewing conflict as an opportunity for growth.
c. Supporting relationships that value honesty, mutual respect, expecting the best from others, and the ability to
exercise personal choice. Collaborative leadership focuses on facilitating the ability of the team to live those values
towards a shared vision that allows people to set common goals and direction.
d. Fostering shared power that implies shared responsibility and accountability for decision making and for learning.
Power is found at the centre of the team rather than at the top of the hierarchy.
e. Practising stewardship and service (rather than focusing on personal power and control) to ensure the interests
and needs of others are being served.
f. Valuing diversity and inclusiveness by respecting individual differences, which will result in freedom to learn
together and exercising collective ownership.

Optimizing Profession, Role and Scope

Exemplary interprofessional care lets all team members work to their full scope of practice, and takes advantages of
the synergies professionals working together can create. The Council of Federations (2012) identified the need for
all health-care professionals to work to their full scope of professional capacity, while the National Interprofessional
Competency Framework (CIHC, 2010) says practitioners must understand not only their roles but also those of other
practitioners on the team. It also says practitioners must be able to articulate their roles, knowledge and skills
and use effective listening skills with other team members. The British Columbia Competency Framework for
Interprofessional Collaboration (2008) states all practitioners must respect each other’s professional culture and
values. The message is that old-fashioned professional “turf ” wars have no place in interprofessional care; rather,
overlapping scopes and roles are embraced as an opportunity to collaborate and advance the role of exemplary
care for patients/clients and their support network.

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Shared Decision Making

BACKGROUND

Shared decision making gives all team members, including patients/clients, the opportunity to contribute their
knowledge and expertise, to arrive collaboratively at an optimal goal (Orchard et al., 2009). It requires respectful and
trusting relationships among providers and between them and the patient/client. For shared decision making to
work, everyone must recognize and respect each others’ knowledge and expertise, regardless of occupation and
formal position (Grinspun, 2007). Everyone must also accept that each team member has both the right and ultimate
responsibility to share knowledge to contribute toward a patient’s/client’s plan of care (Orchard et al., 2009). Shared
decision making also means, importantly, that each team member must be willing to accept responsibility
for decisions.

Shared decision making is not appropriate in every situation. For example, in an emergency such as a code blue, a
patient’s/client’s life depends on the person running the code, making decisions and directing the team quickly and
decisively. However, where decisions are shared, all team members can participate in a review of their responses
after an emergency is over. There are other situations in health care where some team members do not get to offer
input. In those situations, transparency around decision making is very important. Team members can continue to
feel valued and respected if they know in advance which decisions are shared and which are not. Collaboration is a
continuum, from least collaborative, where team members are told what is happening without any opportunity for
input, to most collaborative, in which teams can expect to co-create outcomes with maximum opportunity for input
(D’Amour, Goulet, Labadie, Martín-Rodriguez & Pineault, 2008).

Shared decision making does not mean everything must be decided unanimously. Decisions may be made by one or
more people, or by team consensus. What is important is that each member of the team, including the patient/client,
has an appropriate opportunity to influence the plan of care (Edwards, Davies & Edwards, 2009). Quaschning, Korner, and
Wirtz, (2013) suggest shared decision making is important to optimize patients’/clients’ participation and enhance
a high quality of care.

Effective Group Function

A health-care system that supports effective teamwork can improve the quality of patients/clients care, enhance
patients/clients safety, and reduce workload issues that cause burnout among professionals (Oandasan & Reeves, 2005).
We have adapted our definition of effective team functioning in interprofessional care from Ivy Oandasan and
Scott Reeves (2005), who describe it as the successful interaction or relationship of an interprofessional health-
care team who work interdependently to provide care for patients/clients. In the National Interprofessional
Competency Framework (Canadian Interprofessional Health Collaborative (CIHC), (2010)), effective team functioning is one of
the six competency domains, and its key competency is that “learners/practitioners understand the principles of
team dynamics and group processes to enable effective interprofessional team collaboration” (p.11). The Conceptual
Model for Developing and Sustaining Interprofessional Health Care uses the word group in the domains, rather than
team, to draw attention to the importance of group process development and maintenance (see Figure 2).

To function effectively, interprofessional team members are expected to work collaboratively to formulate, implement
and evaluate care and assess, practice and reflect on whether the group processes they have used were effective (CIHC,
2010, Oandasan et al., 2006).

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In 2011, Adamson examined the empathy between members of interprofessional teams within a hospital environment.
Findings from the study found interprofessional empathy was an important part of the relationships among

BACKGROUND
interprofessional team members. Six themes emerged as critical to the development of effective and highly
empathetic teams:
1. Engaging in conscious interactions;
2. Using dialogic communication;
3. Understanding each other’s roles;
4. Appreciating personality differences;
5. Taking perspective; and
6. Nurturing the collective spirit.

The evidence also found accessibility, team building, overlapping scopes of practice, teachable moments, perception
of workload, empathetic leadership, non-hierarchical work relationships and job security provided the necessary
organizational supports to promote and sustain positive interprofessional relationships (Adamson, 2011).

Competent Communication
Competent communication – openness, honesty, respect for each other’s opinions and effective communication skills –
is part of all domains of interprofessional practice (Humphreys & Pountney, 2006). Team communication goals are achieved
by sharing and responding to information in a timely manner, actively listening to other points of view, communicating
clearly and succinctly, (Shaw, de Lusignan, & Rowlands, 2005) and using established processes and tools for sharing information
(Mulkins, Eng, & Verhoef, 2005). Effective communication enhances interprofessional relationships and therefore patients/
clients care and other work-related activities. Competent communication helps develop and sustain leadership and
actively engages members of the team while demonstrating respect and professionalism (RNAO, 2007c).

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Recommendations and Discussion of Evidence

External/System Recommendations
The following recommendations reflect physical/structural, cognitive, psychological, social, cultural, professional
and occupational components of developing and sustaining interprofessional health care in the workplace that
must be addressed at the external/system level to ensure best practice. The external systems factors contained in
the recommendations include:
RECOMMENDATIONS

Physical/Structural Components:
■ Health-care delivery models;
■ Funding; and
■ Legislation/Policy.

Cognitive/Psychological/Social/Cultural Components:
■ Consumer expectations;
■ Changing roles of family; and
■ Diversity of population and health-care providers.

Professional/Occupational Components:
■ Policies and regulations at the provincial/territorial, national and international levels that influence how
organizations and individuals behave with respect to managing and mitigating conflict in the workplace; and
■ Competencies and standards of practice that influence the behaviour/culture of team members.

1.0 SYSTEM-WIDE PARTNERSHIPS

RECOMMENDATION 1.1:
Leaders of key agencies (governments, academic institutions, regulatory bodies, professional
associations, and practice-based organizations) collaborate to make interprofessional care a
collective strategic priority.

RECOMMENDATION 1.2:
Agencies in the health-care system strategically align interprofessional care with their other
initiatives for healthy work environments.

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RECOMMENDATION 1.3:
Interprofessional care partnerships across organizations agree on an evidence-based approach
to planning, implementation, and evaluation for joint activities.

Discussion of Evidence:
There are C, D and D1 types of evidence to support these recommendations.

RECOMMENDATIONS
The Registered Nurses’ Association of Ontario Best Practice Guideline, “Managing and Mitigating Conflict in
Health-care Teams” (2012) highlighted the importance of system-level collaboration, and coordinated legislative and
regulatory reforms, to bring about overall change to the health-care system. That high-level collaboration is needed
to develop, implement and evaluate interprofessional care because so many stakeholders and contexts will be affected
by it. Some authors have spoken of the need for high-level collaboration across organizations, so they can work to
set priorities, especially in terms of health innovation to strengthen health systems (Government of Ontario, 2010; McPherson,
2008). The final report tabled by the Government of Ontario’s Interprofessional Care Strategic Implementation
Committee (2010) stated:

“In Ontario, although interprofessional care (IPC) has gained a foothold at the grassroots level, a concerted, system-
wide approach to its implementation is needed. Implementing interprofessional care, and establishing a firm base for
interprofessional education (IPE), requires the commitment of a range of stakeholders, including regulatory bodies,
health-care professional organizations, academic institutions, hospitals, insurers, community and support agencies,
organized labour, researchers, patient consumer groups, government, crown agencies, health caregivers, educators,
administrators, patients, and families”(p. 5)

Interprofessional care is an innovative way to strengthen health systems. Over the past decade, discussion in the
literature has focused on the notion that such complex change requires deliberate collaborative efforts across
organizational boundaries (Edwards & Di Ruggiero, 2011; McPherson, 2008, 2012; McPherson & McGibbon, 2010; McPherson, Kothari,
& Sibbald, 2010; National Collaborating Centre for Determinants of Health, 2012). Such partnerships would work much like front-
line collaboration by members of interprofessional teams, and allow for aligning interprofessional care with other
strategic priorities.

Some government policies support interprofessional models but others get in the way, including limited human
resources planning, limited research funding, regulations and laws that create silos and payment methods that
discourage collaboration (RNAO, 2012a). There is a critical need for decision makers to break down those barriers and
develop the infrastructure to support interprofessional care. Promoting better understanding of the nature and
benefits of interprofessional care would also help break down system barriers, and there is increasing pressure to link
best practices in interprofessional care to accountability requirements (Canadian Health Services Research Foundation, 2006).

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2.0 POWER AND HIERARCHY IN SYSTEMS

RECOMMENDATION 2.1:
Show willingness to acknowledge and share power across organizational boundaries by:
a. Talking about power: be open to constructive and courageous conversations that examine
inequities, privilege and power differentials;
b. Building a collaborative inter-organizational environment by recognizing and understanding
RECOMMENDATIONS

your power and its influence on others around you;

c. Creating balanced power relationships through sharing leadership, decision making,
authority and responsibility;
d. Including diverse voices in collaborative decision making;
e. Sharing knowledge with each other, not withholding or hoarding information; and
f. Creating safe collaborative spaces where everyone feels welcome.

Discussion of Evidence:
There are B, C, D and D1 types of evidence to support this recommendation.

The notion of organizational power and hierarchy across the health-care system is well covered in the literature
(D’Amour, Ferrada-Videla, San Martin, & Beaulieu, 2005a; D’Amour et al., 2005b; D’Amour & Oandasan, 2005; Islam & Zyphur, 2005; Hudson, 2002).
Relationships among professions (Kenaszchuk, Wilkins, Reeves, Zwarenstein, & Russell, 2010), and across programs, organizations
and sectors are contextual and embedded in socio-political-historical contexts, both past and present (Freyer et al., 2006;
Hudson, 2006; McDonald, Davies, & Harris, 2009).

Orchard, Curran and Kabene (2005) addressed the importance of power sharing in their article on interdisciplinary
collaborative professional practice. The authors claim that power imbalances between health professionals lead to
a lack of sharing in decision making around patients/clients care. They also state that power imbalances within the
health-care system and between the health-care system and patients/clients frequently lead to exclusion of patients/
clients from the planning for, implementation of, and evaluation of their health care. They conclude that this leads
to frustration amongst all parties who are not part of the decision making process (Jones, 2010).

Nevertheless, for everyone to be part of the decision making process, it is important that neither the health-care team
members nor the patients/clients feel treated as inferior, by any member of the team. Working in an integrated way
and allowing greater decision making power within a team is reported to build confidence, while also allowing for
flexibility to alter the plan of care to meet the patient’s/client’s change in condition (Jones, 2010).

A recent qualitative case study (McDonald, Jayasuriya, & Harris, 2012) examining the influence of power dynamics and
trust on inter-organizational multidisciplinary collaboration highlighted three key themes to power dynamics
among health professionals: their use of power to protect their autonomy; power dynamics between private- and
public-sector providers; and reducing dependency on other health professionals to maintain their power. These
authors found that despite government policies supporting more shared decision making, there is little evidence

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it is happening. The study concluded having primary and community-based health services delivered by different
organizations adds another layer of complexity to interprofessional relationships (McDonald et al., 2012).

The Registered Nurses’ Association of Ontario Best Practice Guideline, “Preventing and Managing Violence in the
Workplace” (2009) recommended governments be role models for equity by eliminating hierarchies in the health
ministry that put nurses in subservient roles. Collaboration across organizational boundaries remains challenging
at the practitioner level due to issues of power and hierarchy. From a system wide perspective, the deliberate
consideration of power and hierarchy by senior decision makers as they work across organizational lines is imperative
(McPherson, 2008). This further supports healthy collaborative inter-organizational relationships as a base to create,
align, and monitor evidence-informed policy mechanisms that support the interprofessional care endeavour.

RECOMMENDATIONS
To create a welcoming inclusive climate, the physical design of work stations needs to be considered. A qualitative
study of interprofessional teams within three rural hospitals emphasized the importance of the work station design
on collaboration and interprofessional care. The evidence showed the general physical environment to have a major
influence on effective collaborative practiceĠ. The poor designs that featured insufficient space and profession specific
space were noted to contribute to communication barriers, frequent interruptions, and lack of privacy, while shared
spaces where the health-care team sat together facilitated both social and professional discourse. Shared space can
imply collective responsibility for the patients/clients outcomes (Gum, Prideaux, Sweet & Greenhill, 2012).

3.0 ACADEMIC ORGANIZATIONS

RECOMMENDATION 3.1:
Academic organizations build interprofessional care knowledge and competencies into their
curricula.

RECOMMENDATION 3.2:
Academic organizations prepare students to work in interprofessional teams by:
a. Instilling values, skills and professional role socialization that will support
interprofessional care;
b. Developing, implementing and evaluating education models that foster interprofessional
values and skills; and
c. Enhancing educational and clinical opportunities for health professions to study and
learn together.

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Discussion of Evidence:
There are B, C, D and D1 types of evidence to support these recommendations.

There is a great deal of evidence that interprofessional education can effectively reduce barriers to collaborative
practice and can promote competent communication (Abu-Rish et al., 2012; Cashman, Reidy, Cody, & Lemay, 2004; Curtis, 2008;
Pinnock et al., 2009). Academic organizations play a key role preparing the health workforce for interprofessional
care. There is sufficient evidence to support the proposition that interprofessional collaborative learning, helps
practitioners and agencies work better together (Almas & Barr, 2008; Anderson, Manek, & Davidson, 2006; Hammick, Freeth, Koppel,
Reeves, & Barr, 2007; Hayashi, et al., 2012). However, not all health professions accept that interprofessionalism is a critical
RECOMMENDATIONS

component of undergraduate education. Supportive academic leaders will have to work with accreditation and
regulatory bodies, professional associations, unions, governments and health-care organizations to bring about
curriculum reform to support interprofessional care.

There have been significant global, national, and provincial efforts to advance education in interprofessional care
in both academic and practice-based settings (e.g., Canadian Interprofessional Health Collaborative, 2010; McMaster University, 2012;
University Health Network, 2012; University of British Columbia, 2012). Results from a quantitative pre-test post-test study at Gunma
University Graduate School of Health Sciences in Japan suggest that the stage of study – first year university students
compared to third year university students – as well as the style of educational delivery, may influence the students’
attitude towards interprofessional education and care. The results demonstrated significant changes in attitudes;
that is, the first-year students who participated in interprofessional education via the lecture style were negatively
inclined, whereas the third-year students learning practice-style interprofessional education were positively inclined.
These findings suggest that the program stage as well as the style of educational delivery may influence students’
interprofessional attitudes (Hayashi et al, 2012).

Anderson and colleagues (2006) evaluated a workshop model for interprofessional education in acute care for
students from eight professions. The model was accepted in the hospital, showing that hospital culture was becoming
committed to education models that would bring together a wide range of students for interprofessional learning.
The authors suggested the workshops they designed offered a practical, replicable model that can be sustained. The
model helped students analyze their future interprofessional working responsibilities.

Another study examined a common curriculum for undergraduate health and social care education implemented
in Norway in 1995, (Almas & Barr, 2008). Government policy had recommended a common core curriculum for
undergraduate health and social work programs in all universities and colleges in Norway, with the belief collaboration
in health-care education would improve collaborative practice and deliver more effective and efficient health care.
All educational institutions adopted the common core, but some taught it separately to each professional group,
while others offered it jointly for all or some of their relevant programs. The study found students with a common
curriculum valued interprofessionalism more highly than those without. The study also demonstrated that students
taught the common core in joint programs valued interprofessionalism more highly than those where it was taught
separately. The authors suggested that those students taught together between professions valued their preparation
for collaborative practice more.

Educational literature shows there are benefits for educators who plan and develop team-taught coursework
collaboratively and monitor its impact. Several authors (Crow & Smith, 2003; Nevin, Thousand, & Villa, 2009) report on
joint-teaching modules that suggest co- or team teaching has the potential to be a model for shared learning and
collaboration. Co-teaching requires shared planning and reflection between the educators. Feedback from students

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and tutors on the co-teaching process were positive and the authors stated co-teaching from different faculties
enhances student learning and improves the effectiveness of teaching.

Educators at McMaster University and the University of Ottawa developed the Team Observed Structured Clinical
Encounter (TOSCE) based on the National Interprofessional Competency Framework (CIHC 2010). TOSCE uses
structured simulated team encounters to promote assessment and learning of interprofessional collaboration skills.
The learners use the simulation to practice and gain skills and receive feedback on their performance. Validation work
shows TOSCE is useful as a formative evaluation tool, and further research is focused on exploring its potential use as
a summative tool (Marshall et al., 2008; Solomon et al., 2011).

RECOMMENDATIONS
Education that embeds essential attributes of interprofessional care is needed to advance nursing practice and
interprofessional care. The partnerships between higher education institutions and health-care organizations
promote interprofessional care and support a workforce that is educated to manage continuous change in service
delivery (Howarth, Holland, & Grant, 2006).

4.0 RESEARCH RECOMMENDATIONS

RECOMMENDATION 4.1:
Researchers partner with decision makers to conduct research examining the impact of
interprofessional care teams on both patient/client outcomes and on health-care teams.

RECOMMENDATION 4.2:
Health research granting agencies develop and maintain a focus on Interprofessional research
priority areas.

RECOMMENDATION 4.3:
Researchers use knowledge translation strategies to encourage action on research findings by
funders, government, professional associations and regulatory bodies, as well as by unions,
health-care organizations, educational institutions, study participants and other stakeholders.

Discussion of Evidence:
There are B, C, D and D1 types of evidence to support these recommendations

Pursuing interprofessional care research is imperative to support evidence-based interprofessional practice. Clear
recommendations for interprofessional care research priorities have been outlined in evidence-based documents,
such as peer-reviewed literature and Registered Nurses’ Association of Ontario healthy work environment best
practice guidelines, for some time (CHSRF, 2007; CIHC, 2010; Cohen & Bailey, 1997; Curran & Orchard, 2007; Oandasan & Reeves, 2005;

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RNAO, 2006). Because the body of knowledge on interprofessional care has been developed only over the past 15 years
or so, more time is needed to examine its complexities, including developing a deeper understanding of it and of
the frameworks we think will positively affect health outcomes.

Oandasan and colleagues (2004) outlined key research priorities for interdisciplinary education for collaborative
patients/clients-centered practice in a report. The report states the highest priority be given to research that
demonstrates the interdependency between interdisciplinary education and collaborative practice initiatives. The
report also recommends major research granting agencies be approached to fund interdisciplinary education and
practice initiatives in the future.
RECOMMENDATIONS

5.0 PROFESSIONAL ASSOCIATIONS, REGULATORY BODIES AND UNIONS

RECOMMENDATION 5.1:
Professional associations, regulatory bodies and unions can support interprofessional care by:
a. Including it in legislation and policies for their members;
b. Working together to develop joint competencies and standards for interprofessional care;
c. Working together to add interprofessional care principles to approval standards for
education programs; and
d. Including interprofessional care as a competency for licensure.

Discussion of Evidence:
There are B, C, D and D1 types of evidence to support this recommendation.

The Canadian Interprofessional Health Collaborative (CIHC) put forth recommendations (including interprofessional
care as a competency for licensure) specifically for organizations such as professional associations, regulatory bodies,
and unions in their National Framework document (2010).

Reeves and colleagues, (2010) conducted a systematic literature review on interprofessional education and its effects
on interprofessional practice and health-care outcomes. They found many provincial health professions’ regulatory
frameworks explicitly discuss interprofessional collaboration or practices. Regulators such as registrars and college
boards need to focus on what elements must be demonstrated to show competence in interprofessional collaboration
as part of licensing.

Whether interprofessional frameworks become part of quality assurance, continuing competence, or continuing
professional development, regulators will find a competency framework useful in determining how to guide members
to integrate interprofessional collaboration into their education and practice and how to work together as a group to
address scope-of-practice issues (Reeves et al., 2010).

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6.0 ACCREDITATION ORGANIZATIONS

RECOMMENDATION 6.1:
Accrediting bodies for organizations and education programs develop standards and
performance indicators for interprofessional care.

Discussion of Evidence:

RECOMMENDATIONS
There are A1, B, C, D and D1 types of evidence to support this recommendation.

Several key sources confirm accreditation standards can directly influence what is taught in health education
programs. In their systematic review, Reeves and colleagues (2010) made several observations on interprofessional
education and its effects on interprofessional care and health-care outcomes. They suggested:
■ Interprofessional education will need to be strengthened in health professional education accreditation programs.
■ Accreditors will need to develop measures for interprofessional education in learners programs and practice.
■ Accreditation Canada develops standards and measures for interprofessional care in its accreditation process.
■ Organizations use a competency framework to guide them in developing interprofessional care (Reeves et al., 2010).

The Accreditation of Interprofessional Health Education (AIPHE) project, funded by Health Canada, was a national
collaborative of eight organizations that accredit pre-licensure education for six Canadian health professions: physical
therapy, occupational therapy, pharmacy, social work, nursing and medicine. One of the project’s goals was to ensure
the integration of interprofessional education standards into accreditation for the six participating professions to
help create collaborative patient/client health and social care (AIPHE, 2011). In its report, the collaborative described the
rationale for emphasizing interprofessional education, articulated guiding principles, and provided possible standards
and examples of evidence, as well as a resource list for education programs (AIPHE, 2011).

The Registered Nurses’ Association of Ontario Best Practice Guideline on Collaborative Practice among Nursing
Teams (2006) specifically mentions accreditation bodies in its system-level recommendations on teamwork.
(See recommendation 5.1. in that document).

7.0 GOVERNMENT

RECOMMENDATION 7.1:
Governments can support the culture required for interprofessional care by:
a. Making interprofessional care a priority, and evaluating its impact; and
b. Providing health-care organizations with the fiscal resources required to develop, implement
and evaluate interprofessional care.

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Discussion of Evidence:
There are C, D and D1 types of evidence to support this recommendation.

Several Registered Nurses’ Association of Ontario Best Practice Guideline, focus on the importance of governments
supporting guidelines (2006, 2007, 2009, 2012). Here again, government commitment is critical to interprofessional
success. Unless governments set specific targets for interprofessional care, and assign funding for it, it probably will
not happen (D’Amour & Oandasan, 2005). Successful interprofessional care will also need governments to work with other
sectors in the system, such as academic institutions and health profession regulatory bodies to break down silos in
professional education and practice, promote full scope of practice, and encourage effective use of all health-care
RECOMMENDATIONS

providers (Interprofessional Care Strategic Implementation Committee Final Report, 2010).

Health policy from all governments (federal, provincial and territorial) affects practice, settings and ultimately
patient/client and system outcomes. Government collaboration with other sectors is important for developing
priorities and strategies and shaping public policy. Many government documents have made the case for collaboration
in policy and planning (Currie, 2011).

Organizational Recommendations
The following recommendations are organized using the Healthy Work Environments framework, and reflect the
physical/structural, cognitive, psychological, social, cultural, professional and occupational components of developing
and sustaining interprofessional health care in the workplace that must be addressed at the Organizational level to
ensure best practice. Organizational factors identified in the various components include:

Physical/Structural Components:
■ Physical characteristics and environment of the organization (e.g. sleep rooms for all staff);
■ Organizational structures and processes created to respond to the physical demands of work
(e.g. decision making process regarding overtime and scheduling);
■ Leadership support;
■ Staffing practices; and
■ Occupational health and safety policies.

Cognitive/Psychological/Social/Cultural Components:
■ Organizational climate, culture and values;
■ Cultural norms, especially those that foster support, trust, respect and safety;
■ Communication practices;
■ Labour/management relations; and
■ Culture of continuous learning and support.

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Professional/Occupational Components:
■ Characteristics of the nature and role of nursing within the organization, including organizational policies that
influence scope of practice, level of autonomy and control over practice; and
■ Nurse intra- and interprofessional relationships within the organization.

8.0 POWER AND HIERARCHY IN ORGANIZATIONS

RECOMMENDATIONS
RECOMMENDATION 8.1:
Organizations must acknowledge the impact of power and hierarchy by:
Identifying imbalances of power and making changes to equalize power and build mutually
supportive, safe interprofessional workplaces.

Discussion of Evidence:
There are A1, C, and D types of evidence to support this recommendation.

There are longstanding, often implicit, inequalities among professions, and between professionals and patient/
client and their families. Organizations need to confront the problems caused by power and hierarchy by openly
acknowledging it and discussing its impact on care and those who give it and receive it.

Healthy organizations empower and validate the contributions of all individuals and promote safe, equitable
environments by fostering respect among all people. They also create opportunities for equitable communication,
group interaction, and provision of care and shared decision making. Collaboration was seen as a partnership,
characterized by the simultaneous empowerment of each participant whose respective power is recognized by all
(D’Amour et al., 2005). Furthermore, such power is based on knowledge and expertise rather than functions or titles
(Henneman, 1995). For example, if an environmental custodian, over the course of doing his/her duty, comes into
contact with a patient/client, and through “chatting” with the patient/client receives information that they believe
may be pertinent to that patient’s/client’s treatment, the custodian should in no way feel intimidated or afraid to
share that knowledge (information) with the patient’s/client’s nurse or care-giving team. If the custodian works in an
environment that is hierarchal and that uses top down approaches to interprofessional relationships and perceives
that the treatment team may scorn him/her or accuse him/her of acting outside of their given hospital role, then s/he
may feel that that they have neither the ability nor the opportunity to influence the course of events for the patient/
client. As a result, if the custodian chooses not to share the knowledge with the team due to the above circumstances,
then an organization is fostering unequal power relationships.

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RECOMMENDATION 8.2:
Organizations need to engage and develop leaders at every level, including among their
point-of-care health professionals, for successful interprofessional care. Strategies for doing
that include:
a. Developing interprofessional care champions/role models in different professions and
programs; and
b. Offering leadership courses to introduce the concepts and competencies of interprofessional
care and its management.
RECOMMENDATIONS

Discussion of Evidence:
There are A1, C, and D types of evidence to support this recommendation.

Leadership can be exercised by different members of the team, at different levels and involves managing boundaries
between: formal and informal roles, clinical roles, different professions, personal life experiences, professional
experiences and the team environment (Chreim, Langley, Comeau-Vallee, Hug & Reay, 2013). Leaders and groups can learn to
work more equitably through programs to develop strategies for addressing issues such as “turf ” protection, bullying
and disrespectful communication (Aksoy, Gurlek, Cetinkaya, Oznur, Yazici & Ozgur et al. 2004; Caplan, Williams, Daly, & Abraham, 2004;
Naylor, Griffiths, & Fernandez, 2004; Sennour, Counsell, Jones, & Weiner, 2009).

In a Canadian study researching how leadership practices were exercised across interprofessional teams, Langly et al.
(2013) identified that boundary work is fundamental to the practice of leadership in interprofessional teams. The
authors found health-care leadership requires the management of fragile tension between reinforcing and eliminating
professional boundaries, boundaries which are necessary but can also be problematic for teams Langly et al. (2013).

Leaders promote open dialogue and other measures for creating a more equitable workplace that include integrating
training in cultural competencies and ethics to strengthen reflective, effective and respectful health-care relationships.
Organizational leaders must ensure the allotment of resources to programs, teams and professions is transparent and
balanced. This transparency in the allotment of resources can also contribute to a decreased sense of hierarchy (RNAO,
2007a, 2009, 2012).

Leadership can facilitate a team to realise high levels of collaboration, trust and respect. This creates an environment
in which collective learning and increased responsibility thrive (Greenfield, 2007). These components together enable
front-line staff or point-of-care leaders to take ownership of their service and to integrate the organising and delivery
of services, and in doing so, improve health-care practice (Greenfield, 2007). Leaders at the point of care and throughout
the organization can accelerate adoption of a culture that supports interprofessional care and practices by acting as
role models and facilitators (Donahue, 2013). It is imperative that interprofessional health-care champions are developed
throughout health-care organizations. Conclusions in the literature suggest that having individual champions who
are role models and demonstrate an understanding of the concepts, competency and basic skills in the areas of
interprofessional care result in a positive experience for team members and patients/clients (Curtis, 2008).

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Support for ongoing interprofessional development is important to facilitate success of an interprofessional approach
to care. To date, the types of leadership skills emphasized in leadership programs for point-of-care professionals
include effective communication, project implementation, change management, interprofessional collaboration,
research analysis and improving processes of care (Doran et al., 2012). Leadership development programs also focus on
mentorship to build confidence and empower others (Doran et al., 2012). Team training and having strong team leaders
or champions are critical to successful implementation and maintenance of the interprofessional approach to health
care (Makowsky et al, 2009).

9.0 OPERATIONAL SUPPORTS

RECOMMENDATIONS
RECOMMENDATION 9.1:
Organizations promote interprofessional care by developing a culture that expects
collaboration and creates the operational supports it will need to succeed by:
a. Establishing human resources plans that allow dedicated time and coverage for staff to
participate in interprofessional activities e.g. team development and effective communication;
b. Designing buildings, spaces, programs and care pathways to accommodate and encourage
interprofessional care; and
c. Considering shared spaces for patients/clients and team members to enhance opportunities
for communication and innovation.

Discussion of Evidence:
There are A1, C, D and D1 types of evidence to support this recommendation.

Organizations that invest human, educational, and leadership resources toward interprofessional care may see direct
benefits such as improved quality of care and safety. A systematic review of 14 studies exploring the role of teamwork
and communication in emergency departments found moderate evidence that teamwork could improve access to care
(Kilner & Sheppard, 2010). In addition, the study also demonstrated that staff were highly satisfied with their teamwork
training and had positive attitudes toward teamwork and communication. When emergency staff prioritized the
importance of teamwork and communication, they identified quality of care and safety as key concepts (Kilner & Sheppard,
2010). Furthermore, the study stated it was important to reduce team turnover to optimize growth of interdisciplinary
teams. That, in turn, will increase adaptability to our rapidly changing health-care system (Kilner & Sheppard, 2010).

A semi-structured interview of 16 practitioners in an integrative care clinic was analyzed by coding for categories and
themes (Mulkins et al., 2005). From the practitioners’ perspectives, four central categories emerged as critical elements for
effective integrative care teams:
1. Effective communication tools;
2. Personal attributes;
3. Satisfactory compensation; and
4. A supportive organizational structure.

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The participants interviewed said the exemplary healing and working environments – achieved by strategies
including weekly team meetings, common patient/client charts, standardized protocols, care and compassion toward
teammates – fostered a nurturing atmosphere and were linked to improved patient/client outcomes (Mulkins et al., 2005).

Having the organizational commitment to design and support shared spaces was also noted to be a significant
influence in an evaluation of interprofessional education that integrated social workers, community nurses
and community officers (Curtis, 2008). The evaluation suggested that greater mutual understanding arose from
co-location. As the team matured, members felt there had been an increased understanding of each other’s roles and
one noted outcome was that the delivery of care was enhanced. There was no evidence that any team members saw
themselves as having higher status or importance than others; all were seen as having a vital part to play in sustaining
RECOMMENDATIONS

team effectiveness and securing better outcomes. There was mutual respect among team members for each other’s
contributions. This study found three clear benefits of learning together and working together:
1. Speed: Undertaking tasks more efficiently was a result of an integrated approach.
2. Flexibility: the willingness to work differently and bend traditional professional boundaries to solve problems.
3. Creativity: a distinct aspect of teamwork that fosters opportunities to think about problems in a fresh way
unencumbered by a legacy of ‘this is the way we do things around here’. (Curtis, 2008).

10.0 COMPETENT COMMUNICATION

RECOMMENDATION 10.1:
Organizations can support interprofessional care through enhanced communication by:
a. Implementing effective communication processes and tools to support collaboration and
communication in teams, professions, with patients/clients and across programs and
organizations;
b. Standardizing documentation and encourage information sharing;
c. Adopting strategies to tackle issues such as “turf” protection and disrespectful
communication; and
d. Creating a culture that promotes regular formal and informal communication among team
members with team rounds and care conferences.

Discussion of Evidence:
There are B, C and D types of evidence to support this recommendation.

As patient/client care becomes increasingly complex, effective communication is essential for teams to function
effectively. The evidence suggests having organizational factors such as interdisciplinary guidelines in place and clear
role definition will support effective communication (Gulmans, Vollenbroek-Hutten, Van Gemert-Pijnen, & Van Harten, 2009). Similar
findings were discussed in a study looking at teamwork and communication in the emergency department. These
findings suggested that teamwork and communication play a role in four main areas in the emergency department:

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improving patient/client satisfaction; improving staff satisfaction; reducing clinical errors and improving patient/
client safety; and, facilitating access to care and admissions (Kilner & Sheppard 2010). This study recommended that
organizations establish and support effective communication through the development of interprofessional teams,
introduction of new team members, and specific training focused on teamwork for all members. Other findings in
the study linked improved quality and safety of care to prioritizing the importance of teamwork and communication
(Kilner & Sheppard 2010).

Team communication can also be enhanced through the provision of opportunities for formal (e.g. meetings) and
informal gathering to gain an understanding of each other’s roles and priorities (King & Ross, 2004). Team meetings
benefit from a structured, active and integrative approach that includes procedures for negotiating, decision making

RECOMMENDATIONS
and conflict management (Thylefors, 2012). Having effective communication processes and tools in place (Mulkins et al.,
2005). Communication, motivation, commitment and enthusiasm contribute to team cohesion and a culture that
supports effective interprofessional care (RNAO, 2006). Communication processes and tools include: integrated care
pathways, weekly team meetings, common patient/client charts, standardized protocols, consistent scheduling of
teams on the same shifts and standardized documentation (Mulkins et al., 2005).

Standardized documentation systems make interprofessional communication easier, encourage transparent decision
making and promote evidence-based planning and care delivery. The evidence identifies effective documentation
as having a positive effect on communication with patients/clients and the rest of the care team, leading to positive
outcomes and an increase in provider satisfaction (Mulkins et al., 2005). Shared documentation in the form of care plans,
evidence informed-practice tools and standardized charts provide easy access to patient/client information, for
clinical decisions and planning by the interprofessional team (Prades & Borras, 2011).

Masso and Owen (2009) found that the use of common clinical assessment tools and development of protocols
improved collaboration between providers, improved coordination and integration of care for patients/clients, and
reduced duplication of services.

Interprofessional care plans have been identified as effective resources for improving teamwork, increasing the
efficiency of care processes within an organization and decreasing risk of burnout for team members in hospital
settings (Deneckers, Euwema, Lodewijckx, Panella, Mutsvari Sermeus et al, 2013). Teams can refine their expertise and improve
outcomes by tailoring care plans to the specific needs of the individual patient/client. This lays the foundation for the
development and fostering of a high performing team (Brennan, Butow, Marven, Spillane, & Boyle, 2011; Deneckers et al. 2013;Murchie,
Campbell, Ritchie, & Thain, 2005).

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Individual/Team Recommendations
The following recommendations are organized using the Healthy Work Environments framework and reflect
physical/structural, cognitive, psychological, social, cultural and professional and occupational components of
developing and sustaining interprofessional health care in the workplace that must be addressed at the individual
level to ensure best practice. The individual factors that are identified in the various components include:

Physical/Structural Components
■ Work demands;
RECOMMENDATIONS

■ Work design;
■ Work characteristics; and
■ Workforce composition.

The Cognitive/Psychological/Social/Cultural Components

■ Cognitive, psychological and social capabilities, and effort;
■ Cultural competency;
■ Gender;
■ Working relationships – communication patterns, decision making, conflict resolution and member mentoring;
■ Role clarity;
■ Role strain;
■ Emotional demands;
■ Job security;
■ Clinical complexity; and
■ Clinical knowledge, coping skills communication skills.

Professional/Occupational Components
■ Experience, skills and knowledge;
■ Personal attributes;
■ Communication skills; and
■ Motivational factors.

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11.0 SUPPORTING INTERPROFESSIONAL TEAM AND CARE DELIVERY

RECOMMENDATION 11.1:
All health-care professionals, as well as volunteers and students, demonstrate their
commitment to the principles of interprofessional care by:
a. Practising and collaborating with colleagues, patients/clients and families in a way that
fosters respect, trust and understanding;

RECOMMENDATIONS
b. Understanding their roles and expertise, reflecting on their practice, being confident in their
own abilities, and expertise, knowing the standards and boundaries of their practice and
recognizing when it’s time to turn to other team members; and
c. Developing communication and conflict-management skills.

Discussion of Evidence:
There are C and D types of evidence to support this recommendation.

Practising and collaborating effectively on interprofessional teams requires individuals to demonstrate trust, respect,
and knowledge of each team member’s role. These are foundational competencies for interprofessional care and are
highly valued by health-care providers (Marshall et al., 2008; St. Joseph’s Health Centre, 2009). Along with these characteristics, it
is important for team members, both as professionals and as integral parts of the team to self-assess (see Appendix F)
and reflect on their practice (King, 2013).

It is important for all team members to participate in creating the systems and processes that support an interprofessional
approach to care, and exchanging and applying knowledge is a key process of developing team care (shown in the
conceptual model for developing and sustaining interprofessional health care, Figure 2). All health-care professionals
should facilitate knowledge understanding on interprofessional teams. In a quantitative study, nurse practitioners
in particular were identified as playing a crucial role in facilitating mutual understanding among members of newly
formed teams (Quinlan & Robertson, 2013). Registered nurses were also identified as critical members of interprofessional
teams, often holding great communication power and demonstrating effective knowledge exchange (Quinlan & Robertson,
2013).

Interprofessional collaboration depends on team members knowing their own role and scope of practice and having
the confidence to provide knowledgeable input into care plans.

Following training and practical involvement in interprofessional program activities, physicians, nurses and other health
professionals confirmed they felt more competent in their own roles, more knowledgeable about the role of others in the
continuum of care of patients/clients, and more confident and motivated in performing their tasks and communicating
with other interprofessional members (Quinlan and Robertson, 2013). Team members also demonstrate their commitment to
interprofessional care by recognizing and respecting each other’s roles and expertise (Oandasan & Reeves, 2005).

The effectiveness of any team depends on the ability of its members to solve problems and be accountable for their
work, to overcome barriers (see Appendix D) and resolve conflict. Conflict in health-care environments has many
sources. For example, the interdependent relationships of team members (including patients/clients and families) are

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sometimes complicated by opposing interests, values, beliefs or interpersonal conflict (De Dreu & Van de Vliert, 1997). Failing
to address interpersonal conflict can lead to bad relationships among co-workers, undermine safety and outcomes and
disrupt the organization. Disagreements often result in anxiety, frustration and jealousy, and interpersonal conflict can
leave people feeling angry, betrayed and frustrated (Bishop, 2004).

Having some understanding of conflict and how to manage it is important for the success of teams (RNAO, 2006)
Research has shown relationship conflicts and task conflictG have different consequences. Relationship conflict
produces negative emotional reactions (Jehn, 1995); when it’s very high, individuals suffer frustration, tension and
fear of being rejected by others on the team (Murnighan & Conlon, 1991). It also causes dysfunction in team work,
diminishes commitment to team decisions and decreases organizational commitment (Jehn, Northcraft, & Neale, 1999).
RECOMMENDATIONS

It raises communication problems on the team (Baron, 1991), job dissatisfaction (Jehn, 1995; Jehn, Chadwick, & Thatcher, 1997),
and increases stress levels (Raymond, Simon, Steven, & James, 2000). However, not all conflict has negative outcomes; it can
sometimes have benefits (De Dreu & Van de Vliert, 1997; Jehn, 1995; Jehn & Mannix, 2001).

Task conflict has different consequences: high levels of intense, prolonged conflict hurt individual and team
performance, but moderate levels of task-related conflict can mitigate biased and defective group decision making
(Brodbeck, Kerschreiter, Mojzisch, Frey, & Schulz-Hardt, 2002). The latter outcome is more likely where there is not also relationship
conflict (De Dreu & Weingart, 2003a; Simons & Peterson, 2000), and when members discuss problems and debate their opposing
views, beliefs and opinions in open-minded ways (De Dreu & Weingart, 2003; Tjosvold, 1998). Some studies show that on
certain occasions, conflict may increase creativity and job quality in a group (Amason, 1996), and improve organizational
effectiveness and development (Eisenhardt & Schoonhoven, 1990). Resolving conflict is critical to shared decision making and
creating a supportive environment for interprofessional practice (SJHC, 2009).

12.0 POWER AND HIERARCHY IN TEAMS

RECOMMENDATION 12.1:
Team members demonstrate their willingness to share power by:
a. Building a collaborative environment through recognizing and understanding power and its
influence on everyone involved;
b. Creating balanced power relationships through shared leadership, decision making;
authority, and responsibility;
c. Including diverse voices in decision making;
d. Sharing knowledge openly; and
e. Working collaboratively with patients/clients and their families to plan and deliver care.

Discussion of Evidence:
There are A1, B, C and D types of evidence to support this recommendation.

The nature of health care gives rise to various issues of disagreement among team members, which is further
exacerbated by the complex issue of power distribution (Janss, Rispens, Segers & Jehn, 2012). In health care, there is power

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associated with positions and titles (hierarchies), and power based on knowledge and expertise (Henneman, 1995). In a
systematic review conducted by Kendra and Seenandan (2012), gender inequalities were also identified as a contributor
to power imbalances within the Canadian health-care system. Resulting power struggles were further correlated with a
lack of interprofessional respect among nursing, medicine and allied health-care professionals (Kendra & Seenandan, 2012).

Janss and colleagues (2012) found that medical team members coordinate, cooperate, and communicate based on
personal motivations and their perceptions of power. They suggest teams acknowledge and accept that conflicts
linked to power exist and propose that teams participate in social and organizational training to mitigate the impact
of this power? Or impact of these conflicts? This will foster improved team relations, highlight the need for greater
understanding of motivational factors in teams, and set the foundation for respectful interactions.

RECOMMENDATIONS
Hills, Mullett and Carol (2007) further concluded that the successful implementation of a multidisciplinary or
interprofessional approach to primary care requires moving away from physician-driven care. They suggest that this
can only be achieved once there is a change in the underlying structures, values, power relations, and roles defined
by the health-care system and the community at large, where physicians are traditionally ranked above other
care providers.

Health-care workers are challenged to look for ways to share power with each other, and build positive working
relationships that are appropriate to an organization’s equality-seeking mandate and members’ skills and abilities. By
making a commitment to working together, health-care workers can build and maintain healthy organizations that
empower and validate the contributions of all individuals. However, despite our most fervent efforts, we may never be
able to eliminate power imbalances completely; that is because power is inherent in every relationship whether we like
it or not. Yet, it is crucial that each one of us examine where our individual ideas of power come from, and consider
how we exercise it with our professional colleagues, other health-care workers and our patients/clients. Recognizing
our power and its influence on others around us is a first step towards promoting an egalitarian and collaborative
team environment. Health-care workers need to start to envision human relations where power differentials are
minimized, where people feel solidarity with others, where empathy outweighs personal interests, and where mutual
aid and support are more important than status systems and systems of authority (St. Joseph’s Health Centre, 2009).

The patient/client relies on health-care team members to use their knowledge and expertise to formulate the most
effective treatment plan, customized to the patient’s/client’s needs. Power imbalances lead to a lack of shared decision
making regarding a patient’s/client’s care (Orchard et al., 2009). When team members are willing to share power, they are
contributing to a healthy work environment where all team members including the patient/client feel engaged,
empowered, respected and validated. (St. Joseph’s Health Centre, 2009).

Key Messages
■ Greater equality is a precondition for good social relations.
■ Power can be covert or overt, subtle or blatant, hidden or exposed.
■ Each person must reflect on the impact of how his/her power affects his/her relationship with others.
■ The goal in any relationship is to limit power differential between people.
■ Each team member has power. Team members exercise their power differently. However, some team members
have more power than others. Those who have power over the work of others may abuse their power through the
control of how others work. Those who feel disempowered may practice their power through the use of passive or
overt resistance.

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■ People who have power must take responsibility for the negative impacts of their actions on disadvantaged people,
whether these actions are intentional or not.
(St. Joseph’s Health Centre, 2009)

Actions that Support the Practice of Power Sharing

■ Rotate the Chair of team meetings
■ Include appropriate team members and patients/clients in treatment discussions (include diverse voices)
■ Share knowledge with each other
RECOMMENDATIONS

■ Validate each other’s work experiences, or at least talk about them

■ Create safe spaces where everyone feels welcomed
■ Have constructive and courageous conversations
■ Share roles and responsibilities between all team members, regardless of education or professional preparation
■ Talk about power: power is recognized by everyone when we have discussions and conversations about inequality,
privilege and power differentials
(St. Joseph’s Health Centre, 2009)

13.0 INTERPROFESSIONAL EDUCATION

RECOMMENDATION 13.1:
Individuals develop skill and competency in precepting, mentoring, and facilitating
interprofessional learning.

Discussion of Evidence:
There are A, C, and D types of evidence to support this recommendation.

Organizations need committed and enthusiastic individuals to be competent and skilled champions of interprofessional
care and interprofessional education. Educating people in interprofessional care helps them overcome barriers to
collaborative practice and promotes competent communication (Banez, et al., 2008). Teams that learn together produce
better patient/client outcomes (Reeves & Reeves, 2008). As organizations increasingly offer interprofessional learning
opportunities to students, various types of professionals will need to be trained in facilitation, preceptorship and
mentorship (CNA, 2004). All employees are expected to contribute to the professional development and learning of
students in their own and other professions. Individuals can take part in educating students by letting them shadow
them on the job, participating in orientation, offering student placements, and becoming a preceptor or mentor
(HFO, 2007; Curran & Orchard, 2007).

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Research Gaps and Future Implications

The Registered Nurses’ Association of Ontario expert panel, in reviewing the evidence for this guideline, identified
the following priority research areas. These areas have been broadly categorized into practice, outcomes and health
system research (see Table 1).

Table 1. Priority Practice, Outcomes and Health System Research Areas

CATEGORY PRIORITY RESEARCH AREA

RECOMMENDATIONS
PRACTICE RESEARCH Establishment of a standardized assessment and documentation tool for use by
interprofessional teams in clinical practice

Contextualize the interprofessional team across the various sectors

Impact of communication technologies and ease of access to information on the

interprofessional team

OUTCOMES RESEARCH The value of integrating patient/family as part of the interprofessional team

Impact of interprofessional-based care on in-patient length of stay

Influence of interprofessional teams on staff satisfaction

Impact of interprofessional education on professional practice and specific clinical

outcomes

Effectiveness of various devices utilized for pressure redistribution/offloading in

diabetic foot ulcers

HEALTH SYSTEM Health economic evaluations of interprofessional care strategies

RESEARCH

The information in Table 1, although in no way exhaustive, is an attempt to identify and proritize the critical amount
of research that is needed in this area. Many of the recommendations in the guideline are based on quantitative and
qualitative research evidence. Other recommendations are based on consensus or expert opinion. Further substantive
research is required to validate the expert opinion. Increasing the research evidence can impact knowledge that will
lead to improved practice and outcomes using an interprofessional approach to the delivery of patient care.

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Implementation Strategies
Implementing guidelines at the point of care is multifaceted and challenging; it takes more than awareness and
distribution of guidelines to get people to change how they practice. Guidelines must be adapted for each practice
setting in a systematic and participatory way, to ensure recommendations fit the local context (Harrison, Graham, Fervers &
Hoek, 2013). Our Toolkit: Implementation of Best Practice Guidelines (2nd ed.) (RNAO, 2012b) provides an evidence-informed
process for doing that.

The Toolkit is based on emerging evidence that successful uptake of best practice in health care is more likely when:
RECOMMENDATIONS

■ Leaders at all levels are committed to supporting guideline implementation;

■ Guidelines are selected for implementation through a systematic, participatory process;
■ Stakeholders for whom the guideline is relevant are identified and engaged in the implementation;
■ Environmental readiness for implementing guidelines is assessed;
■ The guideline is tailored to the local context;
■ Barriers and facilitators to using the guideline are assessed and addressed;
■ Interventions to promote use of the guideline are selected;
■ Use of the guideline is systematically monitored and sustained;
■ Evaluation of the guideline’s impact is embedded in the process;
■ There are adequate resources to complete all aspects of the implementation.

The Toolkit (RNAO, 2012b) uses the “Knowledge-to-Action” framework (Straus, Tetroe, Graham, Zwarenstein & Bhattacharyya, 2009)
to demonstrate the process steps required for knowledge inquiry and synthesis. It also guides the adaptation of the
new knowledge to the local context and implementation. This framework suggests identifying and using knowledge
tools such as guidelines, to identify gaps and to begin the process of tailoring the new knowledge to local settings.

The Registered Nurses’ Association of Ontario (RNAO) is committed to widespread deployment and implementation
of our guidelines. We use a coordinated approach to dissemination, incorporating a variety of strategies, including
the Nursing Best Practice Champion Network®, which develops the capacity of individual nurses to foster awareness,
engagement and adoption of BPGs; and the Best Practice Spotlight Organization® (BPSO®) designation, which
supports implementation at the organizational and system levels. BPSOs focus on developing evidence-based cultures
with the specific mandate to implement, evaluate and sustain multiple RNAO best practice guidelines. In addition, we
offer capacity-building learning institutes on specific guidelines and their implementation annually (RNAO, 2012b, p.19-20).

Information about our implementation strategies can be found at:

■ Registered Nurses’ Association of Ontario (RNAO) Best Practice Champions Network:

http://rnao.ca/bpg/get-involved/champions
■ RNAO Best Practice Spotlight Organizations: http://rnao.ca/bpg/bpso
■ RNAO capacity-building learning institutes and other professional development opportunities:
http://rnao.ca/events
■ RNAO’s nursing order sets as a tool to facilitate BPG implementation, please email BNOS@rnao.ca.

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Evaluation & Monitoring of Guideline

Organizations implementing the recommendations in the Healthy Work Environments Developing and Sustaining
Interprofessional Health Care Best Practice Guideline are encouraged to consider how the implementation and its
impact will be monitored and evaluated. Table 2 is based on a framework outlined in the Toolkit: Implementation of
Best Practice Guidelines (2nd ed.), (RNAO, 2012b) and illustrates some specific indicators for monitoring and evaluation
of this guideline.

Table 2. Example of Indicators for Monitoring and Evaluation

RECOMMENDATIONS
LEVEL OF STRUCTURE PROCESS OUTCOME MEASUREMENT
INDICATOR

Objective To evaluate the To evaluate To evaluate To measure

organizational organizational the impact of and monitor
supports that inteprofessional implementation indicators of
enables the processes and of the guideline structures,
health-care team behaviour recommendations processes and
to develop and related to the in various clinical outcomes.
demonstrate conceptual settings.
effective model.
interprofessional
practices.

Organization/ Specific plans in Communication Organizational Human

Unit the organization mechanisms outcomes such as Resources
to implement established and ■ Metrics for Statistics, staff
the Developing used such as:
quality satisfaction
and Sustaining ■ Remote survey, over
Interprofessional ■ Sick time
access, open time hours, staff
Health Care ■ Stability
of
forums, shared turnover, sick
guideline. leadership staff
documentation. time, retention
Structures ■ Retention rates of nursing and
Workload
consistent with health-care
measurement
recommendations staff in all roles.
tools in place
related to
and used
organizational
appropriately
supports are
to plan
evident in the
interprofessional
organization
staffing
such as:
Systems for
■ Processesfor
monitoring
coordination
results of
of care

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LEVEL OF STRUCTURE PROCESS OUTCOME MEASUREMENT

INDICATOR

■ Processes and effective

technology coordination and
to facilitate delivery of care
continuous e.g. patient/staff
communication satisfaction
and access to
RECOMMENDATIONS

information
■ Professionals
working to
full scope of
practice
■ Shared
governance
through
governance
committees

Individual Availability of Individuals Interprofessional An Inventory

Teams education and in all roles team outcomes of Quantitative
supports for the demonstrate such as Tools Measuring
six domains of interprofessional Interprofessional
■ assessment
interprofessional competencies Education and
of quality
competencies: related to each Collaborative
of learning
of the 6 domains Practice
1. Care expertise experience
as outlined in Outcomes
2. Shared power the guideline ■ satisfaction (2012)
with learning
3. Collaborative Regular
experience
leadership performance
appraisal carried ■ demonstration
4. Opitmizing
out including self of
professional/
assessment interprofessional
role/scope
competencies
5. Shared Leadership
in
decision behaviour is
communication
making assessed as part
and quality of
of performance
6. Effective group care
appraisal
functioning

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LEVEL OF STRUCTURE PROCESS OUTCOME MEASUREMENT

INDICATOR

Patient/ High quality Ongoing Patient/client Satisfaction

Client Interprofessional monitoring satisfaction with with Nursing
care plans are in of effects of interprofessional Care
place interprofessional team care Questionnaire
team care (Eriksen, 2005)
Documented
processes
patient/client Patient length

RECOMMENDATIONS
and decisions
feedback on care of stay
on patients/
client, resource Number of Readmission
allocation and unresolved rates
quality patient/client
care issues
Processes for
patients/clients
to provide
feedback on care
are explained to
patients/client
and accessible

Financial Recruitment and

retention cost
savings

Sick time cost

savings

Overtime cost
savings

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Process for Reviewing and Updating the Healthy

Work Environments Best Practice Guidelines
The Registered Nurses’ Association of Ontario proposes to update the Healthy Work Environments Best Practice
Guidelines as follows:

1. Each Healthy Work Environments best practice guideline will be reviewed by a team of specialists (Review Team)
in the topic area to be completed every five years following the last set of revisions.
RECOMMENDATIONS

2. During the period between development and revision, Registered Nurses’ Association of Ontario Healthy Work
Environments project staff will regularly monitor for new systematic reviews and studies in the field.

3. Based on the results of the monitor, project staff may recommend an earlier revision plan. Appropriate
consultation with a team of guideline development members, comprising original panel members and other
specialists in the field, will help inform the decision to review and revise the guideline earlier than the five-year
milestone.

4. Six months prior to the five-year review milestone, the project staff will commence the planning of the review
process by:

a) Inviting specialists in the field to participate in the Review Team. The Review Team will be comprised of
members from the original panel as well as other recommended specialists.

b) Compiling feedback received and questions encountered during the dissemination phase as well as other
comments and experiences of implementation sites.

c) Compiling relevant literature.

d) Developing a detailed work plan with target dates and deliverables.

5. The revised guideline will undergo dissemination based on established structures and processes.

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Seenandan-Sookdeo, K. A., I. (2012). The influence of power in the Canadian healthcare system. Clinical Nurse
Specialist: The Journal for Advanced Nursing Practice, 26(2), 107-112.

Sennour, Y., Counsell, S. R., Jones, J., & Weiner, M. (2009). Development and implementation of a proactive geriatrics
consultation model in collaboration with hospitalists. Journal of the American Geriatrics Society, 57(11), 2139-2145.

Shaw, A., de Lusignan, S., & Rowlands, G. (2005). Do primary care professionals work as a team: a qualitative study.
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Shindul-Rothschild, J., Berry, D., & Long-Middleton, E. (1996). Where have all the nurses gone?: Final results of our
patient care survey. AJN The American Journal of Nursing, 96(11), 25-39. Retrieved from LWW.

Simons, T. L., & Peterson, R. S. (2000). Task conflict and relationship conflict in top management teams: The
pivotal role of intragroup trust. Journal of applied psychology, 85(1), 102-111. Retrieved from APA AMERICAN
PSYCHOLOGICAL ASSOCIATION.

Solomon, P., Marshall, D., Boyle, A., Burns, S., Casimiro, L. M., Hall, P. et al. (2011). Establishing face and content
validity of the McMaster-Ottawa team observed structured clinical encounter (TOSCE). Journal of Interprofessional
Care, 25(4), 302-304. Retrieved from Informa Healthcare London.

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Sovie, M. D., & Jawad, A. F. (2001). Hospital restructuring and its impact on outcomes: nursing staff regulations are
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St. Joseph’s Health Centre, 2009. A Roadmap for Co-Creating Models of Interprofessional Care Retrieved from http://
www.stjoe.on.ca/education/pdf/roadmap.pdf

Straus, S., Tetroe, J., Graham, I.D., Zwarenstein, M., & Bhattacharyya, O. (2009). Monitoring and evaluating
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UK: Wiley-Blackwell

The British Columbia Competency Framework for Interprofessional Collaboration, 2008; Canadian Interprofessional
Health Collaborative. A National Interprofessional Competency Framework. http://www.cihc.ca/

Thylefors, I. (2012). All professionals are equal but some professionals are more equal than others? Dominance, status
and efficiency in Swedish interprofessional teams. Scandinavian Journal of Caring Sciences, 26(3), 505-512.

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University Health Network [UHN], 2012. Interprofessional Education for Internationally Educated Nurses: A Resource
to Support Group Clinical Placement Program Planning, Implementation, and Evaluation. Retrieved from: http://
coned.georgebrown.ca/section/nurs/IPE-IEN-Toolkit.pdf

University of British Columbia, 2012. British Columbia interprofessional model for simulation-based education in
health care: a network of simulation sites. Retrieved from: http://www.ncbi.nlm.nih.gov/pubmed/22878583

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Appendix A: Glossary of Terms

Accreditation: The act of accrediting or the state of being accredited, including the granting of approval to
an institution of learning by an official review board after the school has met specific requirements.

Circle of Care: The expression includes the individuals and activities related to the care and treatment of
a patient. Thus, it covers the health-care providers who deliver care and services for the primary therapeutic
benefit of the patient. It also covers related activities such as laboratory work and professional or case
consultation with other health care providers. Retrieved from http://www.ic.gc.ca/eic/site/ecic-ceac.nsf/eng/
gv00223.html

Collaborative practice: A joint venture or cooperative endeavour that ensures a willingness to participate.
This relationship involves shared planning and decision making, based on knowledge and expertise rather than
on role and title.

Collaborative Relationship/Practice: is defined as a joint venture or cooperative endeavour that ensures a

willingness to participate. This relationship involves shared planning and decision making, based on knowledge
and expertise rather than on role and title (Henneman, Lee & Cohen, 1995).

Competence: The quality or ability of a registered nurse to integrate and apply the knowledge, skills,
judgments, and personal attributes required to practise safely and ethically in a designated role and setting.
Personal attributes include but are not limited to attitudes, values and beliefs (CARNA, 2006; NANB, 2005).

Competencies: Statements about the knowledge, abilities, skills, attitudes and judgments required to perform
safely within the scope of an individual’s nursing practice or in a designated role or setting (CRNBC, 2006b).

APPENDICES
Correlational studies: Studies that identify the relationships between variables. There can be three kinds of
outcomes: no relationship, positive correlation or negative correlation.

Critical reviews: A scholarly article based on a review of the literature on a particular issue or topic, which
also includes the author’s considered arguments and judgments about it.

Evidence: Evidence is information that comes closest to the facts of a matter. The form it takes depends
on context. The findings of high-quality, methodologically appropriate research provides the most accurate
evidence. Because research is often incomplete and sometimes contradictory or unavailable, other kinds of
information are necessary supplements to, or stand-ins for, research. The evidence base for a decision is the
multiple forms of evidence combined to balance rigour with expedience while privileging the former over the
latter (Canadian Health Services Research Foundation, 2006).

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Expert opinion: The opinion of a group of experts based on knowledge and experience, and arrived at
through consensus.

Health caregivers: Regulated and unregulated health-care providers, personal support workers, caregivers,
volunteers and families who provide health care services at the organizational, practice and community levels.

Health-care team: In health care, the most common types of teams are management teams and care delivery
teams, which are the focus of this guideline. These teams can be subdivided by: Patient population (such as
geriatric teams); Disease type (such as stroke teams); or Care delivery settings (such as primary care, hospital
and long-term care), (CHSRF, 2006).

Healthy work environment: A healthy work environment for nurses is a practice setting that maximizes the
health and well-being of nurses, quality patient outcomes and organizational performance.

Healthy work environment best practice guidelines: Systematically developed statements based on best
available evidence to assist in making decisions about appropriate structures and processes to achieve a healthy
work environment (Fields & Lohr, 1990).

Integrative reviews: The integrative process includes the following component: (1) problem formulation;
(2) data collection or literature search; (3) evaluation of data; (4) data analysis; and (5) interpretation and
presentation of results. Retrieved from http://www.findarticles.com/p/articles/mi_ga4117/is_200503/ai_
n13476203

Interprofessional: Teams made up of different professions working together to reach a common goal
and share decision making to achieve the goal. The goal in health care is to work in a common effort with
APPENDICES

individuals and their families to enhance their goals and values. An interprofessional team typically includes
one or more physicians, nurses, social workers, spiritual advisors, personal support workers and volunteers.
Other disciplines may be part of the team, as resources permit and as appropriate (Ferris et al., 2002).

Interprofessional care (IPC): Provision of comprehensive health service to patients by multiple health
caregivers who work collaboratively to deliver quality care within and across settings.

Interprofessional education (IPE): Process by which two or more health professions learn with, from
and about each other across the spectrum of their life-long professional educational journey to improve
collaboration, practice and quality of patient centered care (Centre for Advancement of Interprofessional Education, 2002).

Nurses: Refers to registered nurses, licensed practical nurses (referred to as registered practical nurses, in
Ontario), registered psychiatric nurses, and nurses in advanced practice roles such as nurse practitioners and
clinical nurse specialists.

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Meta-analyses: The use of statistical methods to summarize the results of several independent studies, thereby
providing more precise estimates of the effects of an intervention or phenomena of health care than those
derived from individual studies (Clark & Oxen, 1999).

Patients/clients: Recipient of nursing services. This includes individuals, family members, guardians,
substitute caregivers, families, groups, populations or entire communities. In education, the patient may be a
student; in administration, the patient may be staff; and in research, the patient may be a study participant (CNO,
2002; Registered Nurses Association of Nova Scotia, 2003).

Qualitative research: A method of data collection and analysis that observational, rather than quantitative.
Qualitative research uses a number of methods to obtain observational data, including interviewing participants
to understand their perspectives or experiences.

Systematic review: Using a rigorous scientific approach to review all the data and evidence on a question.
(National Health and Medical Research Council, 1998). Systematic reviews establish where the effects of health
care are consistent, where research results may be applied across various populations and health-care settings,
and where differences in treatment and effects may vary significantly. The use of explicit, systematic methods
in reviews limits bias (systematic errors) and reduces chance effects, thus providing more reliable results upon
which to draw conclusion and make decisions (Clarke & Oxen, 1999).

Task conflict: Task process conflicts occur when determining how task accomplishment should proceed, who’s
responsible for what, and how things should be delegated (Jehn & Mannix, 2001).

Team: A number of persons associated together in work or activity. (Merriam-Webster on line Dictionary.
Retrieved from http://www.m-w.com/cgi-bin/dictionary)

APPENDICES
Teamwork: That work which is done by a group of people who possess individual expertise, who are
responsible for making individual decisions, who hold a common purpose and who meet together to
communicate, share and consolidate knowledge from which plans are made, further decisions are influenced
and actions determined (Brill, 1976).

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Appendix B: Guideline Development Process

The Registered Nurses’ Association of Ontario (RNAO) has made a commitment to ensure that nursing best practice
guidelines are based on the best available evidence. The Registered Nurses’ Association of Ontario Nursing Best
Practice Guideline Developing and Sustaining Interprofessional Health Care: Optimizing patients/clients, organizational
and system outcomes (2013) is the culmination of the Registered Nurses’ Association of Ontario expert panel’s work
in integrating the most current and best evidence to ensure the validity, appropriateness and safety of the guideline
recommendations and supporting evidence.

The expert panel consists of health-care professionals with expertise in practice, research, policy, education and
administration from various practice areas. The expert panel was supported by an Advisory Committee consisting
of senior health-care executives from the hospital, provincial government and not-for-profit settings.

A systematic review of the evidence was based on the purpose and scope of the guideline and supported by three
clinical questions. The systematic review captured relevant literature and guidelines published between 2002 and
2013. The following research questions were established to guide the literature review:

How does interprofessional care within organizations and systems lead to optimal patient/client satisfaction and
health outcomes?

How does interprofessional care within organizations and systems lead to provider satisfaction, effective team
functioning and integration of care?

How does interprofessional care within organizations and systems lead to effective organizational and system
outcomes?
APPENDICES

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Appendix C: Process for Systematic Review/

Search Strategy
Search Strategy:
A comprehensive literature search was conducted from September to November 2011 by a University Health Network
(UHN) librarian in the following health-related electronic databases: Embase, PsychInfo, Medline, Cochrane (SR),
Cochrane (CCRCT), and CINAHL IP.

English-language systematic reviews, guidelines and primary studies were included if they were within the scope
of the clinical questions and published between 2002 and 2011. There was no preference on the basis of research
design; both qualitative and quantitative primary studies of various designs were included. An additional search was
conducted from September to October 2013 to include studies published to September 2013.

Inclusion Criteria:
■ Abstracts in English
■ French articles
■ Literature published 5-11 years
■ Grey literature
■ International studies
■ Business literature

Exclusion Criteria:
■ Articles on interprofessional education curriculum

APPENDICES
■ Other languages unless the abstract is in English and French
■ Older than 11 years
■ Grey literature older than 5 years

Search Terms Identified Included:

■ Interdisciplinary
■ Multidisciplinary
■ Interprofessional
■ Team
■ Team work
■ Leadership
■ Virtual teams

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■ Enablers to interprofessional collaboration

■ Barriers/challengers to interprofessional collaboration
■ Interorganizational Collaboration
■ Core competencies of interprofessional collaboration
■ External Drivers to interprofessional collaboration
■ Relationships between professionals
■ Interaction patterns of interprofessional collaboration
■ Shared Leadership of interprofessional collaboration
■ System enablers to interprofessional collaboration
■ Regulatory bodies to interprofessional collaboration
■ Social Paradigms and interprofessional collaborationPower and Interprofessional Care
■ Hierarchy and interprofessional collaboration
■ Communication and interprofessional collaboration
■ Team boundaries and interprofessional collaboration
■ Articles from Zwarenstein
■ Articles from Ivy Oandasan
■ CIHC
■ Patient Safety & interprofessional collaboration
■ Medical Error
■ Health Disparity
APPENDICES

■ Diverse Health Care Teams

■ Circle of Care
■ Quality Assurance Literature
■ Context Specific Issues and Team Work
■ Team Effectiveness
■ Peer Support Model

Two research associates (master’s prepared nurses) independently assessed the eligibility of studies according to
established inclusion and exclusion criteria. The Registered Nurses’ Association of Ontario Best Practice Guideline
program manager working with the expert panel, resolved disagreements.

A final summary of literature findings was completed. The comprehensive data tables and summary were provided
to all panel members. In January 2013, the Registered Nurses’ Association of Ontario expert panel convened to revise
and achieve consensus on guideline recommendations and discussion of evidence.

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Search Results:

A total of 6128 abstracts were independently screened for inclusion/exclusion by two Masters Degree prepared nurses
for the three questions: question 1 (2389 abstracts), question 2 (477abstracts), and question 3 (3262 abstracts).
No relevant guidelines were found on this subject and therefore not included in this review. Upon completion of the
independent review, 472 articles were included for full-text relevance review. Of these 472 articles, 248 articles were
subsequently excluded. The remaining 224 articles were independently reviewed for methodological quality and data
extraction. Upon completion of the review for quality, 88 full-text articles were excluded. The remaining 138 studies
were included. Given the diversity with respect to research design across the included studies, a variety of instruments
were used to assess methodological quality as directed by the Registered Nurses’ Association of Ontario See Figure 4).

Figure 4. Instruments Used to Assess Methodological Quality

The following resources were used to guide the critical appraisal of the articles reviewed:
■ Qualitative Studies
Critical Appraisal Skills Programme (CASP): “10 questions to help you make sense of qualitative
research” (Public Health Resource Unit England, 2006)
■ Quantitative Studies
Effective Public Health Practice Project Quality Assessment Tool for Quantitative Studies
(Effective Public Health Project, 2009)
■ Systematic Reviews:
Assessment of Multiple Systematic Reviews (AMSTAR) (Shea et al., 2007)

Articles were subsequently categorized based on relevance to research questions. The reviewers discussed relevant
themes arising from the literature. A summary of evidence was provided to the guideline development panel for

APPENDICES
feedback and revisions as appropriate. As such, the final report represents the culmination of this work and the
shared findings of reviewers and the guideline development panel.

Results:

A review of the extracted data for each of the three research questions suggested five general themes: (1) effective models
of IPC; (2) interventions to enhance IPC; (3) tools to enhance IPC; (4) facilitators of IPC; and (5) barriers to IPC.

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Article Review Process Flow Diagram

The following flow diagram of the review process for guidelines and articles is adapted from D. Moher, A. Liberati,
J. Tetzlaff, D.G. Altman, & The PRISMA Group (2009). Preferred Reporting Items for Systematic Reviews and Meta-
Analyses: The PRISMA Statement. BMJ 339, b2535, doi: 10.1136/bmj.b2535

A complete Bibliography of all articles screened for inclusion is available at

IDENTIFICATION

Articles identified through Additional articles identified

database searching by panel
(n=6128) (n=133)

Articles after duplicates removed

(n=5175)
SCREENING

Articles screened
Articles excluded
(title and abstract)
(n=4703)
(n=5175)

Full-text articles Full-text articles

ELIGIBILITY

assessed for relevance excluded

APPENDICES

(n=472) (n=248)

Full-text articles Full-text articles

assessed for quality excluded
(n=224) (n=88)
INCLUDED

Studies included
(n=136)

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Appendix D:
Enablers and Barriers to Interprofessional Care

CATEGORY ENABLERS BARRIERS

OF FACTORS

INTERPERSONAL ■ Mutual respect1-4 ■ Interdisciplinary

rivalry24, 25
■ Shared commitment to improving care1
■ Lack of mutual
■ Personality of team members2, 5
respect26
■ Understanding of roles/role
■ Lack of understanding
clarity2, 3, 5-9
of mutual roles25
■ Perception of quality of patient/client care10
■ Lack of experience
■ Perceptions of collaborative relationships11 with IPC25
■ Nurse-physician relationships12, 13 ■ Poor provider
■ Nurse-physician communication 13 relations27, 28
■ Role conflict4, 7, 29
■ Teamworking14

■ Communication
■ Characteristics of therapists2, 15
failures9, 27, 30, 31
■ Characteristics of collaboration15
■ Nurse-physician
■ Communication4, 14, 16-19
relations11, 26, 32
■ Role awareness14 ■ Inequitable power

APPENDICES
■ Professional and personal development 3, 14 relations 22, 31, 33

■ Leadership20, 21 ■ Professionalboundary
infringements4, 33
■ Common core knowledge
■ Identity issues4, 23
■ Interpractitioner trust2, 3
■ Different approaches
■ Equitable power relations22, 23
to patient/client
■ Sense of belonging/ownership22 care9, 31, 33
■ Professional ethics17 ■ Professional language
differences 9, 34
■ Inclusive/shared language use9
■ Perceived lack of
organizational
support33
■ Group stereotypes26
■ Attitudinal barriers27

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CATEGORY ENABLERS BARRIERS

OF FACTORS

ORGANIZATIONAL Interventions/Processes/Structures Interventions/Processes/

Structures
■ Daily interdisciplinary team rounds18, 35-39
■ Fee structure24
■ Weekly interdisciplinary team rounds40
■ Liability issues24
■ Interprofessional team rounds after clinic41
■ Organizational and
■ Interdisciplinary action groups/projects23, 42, 42-44
practice structures3, 6, 27
■ Interdisciplinary case conferences43, 45
■ Organizational
■ Daily interdisciplinary team meetings 46
culture19, 71
■ Weekly multidisciplinary team meetings5, 47 ■ Ill-defined hierarchy27
■ Monthly multidisciplinary team meetings18 ■ Degree of therapist
■ Dedicated time for team meetings13, 48 involvement in referral
& assessment process15
■ Review/discussion of patient/client
■ Differentgateways to
documentation9
same patients/clients
■ External facilitators18 profile29
■ Multidisciplinary education49-53 ■ Role
of hospital
■ Interprofessional education 54 executive board29

■ Multidisciplinary facilitation50 ■ Physician-driven care22

■ Multidisciplinary performance improvement ■ Conflicts

in schedules
teams 49, 50, 55 and roles31
APPENDICES

■ Interdisciplinary quality improvement ■ Building

layouts
teams 8, 56-59 hindering interaction31

■ Interdisciplinary complication reviews46 ■ Lack

of time for
teambuilding31
■ Training local champions60
■ Responsibility
■ Multidisciplinary morbidity & mortality
overload27
rounds/death review61, 62
■ Absenteeism31
■ Multidisciplinary process redesign63
■ Constraining rules and
■ Self-assessment audits62
regulations31
■ Pre-operative team briefings64-66 ■ Authority
■ Clear lines of communication 1
(disagreement about
decision making)68
■ Use of quality/feedback information67
■ Lack of training in IPC25

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CATEGORY ENABLERS BARRIERS

OF FACTORS

ORGANIZATIONAL ■ Practice
characteristics (physical layout, same ■ Education68
working hours)2, 5 ■ Patient needs68
■ Characteristics of the environment 4, 15
■ Knowledge68
■ Referral process 15
■ Resources68
■ Business policies 15
■ Time68
■ Time 4, 68
TOOLS
■ Supportive organizational structure5 ■ Time constraints85
■ Institutional leadership 69
■ Challenging to learn
■ Mission clarity 70
to use integrated care
pathways86
■ Supportive/flexible structures22
■ Care pathways that are
■ Teamwork culture71-73
not a multiprofessional
■ Communication training69, 74 record of care104
■ Teambuilding training48, 75-79 ■ Variability in
■ Client-centered care 17, 22 development & use
of clinical protocols &
■ Building on existing relationships23 guidelines29
■ Providing opportunities for formal & informal ■ Health policy29
contact 5, 23, 47

■ Evidence-informed decision making17

APPENDICES
■ Integration of allied health professionals into
healthcare teams2, 3
■ Integrated management systems80
■ Authority(agreed upon leadership and
decision making) 68

■ Education(shared values and goals)68

■ Patient/client needs68
■ Knowledge68

■ Resources68

TOOLS
■ Daily rounds forms74
■ Clinical/integrated care pathways81, 81-92

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CATEGORY ENABLERS BARRIERS

OF FACTORS

ORGANIZATIONAL ■ Interdisciplinary practice

guidelines/protocols5, 6, 21, 55, 92-94
■ Common clinical information systems47
■ Common patientchart5
■ Computerized data tools95
■ Multidisciplinary discharge planning tool96
■ SBAR communication tool97
■ Tailored survivorship care plans98
■ Documentation templates99
■ Consultation and collaboration guidelines1
■ Organizational standards of behaviours97
■ Interdisciplinary team-developed
checklists 44, 100

■ Multidisciplinary audit tools101

■ Standardized orders and medication
charts55, 94, 102
■ Effective communication tools5, 37, 47
■ Business policies15
APPENDICES

■ Electronic medication administration records103

■ Computerized order sets58
■ Multidisciplinary audit tool101

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CATEGORY ENABLERS BARRIERS

OF FACTORS

SYSTEMIC ■ Social variables and community contacts15 ■ Unstablefunding

arrangements105
■ Satisfactory compensation5
■ Funding models
■ Health policy29
that discourage
■ Reinforcement of partnerships between collaboration25
higher education institutions & health & social
■ Political environment15
care institutions14
■ Inconsistent
■ Access17
government policies25
■ Strong national leadership 24
■ Limited health human
■ Interdisciplinary education24
resource planning25
■ Legislation and
regulations obstructing
professions full scope
of practice106
■ Underutilization
of health human
resources106
■ Regulatory/legislative
frameworks that create
silos25
■ Governance/

APPENDICES
organizational
conflicts31

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Appendix D Reference List

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(2) Garner MJ, Birmingham M, Aker P et al. Developing integrative primary healthcare delivery: adding a
chiropractor to the team. Explore: The Journal of Science & Healing 2008;4(1):18-24.

(3) Makowsky MJ, Schindel TJ, Rosenthal M, Campbell K, Tsuyuki RT, Madill HM. Collaboration between
pharmacists, physicians and nurse practitioners: a qualitative investigation of working relationships in the
inpatient medical setting. Journal of Interprofessional Care 2009;23(2):169-184.

(4) Suter E, Arndt J, Arthur N, Parboosingh J, Taylor E, Deutschlander S. Role understanding and effective
communication as core competencies for collaborative practice. Journal of Interprofessional Care 2009;23(1):41-51.

(5) Mulkins AL, Eng J, Verhoef MJ. Working towards a model of integrative health care: critical elements for an
effective team. Complementary Therapies in Medicine 2005;13(2):115-122.

(6) Gulmans J, Vollenbroek-Hutten MM, Van Gemert-Pijnen JE, Van Harten WH. Evaluating patient care
communication in integrated care settings: application of a mixed method approach in cerebral palsy
programs. International Journal for Quality in Health Care 2009;21(1):58-65.

(7) Carpenter J, Schneider J, Brandon T, Wooff D. Working in multidisciplinary community mental health teams:
The impact on social workers and health professionals of integrated mental health care. British Journal of
Social Work 2003;33:1081-1103.

(8) McCahill LE, Ahern JW, Gruppi LA et al. Enhancing compliance with Medicare guidelines for surgical
infection prevention: experience with a cross-disciplinary quality improvement team. Archives of Surgery
2007;142(4):355-361.

(9) Sheehan D, Robertson L, Ormond T. Comparison of language used and patterns of communication in
interprofessional and multidisciplinary teams. Journal of Interprofessional Care 2007;21(1):17-30.
APPENDICES

(10) Chang WY, Ma JC, Chiu HT, Lin KC, Lee PH. Job satisfaction and perceptions of quality of patient care,
collaboration and teamwork in acute care hospitals. Journal of Advanced Nursing 2009;65(9):1946-1955.

(11) Reeves S, Goldman J, Sawatzky-Girling B, Burton A. Knowledge transfer & exchange in interprofessional
education: Synthesizing the evidence to foster evidence-based decision making. Canadian Interprofessional
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July2008.pdf

(12) Estabrooks CA, Midodzi WK, Cummings GG, Ricker KL, Giovannetti P. The impact of hospital nursing
characteristics on 30-day mortality. Nursing Research 2005;54(2):74-84.

(13) Schmidt IK, Svarstad BL. Nurse-physician communication and quality of drug use in Swedish nursing homes.
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(14) Howarth M, Holland K, Grant MJ. Education needs for integrated care: a literature review. [Review] [58 refs].
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(15) Todahl JL, Linville D, Smith TE, Barnes MF, Miller JK. A qualitative study of collaborative health care in a primary
care setting. Families, Systems & Health 2006;24(1):45-64.

(16) Davenport DL, Henderson WG, Mosca CL, Khuri SF, Mentzer RM, Jr. Risk-adjusted morbidity in teaching
hospitals correlates with reported levels of communication and collaboration on surgical teams but not with
scale measures of teamwork climate, safety climate, or working conditions. Journal of the American College of
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(17) Canadian Nurses Association. CNA position statement: Interprofessional collaboration. http://www2.cna-aiic.
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APPENDICES
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APPENDICES

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APPENDICES
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APPENDICES

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2007. Ref Type: Online Source

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Appendix E: Example of Team Charter

Team Charter Example

Interprofessional Care Members

Provide expert advice to surgical team using interdisciplinary approach.

1. JOB DESCRIPTIONS:

■ Chair: Oversees overall operations of the program

Responsible for team function
Ensures the timelines are met
Makes an executive decision in times of crisis situation
■ Facilitator: Rotating position
Creates agenda
Organize meetings
Outlines immediate issues for discussion and facilitates meetings
Keeps discussions on track
Ensures that the meetings start on time
■ Data collector: Voluntary task
Taking minutes
■ Resource person: Research coordinator for outcome measures, advise on data collection and analysis,
assistance with pictorials and models if needed

2. ROLE DEFINITION

APPENDICES
Role of RN in care team is to provide expertise in nursing roles and responsibilities:
■ Provision of quality care by developing nurses´ expertise in management of surgical patients/clients
■ Utilize current evidence and tools related to interprofesssional care
■ Developing prevalence studies
■ Disseminating and integrating of research findings into practice and facilitating change by promoting
nursing best practices related to surgical care
■ Educating and empowering nursing staff
■ Participates in research projects
■ Liaise with team members as appropriate

Role of Social Worker in care team is to provide expertise in:

■ Supporting family, patients/clients and circle of care in obtaining services, resources required to optimize
patients/clients health

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Role of OT in surgical care team is to provide expertise in:

■ Use of modalities
■ Assistive devices
■ Complementary therapies (such as footwear recommendations)
■ Promoting functional independence including ADL and IADL

Role of Physiotherapist in surgical care team is to provide expertise in:

■ Recommendations on positioning patients/clients (specifically focusing on promotion of healing and prevention of
skin breakdown and joint contractures)
■ Improving the mobility of the patient/client in bed and out of bed.

Role of Physician in surgical care team is to provide expertise in:

■ The management of post-op care
■ Assist in educating the team regarding optimal post-op care

Role of Dietitians in surgical care team is to provide expertise in:

■ Expertise in Clinical Nutrition
■ Based on evidence-based literature and best-practice, provide appropriate intervention.
■ Determine appropriate protein, calorie and micronutrient requirements based on individual needs
■ Liaise with Registered Dietitian team to collaborate on best practices.

Role of the researcher/evaluator in surgical care team is to provide expertise in:

■ Facilitate effective interprofessional surgical care practice through a review of current research findings and
determine the gaps for further research to improve patient/client care quality.
APPENDICES

■ Contribute in the development of an environmental scan to determine what supports and resources are needed
internally and externally for an effective interprofessional community of practice.
■ Guide the tracking and monitoring of the evaluation data for the interprofessional care initiative, and will guide the
development of a Program Logic Model.
■ Develop a sustainability plan for the continuation of interprofessional communities of practice.

Working Together:
■ Open communication
■ Trust and commitment
■ Expertise
■ Accountability in knowledge transfer and application
■ Dynamic
■ Be transparent
■ Respect different opinions

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■ Mediate and compromise when necessary

■ Attend meetings with focused agenda and be on time
■ Share and work towards common master plan
■ Take info back to team
■ Set timelines, agreed by consensus

Management Support:
■ Commitment for resources
■ Priority/operational goal
■ Representation on committees

3. ENHANCED COMMUNICATIONS:

■ Who makes decision

a. Minimum required for decision making 50% of membership
b. In stalemate situations – defer to person with expertise
■ Maintain time lines – leader’s accountability
■ Executive decisions
a. In difficult situations – role of chair or/delegate is to provide situational leadership
b. When violation of conduct – chair makes decision based on team’s feedback
■ Frequency of communications
– Team meetings to occur monthly
– E-mail communication in between meetings as necessary

APPENDICES
– Transparency (documents posted for everyone to read)

4. CORE VALUES (refer to Registered Nurses’ Association of Ontario, Best Practice Guidelines model for
interprofessional care)

5. EXPECTATIONS/IMPACT OF THE TEAM

EXPECTED OUTCOME – identify clear indicators using Registered Nurses’ Association of Ontario,
Best Practice Guideline on interprofessional care as a guide

6. CONFLICT RESOLUTIONS – utilize Registered Nurses’ Association of Ontario, Best Practice Guideline on
managing conflict

7. AUTHENTICITY (true to self/others)

8. EDUCATION (refer to surgical care plan)

Evaluation (refer to program logic model and Registered Nurses’ Association of Ontario Best Practice Guideline
on interprofessional care)

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Appendix F: Interprofessional Competency

Framework Self-Assessment
[Adapted from the CIHC National Competency Framework (2010) and the Registered Nurses’ Association of Ontario
conceptual model for developing and sustaining interprofessional health care (2013)]

Interprofessional Competency Framework Self-Assessment Tool

The Registered Nurses’ Association of Ontario Conceptual Model for Developing and Sustaining Interprofessional
Health Care describes the competencies required for effective interprofessional collaboration. Six competency
domains highlight the knowledge, skills, attitudes and values that together shape the judgments that are essential
for interprofessional collaborative practice. These domains are:
■ Care expertise

■ Shared power

■ Collaborative leadership

■ Optimizing profession, role and scope

■ Shared decision making

■ Effective group functioning

The six domains are shown surrounded by an outer circle of expected benefits for the health-care team and the
organization: a healthy work environment with enhanced quality and improved safety. The domains are supported
by competent communication and the three foundational components of the healthy work environment model:
■ Policy, physical, structural

■ Professional/occupational
APPENDICES

■ Cognitive/psychosocial/cultural

This self assessment survey allows you to reflect on your areas of strength in collaborative practice and areas that
you may wish to strengthen. Please indicate how well you believe you perform each of the following indicators.

EXAMPLE: NEVER RARELY SOMETIMES ALMOST DOES NOT

COMPETENCY ALWAYS APPLY

Indicator #1 ✔

Indicator #2 ✔

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1. Care Expertise

Interprofessional care requires collaboration between health-care professionals and patients and their families and
circles of care in order to identify and take advantage of each person’s care expertise. To support interprofessional
practice, learners/practitioners are able to:

INDICATOR NEVER RARELY SOMETIMES ALMOST DOES NOT

ALWAYS APPLY

Support the participation

of patients/clients, their
families, and/or community
representatives as integral
partners alongside health-care
personnel

Share information with

patients/clients (or family and
the community) in a respectful
manner and in such a way that
it is understandable, encourages
discussion, and enhances
participation in decision making

Ensure that appropriate

education and support is
provided to patients/clients,
family members and others

APPENDICES
involved with care or service

Listen respectively to the

expressed needs of all parties in
shaping and delivering care or
services

Conduct a collaborative
interprofessional assessment
to identify what expertise is
required and then individualize
for each patient/client

Coordinated effort to find the

best expert for the patient/client

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INDICATOR NEVER RARELY SOMETIMES ALMOST DOES NOT

ALWAYS APPLY

Patients/Clients are full

participants in their own care

Include specific contributions

and collective knowledge as
dictated by the complexity of the
patient’s/client’s needs

2. Shared Power

Willingness to share power is a commitment to create balanced relationships through democratic practices
of leadership, decision making, authority and responsibility. To support interprofessional practice, learners/
practitioners are able to:

INDICATOR NEVER RARELY SOMETIMES ALMOST DOES NOT

ALWAYS APPLY

Leverage opportunities for all

team members to contribute

Create balanced power

relationships
APPENDICES

Establish a safe environment to

express diverse opinions

Consider points of view of all

care providers

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3. Collaborative Leadership

Collaborative leadership (also called reciprocal or shared leadership) is a people- and relationship-focused
approach based on the premise that answers should be found in the collective (the team). To support interprofessional
practice, learners/practitioners collaboratively determine who will provide group leadership in any given situation
by supporting:

INDICATOR NEVER RARELY SOMETIMES ALMOST DOES NOT

ALWAYS APPLY

Work with others to enable

effective patient/client outcomes

Advance interdependent
working relationships among
all participants

Facilitation of effective team

processes

Facilitation of effective decision

making

Establish a climate for

collaborative practice among
all participants

APPENDICES
Co-create a climate for shared
leadership and collaborative
practice

Apply collaborative decision

making principles

Integrate the principles of

continuous quality improvement
to work processes and outcomes

Share accountability that

addresses power and hierarchy

Utilize structures and processes

to advance exemplary care

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4. Optimizing Profession, Role and Scope

Exemplary interprofessional care lets all team members work to their full scope of practice and takes advantage
of the synergies professionals working together can create. To support interprofessional practice, learners/
practitioners are able to:

INDICATOR NEVER RARELY SOMETIMES ALMOST DOES NOT

ALWAYS APPLY

Describe their role and others’

Recognize and respect the diversity

of other health and social care roles,
responsibilities, and competencies

Perform their own roles in a

culturally respectful way

Communicate roles, knowledge,

skills, and attitudes using
appropriate language

Consider the roles of others in

determining own professional
and interprofessional roles

Access others’ skills and

APPENDICES

knowledge appropriately
through consultation

Consider the roles of other in

determining own professional
and interprofessional roles

Integrate competencies/roles
seamlessly into models of service
delivery

Demonstrate knowledge application

of own profession/role/scope

Explore and integrate roles

of others

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5. Shared Decision-Making

Shared decision-making gives all team members, including patients, the opportunity to contribute their
knowledge and expertise, to arrive collaboratively at an optimal goal. To support interprofessional practice,
learners/practitioners are able to:

INDICATOR NEVER RARELY SOMETIMES ALMOST DOES NOT

ALWAYS APPLY

Recognize and respect each

other’s knowledge and expertise,
regardless of occupation and
formal position

Willing to accept responsibility

for decisions

6. Effective Group Function

A health-care system that supports effective teamwork can improve the quality of patient care, enhance patient
safety, and reduce workload issues that cause burnout among professionals. To support interprofessional practice,
learners/practitioners are able to:

INDICATOR NEVER RARELY SOMETIMES ALMOST DOES NOT

ALWAYS APPLY

Understand the process of team

APPENDICES
development

Develop a set of principles for

working together that respects
the ethical values of members

Effectively facilitate discussions

and interactions among team
members

Participate, and be respectful of

all members’ participation, in
collaborative decision making

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INDICATOR NEVER RARELY SOMETIMES ALMOST DOES NOT

ALWAYS APPLY

Regularly reflect on their

functioning with team learners/
practitioners and patients/clients/
families

Establish and maintains effective

and healthy working
relationships with learners/
practitioners, patients/clients,
and families, whether or not a
formalized team exists

Respect team ethics, including

confidentiality, resource
allocation, and professionalism

Collaborate and engage

together to formulate,
implement and evaluate care

Assess, practise and reflect upon

effective group processes
APPENDICES

7. Competent Communication

Competent communication – openness, honesty, respect for each other’s opinions and effective communication
skills – is part of all domains of interprofessional practice. To support interprofessional practice, learners/
practitioners are able to:

INDICATOR NEVER RARELY SOMETIMES ALMOST DOES NOT

ALWAYS APPLY

Establish team work

communication principles

Actively listen to other team

members including patients/
clients/families

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INDICATOR NEVER RARELY SOMETIMES ALMOST DOES NOT

ALWAYS APPLY

Communicate to ensure common

understanding of care decisions

Develop trusting relationships

with patients/clients/families and
other team members

Effectively use information and

communication technology
to improve interprofessional
patient/client/community-
centered care

Is clear, focused, transparent and

respectful

Constructively manages conflict

Maintains and enhances the

relationship

Review and reflect on the score you have given yourself. The scores reflecting “rarely” and “never” in any
particular domain may be areas you wish to develop further. Having completed your self assessment, it is

APPENDICES
recommended that you discuss your results with your mentor or a trusted colleague in your team.

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Appendix G: Description of the Toolkit

Best Practice Guidelines can only be successfully implemented if there are adequate planning, resources, organizational
and administrative supports and appropriate facilitation. In this light, the Registered Nurses’ Association of Ontario,
through a panel of nurses, researchers and administrators, has developed the Toolkit: Implementation of Best Practice
Guidelines (2nd ed.)(2012b). The Toolkit is based on available evidence, theoretical perspectives and consensus. We
recommend the Toolkit for guiding the implementation of any Healthy Work Environment Best Practice Guideline
in health-care organizations.

The Toolkit provides step-by-step directions to individuals and groups involved in planning, coordinating and
facilitating the guideline implementation. These steps reflect a process that is dynamic and iterative rather than linear.
Therefore, at each phase preparation for the next phases and reflection on the previous phase is essential. Specifically,
the Toolkit addresses the following key steps, as illustrated in the “Knowledge to Action” framework (RNAO, 2012b; Straus
et al., 2009) in implementing a guideline:

1. Identify problem: identify, review, select knowledge (Best Practice Guideline).

2. Adapt knowledge to local context:
■ Assess barriers and facilitators to knowledge use; and
■ Identify resources.
3. Select, tailor and implement interventions.
4. Monitor knowledge use.
5. Evaluate outcomes.
6. Sustain knowledge use.

Implementing guidelines in practice that result in successful practice changes and positive clinical impact is a
complex undertaking. The Toolkit is one key resource for managing this process. The Toolkit can be downloaded
APPENDICES

at http://rnao.ca/bpg.

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Appendix H: Charter Statements

Patient/Client Expectation
As a patient/client in Ontario, I expect my health care to be provided by various health caregivers who respect me
and the health-care choices I make. My caregivers seek to know my health experience and are prepared to work
with me across settings to combine their knowledge and skills to meet my health goals.

Caregiver Commitments

As a health caregiver in Ontario, in supporting the interprofesssional vision,

1. I will seek to know the experience of those I care for, respect and strive to understand their needs, and work with
them to develop their care plans that acknowledge their choices,
2. I will understand my role and understand the role and expertise of other health caregivers,
3. I will inform those who are caring for patients/clients with me about the care I am providing to them,
4. I will ask questions, communicate to be understood, seek input and listen respectfully to generate options for care,
5. I will be aware of how my own behaviour and attitudes impact interprofessional care and how I actively foster a
culture of collaboration, and
6. I will acknowledge that there are limits to what I know and will continue to learn from others so that care can be
better integrated and guided by the best possible ideas.

Leader Commitments

To meet patients/clients expectation and enable caregiver commitments in Ontario, as health system leaders,
1. We will align our language, processes, structures and resources to foster an interprofesssional culture,

APPENDICES
2. We will create opportunities to collaborate within and across sectors to integrate interprofesssional care into
practice, education, policy and research,
3. We will measure and evaluate our interprofessional care initiatives to know what is being achieved, and
4. We will continuously improve interprofessional care in the health-care system by identifying, promoting and
implementing practices that make a difference to patient/client care.

Interprofessional Care Strategic Implementation Committee Final Report 2010

http://www.healthforceontario.ca/UserFiles/file/PolicymakersResearchers/ipc-final-report-may-2010-en.pdf

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Endorsements
ENDORSEMENTS

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January 10, 2014

Doris Grinspun RN, MSN, PhD, LLD(hon), O.ONT.

Chief Executive Officer
Registered Nurses’ Association of Ontario (RNAO)
158 Pearl Street
Toronto, ON M5H 1L3

Dear Dr. Grinspun,

On behalf of the Board of Directors of the Ontario Society of Occupational Therapists (OSOT), I
am pleased to write to communicate the Society’s endorsement of the RNAO’s evidence-based
Healthy Work Environment Best Practice Guideline- Developing and Sustaining Interprofessional
Health Care: Optimizing patient, organizational, and system outcomes.

OSOT is the professional association of over 3800 Ontario occupational therapists. The Society
promotes and develops the profession of occupational therapy to participate as a valued
profession in health care teams across the continuum of care in Ontario’s health care system.
Occupational therapists (OTs) work with clients whose ability to do what they need and want to
do has been compromised by injury, illness or disability. Their work and contribution to the
Ontarians’ health and our health care system is magnified in the context of effective
interprofessional care. To this end, RNAO guideline is directly related to our mandate of
working closely and collaboratively with other members of the health care team for better
client outcomes. We were pleased to have an occupational therapy perspective included
amongst the guideline development process through Bonny Jung’s membership on the expert
guideline development panel.

The rigorous process RNAO uses in guideline development has resulted in a set of evidence-
based recommendations related to individual and team practice, organizations and the system
that will influence healthy teamwork among all professions. Ontario’s Occupational Therapists
are committed to having the healthiest clients/patients and the best healthcare system. This
guideline will be a valued resource and support our members to continue making positive ENDORSEMENTS
contributions to interprofessional team work.

Sincerely,

Christie Brenchley
Executive Director

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Notes
N OT E S

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Notes

N OT E S

BEST PRACTICE GUIDELINES • w w w. R N A O . c a 99

 Best Practice Guidelines

DECEMBER 2013

Developing and Sustaining

Interprofessional Health Care:
Optimizing patient, organizational and system outcomes

ISBN 978-1-926944-55-5