An Overview of Reviews on Interprofessional Collaboration in Primary Care: Barriers and Facilitators

Introduction: Interprofessional collaboration (IPC) is becoming more widespread in primary care due to the increasing complex needs of patients. However, its implementation can be challenging. We aimed to identify barriers and facilitators of IPC in primary care settings. Methods: An overview of reviews was carried out. Nine databases were searched, and two independent reviewers took part in review selection, data extraction and quality assessment. A thematic synthesis was carried out to highlight the main barriers and facilitators, according to the type of IPC and their level of intervention (system, organizational, inter-individual and individual). Results: Twenty-nine reviews were included, classified according to six types of IPC: IPC in primary care (large scope) (n = 11), primary care physician (PCP)-nurse in primary care (n = 2), PCP-specialty care provider (n = 3), PCP-pharmacist (n = 2), PCP-mental health care provider (n = 6), and intersectoral collaboration (n = 5). Most barriers and facilitators were reported at the organizational and inter-individual levels. Main barriers referred to lack of time and training, lack of clear roles, fears relating to professional identity and poor communication. Principal facilitators included tools to improve communication, co-location and recognition of other professionals’ skills and contribution. Conclusions: The range of barriers and facilitators highlighted in this overview goes beyond specific local contexts and can prove useful for the development of tools or guidelines for successful implementation of IPC in primary care.


CINAHL
(1) MH ("Cooperative Behavior" OR "Interprofessional Relations" OR "Nurse-Physician Relations" OR "Multidisciplinary Care Team") OR TI (collaborati* OR cooperati* OR co-operati* OR crossdisciplinar* OR cross-disciplinar* OR integrated care OR interdisciplin* OR inter-disciplin* OR interprofession* OR inter-profession* OR multidisciplin* OR multi-disciplin* OR multiprofession* OR multiprofession* OR team* OR transdisciplin* OR trans-disciplin*) OR AB (collaborati* OR cooperati* OR co-operati* OR crossdisciplinar* OR cross-disciplinar* OR integrated care OR interdisciplin* OR inter-disciplin* OR interprofession* OR interprofession* OR multidisciplin* OR multi-disciplin* OR multiprofession* OR multi-profession* OR team* OR transdisciplin* OR trans-disciplin*) AND (2) MH ("Community Health Centers" OR "Community Health Services" OR "Community Health Nursing" OR "Community Mental Health Services" OR "Home Health Care" OR "Family Practice" OR "Physicians, Family" OR "Primary Health Care" OR "Office Visits") OR TI ((community or primary) N3 (care or health or healthcare or practitioner*)) OR TI ((community based medicine or (communit*3 N5 nurse*2) or community nursing or community pharmac* or family doctor* or family medicine or family physician* or family medical practice* or family practi* or GP or GPs or general medical practice or general medicine or general healthcare or practitioner*)) or (community based medicine or (communit$3 adj5 nurse?) or community nursing or community pharmac* or family doctor* or family medicine or family physician* or family medical practice* or family practi* or GP or GPs or general medical practice or general medicine or general physician* or general practi* or health center? or health centre? or medical home* or primary practice)).ti,ab,id.) AND (3) (Meta Analysis/ or (meta analy* or metanaly* or metaanaly* or meta regression).ti,ab. or ((systematic* or evidence*) adj3 (review* or overview*)).ti,ab. or (search strategy or search criteria or systematic search or study selection or data extraction).ab. or (search* adj4 literature).ab. or (concept synthesis or conceptual review or critical interpretive synthesis or framework synthesis or integrative review or integrative literature review or literature review or meta-data-analysis or meta-ethnography or (meta adj2 narrative) or meta-study or meta-synthesis or mixed method* review or mixed research synthesis or mixed studies review or narrative review or narrative synthesis or realist review or realist synthesis or scoping review or scoping study or qualitative evidence synthesis or qualitative interpretive meta-synthesis or qualitative research synthesis or qualitative systematic review or thematic synthesis or theoretical synthesis).ti,ab.) (1) ((collaborati* or cooperati* or co-operati* or crossdisciplinar* or cross-disciplinar* or integrated care or interdisciplin* or interdisciplin* or interprofession* or inter-profession* or multidisciplin* or multi-disciplin* or multiprofession* or multi-profession* or team* or transdisciplin* or trans-disciplin*) AND (2) (((community or primary) near/3 (care or health or healthcare or practitioner*)) or (community based medicine or (communit* near/5 nurse?) or community nursing or community pharmac* or family doctor* or family medicine or family physician* or family medical practice* or family practi* or GP or GPs or general medical practice or general medicine or general physician* or general practi* or health center? or health centre? or medical home* or primary practice))):ab,ti JBI Database of Systematic Reviews and Implementation Reports

Cochrane
(1) (Cooperative Behavior/ or Interprofessional Relations/ or Physician-Nurse Relations/ or Interdisciplinary Communication/ or Patient Care Team/ or (collaborati* or cooperati* or co-operati* or crossdisciplinar* or cross-disciplinar* or integrated care or interdisciplin* or inter-disciplin* or interprofession* or inter-profession* or multidisciplin* or multi-disciplin* or multiprofession* or multi-profession* or team* or transdisciplin* or trans-disciplin*).ti,hw,sa.) AND (2) (Community Health Centers/ or Community Health Services/ or Community Health Nursing/ or Community Mental Health Services/ or Community Pharmacy Services/ or Home Care Services/ or General Practice/ or Family Practice/ or General Practitioners/ or Physicians, Family/ or Physicians, Primary Care/ or Primary Health Care/ or Office Visits/ or Primary Care Nursing/ or community health.sa. or (((community or primary) adj3 (care or health or healthcare or practitioner*)) or (community based medicine or (communit$3 adj5 nurse?) or community nursing or community pharmac* or family doctor* or family medicine or family physician* or family medical practice* or family practi* or GP or GPs or general medical practice or general medicine or general physician* or general practi* or health center? or health centre? or medical home* or primary practice)).ti,hw,sa.) AND (3) (meta-analysis/ or meta-analysis as topic/ or (meta analy* or metanaly* or metaanaly* or meta regression).ti,tx. or ((systematic* or evidence*) adj3 (review* or overview*)).ti,tx. or (search strategy or search criteria or systematic search or study selection or data extraction).tx. or (search* adj4 literature).tx. or (concept synthesis or conceptual review or critical interpretive synthesis or framework synthesis or integrative review or integrative literature review or literature review or metadata-analysis or meta-ethnography or (meta adj2 narrative) or meta-study or meta-synthesis or mixed method* review or mixed research synthesis or mixed studies review or narrative review or narrative synthesis or realist review or realist synthesis or scoping review or scoping study or qualitative evidence synthesis or qualitative interpretive meta-synthesis or qualitative research synthesis or qualitative systematic review or thematic synthesis or theoretical synthesis).ti,tx. or ("systematic review protocols" or systematic reviews).pt.)

PROSPERO
(1) ((collaborati* or cooperati* or co-operati* or crossdisciplinar* or cross-disciplinar* or integrated care or interdisciplin* or interdisciplin* or interprofession* or inter-profession* or multidisciplin* or multi-disciplin* or multiprofession* or multi-profession* or team* or transdisciplin* or trans-disciplin*) AND (2) (community based medicine or community care or community health or community healthcare or community mental health service* or community mental health nursing or community nurse or community nurses or community nursing or community pharmac* or community practitioner* or family doctor* or family medicine or family physician* or family medical practice* or family practi* or GP or GPs or general medical practice or general medicine or general physician* or general practi* or health center or health centers or health centre or health centres or medical home* or primary care or primary health or primary healthcare or primary practice or primary practitioner*)):CM,CS,CT,IV,OP,PA,RQ,SM,TI EPISTEMONIKOS (1) title:(collaborati* or cooperati* or co-operati* or crossdisciplinar* or cross-disciplinar* or integrated care or interdisciplin* or inter-disciplin* or interprofession* or inter-profession* or multidisciplin* or multi-disciplin* or multiprofession* or multiprofession* or team* or transdisciplin* or trans-disciplin*) AND (2) title:("community based medicine" OR "community care" OR "community health" OR "community healthcare" OR "community mental health service" OR "community mental health services" OR "community mental health nursing" OR "community nurse" OR "community nurses" OR "community nursing" OR "community pharmacy" OR "community pharmacies" OR "community practitioner" OR "community practitioners" OR "family doctor" OR "family doctors" OR "family medicine" OR "family physician" OR "family physicians" OR "family medical practice" OR "family medical practices" OR "family practice" OR "family practitioner" OR "family practitioners" OR GP OR GPs OR "general medical practice" OR "general medicine" OR "general physician" OR "general physicians" OR "general practice" OR "general practitioner" OR "general practitioners" OR "health center" OR "health centers" OR "health centre" OR "health centres" OR "medical home" OR "medical homes" OR "primary care" OR "primary health" OR "primary healthcare" OR "primary practice" OR "primary practitioner" OR "primary practitioners") ☐ Not specified Type of review, as cited by authors (e.g. "narrative review", "integrative review", "qualitative synthesis"):

Population of review
Restrictions on patients characteristics: ☐ age: ☐ condition: ☐ gender/ethnicity/other:

☐ No restrictions in patient characteristics
Context / setting of review Definition/description of the primary care setting: The primary studies of the review includes the following settings: ☐ GP offices / office-based practices (☐ solo, ☐ group) ☐ Community health centers ☐ Primary health care practices ☐ Patient-centered medical home (PCMH) ☐ Across settings: interface between primary care and secondary/tertiary/community care/other organizations services ☐ "Primary care" (unspecified) ☐ "Community care" (unspecified) ☐ Other: Geographic boundary of the review: ☐ No geographic boundary

Definition of IPC / description of the intervention
Definition of IPC (theoretical and/or operational) / of the intervention: Typology of collaboration ☐ Collaboration within primary care practices/institutions ☐ Collaboration between primary care provider(s) and other healthcare professional(s) working outside the primary care sector ☐ Dyad (e.g. GP-nurse, GP-pharmacist) ☐ More than 2 health disciplines Notes: Outcomes assessed ☐ Barriers and/or facilitators ☐ Effect of IPC on quality of care (process and/or outcome) ☐ … at the patient level ☐ … at the healthcare professional level ☐ … at the organizational level (other than cost) ☐ cost-effectiveness ☐ Theoretical models, typologies or conceptual frameworks More precisely:

Author, year Main results (Barriers and Facilitators) Level
System Organisat. Interindiv.

Individual
• Uncertainty over professional contribution and value

Facilitators
Strategies for Organizational Change toward Co-operative Practice:

Author, year Main results (Barriers and Facilitators) Level
System Organisat. Interindiv.

Individual
• Patient lifestyle, health system practices, lack of staff training, hierarchy and chain of responsibility, and lack of network services such as physiotherapy and occupational therapy Organizational level • Work overload, power struggles in labor relations, gaps in care, efficiency, organization of practices, regulating flow of patients and the lack of professionals.

Relational level
• Professional thinks he/she owns the patient and does not talk about the case with others, lack of common goals and space to exchange ideas, lack of team cohesion Others • Conflicts: acquisition of knowledge and skills from other professionals, difficulties and bad communication strategies, lack of common vision, problems with physicians, referral as a source of tension, ambiguous relations between professionals, cohesion of the team, trouble understanding role of others, patient is a source of tension, conflict between professionals, struggle for power and space between professionals, tensions within the team, contribution of knowledge undervalued and not put into practice, questioning competence of nurse • Working determinants: social division of labor, workload, different in employment contracts and wages • Biomedical paradigm: views of professionals and patients (physicians feel responsible, division of labor in nursing teams, patients not trusting professionals other than physicians & seeking medical consultations in PC) • Referral: difficulty in getting necessary references

Author, year Main results (Barriers and Facilitators) Level
System Organisat. Interindiv.

Facilitators
• Attitudes and beliefs: understanding and appreciation of teamwork, communication, confidence, humility, sense of belonging, shared responsibility, and time to listen and talk • Roles and responsibilities: recognition of members' roles, willingness to understand and respect work of members, rethink traditional practices to handle complex cases • Practice: integration, synergy, availability, reliability, balance between autonomy and interdependence of professions, collaboration, and responding to the patient's integral care needs.
• Communication: being open, understanding importance to listen and talk, informal meetings and frequent meetings, common language of team, explaining to other members, discussions of cases and treatments, recognition of limits to sharing information, exchanging specific information on work, consensus building, coordination of actions • Space: access to others, face-to-face contact & discussion, sharing and sociability • Leadership: to promote interprofessional practice, make team work together, must be shared, dependent on set of skills and influenced by traditional status of physician as leader • Philosophies of care (comfort and connection with patients, team common goal of meeting health needs, involving family and community in the care process) • Referral: referral to network, facilitated by effective, patient-centered relations • Education and training: integrating teamwork as part of undergraduate study curricula    

Author, year Main results (Barriers and Facilitators) Level
System Organisat. Interindiv.

Individual
• Working determinants: social division of labor, workload • Biomedical paradigm: professionals' and patients' views about teamwork

Barriers
Team structure: • Team premises: team members with separate bases or buildings can result in less integration with the team, limiting team functioning and effectiveness •Team size & composition: larger teams had lower levels of participation compared with smaller sized teams, but larger teams were externally rated by Health Authority management, the NHS parent Trust and GP, to be more effective in dimensions of clinical practice and teamworking; Status of team members may inhibit members from participating in the decision-making process and from providing input during team meetings • Leadership: lack of clarity about leadership caused frustration, led to poor decisionmaking, predicted lower levels of team effectiveness & was associated with poor quality teamworking

• Moving of members to other areas
Organization support: • Lack of organizational rewards for the team's improved working caused team members to feel concerned and disappointed with lower effectiveness over time • Lack of organizational support to implement changes led to team members feeling powerless, discouraged Team processes:

Author, year Main results (Barriers and Facilitators) Level
System Organisat. Interindiv.

Individual
• Time pressure was a barrier to regular team meetings

• Lack of communication as causing misconceptions about each profession's roles and responsibilities
• Conflict related to professional identity as a barrier to positive relations in the team and effective teamwork Clear goals and objectives

Facilitators
Team structure: • Team premises enhance information transaction, facilitate communication, and increase personal familiarity • Team size & composition: larger teams appear to have lower levels of participation compared with smaller sized teams but larger teams were externally rated by Health Authority management, the NHS parent Trust and GP, to be more effective in dimensions of clinical practice and teamworking; teams with greater occupational diversity introduced more radical innovations ; teams with a high proportion of fulltime staff and having worked together for longer (stability) Organization support: • Organizational support both for team working and for the team's members • Teams' openness to innovation and change • High support for innovation  

Author, year Main results (Barriers and Facilitators) Level
System Organisat. Interindiv.

Individual
Team processes: • Regular team meetings: associated with greater levels of innovation and increased participation of members in meeting, members considered them of high value (break down professional barriers and improve interprofessional communication), resolved interprofessional conflict and promoted positive interpersonal relations

Organizational facilitators
• Establish procedures for inter-professional meetings, documentation and handling of patient data (e.g. e-communication) • Facilitate knowledge sharing between disconnected professionals • Establish local, specialized multi-professional teams • Establish system-level foundation that supports local management and leadership of MPC

Processual facilitators
• Enhance collaborative skills before introducing new professional teams, roles and responsibilities • Develop common quality-management systems across institutions • Allocate sufficient time for professionals to share reflections and engage in mutual learning

Relational and contextual facilitators
• Invest in professional relations that build trust, respect and continuity   

Author, year Main results (Barriers and Facilitators) Level
System Organisat. Interindiv.

Individual
• Improve professionals' knowledge of each other's skills and roles through interprofessional education

Mulvale, 2016
Facilitators 18 factors identified as being associated with collaboration in IPCT by using the gear model: •

Barriers
Coherence: • Insufficient understanding of CC model, unfamiliarity with model, lack of educational programs Cognitive participation: System Organisat. Interindiv.

Individual
• Lack of PCP engagement due to time pressure and competing interests in PC, problems with reimbursement, PCP being uncomfortable with diagnosing and treating mental health illness, concerns about sharing patient's private data Collective action: • Absence of co-location and of regular interaction • Lack of space for additional staff • IT systems (information technology) mostly described as hindering effective communication between actors • Difficulty in managing mental health problems due to multifaceted nature of patients' problems (in terms of severity and/or complexity) • Extra time needed for CC described as a problem by PCP • Availability of funding for CC implementation Reflexive monitoring: • CC difficult to set up in clinics that did not have systems for monitoring patients' progress • Absence of immediate access to objective data on patient progress

Facilitators (according to the 4 dimensions of NTP)
Coherence: • Educational programs to provide participants with principles & tools of CC model • Use of physician champions to help professionals understand model

Author, year Main results (Barriers and Facilitators) Level
System Organisat. Interindiv.

Individual
• Clarifying roles and responsibilities between participants from primary and secondary care Cognitive participation: • Engagement of professionals involved

Author, year Main results (Barriers and Facilitators) Level
System Organisat. Interindiv.

Individual
• Breakdowns in networks and communication pathways (poor communication between professional groups or limited technology to support timely communication)

Sustainability
• Insufficient funding to maintain program after research was conducted

Facilitators to the implementation of CC:
Multi-professional team working

Roles and responsibilities
• Lack of clarity around nursing roles and scope of practice  

Author, year Main results (Barriers and Facilitators) Level
System Organisat. Interindiv.

Individual
• GP territorialism by protecting own professional boundaries and expertise, particularly when roles perceived as overlapping • Nurses refusing to expand their role, due to lack of clarity around their roles and responsibilities Respect, trust and communication

Author, year Main results (Barriers and Facilitators) Level
System Organisat. Interindiv.

Carmont, 2017
Barriers to engagement of GP with specialist secondary services in integration of palliative care: • Health system barriers: financial constraints for GP & hospital, workload, lack of standardized documents and systems, bureaucratic procedures, professional silos, lack of services and lack of infrastructure • Oncology providers indicated feeling this long-term commitment provided patients with reassurance that any potential problems would be detected as early as possible • Oncology specialists stated struggling with discharging survivors because of the bonds established with patients, their concern for survivors' needs, and having become "emotionally invested" in patient's success (wanted to remain involved after completion of active treatment) PCP role in cancer continuum

Individual
• Shared goals (confidence in outcomes): GP and CP negative expectations of collaboration, mostly related to patient care, GP concerns about patient confidentiality (such as patients not wanting to share information with pharmacists, risk to increased fragmented healthcare and duplication of tasks causing increased healthcare costs) • Capabilities: GP perceived CP as having a lack of knowledge and skills regarding (increased) patient care, CP perceptions included that GP lacked knowledge of pharmacists' development of patient care skills and that GP had misconceptions and lacked understanding of pharmacy services • Different perspectives: GP and CP differed in their perceptions of preferred communication methods, extending the pharmacist role (GP seeing them as retailers, while pharmacists perceived themselves as clinically competent) and accessibility to each other's practices

• CP contributions
Structural and organizational facilitators and barriers: • Environment

Individual
• Workload of personnel, staff turnover, time constraints and scarcity of various trained human resources such as care coordinators, public health workforce and allied dentists • Recruitment and retention of dental and non-dental staff were considered challenging, mostly due to the limited number of professionals interested in working in primary integrated clinics and shortage of dentists in rural and remote regions.
• deficient administrative infrastructure (such as absence of dental health records in medical records, cross-domain interoperability and domain-specific act codes) considered as contributor to general perception of dental care as an 'optional' service, hindering medical professionals from performing basic dental services.
Discipline-oriented education and lack of competencies: • Lack of interprofessional education • Focusing on discipline-oriented training in health • Lack of competencies • Knowledge, attitudes and skills were the most reported meaning units of competencies of PHP • Lack of knowledge regarding integrated care practices (for both dental and nondental care providers) • Patients and most of PHP did not attribute value to continuity of care in the field of oral health because oral health conditions are rarely life threatening (may be explained by lack of knowledge and awareness of the impact of oral health on general health and well-being)

Author, year Main results (Barriers and Facilitators) Level
System Organisat. Interindiv.

Individual
Patient's oral healthcare needs: • Patients' decision to accept or refuse integrative care was mainly based on their need perception rather than the assessment of healthcare providers

Facilitators
Globally: • Collaborative practices in the functional domain and financial support in the system integration domain, at the macro level Supportive policies and resources allocation: • Importance of financial support from governments, stakeholders and non-profit organizations at the macro level • Partnerships and common vision among governments, communities, academia, various stakeholders and non-profit organizations • Healthcare policies and reimbursements to trained PCP for oral screening, patient education and fluoride varnish applications Interprofessional education and PCP in preventive oral health Collaborative practices: • Perceived responsibility and role identification, case management and incremental approach.
Local strategic leaders:

Author, year Main results (Barriers and Facilitators) Level
System Organisat. Interindiv.

Individual
• Lack of leadership • Uncertainty about funding • Differences between shared interest of professional organizations (interest in the program) and of volunteer groups (increased club memberships), different cultures in PC and sport sector (preferred meeting time and target groups) led to difficulties in engaging sport organizations in the partnership • Sport organizations did not always recognize benefits of partnership or were not familiar with types of participant in intervention program (obese people, often in combination with low socio-economic status) • Health professionals' lack of time to establish partnerships or to refer patients

Facilitators
Collaborative initiatives to refer PC patients to sport facilities • Collaboration provided physicians with a better understanding and awareness of the services and support available to their patients • Referral scheme also laid groundwork for a relationship between physicians and sport organizations • Referral process provided a welfarist and commercial benefit for leisure • Funding or remuneration as a priority or a key influence on ongoing implementation Collaborative initiatives to organize activities to promote PA among the community For partnership formation:

Author, year Main results (Barriers and Facilitators) Level
System Organisat. Interindiv.

Individual
• Trust and shared interests among members • Engagement of more than one person from a sport organization (key leaders that influence strategic direction of the sports club) • Professional organization (reduce impact of staff turnover) • Visibility of results for the partners

Kirst, 2017
Barriers (identified in mixed results and unsuccessful program) • Challenges to provider commitment: lack of incentives for physicians to participate in IC program activities, limited provider enthusiasm from significant changes in practice (from implementation), and limited flexibility for providers to make operational changes; providers viewed team meetings as time-consuming, and did not fully understand how to use program protocols due to limited training ; GP under a   