The aim was investigate to the factors contributing to effective IPP in rural contexts, to examine how IPP occurs in rural contexts, and to identify barriers and enablers. There was clear evidence of IPP in the rural settings where this study was conducted that was supported by many descriptions of collaborative and integrated practice. There were also instances where IPP doesn’t and could happen. This uneven implementation of IPP within our study is consistent with the mixed results of IPP found in the literature [23, 29]. In spite of the diversity and complexity of IPP in rural contexts there were a number of characteristics identified that significantly impacted on IPP. These were: the strong community connection and the history of shared experience; health professionals with authority and opportunity to initiate processes that engage others; funding to support IPP; proximity and colocation; workload and workforce limitations; the presence of a shared philosophical position characterised by recognition of the benefits of IPP and valuing of and respect for others; and absence and fragmentation of health services.
Community connection and local knowledge plays a key role in rural health service provision. For instance, nurses have been described as the “'agents of connectivity'…providing essential linkages between the system's many users, health professionals and service arrangements” . Rural nurses in general have described ‘knowing’ their local community as a positive characteristic of their role and this enables them to facilitate links between local health providers and advise patients on available community resources [30, 31]. This was reinforced in our data, particularly with the hospital-based Discharge Planner who indicated that good local knowledge informed care plans as well as follow-up.
This highlights the importance of professional roles that span boundaries and facilitate communication across sectors. The Discharge Planner strengthened ties and communication between acute and community services. In addition, GPs in primary care were pivotal in engaging other health professionals in coordinated care for those patients with chronic conditions. Gittell  describes these roles as “boundary spanners” – individuals who cross functional or organizational boundaries in order to integrate or link the work of other care providers.
GPs are also pivotal in integrating care across the primary and acute care settings in rural areas as they generally have existing connections with local hospitals . Although referrals from GPs to other health professionals have been supported by Commonwealth government rebates under the Enhanced Care/Chronic Care Programs , there is evidence to indicate that having the GP as the pivot or care coordinator is not without problems. Collaboration between GPs and other health care providers have been marred by imprecise and contradictory role definitions , mistrust and perceived threats to autonomy and independence . In addition GPs have a history of referring patients to other health professionals in an inconsistent and uncoordinated manner . A number of participants (including a medical officer) discussed barriers associated with the attitude of the medical profession to IPP. Some of the associated issues included lack of awareness of how other professions can contribute to decision making, difficulties in engaging doctors in the process as well as the perceptions of medicine’s place in the health hierarchy. Additionally, our study also revealed some fragmentation of IPP mechanisms across sites and contexts. Spanning organizational boundaries in the delivery of health care confounds IPP as the boundaries between services, roles and professional groups are changing and this adds to uncertainty and the vulnerability of those involved .
Funding arrangements for health care in rural areas impact significantly on the potential for IPP. Primary health services in Australia are delivered via a complex mix of private providers, state government-funded health services and fee-for-service arrangements supported by Commonwealth funding . Linkages between GPs and other health professionals have been promoted via government funding for Practice Nurses and Medicare rebates for referrals to AHPs under Enhanced Care/Chronic Care Programs [34, 38]. Integration of primary health care services (such as MPSs) has also been funded by various decentralized initiatives funded by both state and Commonwealth governments . Our data supports the evidence that collaboration between GPs and other health professionals has been boosted by government funding and additional Medicare rebates.
Co-location of health providers fosters collaboration, is likely to provide the greatest benefit to those suffering chronic illness [34, 39] and has been viewed as a key factor in sustaining IPP in a range of settings [21, 34, 40]. In our study, co-location was seen as particularly beneficial in facilitating informal discussion and review between practitioners and providing integrated services in a GP practice or MPS for those with chronic illness. Co-location of services alone, however, does not necessarily guarantee integration of services.
Rural health services face substantial challenges in recruiting and retaining adequate numbers of health professionals . Such workforce shortages mean that rural practitioners struggle with problems of inadequate locum coverage, limited professional support networks and excessive workloads [6, 7]. For some of our participants, workforce shortages and extended vacancies in particular disciplines made IPP challenging. Furthermore, heavy workloads can place undue stress on clinicians and hamper their readiness to engage in IPP. Yet in other instances, heavy workloads became a driver for clinicians to work interprofessionally. This supports the view that collaboration and teamwork in rural practice are influenced by workforce limitations and the “consequent need to work cooperatively to ‘get the job done’” , p. 145].
The reduced number of health professionals means that clinicians are often working alone or as solo practitioners in a small team . Our study presents evidence of how professional isolation can be alleviated via teamwork and successful IPP. Nursing staff, managers and AHPs consistently expressed how interprofessional teams offered professional support as well as provided them with a strong sense that they were not managing alone. Such findings support an earlier commentary that in comparison to urban teams, there appears to be greater respect for the work of different professions in rural and remote practice .
Change is occurring in the ways rural professionals engage with each other and how their relationships inform models of care for people with varying health problems. Funding models are driving change through funding linked to joined-up care, recognising the need for transition and the potential for gaps across sectors. The difficulties confronting professionals and the IPP agenda are complex and often historically embedded.
To achieve optimum IPP outcomes there is a need for cultural change, trust, respect and sharing of information and communication across professionals. Mutual respect and shared values along with an knowledge of the roles and responsibilities of other care providers have been noted as key competencies for interprofessional working . These elements can be fostered by clinicians sharing information and learning from one another during practice as well as by interprofessional education efforts . As Gittell  notes “Even timely, accurate information may not be heard or acted upon if the recipient does not respect the source” (p. 16).
Whilst the lack of sufficient numbers of professionals and professions available in or to rural areas impacts greatly on the capacity for IPP, there is also space for development and extension of models that involve sharing of work across disciplines. Perhaps, most significant is the need for recognition and support of pivotal roles and the processes employed by these individuals to engage others and act as a central resource for patients and their families. Additionally there is some evidence that IPP can help combat the effects of professional isolation which addresses one of the issues associated with the challenges of recruitment and retention of rural health practitioners . Overall, it is evident that the processes underpinning the delivery of care are just as important as what care is delivered.
Study strengths and limitations
A strength of the study was that data were gathered across a range of professionals, settings and contexts. A number of references to Practice Nurses by participants highlighted that inclusion of Practice Nurses’ perspective and understanding of how they contribute to rural IPP would have informed a more comprehensive understanding of contemporary primary rural health care. Further, a more holistic perspective would be gained by inclusion of patients reports of their experiences with various health professionals.