In this section, we start by presenting the comprehensive model that emerged from the analysis, and then move to a presentation of each of the elements of the model.
The model is presented in Figure 1. Based on the findings from our study and on the literature on professional boundaries and collaboration, we categorized roles along two dimensions - as autonomous or collaborative, and as interchangeable or differentiated. The autonomous-collaborative category of role boundaries refers to the manifestation of interprofessional interactions on a team; less interaction generally implies more autonomy. We use the term ‘differentiation’ to indicate the delineation of team members’ responsibilities and ‘interchangeability’, where one profession performs some of the same tasks as another. Situated in the middle of the diagram are the boundaries that form around interprofessional interactions (collaborative and autonomous roles) and the distribution of professional responsibilities (interchangeable and differentiated roles). These are four ideal types of roles and there is fluidity around how the boundaries of roles are constructed and re-constructed. At the top of the diagram are the influences that shape the boundaries around roles as per our findings. The variable nature of these different types of influences and the team context means that the former do not always manifest themselves in a pre-determined fashion (e.g. staff turnover could be high or low). These influences are not mutually exclusive and can affect each other. For example, rapid staff turnover makes it difficult for team members to build trust between each other. As indicated at the bottom of the diagram, the construction of role boundaries on an interprofessional team also has implications for team members and patients. Role construction is a dynamic process: the arrow from ‘implications’ to ‘influences’ illustrates a feedback loop.
Role boundaries
Collaborative roles occur where team members have frequent interactions and knowledge exchanges; autonomous roles occur where team members have fewer interactions, less collaboration and work more independently from each other (note that these autonomous roles still have the potential to be complementary to the team).
“I really rely heavily on the other people that work here…I often share my findings on a patient with other colleagues or they share with me.” Team 2, NP - Participant 4 (collaborative)
“I’m with patients all day…I’m not going to sit there and talk about work ever with anybody really…I’m more independent.” Team 1, Chiropodist - Participant 13 (autonomous)
Interchangeable roles arise where the responsibilities of different team members overlap and they can be beneficial for example, by helping to ease the workload of another health professional. Differentiated roles occur when team members have separate and distinct responsibilities.
“[New patients] fill out an intake form…Once that is filled out, we have them book an intake appointment where they may meet with the RN, RPN or the NP, depending on availability, where the intake is reviewed. Team 2, Clinical director - Participant 1 (interchangeable)
“NPs have a larger practice… They can prescribe, they can make a diagnosis, we (RNs) cannot.” Team 1, RN - Participant 9 (differentiated)
Influences
In this section, we discuss structural, interpersonal and individual influences on role construction and boundaries by attending to impacts on interaction and distribution of responsibilities.
Structural influences
Structural influences refer to the characteristics of the workplace and include physical space, workloads, turnover, hierarchy and team composition. Physical space is an influence that is often mentioned by participants from Team 1 yet is rarely seen to have a direct effect by Team 2. Some health professionals will be located in proximity to one another while others will be farther apart. The layout of clinical space can affect the potential for interactions among team members. On Team 2 physical space may be perceived to have a smaller impact because team members are at close distance to each other and therefore see one another frequently. During visits with Team 1, we observed that team members were located on different floors and buildings whereas almost all members of Team 2 had offices in the same hallway. The interview data supports these observations: many Team 1 participants commented that their physical distance from other team members had an impact on their ability to interact with each other whereas members of Team 2 did not address the issue of physical distance. It is possible that physical space is seen as an influence by team members when it prevents interactions whereas, the positive impacts of clinical space may be accepted as the status quo.
On Team 1, workloads influence role construction both in terms of the frequency of interactions between health professionals and the distribution of responsibilities. For example, a heavy workload can be a factor in reducing opportunities for interaction with others. Also, the presence of long waiting lists for patients to schedule appointments with some allied health professionals tends to create a situation where NPs and physicians offer some services that are in the area of expertise of another health professional so that patients can avoid the wait. This strategy also alleviates some of the work pressure on the allied health professional in question.
“The chiropodist is specialized in foot care, wounds, warts, injuries, nails…But we [NPs] still do wart treatments. So there is a duplication of services provided but she can’t see everyone: she’s already got a ridiculously long waiting list.” Team 1, NP - Participant 8
Team 2 appears to have some buffering characteristics that facilitate interaction in spite of workload. All Team 2 members are located in proximity to each other which allows for frequent informal meetings as team members walk up and down the hallway. Also, Team 2 has more intensely scheduled team interactions (e.g. a two-hour team meeting every month vs. a one-hour team meeting every two months for Team 1). Similarly to Team 1, the workload on Team 2 tends to affect how responsibilities are spread out among team members: the amount of work to be accomplished can compel NPs to retain responsibilities or to delegate more to others so that they can focus on the areas of their expertise that do not overlap with other team members.
Turnover, similar to physical space, is seen to have an influence by Team 1 but not by Team 2 participants. In comparing the two cases, it can be noted that Team 2 is quite young – at the time of interviews, many of the team members had not yet experienced the effects of staff turnover on this team – therefore it is unlikely that current team members have a good indication of how and if turnover affects their role construction in this context. On Team 1, participants commented on the high turnover among some professions which appears to affect role boundaries in terms of team members’ ability to develop collegial relationships and collaborate. It also influences whether primary care providers choose to access chronic disease management programs and services, an aspect that can change the primary care providers’ responsibilities towards the patient.
On both teams, physicians and/or NPs are at the top of the hierarchy and chain of responsibility for the patient and have the power to refer and delegate responsibilities. They can influence the types of responsibilities associated with other roles on the team and also the extent to which they collaborate and are interrelated with other health professionals. For example, some physicians were found to use their status to facilitate the professional development and growth of the NP and other allied health professional roles on Team 1.
“There are definitely power dynamics. I think in general physicians tend to hold more weight.” Team 1, Mental health counselor - Participant 12
Positional power may be used to influence roles positively or negatively. The following example illustrates how team members higher in the hierarchy may exert influence over the roles and interactions with other professions:
“One of the interesting things that we found and worked through was the whole ‘grabbing-and-letting-go’ process because there are a lot of similar tasks in the roles [of NPs and RNs]…How we worked to build a process was to keep reminding the nurse practitioners in this model that you are now similar to a family doctor and those RNs are similar to the nurse practitioners. So you know exactly what it’s like to feel like you’re compressed and not working your full scope, why would you do the same to an RN? And when they start thinking like that and putting themselves in that position, that’s when they start working together and they learn how to truly work as colleagues.” Team 2, Manager - Participant 2
In addition, a team member’s responsibilities can change as a function of the professional composition of the team. When the professional composition changes, the responsibility for certain tasks might shift as well. For example, adaptation may take place because a new team member has more knowledge in an existing area of health service delivery. Different combinations of professions on the team, including the types of professions and number of work hours, results in different interactions and distributions of responsibilities among the team members.
Interpersonal influences
Interpersonal dynamics are the dynamics between team members and include such elements as professionals’ education and understanding of each other’s roles, trust, leadership, and consultation of each other based on the relevance of professional knowledge. Education is an important influence because health professionals will not necessarily join the team with an understanding of the responsibilities of all the other professions and how to engage these professionals’ services in the care of the patient. For both teams, education influences autonomous-collaborative role boundaries.
“As part of my orientation when I started working here, I spent some time with each of those disciplines to get a little bit clearer idea of what their role is. I think it enhances the team, it enhances my work.” Team 2, NP - Participant 5
Trust is a relational factor that affects the extent to which professionals are collaborative and are willing to delegate and share responsibilities. On both teams, providers develop trust by interacting with colleagues on a professional and personal level. The presence of trust makes providers feel more comfortable in relying on each other’s expertise and can foster greater sharing of responsibilities.
“If you’ve got a clinical pharmacist who is very approachable, demonstrates to the physicians and NPs…that she’s very knowledgeable…, answers their questions in a very helpful manner, provides good advice to them and to their patients, then people consult the pharmacist and the things they ask the pharmacist to do on behalf of their patient continue to increase.” Team 1, Manager - Participant 1
Leadership can influence the distribution of responsibilities and foster the collaborative tendencies of the team. Staff from both teams readily identified with formal leadership (e.g. clinical director and team manager). At this level, leaders can be key in helping to integrate new professionals into the team and creating a sense of team belonging.
“We all have a say in the hiring of our teammates and we discuss roles ahead of time. We collaboratively get together and say ‘okay, what are we missing in our model of care and which position would be able to fill that void’.” Team 2, Manager - Participant 2
Leadership can also facilitate opportunities for interprofessional interactions through formalized events such as team meetings. Leaders can contribute to making these meetings a space for team members to initiate new opportunities for team collaboration. For example, during a Team 1 meeting, we observed a nurse practitioner bringing forward her idea for a new ‘internal education day’ where team members would present and teach each other about different clinical topics. The leaders facilitated this endeavour by including it on the agenda, introducing the item in a supportive manner and ensuring that a date and presenter were chosen for the first education day. Formal leaders on Teams 1 and 2 are active in empowering staff to grow in their roles and in giving them more autonomy to pursue clinical areas of interest to them.
Team members consult some colleagues for advice and expertise more regularly than others. The relevance of professional knowledge is an influence on collaborative role boundaries because health professionals tend to collaborate more frequently with the professions that can provide them with additional knowledge and information to inform their care decisions and vice versa.
“I really rely on the pharmacist to ensure…I’m using the optimal medication for an individual patient…so I interact with him a lot. I do interact with the dietician and social worker as well, but it’s more…on a nice-to-know type of basis rather than really relying on the skill set of another professional to help me in my role.” Team 2, NP - Participant 4
For Team 1 and Team 2, the relevance of professional knowledge and expertise can have an impact on the frequency of interaction between different professions on the team. This dynamic may contribute to the construction of more autonomous or more collaborative role boundaries.
Individual influences
Individual attributes, such as an individual’s approach to care or perspective on interaction with other team members, can be a factor in determining how much team members are willing to work and grow in their role collaboratively (in addition to having autonomy) and can also affect the distribution of responsibilities.
“Some providers feel that as primary care provider they should be providing all of the primary care and doing everything and they really don’t refer a lot. But they might use my services in another way: drug information questions. So for some physicians I’m really exclusively a drug information pharmacist. For other physicians, I’m much more involved in a collaborative care approach where they’ll refer me a patient and ‘can you recommend what should I do about this’ and in those instances it’s collaborative and I’m a part of patient care, whereas with others it’s very separate.” Team 1, Participant 11 – Pharmacist
Some providers may see the patient as the ‘team’s patient’ and this view can influence them to delegate more responsibilities and to collaborate with other health professionals. Others see the patient ultimately as their responsibility and may feel uncomfortable in relying on other team members to provide care for their patients. Also, individual traits such as timidity and confidence can influence team members’ integration within an interprofessional team and their interaction with other health professionals.
Implications for professionals and patients
In terms of the implications stemming from autonomous-collaborative role boundaries, both Team 1 and 2 participants find an advantage in being supported by the knowledge of other professions (for example, physicians and NPs see consultations with a pharmacist as valuable encounters) and link collaborative exchanges with professional satisfaction. Some professionals also expressed that they gained satisfaction from the autonomous dimensions of their role.
“I love having our pharmacist here…the NP. They’re great supports and it’s nice feeling that you’re not alone in taking care of a huge number of people. That there is a safety net. It’s nice to know that there are other people you can call and say I’ve got to change her off of all of these medications, can you please help me here.” Team 1, Physician - Participant 4
“I think if I were on [another team], I would not be seeing every patient; I would be perhaps seeing more routine types of patients; and then there would be these doctors asking me about my patient care all the time, and questioning me on that. And here we don’t have that. So being given that autonomy, being given that responsibility for me is just to work extra hard to do a really good job, and that’s what I strive for every day…It’s like a breath of fresh air, compared to anywhere else I’ve ever worked. Even though they all say it’s a team, it’s not a team compared to here. I can’t stress that enough; this is amazing here in that way.” Team 2, Participant 5 – NP
Participants mentioned that patients can benefit from collaborative endeavours by receiving more holistic care and through better coordination and continuity of health services. Turning to the implications of interchangeable-differentiated role boundaries, interviewees on both teams commented that the interchangeable nature of some responsibilities contributes to alleviating the burden of their workload.
“With the ‘Well-Baby’ visits…I usually do immunizations but, if I’ve got two to give, then sometimes they [NPs] will come in and help me, even though that’s really not their role. But it’s still within their scope…so they will come and help me do it.” Team 2, RN - Participant 6
Nevertheless, overlapping responsibilities can also engender confusion around roles: this situation is experienced by members of Team 1 but was not a salient issue for Team 2. Possible explanations for the variability in this implication may include that Team 2 has more opportunities for addressing misunderstandings. Team 2 holds team meetings more frequently than Team 1 which may make it easier to facilitate a standardized understanding of roles and responsibilities and clarify procedures and explanations. For instance, during one of Team 2’s meetings, the clinical director shared an experience with miscommunication at the clinic and solicited input for creating better risk management for verifying pharmaceutical information on new patients’ intake forms. Team members discussed various ideas around how to modify the oversight of pharmaceutical information. With the entire team present and participating, the challenge was addressed, a new protocol for verifying drug information was agreed upon and revised responsibilities for the pharmacist were elaborated. On Team 1, the staff meetings happened less frequently and discussions tended to remain at the level of administrative issues and program updates. The manager chairing the meetings commented several times on the need to attend to items quickly and efficiently because of time constraints. Team 2 appears to have more opportunities for interactions to raise issues and refine shared understandings of responsibilities and areas of expertise.
Team members from both cases suggest that the differentiation of roles can entail certain advantages such as allowing the skills and abilities of professionals to be focused on a specific area of expertise within the team (maximization of skills) and decreasing the likelihood of power struggles related to overlapping responsibilities.
“I don’t know if I think anybody has any more power. I work really collaboratively with most of the NPs. I don’t feel like I could do their role and I don’t think that they really feel that they could do mine. So I think that we respect each others’ boundaries and limits.” Team 1, Pharmacist - Participant 8
Similarly to the way in which the interchangeability of responsibilities can ease the workload of a health care provider, it was also found to result in shorter wait times for patients of both teams. Greater familiarity with the whole care team, due to the interchangeability of responsibilities, is also an advantage suggested by Team 2.