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Journal of Interprofessional Care

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Allied health professionals’ perceptions of interprofessional collaboration in primary health care: an integrative review

Jack Seaton, Anne Jones, Catherine Johnston & Karen Francis

To cite this article: Jack Seaton, Anne Jones, Catherine Johnston & Karen Francis (2021) Allied health professionals’ perceptions of interprofessional collaboration in primary health care: an integrative review, Journal of Interprofessional Care, 35:2, 217-228, DOI: 10.1080/13561820.2020.1732311

To link to this article: https://doi.org/10.1080/13561820.2020.1732311

Published online: 16 Apr 2020.

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ORIGINAL ARTICLE

Allied health professionals’ perceptions of interprofessional collaboration in primary health care: an integrative review Jack Seaton a, Anne Jones a, Catherine Johnston b, and Karen Francis c

aDiscipline of Physiotherapy, College of Healthcare Sciences, James Cook University, Townsville, Australia; bDiscipline of Physiotherapy, School of Health Sciences, the University of Newcastle, Callaghan, Australia; cDiscipline of Nursing, College of Health and Medicine, The University of Tasmania, Launceston, Australia

ABSTRACT This integrative review synthesizes research studies in order to explore the perceptions of allied health professionals regarding interprofessional collaboration in primary health care. A comprehensive literature search was conducted using three electronic databases and a manual search of the Journal of Interprofessional Care. The Crowe Critical Appraisal Tool was used to assess the quality of included papers. Study findings were extracted, critically examined and grouped into themes. Twelve studies conducted in six different countries met the inclusion criteria. Thematic analysis revealed five themes: (1) shared philosophy; (2) communication and clinical interaction; (3) physical environment; (4) power and hierarchy; and (5) financial considerations. This review has identified diverse key elements related to interprofessional colla- boration in primary health care, as perceived by allied health professionals. Opportunity for frequent, informal communication appeared essential for interprofessional collaboration to occur. Allied health professionals working in close proximity to health practitioners from other professions had more regular interprofessional interactions than those who were geographically separated. Co-location of multiple primary health care services within the same physical space may offer increased opportunities for inter- professional collaboration. Future research should avoid reporting on allied health professionals in primary health care collectively, and isolate data to the individual professions. Direct observational methods are warranted to investigate whether allied health professionals’ perceptions of interprofessional collaboration align with their actual clinical interactions in primary health care settings.

ARTICLE HISTORY Received 23 November 2018 Revised 7 September 2019 Accepted 15 February 2020

KEYWORDS Interprofessional collaboration; primary health care; allied health professionals; integrative review

Introduction

Interprofessional collaboration is a complex and dynamic phe- nomenon defined by the relationships and interactions that occur between health practitioners from various professional back- grounds to deliver safe, high-quality patient care (Reeves et al., 2010; World Health Organization (WHO), 2010). Interprofessional collaboration is an expected standard of practice for health practitioners and is a widely acknowledged solution to facilitate more effective and appropriate patient care (Bookey- Bassett et al., 2017; WHO, 1978). Responsibility, accountability, coordination, communication, cooperation, assertiveness, auton- omy, mutual trust and respect are deemed essential for successful collaborative practice in health care (Ontario College of Family Physicians, 2000). Research indicates that interprofessional colla- boration can have positive effects on both the health care system and health outcomes. Interprofessional collaboration has been shown to be an integral component in the provision of cost- effective health care and contributes to superior patient outcomes and enhanced patient and practitioner satisfaction (Reeves et al., 2017). Despite the documented benefits of interprofessional col- laboration, it remains a variably understood concept and difficult to implement in particular health care settings, including primary health care (Karam et al., 2018; Reeves et al., 2018; Xyrichis & Lowton, 2008). The aim of this integrative review was to

synthesize the available evidence on the perceptions of allied health professionals regarding interprofessional collaboration in primary health care.

Background

Interprofessional collaboration is considered essential in the management of chronic disease and makes best use of available resources (Green & Johnson, 2015; Supper et al., 2015; WHO, 2010). Increasing prevalence of chronic illness is creating significant burden for patients, families and health care systems (Moore, 2018). As the first point of contact, primary health care plays a key role in preventing, delaying and reducing the progression of chronic diseases (Department of Health, 2013a; WHO, 1978). Due to their high and complex needs, management of people with chronic conditions is typically delivered by multiple pri- mary health care practitioners from a range of professional backgrounds (Van Dongen et al., 2016). The knowledge, skills, and experience of health practitioners from each profession are brought together to produce the best out- come for individuals with chronic illness (Körner et al., 2016; Xyrichis & Lowton, 2008).

CONTACT Jack Seaton jack.seaton@my.jcu.edu.au Discipline of Physiotherapy, College of Healthcare Sciences, James Cook University, 101 Angus Smith Drive, Townsville, QLD 4811, Australia

JOURNAL OF INTERPROFESSIONAL CARE 2021, VOL. 35, NO. 2, 217–228 https://doi.org/10.1080/13561820.2020.1732311

© 2020 Taylor & Francis Group, LLC

Primary health care services are offered within both the pub- lic and private health sectors in settings such as general practice, community health centers and allied health clinics (Reddy, 2017). While the majority of people access primary health care through a general practitioner, these services may also be pro- vided by the nursing and allied health professions (Lizarondo et al., 2016; McInnes et al., 2015). However, an overwhelming shortage of general practitioners is of international concern to the primary health care workforce, particularly in regional, rural and remote areas (Grover & Niecko-Najjum, 2013; Kamien & Cameron, 2006). As first-contact primary health care practi- tioners, allied health professionals are able to assess, treat and manage patients without a medical referral (Allied Health Professions Australia (AHPA), 2017a; Stute et al., 2018). Consequently, allied health professionals have significant poten- tial to reduce the burden on general practitioners with expertise in their relevant fields (Salmon et al., 2017). The complex health care needs of patients with chronic illness often require specia- lized skills that medical practitioners may not possess and may be more appropriately provided by allied health professionals (Australian Physiotherapy Association (APA), 2009).

The features of effective interprofessional collaboration in primary health care are poorly defined in the literature. Primary health care differs from other health care settings with regard to organizational structure and daily service deliv- ery (Duckett & Willcox, 2015; Keleher & MacDougall, 2016). Unlike secondary and tertiary settings, such as hospitals, primary health care is largely affected by the issues of location and time (Oandasan et al., 2009). Subsequently, health practi- tioners working in primary health care might not share the same space or maintain face-to-face contact with members of their team and may only have limited opportunity for formal meetings to discuss specific patient cases (Mulvale et al., 2016).

In many countries, government funding schemes have been introduced to enable individuals with chronic diseases to receive subsidized services in private primary health care facilities (Australian Institute of Health and Welfare (AIHW), 2016; Cumming, 2011; Hutchison et al., 2011). Within the private health sector, a common allied health service delivery model is a small monodisciplinary clinic (Department of Health, 2013b). That is, a facility whereby an allied health professional may be the sole practitioner, or a facility only employing practitioners from one allied health profession, thus limiting occasions for interprofessional interactions. Although larger allied health practices which may be co- located with other health services are becoming increasingly common, allied health professionals working in primary health care, for the most part, continue to operate in mono- disciplinary practice settings (Department of Health, 2013b). The shift toward co-location of multiple primary health care services within the same physical space may offer allied health professionals increased opportunities for interprofessional collaboration (Bonciani et al., 2018; Rousseau et al., 2017; Wener & Woodgate, 2016).

Allied health professionals have been described as critical to the success of primary health care (Department of Health, 2013b; Lizarondo et al., 2016). Allied health professionals are

encouraged to collaborate with practitioners from diverse health professions to deliver optimal patient care, however there is little published evidence exploring the characteristics of their interprofessional interactions, especially in the pri- mary health care setting (D’Amour et al., 2008). The experi- ences of health practitioners regarding interprofessional collaboration in primary health care has attracted previous attention in the literature, however most of this research concerns the professions of medicine and nursing (McInnes et al., 2015; Morgan et al., 2015; Schadewaldt et al., 2013). The features of interprofessional collaboration, as perceived by allied health professionals working in primary health care, remain largely unknown and unexplored.

Methods

Study design

The framework developed by Whittemore and Knafl (2005) was used to guide this integrative review. This method enables the synthesis and analysis of both quantitative and qualitative research, therefore providing a more holistic picture of the research landscape of a specific topic area (Grant & Booth, 2009). Integrative reviews are particularly suitable in health research, as they can generate answers to more complex questions which health practitioners may encounter in the clinical setting (Whittemore & Knafl, 2005).

Search strategy

A comprehensive literature search was conducted in May 2018 using three electronic databases: Cumulative Index to Nursing and Allied Health Literature (CINAHL), Ovid Medline and Scopus. To prevent accidental omission of relevant key articles, a manual search of articles published in the Journal of Interprofessional Care (inception – May 2018) was also per- formed. Multiple keyword combinations were used in the search strategy, which was developed in conjunction with the health liaison librarian at James Cook University (Table 1). Reference lists of included studies were also reviewed to identify additional articles not found during the database search.

Study eligibility criteria

Study selectionwas completed by two reviewers (JS and AJ), who independently scanned the titles and abstracts of citations iden- tified through the search for inclusion in the review. For the purpose of this review, allied health professionals were defined as those professions listed by both Allied Health Professions Australia (AHPA) and the Australian Health Practitioner Regulation Agency (AHPRA). Allied Health Professions Australia is the peak national organization for allied health professionals in Australia, representing twenty allied health pro- fessions (AHPA, 2017b), while the Australian Health Practitioner Regulation Agency supports the fifteen National Boards that are responsible for regulating the health professions (AHPRA, 2017). The professions comprised chiropractic; occu- pational therapy; optometry; osteopathy; physiotherapy;

218 J. SEATON ET AL.

podiatry; and psychology. Each of the seven allied health profes- sions have been reported in the primary health care literature to varying extents, so were deemed appropriate for final inclusion in the review.

To be included in this review, the publication had to:

● Relate to interprofessional collaboration and/or colla- borative practice among allied health professionals within primary health care

● Report on allied health professionals’ perceptions of interprofessional collaboration and/or collaborative practice in primary health care

● Contain at least one allied health profession or more ● Contain original research where primary data collection

and analysis was evident ● Be English language research papers published in peer-

reviewed journals

Studies were excluded if:

● They were primarily concerned with evaluation of an interprofessional practice intervention

● They related to interprofessional collaboration and/or collaborative practice between health practitioners and patients

● They related to interprofessional collaboration and/or collaborative practice within an interprofessional educa- tion context

● Participants included pre-qualified health practitioners (for example, allied health students)

● They were literature reviews, or non-research articles (for example, editorials, dissertations, anecdotes, opi- nion pieces or commentaries)

● Participants were not working in clearly defined primary health care settings

Quality assessment

The Crowe Critical Appraisal Tool (CCAT) was used to assess the methodological quality of included studies. The CCAT was developed as a structured tool for evaluation of health research and has established validity and reliability with high intra-class correlation (Crowe & Sheppard, 2011; Crowe et al., 2011, 2012). The tool consists of eight categorical items: pre- liminaries; introduction; design; sampling; data collection; ethical matters; results; and discussion (Crowe & Sheppard, 2011). Each categorical item was scored from 0 (no evidence) to 5 (high evidence) and summed to provide a total score for each article that was presented as a percentage (that is, [score/ 40] x 100). Based on criteria from a previous study (Sznitman & Taubman, 2016), the total score for each paper was con- sidered as “poor quality” (≤ 50%), “moderate quality” (51–- 74%) and “high quality” (≥ 75%). Scoring was undertaken independently by two reviewers (JS and AJ) with discrepan- cies in scores being resolved through discussion. No paper was excluded based on methodological quality (Whittemore & Knafl, 2005).

Data abstraction and synthesis

Thematic analysis was undertaken to interpret the large amount of information presented in the papers, as this approach is flexible and allows clear identification of pro- minent themes (Braun & Clarke, 2006). To facilitate analy- sis, data were extracted into an evidence table according to authors and location; study aims; methodology; sample characteristics; and main findings. The organization of qua- litative and quantitative data within a single matrix sup- ported the integration of both narrative and statistical evidence (Whittemore, 2005). Tabulated data were viewed by all authors to identify patterns and relationships via an iterative process. Preliminary themes were discussed, com- pared collectively, and agreement reached before one author (JS) categorized them into a final set of themes and sub-themes, which were checked and rechecked (Braun & Clarke, 2006).

Table 1. Electronic database search strategy.

MEDLINE search strategy

(1) (interprofession$ or inter-profession$).tw. (2) (interdisciplin$ or inter-disciplin$).tw. (3) exp interprofessional relations/ (4) exp interdisciplinary communication/ (5) collaborat$.tw. (6) or/1–5 (7) (chiropract$ or optometr$ or osteopath$ or phy-

siotherapy$ or podiatr$ or psycholog$).tw. (8) “occupational therap$”.tw. (9) “physical therap$”.tw.

(10) “allied health”.tw. (11) allied health occupations/ (12) exp occupational therapy/ (13) exp physical therapy/ (14) exp chiropractic/ (15) exp optometry/ (16) exp podiatry/ (17) or/7–16 (18) 6 and 17 (19) “private$ practi$”.tw. (20) “private sector”.tw. (21) “primary care”.tw. (22) “primary health”.tw. (23) exp private practice/ (24) exp private sector/ (25) exp primary health care/ (26) or/19–25 (27) 18 and 26 (28) limit 27 to english language (29) limit 29 to systematic reviews (30) 28 not 29 (31) limit 30 to journal article

CINAHL search strategy

(SU interprofession*) or (SU interdisciplin*) or (SU collaborat*) or (MH interprofessional relations) AND (SU chiropract*) or (SU “occupational therap*”) or (SU optometr*) or (SU osteopath*) or (SU physiotherapy*) or (SU “physical therap*”) or (SU podiatr*) or (SU psycholog*) or (SU “allied health”) or (MH chiropractic) or (MH occupational therapists) or (MH optometry) or (MH osteopathy) or (MH physical therapists) or (MH podiatry) AND (SU “private* practi*”) or (SU “private sector”) or (SU “primary health”) or (MH “private practice+”) AND narrow by language: -english

Scopus search strategy

TITLE-ABS-KEY(interprofession* OR inter-profession* OR interdisciplin* OR inter-disciplin* OR collaborat* AND chiropract* OR “occupational therap*” OR optometr* OR osteopath* OR physiotherap* OR “physical therap*” OR podiatr* OR psycholog* OR “allied health” AND “private* practi*” OR “private sector” OR “primary care” OR “primary health”)

JOURNAL OF INTERPROFESSIONAL CARE 219

Results

Study selection

In total, 2,851 articles were identified during the literature search. Of these, 2,846 were found through database search- ing, and an additional five articles were identified from a manual search of the Journal of Interprofessional Care. After the removal of duplicates, 2,272 papers were excluded based on title and abstract. Of the remaining 70 articles, four were not accessible and were excluded. Full-text analysis was conducted on the remaining 66 articles, resulting in nine studies appropriate for review. An additional three relevant articles were identified following review of reference lists (Figure 1).

Study characteristics

Twelve papers met the inclusion criteria and are presented in Table 2. Six of the reviewed studies were conducted in Canada (Brown et al., 2015; Dufour et al., 2014; Gaboury et al., 2009; Perreault et al., 2014, 2016, 2018), two in Australia (Grace & Higgs, 2010; Gray & Orrock, 2014), two in Europe (Doekhie et al., 2017; Myburgh et al., 2014) and one study took place in each of New Zealand (Pullon et al., 2016) and the United Kingdom (Sargeant et al., 2008).

Physiotherapists were represented in seven studies (Doekhie et al., 2017; Dufour et al., 2014; Perreault et al., 2014, 2016, 2018; Pullon et al., 2016; Sargeant et al., 2008); three separate studies included chiropractors (Gaboury et al., 2009; Grace & Higgs, 2010; Myburgh et al., 2014) and occupational therapists (Brown et al., 2015; Doekhie et al., 2017; Sargeant et al., 2008); psychol- ogists were included in two studies (Brown et al., 2015; Doekhie et al., 2017); and osteopaths were participants in one study (Gray & Orrock, 2014). No studies met the inclusion criteria exploring interprofessional collaboration from the perspectives of optome- trists and podiatrists. Five of the included papers did not isolate data to the allied health professions (Brown et al., 2015; Gaboury et al., 2009; Grace & Higgs, 2010; Pullon et al., 2016; Sargeant et al., 2008).

For studies that articulated sample size, there was a large variation, ranging from six to 327 participants. In two studies, details regarding the precise number of participants were diffi- cult to obtain (Grace & Higgs, 2010; Pullon et al., 2016). Participants practised in primary health care settings at various stages of development from emerging to established teams and were responsible for delivering a broad range of primary health care services. Participants worked across different primary health care settings with respect to organizational structure, including monodisciplinary, multidisciplinary and co-located practice facilities.

Records identified through database searching

(n = 2,846)

Records identified through hand searching (n = 5)

Records after duplicates removed (n = 2,342)

Titles/abstracts screened (n = 2,342)

Records excluded (n = 2,276)

• Did not meet inclusion criteria • No access

Full-text articles assessed for eligibility (n = 66)

Full-text articles excluded (n = 57)

• Participants: allied health professionals not included, patients, students

• Setting: hospitals, residential aged care, research/academia, schools

• Outcome: perceptions of interprofessional collaboration not reported, evaluation of an interprofessional practice intervention

Studies included in review (n = 12)

Additional records identified through reference lists (n = 3)

Figure 1. Flow chart illustrating th selection of papers for the review.

220 J. SEATON ET AL.

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ph ys io th er ap y pr iv at e se ct or

Fa ct or s th at

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al pr ac tic es

w er e re la te d to

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JOURNAL OF INTERPROFESSIONAL CARE 221

Studies ranged considerably regarding their degree of pro- cedural rigor. Quality assessment scores ranged from 16 to 34 out of 40 possible points on the CCAT, with a mean score of 26. Four studies were of high quality (Doekhie et al., 2017; Gaboury et al., 2009; Perreault et al., 2014; Pullon et al., 2016), six of moderate (Brown et al., 2015; Dufour et al., 2014; Grace & Higgs, 2010; Gray & Orrock, 2014; Perreault et al., 2016; Sargeant et al., 2008) and two of low quality (Myburgh et al., 2014; Perreault et al., 2018). Most studies reported using qualitative methods (Dufour et al., 2014; Gaboury et al., 2009; Grace & Higgs, 2010; Gray & Orrock, 2014; Perreault et al., 2014; Pullon et al., 2016; Sargeant et al., 2008), while three reported mixed methods (Brown et al., 2015; Doekhie et al., 2017; Myburgh et al., 2014) and two reporting using quantitative methods (Perreault et al., 2016, 2018). Among the qualitative studies, few addressed the researchers’ influence on the study, many did not report sampling until data saturation was achieved and only one study performed member checking to ensure that responses collected from participants were accurate and credible. Among the mixed methods studies, one paper did not provide a rationale for a mixed method design nor mention how the qualitative and quantitative data were meaningfully incorporated to explore the research ques- tions. Among the quantitative studies, both reported an acceptable response rate, but for one study the representative- ness of the sample population was unclear, and the validity of the data collection tool was not adequately described.

Thematic analysis identified five themes relating to inter- professional collaboration in primary health care, as perceived by allied health professionals: (1) shared philosophy; (2) com- munication and clinical interaction; (3) physical environment; (4) power and hierarchy and (5) financial considerations.

Shared philosophy

A common goal to respond to primary health care needs sur- faced as a factor promoting interprofessional collaboration. A mutual understanding regarding primary health care princi- ples provided an important basis for facilitating interprofes- sional collaboration in ten of the reviewed studies (Brown et al., 2015; Doekhie et al., 2017; Dufour et al., 2014; Gaboury et al., 2009; Grace & Higgs, 2010; Gray & Orrock, 2014; Perreault et al., 2014, 2016; Pullon et al., 2016; Sargeant et al., 2008). Allied health professionals in several studies shared the belief that primary health care settings are dynamic and require commitment and work to develop and maintain (Doekhie et al., 2017; Dufour et al., 2014; Gaboury et al., 2009; Gray & Orrock, 2014; Pullon et al., 2016; Sargeant et al., 2008). Indeed, inter- professional collaboration was perceived by many allied health professionals as the result of active, ongoing effort (Myburgh et al., 2014). One study emphasized that allied health profes- sionals should not work in isolation and only focus on a patient’s needs within their own field of expertise, rather they should collectively attempt to address the patient’s needs by adopting a collaborative approach (Doekhie et al., 2017). Four of the studies identified that allied health professionals worked in facilities where there was a clear organizational vision to engage in interprofessional collaboration (Doekhie et al., 2017; Gray & Orrock, 2014; Perreault et al., 2014).Ta

bl e 2.

(C on

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St ud

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AT (%

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d Sa m pl e

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di ng

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(2 01 6)

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ph ys io th er ap is ts ’

in te rp ro fe ss io na lp

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re ga rd in g LB P

m an ag em

en t an d id en tif y or ga ni za tio

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Q ua nt ita tiv e st ud

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Ph ys io th er ap is ts re po

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bu t in fr eq ue nt

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m ea ns

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PH C te am

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re co gn

iz in g th at

te am

s re qu

ire w or k; un

de rs ta nd

in g PH

C; w or ki ng

to ge th er :p

ra ct ic al “k no

w -h ow

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pa tie nt

ca re ;a nd

co m m un

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AH P,

al lie d he al th

pr of es si on

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CC AT

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pr ai sa l To ol ; FH

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te am

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ge ne ra l pr ac tit io ne r; IH C,

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ER K,

Pr ov id in g Ef fe ct iv e Re so ur ce s an d Kn

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U ni te d Ki ng

do m .

222 J. SEATON ET AL.

Communication and clinical interaction

Effective communication and meaningful interprofessional interactions help to foster collaborative practice in primary health care. Opportunities for informal communication was highlighted as an important factor for reinforcing interprofes- sional relationships in half of the reviewed studies (Brown et al., 2015; Doekhie et al., 2017; Gray & Orrock, 2014; Perreault et al., 2016; Pullon et al., 2016; Sargeant et al., 2008). Allied health professionals considered indirect rather than direct interactions as the primary means of interaction with other health practitioners, for example, using patients to deliver correspondence, and interactions were often unplanned rather than planned (Perreault et al., 2014, 2016). While participants in one study were advocates for regular formal meetings to discuss patient cases (Sargeant et al., 2008), two other studies found electronic communication to be preferred over formal meetings due to convenience and caseload demands (Doekhie et al., 2017; Perreault et al., 2016).

Three studies showed that the mainstay of physiothera- pists’ interprofessional interactions were with general practi- tioners (Perreault et al., 2014, 2016, 2018). In addition, many physiotherapists reported frequent interactions with occupa- tional therapists, less frequent interactions with osteopaths, and little or no contact with psychologists (Perreault et al., 2014). Myburgh et al. (2014) highlighted that only 11% of Danish chiropractors interacted with general practitioners in their clinical practice, while a larger proportion collaborated with massage therapists (82%), physiotherapists (58%) and acupuncturists (37%). However, within this study it was found that these professional groups were often employees within chiropractic clinics.

Knowing health practitioners from other professions per- sonally was viewed as positively influencing interprofessional collaboration by increasing levels of familiarity and trust (Doekhie et al., 2017; Perreault et al., 2014, 2018). Sharing a common language and treatment approach greatly influ- enced the frequency and quality of communication in four studies (Gaboury et al., 2009; Grace & Higgs, 2010; Perreault et al., 2014; Sargeant et al., 2008). Frequency and content of communication was shown to be related to the degree of task interdependency between health practitioners and the patient’s medical condition (Doekhie et al., 2017). When patient complexity and acuity was low, communication was less structural and more incidental (Doekhie et al., 2017). However, Doekhie et al. (2017) asserted that when allied health professionals shared minimal task interdependency, the value of collaboration was difficult to see, and therefore less likely to occur.

Physical environment

Allied health professionals’ workplace location and service delivery model emerged as a dominant theme influencing interprofessional collaboration in primary health care.

Half of the reviewed studies identified physical proximity and space allocation as a factor that facilitated or limited interprofessional collaboration (Brown et al., 2015; Doekhie et al., 2017; Gray & Orrock, 2014; Perreault et al., 2014, 2018;

Pullon et al., 2016). For allied health professionals working in a monodisciplinary practice, the concept of collaboration usually applied to practitioners from the same health profes- sion (Doekhie et al., 2017; Perreault et al., 2014, 2018). Another study showed that although chiropractors in mono- disciplinary facilities acknowledged the importance of inter- professional collaboration, 69% did not consider their current clinical practice to be collaborative in nature (Myburgh et al., 2014). Two studies found that allied health professionals who worked in small, long-established multidisciplinary primary health care settings had the advantage of sharing a high degree of trust with health practitioners from various professional backgrounds (Pullon et al., 2016; Sargeant et al., 2008). Multidisciplinary team structures created a supportive envir- onment where complex, shared decision-making could be successfully achieved and maintained (Sargeant et al., 2008). Co-location of health services was perceived to allow patients to get the most from multiple health practitioners in one convenient place (Gray & Orrock, 2014). In co-located set- tings, allied health professionals viewed referral processes as being more efficient because feedback from other health practitioners within the nearby facilities generally occurred much faster (Doekhie et al., 2017; Gaboury et al., 2009).

Power and hierarchy

Power imbalances and conflicts can impede interprofessional collaboration in primary health care. Two studies revealed that when autonomy was low, allied health professionals did not feel like their knowledge, skills and expertise was utilized to the best of their ability (Grace & Higgs, 2010; Gray & Orrock, 2014). Some allied health professionals found this practice restrictive, while others appreciated a directive for guided treatment (Grace & Higgs, 2010). Two reviewed stu- dies found attendance at formal meetings as a key responsi- bility to ensure the effectiveness of the collaborative process, holding potential for roles to be clarified and conflicts to be resolved (Brown et al., 2015; Sargeant et al., 2008). However, for allied health professionals working in co-located primary health care settings, many stated that significant autonomy was given to them and conflict was largely non-existent (Grace & Higgs, 2010; Pullon et al., 2016). These facilities supported a non-hierarchal interprofessional referral network, where all health practitioners were considered equally impor- tant (Gray & Orrock, 2014).

Financial considerations

Monetary aspects of primary health care service provision have capacity to enable or hinder interprofessional colla- boration. Financial factors influencing interprofessional col- laboration largely applied to private primary health care facilities (Gaboury et al., 2009; Perreault et al., 2014, 2018; Pullon et al., 2016), however public sector funding issues were also reported (Dufour et al., 2014; Pullon et al., 2016). Within the private practice setting, a patient’s financial status was seen to impact on referrals to other health practi- tioners (Perreault et al., 2014, 2018). When a patient’s abil- ity to pay for treatment was perceived to be limited, some

JOURNAL OF INTERPROFESSIONAL CARE 223

allied health professionals refrained from referring to another health practitioner, even if the referral was consid- ered important (Perreault et al., 2014). One reviewed study revealed that referrals to health practitioners employed at a different organization were approached with caution (Perreault et al., 2014). For example, a physiotherapist might refrain from referring a patient to an occupational therapist at another organization if physiotherapy services were also available within the same organization. This was viewed as a considerable threat to business that could lead to a potential loss of clientele (Perreault et al., 2014).

Discussion

This is the first methodologically inclusive literature review undertaken to explore allied health professionals’ perceptions of interprofessional collaboration in primary health care. The analysis of included studies revealed that shared philosophy, communication and clinical interaction, the physical environ- ment, power and hierarchy, and financial considerations were prominent themes when examining interprofessional colla- boration from the perspective of allied health professionals in primary health care.

Opportunity for shared, frequent brief informal communica- tion appeared to be essential for interprofessional collaboration in primary health care to occur. However, interprofessional collaboration within private primary health care facilities was perceived to be indirect and mostly limited to referrals to health practitioners from other professions. Therefore, private sector allied health professionals’ perceptions regarding collaborative practice do not match often-found definitions of interprofes- sional collaboration that typically involve formal meetings to discuss specific patient cases (Reeves et al., 2010). This highlights the need to investigate the factors influencing interprofessional collaboration in primary health care settings where formal meet- ings are less likely to occur, such as monodisciplinary private practice facilities (Perreault et al., 2014).

This review demonstrates the importance of task interde- pendency in primary health care. The findings suggest that the extent to which allied health professionals collaborated with other health practitioners was related to task interdepen- dency. Wageman (1995) describes this concept as the degree to which a task requires collaborative action through the sharing of knowledge and resources. When task interdepen- dency was minimal, the perceived need for allied health pro- fessionals to communicate and collaborate with other health practitioners was low. In some primary health care settings, this may be because certain influences are more significant than others, leading to different manifestations of role distri- bution and task interdependency between health practitioners (MacNaughton et al., 2013). Most of the reviewed studies included allied health professionals who were employed in multidisciplinary practice facilities, however little information was provided regarding task interdependency for those prac- tising in the absence of formalized team structures. Understanding how task interdependency is perceived by allied health professionals in various primary health care set- tings, including monodisciplinary clinics and co-located health services, suggests an area for future study.

Many allied health professionals in primary health care perceived themselves as members of a non-hierarchal inter- professional network, practising with considerable autonomy. Within these networks, it would appear that when defined roles and professional respect and trust are present, shared leadership can exist. This professional respect among health practitioners in primary health care supports the referral of patients and enhances the collaborative experience for all involved. However, dependent on a patient’s unique health care needs, interprofessional network membership will inevi- tably vary (D’Amour et al., 2008). Establishing who the inte- gral members within an interprofessional network are will enable allied health professionals to develop greater levels of trust and respect for other health practitioners. These profes- sional virtues will strengthen interprofessional interactions and communication between allied health professionals and other health practitioners in the primary health care setting.

The physical environment was found to play an important role in determining the extent of interprofessional collabora- tion for allied health professionals in primary health care. This review argues that allied health professionals working in close proximity to health practitioners from different professions have more regular interprofessional interactions compared to those who are geographically separated. Allied health profes- sionals widely acknowledged the importance of interprofes- sional collaboration in primary health care, however the majority of participants in one study who worked in mono- disciplinary facilities were not engaged in collaborative prac- tice (Myburgh et al., 2014). Co-location of multiple primary health care services within the same physical space has demonstrated the potential to increase the frequency of infor- mal communication patterns between health practitioners, while supporting the shift away from traditional monodisci- plinary, or sole practitioner, service delivery models (Bonciani et al., 2018). A recent study illustrated that interprofessional collaboration between general practitioners and psychologists may not have occurred without the provision and assistance of organizational structure from the onset (Farmanova et al., 2017). However, co-location of multiple health services is unlikely to facilitate interprofessional collaboration on its own, and it is perhaps a misguided assumption that health practitioners, including allied health professionals, already possess the necessary skills for collaborative practice in pri- mary health care (Szafran et al., 2018).

Implications for interprofessional practice

Findings from this review have the potential to inform changes in practice in primary health care that could improve the nature and quality of interprofessional interactions between allied health professionals and other health practi- tioners from a range of professional backgrounds. This review highlights the significance of personally knowing health prac- titioners from different professions in order to create primary health care settings that are conducive to interprofessional interactions. Therefore, providing occasions for all health practitioners involved in an individual’s care to interact in social contexts could be beneficial. By participating in these informal exchanges, health practitioners can gain more

224 J. SEATON ET AL.

knowledge of other professions’ roles and responsibilities and build on their mutual levels of respect, trust and understand- ing (Doekhie et al., 2017). Moreover, co-location of multiple primary health care services within the same physical space appears to positively influence allied health professionals’ interprofessional interactions. Encouraging the close physical proximity of allied health professionals and health practi- tioners from different professions could lead to the identifica- tion of preferred organizational models in primary health care (Perreault et al., 2014).

Implications for interprofessional education

As primary health care continues to develop, and health practitioners’ scopes of practice expand and evolve, allied health professionals may benefit from ongoing training. Educational strategies in primary health care should deliver specific information related to interprofessional collaboration in order to optimize the quality of relationships between allied health professionals and health practitioners from different professional backgrounds. Training innovations in primary health care could offer opportunities for allied health profes- sionals’ scopes of practice to be clarified, and their roles and responsibilities to be asserted, subsequently stimulating appropriate patient referrals. Additionally, findings from this review may be used by tertiary institutions to inform curri- culum development as it relates to interprofessional collabora- tion in primary health care. Such preparation and training at entry-level will foster a collaborative clinical environment for allied health graduates to embrace upon entering the health workforce.

Implications for interprofessional research

Allied health professionals are often reported collectively in the literature, as was found in a number of included studies in this review. Consequently, there is a paucity of research con- cerning individual allied health professions in primary health care. Transferability across allied health professions in pri- mary health care should not be assumed, therefore future research that isolates data to the specific professions is recom- mended. Studies that included patients as participants were excluded from the review, omitting an important voice in relation to interprofessional collaboration. At present, research suggests that patients lack opportunities to provide direct feedback concerning their service needs and preferences in primary health care (Soklaridis et al., 2009). While it was beyond the objective of this review, an in-depth understand- ing of the patient perspective is required to improve the overall quality of collaborative processes in primary health care. Furthermore, it remains largely unknown how privately practising allied health professionals’ experiences of interpro- fessional collaboration differ from those employed in primary health care settings within the public health sector. Research is indicated to explore allied health professionals’ self-reported perceptions regarding interprofessional collaboration in pri- vate practice, and to document the nature of interprofessional interactions that occur within these facilities.

Limitations

There are several limitations of this integrative review. Firstly, the review is limited by the quality of included studies. The CCAT scores indicate that the reviewed studies were of moderate methodological quality, with the average score being 65%. The heterogenous quality and design of the included studies reduces the strength and validity of the conclusions drawn in this review. Next, caution must be applied when interpreting the findings of this review, as some studies did not isolate data to allied health professions. While every attempt was made to only report findings related to allied health professionals, it may be possible that some findings incorporate health practitioners from various other professions. To minimize this, two indepen- dent reviewers appraised the articles and discussed the find- ings to reach a consensus that the themes adequately reflected the experiences of allied health professionals. Additionally, eleven of the reviewed studies relied entirely on self-report to examine interprofessional collaboration in primary health care. Consequently, allied health profes- sionals’ perceptions may be predisposed to elements of per- sonal bias. To overcome the biases and shortcomings apparent in self-reported accounts, direct observational methods have been suggested as more appropriate for under- standing complex and difficult to measure phenomena, including interprofessional collaboration (Morgan et al., 2015). Furthermore, the literature on interprofessional col- laboration is difficult to retrieve given there are no words both sensitive and specific to the subject (Supper et al., 2015). Although this review was detailed, it was not exhaus- tive, as some papers outside the search strategy may have been omitted. However, the systematic search, developed in conjunction with a professional librarian and combined with a manual search to identify all essential literature related to the topic, was a strength of this review.

Conclusion

This integrative review has identified diverse key elements related to interprofessional collaboration in primary health care as perceived by allied health professionals. Future research should employ direct observational methods to investigate whether allied health professionals’ self-reported perceptions of interprofessional collaboration align with their actual interactions in the primary health care setting. The results of such research may guide the development of effec- tive interventions aimed at optimizing interprofessional colla- boration between allied health professionals working in primary health care and other health practitioners.

Acknowledgments

This research is supported by an Australian Government Research Training Program Scholarship (RTPS). The research team would like to acknowledge and thank Sharon Bryan (Blended Learning Librarian, James Cook University, Townsville) for her assistance with the search strategy.

JOURNAL OF INTERPROFESSIONAL CARE 225

Declaration of Interest

The authors have no conflicts of interest relevant to this article.

Funding

No funding or material support of any kind was received for the work described in this article.

Authors’ contributions

JS led the study design, data collection, analysis and interpretation, and drafted the manuscript. AJ significantly contributed to study design, data collection, and data analysis and interpretation. CJ and KF participated in study design. All authors contributed to manuscript preparation and approved the final manuscript.

Notes on contributors

Jack Seaton, BPhysio (Hons), is a PhD candidate within the College of Healthcare Sciences and a Lecturer in Public Health within the College of Public Health, Medical and Veterinary Sciences at James Cook University, Townsville, Australia. Jack is also a registered Physiotherapist with the Australian Health Practitioner Regulation Agency (AHPRA).

Anne Jones, PhD, is a Senior Lecturer and Academic Head of Physiotherapy at James Cook University, Townsville, Australia.

Catherine Johnston, PhD, is a Senior Lecturer and Program Convenor of Physiotherapy at University of Newcastle, Callaghan, Australia.

Karen Francis, PhD, is a Professor in Nursing at the University of Tasmania, Launceston, Australia.

ORCID

Jack Seaton http://orcid.org/0000-0003-0942-8954 Anne Jones http://orcid.org/0000-0002-4556-9159 Catherine Johnston http://orcid.org/0000-0002-9422-2063 Karen Francis http://orcid.org/0000-0003-3578-2498

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