Community Health Centers

SHORT REPORT

Primary health care teams: team members’ perceptions of the collaborative process

SHERRY L. DIELEMAN1, KAREN B. FARRIS2, DAVID FEENY1 ,4,

JEFFREY A. JOHNSON3 ,4, ROSS T. TSUYUKI4

,5 & SANDRA BRILLIANT1

1 Faculty of Pharmacy and Pharmaceutical Sciences, University of Alberta, Edmonton, AB Canada,

2 College of Pharmacy, University of Iowa, Iowa, USA,

3 Department of Public Health Sciences,

Faculty of Medicine & Dentistry, University of Alberta, Edmonton, AB Canada, 4 Institute of

Health Economics, Edmonton, AB Canada and 5 Division of Cardiology, Faculty of Medicine &

Dentistry, University of Alberta, Edmonton, AB Canada

Introduction

Collaboration and health care teams are common in hospitals and long-term care facilities, but

teams are often not available to providers in the community where most practitioners work

independently. A team environment could provide support for these community-based health

care providers as well as allow for more efficient sharing of information.

This paper examines the perceptions of pharmacists, physicians and nurses as they worked

together in community-based teams to provide care to 199 high-risk community dwelling

individuals. The study was part of a larger demonstration project from September 1999 to

April 2000 (Côté et al., 2002; Farris et al., 2003).

Methods

Twenty-two providers were invited to participate in the project to form six primary healthcare

teams. The teams included family physicians, community pharmacists, office nurses and home

care nurses. Informed consent was obtained and ethical approval was received from the

University of Alberta, Health Research Ethics Board.

A simple pre and post-test design was used to evaluate the impact of team care on providers’

attitudes. Questionnaires were administered at the beginning, twice during the study and at

the end. The basic questionnaire contained five questions examining job satisfaction (Melville,

1980), nine questions examining role recognition and experience in the team (Young, 1994),

and nine questions addressing satisfaction with the collaborative process, care decisions and

quality of care (Baggs, 1994). Three questions, developed by the research team, were added to

Correspondence to: Karen B. Farris, College of Pharmacy, University of Iowa, Iowa City, IA 52240, USA. Tel:

319.384.4516; Fax: 319.353.5646; E-mail: [email protected]

JOURNAL OF INTERPROFESSIONAL CARE, VOL. 18, NO. 1, FEBRUARY 2004

ISSN 1356–1820 print/ISSN 1469-9567 online/04/010075–04 # Taylor & Francis Ltd DOI: 10.1080/13561820410001639370

measure the perception of the team’s impact on the quality of patient care. Each question was

scored on a Likert-type scale from 1 (disagree strongly) to 7 (agree strongly). Open-ended

questions were also included.

The teams were divided into two groups based on qualitative analysis of team process

meetings (Dieleman, 2003). One group consisted of the most successful and best functioning

teams and the other group contained the remaining teams. The scores for the two groups were

compared at Time 4 focusing on decision making and collaboration. In addition, Time 4

scores were subtracted from Time 1 scores to give an indication of change in the two groups

over the study period.

Results

The 22 providers ranged in age from 23 to 52 years, with a mean age of 38.8 years (SD = 8.7).

All physicians were male and all the nurses were female. Pharmacists were essentially all female

with the exception of one male.

Five items were found to be significantly different over the four time periods as shown in

Table 1. Job satisfaction of providers compared to their current jobs improved over time (4.8

(SD = 1.1) at baseline to 5.5 (SD = 0.9) at end of study, p = 0.02). The examination of the six

teams as two groups based on their ability to function well is shown in Table 2. The better

performing teams all had positive change scores.

Table 1. Perceptions of Working in a Primary Health Care Team

Mean (Std. Deviation) 1,2,3

Collective Activities (n = 22) Time 1 Time 2 Time 3 Time 4

Liaise about care 6.5 ( + 0.6) 6.7 ( + 0.6) 6.6 ( + 0.7) 6.7 ( + 0.6) Others not confused about my professional role

4 5.3 ( + 1.5) 5.6 ( + 1.6) 5.9 ( + 1.4) 6.3 ( + 1.2)***

Team meeting useful 6.7 ( + 0.5) 6.5 ( + 0.9) 6.4 ( + 0.9) 6.8 ( + 0.5) Do not need more patient information (n = 21) 2.6 ( + 1.2) 4.1 ( + 1.7) 4.2 ( + 1.5) 4.1 ( + 1.8)*** Feel part of a team 6.5 ( + 0.6) 6.5 ( + 0.8) 6.4 ( + 0.9) 6.8 ( + 0.4)*** Other professionals’ notes are available (n = 21) 5.7 ( + 1.1) 5.7 ( + 1.4) 5.3 ( + 1.5) 5.8 ( + 1.4) Working with others is helpful 6.6 ( + 0.6) 6.5 ( + 0.7) 6.6 ( + 0.7) 6.9 ( + 0.4)* Referrals are appropriate (n = 16) 5.9 ( + 1.0) 5.6 ( + 1.3) 5.6 ( + 1.1) 6.1 ( + 1.2) Do not see too many patients

4 (n = 21) 3.8 ( + 1.6) 3.9 ( + 2.0) 3.1 ( + 1.9) 3.7 ( + 1.9)

Equity in decision making process 5

(Bagg’s Collaboration Score) (n = 21)

5.9 ( + 0.7) 5.8 ( + 0.6) 5.7 ( + 0.9) 5.9 ( + 0.9)

Satisfaction with decision making process 4

6.2 ( + 0.5) 6.1 ( + 1.3) 6.3 ( + 1.2) 6.3 ( + 0.8) Satisfaction with decisions 5.0 ( + 1.3) 5.5 ( + 1.2) 5.9 ( + 1.0) 5.6 ( + 1.5) Perceived Impact

Improves quality of patient care 6.7 ( + 0.6) 6.5 ( + 0.9) 6.4 ( + 0.9) 6.7 ( + 0.6) Improves medication use

4 5.9 ( + 1.4) 6.0 ( + 0.9) 5.9 ( + 1.4) 6.3 ( + 0.8)

Improves patients’ health status 5.7 ( + 1.5) 6.1 ( + 1.0) 6.1 ( + 0.8) 6.5 ( + 0.7)**

1 Tests across time used Repeated Measures ANOVA

2 Scale 1 = Disagree Strongly and 7 = Agree Strongly

3 Expectations measured at Time 1

4 Original question negatively worded

5 Originally based on a combined score of 7 questions (Baggs, 1994), Cronbach’s alpha reliability = 0.89 at

Time 1

*p 5 0.04 significant difference Time 1 to Time 4 **p 5 0.03 significant difference Time 1 to Time 4 ***p 5 0.01 significant difference Time 1 to Time 4

76 SHERRY L. DIELEMAN ET AL.

Content analysis of the open-ended questions in the final questionnaire identified many

common themes among the providers and teams. The general themes included the

development of a better understanding of other team members, an increased comfort level

when interacting with other professionals, and a preference to work in a team environment

when providing care for high-risk individuals.

Five of the teams responded by explaining the working in the team gave them a better

appreciation of the other team members’ perspectives and roles in health care.

I have an even greater understanding of my team’s work load, time constraints and the

broad scope their jobs involve. When we each work in an isolated cage it’s hard to truly

understand what’s going on in another professional’s ‘cage’. (Pharmacist)

Specifically the role of the pharmacist and home care nurse were mentioned as being better

understood.

Working in the Collective was a very good experience for me especially to find out the

pharmacist’s role and how essential they are for patient care. (Home Care Nurse)

Communication was also enhanced within the team. Providers indicated that trust and respect

for each other was important to the way their teams operated.

Our making of a decision making community made it possible to come up with decisions

using consensus. We seemed to trust each other and respect each other. (Physician)

Discussion

The providers found that working in a team environment was very useful when they dealt with

complex primary-care patients. They identified open communication, respect for other team

members, understanding of their roles and expertise, and being open to learning as important

for collaboration.

When the skills and roles of other community health care workers are understood, effective

teamwork is possible (Galvin et al., 1999; Long, 1996). In this study, the providers came to rely

Table 2. Comparison of change scores in primary health care teams

Mean (Std. Deviation) 1,2

Team Activities

Teams 1, 5 & 6

(n = 11)

Teams 2, 3 & 4

(n = 11)

All Teams

(n = 22)

Working with others is helpful 0.5 (0.7) 0.2 (0.6) 0.3 (0.6)

Equity in decision making process 3

0.3 (0.5) 7 0.1 (1.4) 0.1 (1.1) Satisfaction with decision making process

4 * 0.5 (0.5) 7 0.5 (1.4) 0.0 (1.1)

Satisfaction with decisions** 1.5 (1.6) 7 0.4 (1.7) 0.5 (1.9)

1 Change scores (Time 47Time 1)

2 Comparison between teams used Mann – Whitney U-test

3 Originally based on combined score, n = 10 for Teams 1, 5 and 6 and n = 21 for All Teams

4 Original question negatively worded

*p = 0.03 significant difference between the best functioning teams (1, 5 and 6) and the other teams

**p = 0.02 significant difference between the best functioning teams (1, 5 and 6) and the other teams

PRIMARY HEALTH CARE TEAMS 77

on their fellow team members for support. Before they could trust other providers, each person

had to learn about that provider. More precisely, providers needed to know what knowledge,

skills and abilities other providers could offer to the team.

Communication was an important part of the team environment. Providers felt that they

were able to access the patient information that they needed. This access enabled better patient

care and communication among the team. In the present study, the teams found that taking

the time to be comfortable with each other enhanced communication.

When providers’ satisfaction with their current job was compared with their final satisfaction

in the team, the level of satisfaction had increased. This coincides with other studies that have

found that a collaborative work environment can positively affect job satisfaction (Abbott et al.,

1994; Byers et al., 1999).

The small number of self selected providers limits the generalizability of this study. A larger

sample size would allow for an examination of the differences between the various professions

and groups with unique patient populations. The addition of a control group would further

ensure that the results reflected the effects of working in the team.

Conclusion

While much has been written about collaboration, few studies have systematically examined

the perceptions of health care workers collaborating in the community. This study is important

as it adds empirical information about community teams, including the importance of open

communication, respect, and understanding the expertise of other members.

Acknowledgements

This project received financial support from the Health Transition Fund, Health Canada and

Alberta Health. The views expressed herein do not necessarily represent the official policy of

Health Canada or Alberta Health.

References

ABBOTT, J., YOUNG, A., HAXTON, R. & VAN DYKE, P. (1994). Collaborative care: a professional model that influences

job satisfaction. Nursing Economics, 12, 167 – 169.

BAGGS, J.G. (1994). Development of an instrument to measure collaboration and satisfaction about care decisions.

Journal of Advanced Nursing, 20, 176 – 182.

BYERS, V.L., MAYS, M.Z. & MARK, D.D. (1999). Provider satisfaction in army primary care clinics. Military Medicine,

164, 132 – 135.

CÔTÉ, I., FARRIS, K.B., FEENY, D., JOHNSON, J.A., TSUYUKI, R., DIELEMAN, S.L., BRILLIANT, S., BAYNE, R., GARDNER,

L., MOORES, D. & SANDILANDS, M. (2002). Using Multi-Disciplinary Teams to Improve Primary Care: Quality of

Medication Use in the Community. Working Paper Series: 02 – 01. Edmonton: Institute of Health Economics.

DIELEMAN, S.L. (2003). Primary Health Care Teams: The Collaboration of Pharmacists, Physicians and Nurses. Master’s

Thesis, University of Alberta.

FARRIS, K.B., CÔTÉ, I., FEENY, D., JOHNSON, J.A., TSUYUKI, R., BRILLIANT, S. & DIELEMAN, S. (2003). Using multi-

disciplinary teams to enhance primary health care: a demonstration project. Canadian Family Physician

(forthcoming).

GALVIN, K., ANDREWES, C., JACKSON, D., CHEESMAN, S., FUDGE, T., FERRIS, R. & GRAHAM, I. (1999). Investigating

and implementing change within the primary health care nursing team. Journal of Advanced Nursing, 30, 238 – 247.

LONG, S. (1996). Primary health care team workshop: team members’ perspectives. Journal of Advanced Nursing, 23,

935 – 941.

MELVILLE, A. (1980). Job satisfaction in general practice: Implications for prescribing. Social Science and Medicine, 14A,

495 – 499.

YOUNG, K.R. (1994). An evaluative study of a community health service development. Journal of Advanced Nursing, 19,

58 – 65.

78 SHERRY L. DIELEMAN ET AL.