collaboration : a tool for optimal patient care

In collaborative practice, several professionals from a variety of fields with different training work together to provide care for patients. We will not identify them all here, as there are many. However, physicians, pharmacists, and nurses are the professionals with whom the PHCNP interacts on a regular basis. A good collaborative relationship among these professionals fosters a positive work climate and helps to optimize quality of care and patient management.

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Collaborative practice defined

Collaborative practice is a process of communication and decision-making that allows various professionals to contribute their own specific knowledge and skills synergistically to the care provided to patients, families, and the public. It is the process whereby professionals develop a cohesive practice that can respond comprehensively to patients’ needs.

Source et validity of these recommendations

The information presented here comes from two sources: 1) the results of a systematic review of the scientific literature on advanced nursing practice in primary care, and 2) the results of six case studies of settings that have integrated PHCNPs in three health regions of Quebec. Details of the methodologies used for each of these two research efforts are presented in the Methodology section. The analyses of the data produced in each of these two components were used to inform each other reciprocally. Thus, the data from the scientific literature were analyzed in relation to the various models of integrating PHCNP practice found in Quebec, while the empirical data were interpreted based on themes identified in the literature.

There is extensive literature on interprofessional collaboration and on the relationships between physicians and nurses. Several studies have focused specifically on relationships between PHCNPs and physicians. There is strong consensus in the literature that effective collaboration facilitates service provision and improves quality of care and of patient management. Analyzed together, these studies present a convergent picture of the obstacles and facilitators involved in developing and maintaining harmonious and productive relationships. There is also literature, though less extensive, on concrete means of developing and sustaining collaboration.

FACTORS that promote or impede interprofessional and collaborative practice

The literature on factors influencing collaboration identifies three types of determinants:

1. interpersonal determinants, mentioned particularly in studies on PHCNP–physician collaboration:

  • confidence in oneself and in others that enables one to be open to collaboration;
  • each person’s attitudes, based on respect and avoiding preconceived notions;
  • communication skills and effective communication among team members

2. organizational determinants, including particularly:

  • the quality of leadership oriented explicitly toward developing and maintaining collaborative practice;
  • a work climate that supports egalitarian relationships;
  • a certain formalization of roles and responsibilities that clarifies what is expected of each person;
  • effective coordination mechanisms that support a process of care continuity in which each professional contributes optimally;
  • efficient and egalitarian communication mechanisms that support work coordination.

3. systemic determinants:

  • regulatory and legal frameworks that open or close professional jurisdictions;
  • funding and remuneration models that can act either as incentives or barriers to collaboration;
  • an educational system that trains new professionals in interprofessional collaboration.

Déveloping and supporting collaboration

The literature identifies a range of strategies for developing and supporting collaboration when integrating PHCNPs into primary care teams. We have grouped these into three broad themes:

1.  Supporting collaboration with appropriate management and leadership
The empirical data appear to demonstrate that collaboration is most effective when all members of the team have a good understanding of the PHCNP’s role, strengths, limitations, and potential contribution to patient management. For collaboration to occur, leadership is required at several different levels (see the Support to practice section). Collaboration at the strategic level, among the different managers, is crucial to guide the orientations of local or regional institutions in the development of advanced practice and collaboration.
Leadership from the physician partner is a key factor in many respects, especially to create medical team cohesion around collaboration with PHCNPs. Nursing leadership working in tandem with administrative leadership can produce an innovative vision and support team development.
It is important to identify leaders, both managers and clinicians, to whom team members can turn for support to settle differences, resolve problems, or provide help in situations where communication is problematic. The empirical data show that collaboration appears to be more effective when physicians work together in a group practice team model rather than in parallel practice. Physicians also need the opportunity to discuss the advantages and disadvantages of having a PHCNP on the team and their vision of the PHCNP’s role, and they need to believe in the added value a PHCNP will bring. The data seem to indicate that a previously existing collaboration with a nurse clinician will facilitate the emergence of a shared and positive view of collaboration with a PHCNP.

2. Providing time and space for collaboration
Developing collaboration among clinicians, whether inter- or intraprofessional, requires time. Studies on relationships between physicians and PHCNPs, in particular, agree it takes time for mutual trust to develop, since this is often a new professional title with a new role to be integrated. For this trust to be built, new PHCNPs first need to demonstrate their competence in managing patients.
Time also needs to be allocated to giving team members opportunities to talk about values and their vision of the role and how it can contribute to service provision. Professionals need time to negotiate roles, construct protocols, and discuss cases—in short, to get to know each other so they can learn how to work together more effectively.
Space is also a strategic element in collaboration. Professionals need to be able to meet and talk together both formally and informally. If professionals are not located in proximity to each other, they will work in silos, which runs counter to the objective targeted by integrating PHCNPs into primary care. Lack of appropriate space can also impede optimal deployment of the PHCNP role and of collaboration.
The empirical data analyzed in this research project confirm that trust is built up slowly over time. In some settings PHCNPs feel fully supported and have a great deal of latitude, while in others they feel vulnerable and have little room to manoeuvre. The status of candidate or of specialized nurse practitioner with provisional license is difficult not only for PHCNPs but also for the physician partners. In effect, such candidates cannot be totally present in the setting because they are studying for exams and have not yet fully developed their competencies. This is a pivotal period in building trust.
Collaboration between PHCNPs and nurse clinicians is also a key issue. The empirical data show that a period of adjustment is required during which the nurses can get to know each other and talk about their vision and respective responsibilities, building up their collaborative relationship over time. Some good examples of this mutual construction show it can result in better service for patients. On the other hand, in some settings there is no collaboration between PHCNPs and nurse clinicians, which could indicate they are working in silos.

3. Planning for training in collaboration
Collaborative practice does not emerge spontaneously. Interprofessional training is needed to develop collaborative practice and ensure comprehensive patient management. According to the Centre for the Advancement of Interprofessional Education, the competencies professionals need to develop are:

  • an understanding of the roles, qualifications, and expertise of other professions;
  • team work skills, such as seeing the patient as a key member of the team,

developing processes for team decision-making, reaching consensus and resolving conflicts, and applying communication skills.
The literature presents a certain number of experiences in training for physician–PHCNP collaboration in primary care. These articles recommend a variety of learning strategies, such as case discussions, scenario building, journal clubs, or discussions around clinical and organizational issues.
Our empirical data showed that PHCNPs greatly appreciated activities involving joint training or clinical case discussions. Even though there was little time available for such encounters, some settings organized joint physician–nurse training sessions and “team-building” activities. On the other hand, in other settings, the PHCNPs were disappointed not to be included in training activities and had few opportunities to construct a joint practice. In all the cases, the PHCNPs very much appreciated occasions when they were able to discuss clinical situations with other team members.

To conclude, it may be good to keep in mind that the literature on collaborative practice, regardless of setting, emphasizes a patient-centred approach. In fact, it is around patients’ needs that professionals collaborate best when they embody the vision of “the most effective provider providing the necessary care.”

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For more information :

  • Bailey, P., Jones, L., & Way, D. (2006). Family physician/nurse practitioner: stories of collaboration. [I]. Journal of Advanced Nursing, 53(4), 381-391.
  • CAIPE. (2011). Principles of Interprofessional Education. Centre for the Advancement of Interprofessional Education.
  • Canadian Health Services Research, F. (2006). Teamwork in healthcare: Promoting effective teamwork in healthcare in Canada (1 ed., pp. 1-46). Ottawa, ON.
  • Canadian Nurse Practitioner, I. (2006). Implementation and Evaluation Toolkit for Nurse Practitioners in Canada (pp. 1-84). Ottawa, ON: Canadian Nurses Association.
  • Clarin, O. A. (2007). Strategies to overcome barriers to effective nurse practitioner and physician collaboration. [II]. Journal for Nurse Practitioners, 3(8), 538-548.
  • Curran, V., & Primary Health Care Transition, F. (2007). Collaborative Care. Synthesis Series on Sharing Insight (pp. 1-54). Ottawa, ON: Health Canada.
  • D'Amour, D., & Oandasan, I. (2005). Interprofessionality as the field of interprofessional practice and interprofessional education: An emerging concept. Journal of Interprofessional Care, 19(s1), p.9
  • D’Amour, D. Goulet, L., Labadie, J.F., San Martin-Rodriguez, L. & Pineault, R. (2008). A model of collaboration among professionals in healthcare organizations, BMC Health Services Research, 8, 188-202.
  • Goldman, J., Meuser, J., Rogers, J., Lawrie, L., & Reeves, S. (2010). Interprofessional collaboration in family health teams: An Ontario-based study. [I]. Canadian Family Physician, 56(10), e368-e374.
  • Koren, I., Mian, O., & Rukholm, E. (2010). Integration of nurse practitioners into Ontario's primary health care system: variations across practice settings. [I]. Canadian Journal of Nursing Research, 42(2), 48-69.
  • Ontario Medical Association, & Registered Nurses Association of Ontario. (2003). The RN(EC)-GP relationship: A good beginning (pp. 1-40): Ontario Medical Association & Registered Nurses Association of Ontario.
  • Poochikian-Sarkissian, S., Hunter, J., Tully, S., Lazar, N. M., Sabo, K., &Cursio, C. (2008). Developing an innovative care delivery model: Interprofessional practice teams. [I]. Healthcare Management Forum, 21(1) (pp 6-11).
  • San Martin Rodriguez L, Beaulieu MD, D’Amour D, Ferrada M (2005). The determinants of successful collaboration: a review of theoretical and empirical work. Journal of Interprofessional Care, Suppl 1: 132-147
  • Way, D., Jones, L., & Busing, N. (2000). Implementation Strategies: “Collaboration in Primary Care – Family Doctors & Nurse Practitioners Delivering Shared Care" (pp. 1-12). Toronto, ON: Ontario College of Family Physicians.

Citing this document: Project (2013). Information sheet on collaboration. Collaboration: a tool for optimal patient care. Montreal, December 2013.


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The future of primary care depends on collaborative and interprofessional practice.