Abstract

Collaborative practice and teamwork can contribute to improve universal access and the quality of healthcare. However, the operationalization of interprofessional work constitutes a current challenge. This challenge is increased by conceptual imprecisions in the study of interprofessional work, in which terms like collaboration and teamwork are often used as synonyms. This article aims to present current concepts of interprofessional work, problematizing them in the context of primary care. We conclude that teamwork and collaborative practice in primary care need to be addressed in a contingent manner, according to the characteristics of service users/catchment population as well as to the context and working conditions. We highlight that collaboration involves professionals willing to work together to provide better healthcare, and can occur both as “Team collaboration” and “Intersectoral and community collaboration”.

Keywords:
Patient care team; Primary Care; Intersectoral collaboration

Introduction

The teamwork proposal emerged in the 1960s/1970s, with the movements of Preventive, Community, and Comprehensive Medicine. It gained renewed attention from the 1990s onwards, in the context of debates about models of healthcare and health systems organization, in view of the need to replace health professionals’ uniprofessional education by interprofessional education.

Since the year 2000, teamwork has been associated with collaborative practice, as it is not sufficient to have integrated and effective teams to improve the access and quality of healthcare. It is necessary that teams from the same service collaborate with each other, and that professionals and teams from a service collaborate with professionals and teams from other services and sectors in the logic of networks.

Primary care has been the locus where proposals for the organization of health services based on teamwork and collaborative practice have most advanced. Comprehensive primary care is recognized as the best strategy for organizing health systems, as well as the most efficient way of facing health problems and fragmentation of actions and of the system itself. In Brazil, studies have shown the effectiveness of primary care, as it produces positive impacts on the access and quality of healthcare^1-4.1. Macinko J, Harris MJ. Brazil's family health strategy - delivering community-based primary care in a universal health system. N Engl J Med. 2015; 372(23):2177-81.

It has been argued that interprofessional education and interprofessional practice can contribute to promote universal access and improve the quality of healthcare^5-105. Reeves S, Pelone F, Harrison R, Goldman J, Zwarenstein M. Interprofessional collaboration to improve professional practice and healthcare outcomes. Cochrane Database Syst Rev. 2017; 6:CD000072.. However, the operationalization of interprofessional practice is a current challenge¹¹11. Agreli HF, Peduzzi M, Bailey C. The relationship between team climate and interprofessional collaboration: preliminary results of a mixed methods study. J Interprof Care. 2017; 31(2):184-6., and initiatives in Brazil are still incipient¹²12. Silva JA, Peduzzi M, Orchard C, Leonello VM. Educação interprofissional e prática colaborativa na Atenção Primária à Saúde. Rev Esc Enferm USP. 2015; 49 Spe 2:16-24.. The majority model is that of professionals who “continue to be educated separately to work together in the future”¹³13. Costa MV. A educação interprofissional no contexto brasileiro: algumas reflexões. Interface (Botucatu). 2016; 20(56):197-8. (p. 198), reproducing the strong division of health work and the tribalism of professions¹⁴14. Braithwaite J, Clay-Williams R, Vecellio E, Marks D, Hooper T, Westbrook M, et al. The basis of clinical tribalism, hierarchy and stereotyping: a laboratory-controlled teamwork experiment. BMJ Open. 2016; 6:e012467..

In addition to the difficulty in operationalizing interprofessional education and practice, the study of the themes is marked by polysemy and conceptual imprecision, which end up hindering their advance⁸8. Zwarenstein M, Goldman J, Reeves S. Interprofessional collaboration: effects of practice-based interventions on professional practice and healthcare outcomes. Cochrane Database Syst Rev. 2009; (3):CD000072.. Terms like collaboration, coordination and teamwork are frequently used as synonyms.

The present article aims to present the current concepts of interprofessional work, problematizing them in the context of primary care.

Teamwork, interprofessional collaboration and interprofessional collaborative practice

Interprofessional teamwork has been defined as work that involves different professionals, not only from the area of health, who share the sense of belonging to a team and work together in an integrated and interdependent way to meet health needs^15,1615. Institute of Medicine. Measuring the impact of interprofessional education on collaborative practice and patient outcomes. Washington, DC: National Academy Press; 2015.. Constituting a team demands hard work. It is a construction, a dynamic process in which professionals get to know each other and learn to work together, in order to: Recognize each profession’s work, knowledge and roles; learn about the profile of the catchment population, that is, users’ and population’s health characteristics, demands and needs; define, in a shared way, the team’s common objectives, and plan, also in a shared way, actions and healthcare - for example, the shared construction of individual therapeutic projects for users and families in complex health situations. Interprofessional teamwork involves elements from the social, political and economic context¹⁷17. Fox A, Reeves S. Interprofessional collaborative patient-centred care: a critical exploration of two related discourses. J Interprof Care. 2015; 29(2):113-8..

In the international scenario, Reeves et al.¹⁸18. Reeves S, Lewin S, Espin S, Zwarenstein M. A conceptual framework for interprofessional teamwork. In: Barr H, editor. Interprofessional teamwork for health and social care. Chichester: Wiley-Blackwell; 2010. criticized the scarcity of studies and theoretical models incorporating the sociological perspective in the understanding of the complexity of interprofessional health work. The authors proposed a model for the understanding of interprofessional work in its relational, contextual and work organization dimensions. In the model, the authors explain the difference between modalities of interprofessional work: “Teamwork”, characterized by intense sharing of values, objectives and team identity, and intense interdependence and integration of actions, tends to respond to unpredictable, urgent and complex care situations; “Interprofessional Collaboration” is a more flexible form of interprofessional work, with lower levels of sharing and interdependence of actions; and “Net work”, in which there is even more flexibility and less interdependence of actions, but networked integration is maintained. The authors argue that teams alternate between the different forms of work described above (teamwork, collaboration, net work) according to local needs, in a contingent approach to interprofessional work. This approach to interprofessional work recognizes that teams do not vary in a linear model that ranges from “weak to strong”, “real or pseudo teams”. Rather, teams become more effective as they succeed in adapting different forms of interprofessional work - teamwork, collaboration and net work - in a contingent manner, according to the needs of users, families and the community.

The contingent approach proposes that it is necessary to expand the traditional notion of interprofessional work, which, usually, is based only on teamwork, and add others forms of interprofessionality, such as collaboration and interprofessional collaborative practice¹⁸18. Reeves S, Lewin S, Espin S, Zwarenstein M. A conceptual framework for interprofessional teamwork. In: Barr H, editor. Interprofessional teamwork for health and social care. Chichester: Wiley-Blackwell; 2010..

Morgan et al.¹⁹19. Morgan S, Pullon S, McKinlay E. Observation of interprofessional collaborative practice in primary care teams: an integrative literature review. Int J Nurs Stud. 2015; 52(7):1217-30. consider “Interprofessional Collaboration” an umbrella term that houses other two terms (Figure 1): “Interprofessional collaborative practice”, used to describe collaboration elements implemented in the practice of health services, and “Interprofessional teamwork”, a deeper level of interprofessional work with intense interdependence of actions.

The different terms presented above are related to each other but are not synonyms and cannot be interchanged, as they refer to different modalities of interprofessional work that, we propose, should be apprehended under the contingent perspective, that is, depending on the health needs of users, families and the community, on their context, and on professionals and services. In this approach, interprofessional work is presented as: Teamwork, interprofessional collaboration, interprofessional collaborative practice, and net work.

D’Amour et al.²¹21. D'Amour D, Goulet L, Labadie JF, Martín-Rodriguez LS, Pineault R. A model and typology of collaboration between professionals in healthcare organizations. BMC Health Serv Res. 2008; 8:188. use the term collaboration to refer to situations in which professionals from different areas want to work together to provide the best healthcare for users but, at the same time, recognize they have their own interests and want to maintain some degree of autonomy. Instead of reinforcing the expectation of full autonomy and independence of each profession, in collaborative practice, professionals aim to reduce competition²¹21. D'Amour D, Goulet L, Labadie JF, Martín-Rodriguez LS, Pineault R. A model and typology of collaboration between professionals in healthcare organizations. BMC Health Serv Res. 2008; 8:188. and replace unbalanced power relations in healthcare with relations marked by interprofessional partnership and collective responsibility²²22. Khalili H, Hall J, DeLuca S. Historical analysis of professionalism in western societies: implications for interprofessional education and collaborative practice. J Interprof Care. 2014; 28(2):92-7..

The literature on collaborative practice frequently goes beyond interprofessional issues and includes the perspective of users, families and the community, with the aim of ‘caring together with people, instead of caring for people’²³23. Domajnko B, Ferfila N, Kavcic M, Pahor M. Interprofessional education In Europe: policy and practice. Beyond interprofessionalism: caring together with rather than for people. Antwerpen/Apeldoorn: Garant; 2015.. This approach recognizes patient-centered care as a central element of interprofessional collaborative practice. Shifting professions’ and services’ focus to people’s health needs - therefore, to patient-centered care - is described as a component of change in the care model, with potential for improving the quality of healthcare and for rationalizing the costs of health systems²⁴24. Agreli HF, Peduzzi M, Silva MC. Atenção centrada no paciente na prática interprofissional colaborativa. Interface (Botucatu). 2016; 20(59):905-16.. The important participation of users, families and the community in collaborative practice clarifies the notion that this practice is not restricted to relationships among professionals, although the term “interprofessional” is frequently used to designate it.

Although the conceptual definitions reveal differences between the terms teamwork, collaboration and collaborative practice, it is recognized that all the forms of interprofessional work have teams as their nucleus and focus on patient-centered care. The literature on teamwork and interprofessional collaboration highlights the relevance of relational aspects and work organization among professionals to the establishment of effective, integrated, and collaborative teams^17,25,2625. Peduzzi M. Equipe multiprofissional de saúde: conceito e tipologia. Rev Saude Publica. 2001; 35(1):103-9.. Distinguishing teams according to their effectiveness and impact on the quality of healthcare is necessary and can be performed by the analysis of teamwork climate²⁷27. Anderson NR, West MA. Measuring climate for work group innovation: development and validation of the team climate inventory. J Organ Behav. 1998; 19(3):235-58., as the concept of climate is considered an adequate proxy^(c)(c)Proxy: The term proxy is used here in the sense assigned to it in the area of Statistics, that is, as a variable measured to infer the value of a variable of interest. In this sense, the variable team climate is measured and used to infer the variable teamwork climate. to analyze the phenomenon of teamwork.

Interprofessional collaborative practice and teamwork climate in primary care^(d)(d)The discussion presented here is based on the Doctoral dissertation “Prática interprofissional colaborativa e clima do trabalho em equipe na Atenção Primária à Saúde”, carried out at Universidade de São Paulo in collaboration with the University of Southampton, authored by Heloise Agreli and supervised by Marina Peduzzi and Christopher Bailey.

Teamwork climate

Teamwork climate is defined as the set of perceptions and meanings shared by the members of a team concerning the policies, practices and procedures they experience at the workplace²⁸28. Schneider B, Ehrhart MG, Macey WH. Organizational climate and culture. Ann Rev Psychol. 2013; 64:361-88.. Based on the theoretical framework of team climate for innovation, Anderson and West²⁷27. Anderson NR, West MA. Measuring climate for work group innovation: development and validation of the team climate inventory. J Organ Behav. 1998; 19(3):235-58. developed the scale Team Climate Inventory (TCI), which was validated by Silva²⁹29. Silva MC. Adaptac¸a~o transcultural e validac¸a~o de instrumento de avaliac¸a~o de trabalho em equipe: Team Climate Inventory no contexto da Atenc¸a~o Primária a` Sau´de no Brasil [dissertac¸a~o]. Sa~o Paulo: Escola de Enfermagem, Universidade de Sa~o Paulo; 2014. in the Brazilian primary care context, within the Brazilian National Health System (SUS). Silva et al.³⁰30. Silva MC, Peduzzi M, Sangaleti CT, Silva DD, Agreli HF, West MA, et al. Cross-cultural adaptation and validation of the teamwork climate scale. Rev Saude Publica. 2016; 50:52. highlight that the conception of team climate adopted in the TCI corresponds to the understanding of teamwork described in Brazilian studies in the sphere of the public policy of the SUS, that is, articulation of actions and interaction among professionals, with communication playing a major role³¹31. Fortuna CM, Mishima SM, Matumoto S, Pereira MJB. O trabalho de equipe no programa de saúde da família: reflexões a partir de conceitos do processo grupal e de grupos operativos. Rev Lat Am Enfermagem. 2005; 13(2):262-8..

It is believed that the study of teamwork climate is capable of providing insights about professional relationships, teamwork organization, and aspects of interprofessional collaboration. According to Agreli et al.³²32. Agreli HF, Peduzzi M, Bailey C. Contributions of team climate in the study of interprofessional collaboration: a conceptual analysis. J Interprof Care. 2017; 31(6):679-84., teamwork climate and interprofessional collaboration have four conceptual elements in common:

The intersection areas outlined above between teamwork climate and collaboration reveal, conceptually, the relation between the themes and suggest that the understanding of macro aspects from the organization of interprofessional work, like collaboration for the establishment of Rede de Atenção à Saúde (RAS - Healthcare Network), includes the study of aspects from the micro sphere (of social interaction) in the immediate context of teamwork in primary care.

Teamwork in primary care

Understanding primary care, specifically the Family Health Strategy, as a strategy to reorganize the health system implies recognizing it as the coordinator of primary care and the communication center of the RAS and specialized networks. Networks are a way of facing the hegemony of fragmented healthcare systems. It is argued that the change from fragmented systems to the RAS will only be fulfilled if it is supported by high-quality primary care³³33. Mendes E. O cuidado das condições crônicas na Atenção Primária à Saúde: o imperativo da consolidação da Estratégia de Saúde da Família. Brasília: CONASS, OPAS; 2012., with teams capable of amplifying interprofessional action beyond the scope of the team, to other teams that work in the RAS and in partnership with users and the community. Collaborative practice refers to this broader situation of interprofessional action - intra-teams, inter-teams and in network, with the participation of users.

In Brazil, primary care has approximately 43,160 teams implemented in the Family Health Strategy, attending approximately 64.9% of the population³⁴34. Departamento de Atenção Básica. Teto, credenciamento e implantação das estratégias de Agentes Comunitários de Saúde, Saúde da Família e Saúde Bucal [Internet]. Brasília; 2018 [citado 25 Mar 2018]. Disponível em: https://egestorab.saude.gov.br/paginas/acessoPublico/relatorios/relHistoricoCobertura.xhtml.
https://egestorab.saude.gov.br/paginas/a... . The thousands of teams of the Brazilian primary care have contributed significantly to improve the access and quality of healthcare. They are capable of meeting health needs in spite of barriers to interprofessional work articulated in different sectors, with focus on and participation of users, families and the community. Among these barriers, we cite: Communication and coordination problems in net works³⁵35. Kell MCG, Shimizu HE. Existe trabalho em equipe no Programa Saúde da Família? Cienc Saude Colet. 2010; 15 Supl 1:1533-41.; absence of specialized networks adequate to the population’s demand and articulated with primary care; fragmentation of care in primary care services³⁶36. Cunha GT, Campos GWS. Apoio Matricial e Atenção Primária em Saúde. Saude Soc. 2011; 20(4):961-70.; and social inequities that intensify unbalanced power relationships between professionals and users. Fox and Reeves¹⁷17. Fox A, Reeves S. Interprofessional collaborative patient-centred care: a critical exploration of two related discourses. J Interprof Care. 2015; 29(2):113-8. analyzed the last barrier mentioned above, discussing the risk of collaborative practice reiterating hierarchical and unequal relationships between professionals and users, and the risk of collaborative practice and primary care becoming rhetorical discourses.

However, it is important to mention some characteristics of primary care in the context of the SUS, approached in the national literature, which can contribute to collaboration in the sphere of teams and networks:

In view of the peculiarity of different health systems, the World Health Organization suggests that efforts to establish and consolidate collaborative practice should be grounded on the exploration of aspects of the local reality⁷7. Organização Mundial da Saúde. Framework for action on interprofessional education and collaborative practice [Internet]. Geneva: OMS; 2010 [citado 4 Abr 2017]. Disponi´vel em: http://www.who.int/hrh/resources/framework_action/en/.. Although there has been an increasing number of national publications focusing on the interprofessional theme, little is known about the characteristics of collaborative practice in the Brazilian primary care.

Collaborative practice and teamwork climate in the primary care of the SUS

A recent study conducted in the Family Health Strategy by Agreli²⁰20. Agreli HLF. Prática interprofissional colaborativa e clima do trabalho em equipe na Atenção Primária à Saúde [tese]. São Paulo, SP: Escola de Enfermagem, Universidade de São Paulo; 2017. revealed a relationship between collaborative practice and teamwork climate, namely, that teamwork climate is a key element for collaboration, as Pullon et al.³⁹39. Pullon S, Morgan S, Macdonald L, McKinlay E, Gray B. Observation of interprofessional collaboration in primary care practice: a multiple case study. J Interprof Care. 2016; 30(6):787-94. had already discussed in the sphere of international literature. In the study of the Brazilian primary care, it was found that teams with good teamwork climate presented: Intense participation of their members in decision-making; activities oriented by consolidated work assessment mechanisms, such as individual feedback and team reflection meetings; support to new ideas; and user-centered care (developing consolidated health promotion and prevention actions with the participation of users and the community). Teams with higher climate scores were also those that were most able to expand collaboration from the sphere of teams to that of networks and work articulated with other sectors. This result suggests that investing in teams’ permanent education is an important step to comprehensive care and work in the RAS, not only because it is through teamwork that different professionals integrate their expertise, but because collaborative teams are also capable of integrating different social and health services, as well as the participation of users, families and the community⁴⁰40. Presidência da República (BR). Lei nº 8080, de 19 de Setembro. Dispõe sobre as condições para a promoção, proteção e recuperação da saúde, a organização e o funcionamento dos serviços correspondentes e dá outras providências. Diário Oficial da União. 19 Set 1990..

According to Agreli²⁰20. Agreli HLF. Prática interprofissional colaborativa e clima do trabalho em equipe na Atenção Primária à Saúde [tese]. São Paulo, SP: Escola de Enfermagem, Universidade de São Paulo; 2017., collaboration as a form of interprofessional work in primary care can be understood in two modalities that alternate depending on users’ conditions and needs. The first modality is “Team collaboration”, in which professionals search for alternatives among the members of their team or among teams from the same primary care unit to improve the quality of healthcare, and collaborate with each other to increase users’ participation in individual clinical care (supported self-care^(e)(e)Supported self-care is a proposal for care management that incorporates collaboration between the health team and users, instead of a merely prescriptive action33,41.).

The second modality is “Intersectoral and community collaboration”, in which team professionals search for alternatives in the team and also in other services, sectors, and with users, families and the community. This collaboration modality highlights the importance of interprofessional teamwork in the promotion of intersectoral work and social participation^(f)(f)Social participation, which expresses the relationship between civil society and the State, exercised in the SUS by means of Management Councils and Health Conferences40, expands the sharing of decision-making from the sphere of the therapeutic project to the management of the health system.. In addition, it emphasizes the strong relationship between collaborative practice and primary care, which, together, constitute the teams’ movement to include users as protagonists, stimulating their participation in the “doing together” of the interprofessional team.

Final remarks

There must be integration and collaboration in the sphere of teams and also between them and the other services of the healthcare network, in view of the increasing complexity of healthcare. As we presented above, collaboration is characterized especially by effective communication among professionals, users and the population in the construction of partnerships:

These partnerships can even constitute forms of resistance against threats of regression in the health policies that constituted and consolidated the SUS, and expand the access to primary care services. It is important to highlight that, in Brazil, the Family Health Strategy is a consolidated interprofessional intervention, as it has been in force for more than two decades.

In the present article, we aimed to present current concepts of interprofessional work. Teamwork and collaborative practice must contribute and have repercussions in two directions: Improving the access and quality of the healthcare provided for the territory’s users and population, and promoting job satisfaction among the professionals involved. To achieve this, teamwork and interprofessional collaboration in primary care need to be addressed in a contingent manner, that is, according to the characteristics of users/catchment population and according to the context (health policies, care models, etc.) and working conditions. It is important to emphasize that collaboration requires the desire to cooperate with/contribute to the work developed by the other professional. It can occur both in the micro-context of teams (Team collaboration) and in a broader way, in the scenario of the RAS and the community (Intersectoral and community collaboration).

Finally, we highlight the importance of interprofessional collaborative practice performed jointly with users, families and the community, which requires ensuring conditions for their effective participation.

References

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