Interprofessional Working in Hospitals: The Case of Nepal Bachchu Kailash Kaini (Cert in Clinical Audit in H&SC – London, PG in Hospital & Health Mgmt – IIHMR, Jaipur; MBA, LLB, BEd – TU, Nepal) PhD Research Student (Final Year, Part Time), University of Greenwich, London Clinical Governance Manager, Queen Elizabeth Hospital, London Councillor, Dartford Borough Council, Dartford, Kent, UK

Context Changes in demographic structure and disease pattern Increased cost of care Concept of specialties and sub-specialties emerging Well informed patients and more choices Expansion of roles of health care professionals (HCPs) Changing health care environment requires new ways of working & collaborative practice

Interprofessional Care (IPC) IPC is a collaborative working in which HCPs share common purpose of developing mutually negotiated goals which are achieved through agreeing a care plan, the management of it and procedures (HFO, 2007; Hawley, 2007; Leathard, 2003; Payne, 2000; Pietroni, 1992; Colyer, 2012). Interprofessional working (IPW) to happen in practice, HCPs: Pool their skill, knowledge and expertise Shared professional view points Make joint decision Learn from each other

Literature Review Collaboration, IPW and effective communication: reduces the clinical incidence, misunderstanding and errors, and enables HCPs be more readily aligned to the departmental and organisational vision (Verhorsek et al, 2010;. Mills et al, 2008; CHSRF, 2006; Joint Commission, 2005) More positive health care outcomes are achieved by collaborating effectively between HCPs (Byrnes et al, 2009; CHSRF, 2006; Nolte, 2005; EICP, 2005; Holland et al, 2005; Pollard, 2005; Dow and Evans, 2005; McAlister et al, 2004; Leathard, 2003; Miller et al, 2001; Biggs, 1997; Ritter, 1983) Other aspects of IPW researched and assessed in the past

Power Perspectives of Theory of Professions Theory of Professions: division of labour based on skills, knowledge and expertise Knowledge is a source of power and it has great influence in determining professional behaviour and dominance Medical dominance exists in health care and professional dominance of medical professionals comes from autonomy (Freidson, 1970a; 1970b)

Research Objectives To identify and analyse various factors that support and hinder IPW in Nepalese hospitals To examine understanding and perceptions of IPW among HCPs To assess perceptions of IPW on health care delivery in Nepal To examine professional power perspectives of theory of professions in relation to IPW To make recommendations for improving interprofessional collaborative practices

Research Methodology Qualitative research method, case study Purposive sampling Three hospitals in Kathmandu, 38 HCPs (40% nursing, 34% Medical and 26% AHPs) Use of semi structured interview schedule & analysis of documentary evidence Qualitative content analysis Interpretive thematic approach Open coding, categorisation, theme generation, establish relationships, interpretation & conclusion

Demographics

Main Findings IPW is widely understood, recognised and valued by HCPs HCPs carry out different roles, values, status and responsibilities Verbal means of communication is used most of the time. Other common forms: medical notes, team meetings Service users involvement in IPC is valued

Main Findings Power differences in medical, nursing and AHPs Dominance of medical professionals exists in Nepalese hospitals Medical professionals lead IPC team HCPs perceived different levels of autonomy Boundaries between HCPs changing Cultural and gender differences in medical, nursing and AHPs

Main Findings HCPs do not have significant contact with one another during their formal or university education HCPs learn IPC skills at work and they felt competent IPW is not sufficiently motivated amongst HCPs and adequate appreciation is lacking Concept of IPW and power perspectives of theory of professions are equally applicable in Nepalese context

Perceived Barriers to IPW Organisational: Lack of training and education, no protocol for IPW, high workload & no support from management Professional: Professional dominance and isolation, hierarchy & no understanding of other professions Personal: Poor communication, ego, negative attitude & no mutual respect

Recommendations for Improving IPW Training and education Policies and guidance Clinical leadership Organisational structures and support Appropriate communication