JOURNAL OF INTERPROFESSIONAL CARE

2023, VOL. 37, NO. 4, 532–540

https://doi.org/10.1080/13561820.2022.2102591

EMPIRICAL RESEARCH ARTICLES

Enacting primary healthcare interprofessional collaboration: a multisite ethnography

of nurse practitioner integration in Ontario, Canada
Annie Rioux-Duboisa and Amélie Perronb
a
Department des sciences infirmières, Université du Québec en Outaouais, Saint-Jérôme, QC, Canada; bSchool of Nursing, University of Ottawa,
Ottawa, ON, Canada

ABSTRACT ARTICLE HISTORY

Interprofessional collaboration (IPC) is known to enhance patient outcomes and satisfaction. In primary Received 13 April 2021
healthcare (PHC), IPC aims to transform care provision and team functioning, but its implementation is Revised 07 July 2022
challenging and has yielded mixed results. We aimed to describe the enactment of IPC in PHC settings, Accepted 8 July 2022
particularly as it relates to nurse practitioner (NP) integration. A multisite ethnography involving 6 KEYWORDS
Canadian PHC clinics was carried out. We conducted 330 hours of direct observation, 23 semi- Interprofessional
structured interviews with PHC NPs, informal interviews with key PHC partners, and document analysis. collaboration; primary
IPC in PHC was found to rest on human and non-human actors that interact in complex ways. healthcare; nurse
Organizational mandates and remuneration models, physical spaces and schedules played a decisive practitioners; network;
role in the enactment of IPC. Power structures embedded in certain designations (i.e., most responsible ethnography; professional
provider) or NPs’ commitments to physicians’ practices stood in contrast with the principles of IPC. NPs boundaries
enacted various role to develop, enhance, and maintain IPC. Despite shifts in PHC provision, IPC remains
poorly defined and precariously sustained.

Introduction models: Community Health Centers (CHC), Family Health

Teams (FHT), and NP-Led Clinics (NPLC). CHCs were the
Interprofessional collaboration (IPC) is a key tool through which
first interprofessional model, introduced in the 1970s. They are
care is structured to benefit from the expertise and capabilities of at
characterized by a community health approach to care with
least two health professionals from different professions working
salaried employees, including NPs and physicians. FHTs were
toward common goals and making the best possible use of
introduced in the mid-2000s, pushing solo physicians to tran­
resources (Rawlinson et al., 2021). IPC is effective in primary
sition to medical group practices where members of other
healthcare (PHC) and contributes to better care processes, and
professions (mostly nurses and NPs) “support” their work.
patient satisfaction (Carron et al., 2021). Favorable patient out­
NPLCs appeared in the context of NP unemployment and are
comes also occur when professionals such as nurse practitioners
managed by NPs with the explicit mandate of caring for
(NP) are part of primary care teams (Norful et al., 2017). IPC is
patients without another primary provider (Heale, 2012).
often central to healthcare transformations and reforms worldwide,
These major organizational changes disrupted Canadian PHC
to mitigate the challenges brought on by scarce human resources,
teams that were left without much support and leadership to
an aging population, and care fragmentation (Virani, 2012).
help shift the paradigm (Virani, 2012).
IPC innovation influences the traditional division of labor,
IPC literature often emphasizes its core principles and
team composition and functioning (Schot et al., 2020), IPC
values, but few scientific articles examine its daily application
facilitators include “tools” that improve communication, co-
location, and recognition of collaborators’ skills and contribu­ in PHC settings with differing organizational mandates, struc­
tion (Rawlinson et al., 2021). Barriers include lack of time, tures, and values (Heale, 2012). We sought better understand­
training, clear professional roles and identity, fears, and poor ings of how IPC occurs in the three main PHC models,
communication (Rawlinson et al., 2021). IPC sometimes particularly as it relates to NP integration and roles, team
entails risks of interprofessional conflicts (Sullivan-Bentz functioning, and PHC reform in general.
et al., 2010), divergent expectations, critical negotiations of
professional territories (Kilpatrick et al., 2012), and medical Theorical underpinnings
resistance (Cashin et al., 2017).
IPC and NP integration have the potential to disrupt relatively
organized, stable systems traditionally governed by
Background a biomedical model. We used Actor-Network theory (ANT;
In the Canadian province of Ontario, IPC innovation in pri­ Latour, 2005), which seeks to describe social phenomena by
mary healthcare took place through the introduction of NPs, defining human and non-human actors (actants) involved and
care reorganization, and the creation of three new PHC follow them to understand how they work to organize the

CONTACT Annie Rioux-Dubois [email protected] Department des sciences infirmières, Université du Québec en Outaouais, Saint-Jérôme, QC, Canada
© 2022 Taylor & Francis Group, LLC
 JOURNAL OF INTERPROFESSIONAL CARE 533

social world and associated phenomena (e.g., IPC, NP integra­ Multiple informal discussions with care providers took place
tion). ANT opposes traditional dualisms, such as nature/cul­ to understand the organizational culture and obtain their per­
ture or subject/object, and invites researchers to produce ceptions, concerns, and feedback regarding observations.
detailed descriptions of these concepts, showing instead that Document analysis helped understand organizational con­
they are composed of complex networks of semiotic entities in texts. Access to institutional documentation was requested, and
interaction. Core ANT concepts have been described elsewhere additional documents were identified on walls and notice
(Rioux-Dubois & Perron, 2016). boards throughout all clinics. Documents analyzed included
organizational charts, strategic plans, organizational missions
and visions, annual reports, job descriptions, policies and pro­
Method cedures regarding IPC, minutes of meetings, and codes of
conduct. This analysis informed interviews with NPs, helping
A critical multisite ethnography was performed to examine the
to contextualize their discourses, meanings, and reflections.
daily activities of PHC teams. A critical perspective adds
Data were collected over 8 months; saturation for each model
a political dimension to ethnographic work by questioning
was reached when no new information was captured that helped
established structures and discourses, particularly those that
understand NP integration, IPC, and role negotiation in PHC.
create problems or inequities for certain groups (Madison,
2012). Multisited ethnography allows for the strategic selection
of multiple observation sites for comparison (Marcus, 1995).
Data analysis
All this allowed us to identify IPC and NPs’ integration as
a broad phenomenon that transcends the walls of the organiza­ Data collection and analysis were simultaneous. Thematic
tions where they occur, and helped us to see how things could analysis was performed in keeping with Actor-Network
be, rather than how things are. Theory, beginning during interview transcriptions.
Transcripts were first coded line by line, and codes were
grouped in clusters. This process was also applied to organiza­
Setting tional documents and the three types of field notes: (a) direct
Special attention was paid to the diversity of research settings site observations, (b) meetings observations, and (c) researcher
by including two sites for each PHC model (CHC, FHT, and reflexive notes. A second level analysis was performed using
NPLC), for a total of six sites representing rural, regional- critical discourse analysis (Blommaert, 2005) to unpack orga­
urban, and urban areas and Canada’s official languages nizational narratives and discourses, the taken for granted
(French and English). All participating sites provided support assumptions (e.g., roles and responsibilities, care priorities)
letters granting access to the physical spaces and clinic employ­ governing clinics’ activities and NPs, and other professionals’
ees. The study received ethical clearance from the authors’ work.
institution (H 01–14-09). Dependability was achieved by keeping a decisions trail.
Credibility was established through prolonged engagement,
the inclusion of multiple sources of data, peer debriefing,
Data collection member checking, and negative case analysis. Interim findings
were shared with participants, managers, NPs, and collabora­
Multiple data collection techniques were used including inter­
tors, and feedback about their accuracy was integrated.
views with NPs, document analysis, and observation.
Transferability was addressed with detailed description from
Convenience sampling was used to recruit NP participants
field notes and interview data. Confirmability was achieved
for individual interviews. Demographic information collected
through use of comparative data and reflexivity. Risk of main
included participants’ age, gender, employment status, nursing
researcher’s personal bias was lessened using a reflexive jour­
experience, type/level of education, number of collaborating
nal, member checking and continuous consultations, and dis­
physicians, and changes in their position or roles as NPs. We
cussions with collaborators.
conducted 23 semi-structured interviews with PHC NPs
(mostly in their workplace; duration from 30 minutes to
3 hours). Interviews were audio-recorded and transcribed.
Results
NPs were asked to describe the PHC model where they worked,
IPC implementation and dynamics, organizational culture, and A more generic reporting of our findings has been published
NP role integration. elsewhere (Rioux-Dubois & Perron, 2021). Here, we focus on
We completed 330 hours of direct observation of physical the configuration of IPC in PHC. Contextual descriptions are
spaces and team interactions; approximately 100 hours per based mainly on observational data and document analysis. We
model of which 40 hours were dedicated to interprofessional first describe the mandate of each PHC model and the inter­
or administrative meetings involving NPs, nurses, managers, professional arrangements for each. We then explore the mul­
other healthcare professionals (mental health workers, dieti­ tifaceted presentations of IPC in PHC and the ways it was
cians), and least often, physicians. Before all observed meet­ impacted by environmental and socio-professional elements.
ings, managers notified staff about the researcher’s presence. This second portion is based mainly on interview data.
Staff could accept or refuse to be observed. In case of refusal or During data collection, most NPs held full-time positions
inability to obtain consent, the researcher did not record field (78%) and had been in their position for less than 5 years
notes about these individuals (e.g., input during meetings). (87%). One participant identified as male. NPs either had
534 A. RIOUX-DUBOIS AND A. PERRON

a master degree (43.5%) or a NP graduate degree (56.5%). NPs Team size, composition and allocation
aged 30–39 years old were most represented in our sam­
We compared interprofessional teams across all research sites.
ple (44%).
All sites team members included NPs, physicians, nurses, dieti­
cians, mental health providers, and administrative assistants.
PHC model mandates, direction and remuneration Community workers were part of the CHCs. NPLC physicians
schemes were ad hoc visitors thus not always present. One FHT included
a kinesiologist. NPs collaborated with 1 to 3 physicians in CHCs,
Direct observation and document analysis showed impor­ compared to 5 to 25 physicians in FHTs. The number of colla­
tant differences in the organizational mandates of the borators greatly increased when NPs worked in advanced access
three PHC models that were more explicitly detailed in or chronic disease programs. A high number of providers did not
a previous publication (Rioux-Dubois & Perron, 2021). necessarily mean success for some NPs: “The bigger the setting,
These mandates influenced IPC terms and arrangements, the harder it is. I think the dream of having huge FHTs . . . it’s
decision-making processes, and providers’ roles and hard to develop close connections” (NP14, FHT). NPs, physi­
responsibilities. cians, and other team members were located on the same floor in
CHCs are grounded in community health approaches only two of the six research sites; hence most team members
inspired by the principles of PHC and the social determi­ were physically scattered and distant from one another.
nants of health. When CHCs were created, IPC was a core
mandate. NPs and physicians are salaried, and IPC is
integral to their job descriptions. They do not hold formal Multifaceted interprofessional collaboration
management roles. Rosters of at least 1,300 vulnerable
patients are shared between NP-physician duos wherein According to participants, IPC involved various forms of col­
both are the most responsible provider (MRP) for 600–700 laborative activity, which were identifiable during direct
patients. observation.
FHTs are governed by the principles of primary care (rather
than PHC) grounded in the biomedical paradigm. Community Mentorship
interventions focus on health promotion and sharing commu­ NP participants described a mentor as an experienced
nity resources during patient visits. Physicians’ salary come employee skilled in properly guiding and advising a less experi­
from blended remuneration, per capita, and fee-for-service; enced person and promoting strong collaborative values. NPs
NPs are salaried employees. In job descriptions and other clinic initially expected to be paired with an NP or physician mentor,
documents, IPC was described as “in support to medical prac­ although this did not occur for most of them. Mentorship was
tice.” Physicians’ job descriptions were unavailable for analysis. difficult to seek out and was mainly informal. This led to
Physicians were identified as the sole MRP. Physicians hold difficulties for these NPs to integrate the setting and develop
formal management roles; NPs do not, although they often lead confidence regarding self-determination (e.g., engaging in full
chronic disease programs. A roster of 1,300 patients from the scope of practice). Participants turned to other sources of
general population is minimally required of a full-time equiva­ support both internally (e.g., nurses, clerks) and externally
lent (FTE) physician. Enrollment of 5,000 patients by (e.g., past preceptors, medical databases):
a physician group can fund an NP FTE, allowing for an addi­
Do you know who mentored me at first? The secretary. Yeah, she
tional 800 patients to the roster. Constituting a strong financial really helped me. [. . .] I was lucky also because there was this nurse
incentive, this arrangement became the main driver to aban­ [. . .] she helped me a lot (pause). [. . .] And the doctor a bit, too.” (NP6,
don solo medical practice in favor of FHTs. CHC)
NPLCs are run by NPs through boards of directors com­
Lack of formal mentorship could jeopardize NPs’ integration:
posed of 51% NPs. Created in 2007, NPLCs were requested to some NPs sought out potential (informal) mentors but were
adopt the FHT approach of primary and family care. sensitive to whether the partner was interested in that role. NPs
A community health focus was implemented through empha­ carefully read signs suggesting openness to collaboration – or
sis on rural and satellite clinics, and assistance provided to lack thereof: “One physician always has their door open, except
community programs. NPs are salaried, and the salary of when with patients. Whereas the other physician, the door is
physicians (considered “consulting physicians”) comes from always closed (. . .) You assume he doesn’t want to be dis­
blended remuneration, fee-for-service, and a lump sum for turbed” (NP18, CHC). NPs were cautious not to impose on
consultation with NPs ($10,000/year per consulting NP). IPC partners and trigger reluctant attitudes, thereby engaging in
was an integral part of the creation and mandate of NPLCs. It is a delicate balancing act between obtaining guidance and nur­
an explicit requirement in NPs’ job descriptions; physicians’ turing budding yet fragile relationships with new collaborators.
job descriptions were not available to us, but NPLC partici­
pants indicated that, when hiring a physician, they actively Interprofessional education (IPE)
verified their inclination to engage in IPC. Physicians are Participants described IPE as a manifestation of IPC, consisting
invited to committee meetings but rarely attend. NPs hold of often spontaneous and reciprocal exchanges of knowledge
formal administrative roles, especially NP clinic managers and ideas between colleagues to support each others’ practice.
who must dedicate 50% of their time to management-related Although infrequent, NPs appreciated it when it occurred:
duties. “One of them [physician] always sends us really good articles
 JOURNAL OF INTERPROFESSIONAL CARE 535

(. . .) and he tries to come to [team meeting]. He has really good I do rely on the other disciplines, like the pharmacist and the
ideas. (. . .) Because he works [elsewhere], he’s got access to dietician. (. . .) I collaborate with them and ask them, okay in this
situation, what would you suggest or what’s the best course of
a different part of learning than I do” (NP2, NPLC). action? (. . .) We work really well as that interdisciplinary team,
Disseminating research articles as a form of IPE was per­ and just using the expertise of these other disciplines. (. . .) I feel it
ceived as sustaining NPs’ professional practice and role inte­ has kind of come together.” (NP3, NPLC)
gration. Some settings formalized IPE by requesting members
to present a scientific topic to their peers, but this was deemed Cooperation was deemed to build and solidify over time,
less targeted and effective in meeting NPs’ emerging learning reflecting team growth, stability, and maturity. However, the
needs. IPE also occurred when professionals engaged in knowl­ context of PHC created greater challenges in that regard due to
edge gathering efforts with colleagues, through the consulta­ greater staff and manager turnover:
tion of medical books or scientific databases:
Every time someone new arrives, it destabilizes (. . .) It’s like any
Sometimes I would ask questions, he [physician] would say: “It’s human being: at first you grow, get to know others. Then as
good to have new people here because it makes me think about my a teenager you become more confident. Then comes a time when
things”. He’d be like: “I don’t know, hold on, let’s check the book” you consolidate, you’re an adult and then changes are more diffi­
(laughs). Or I’m telling him about something and he goes: “I’ve cult to deal with. (NP9, FHT)
never heard of that, let’s look it up (NP8, CHC)
Cooperation was supported by effective managers and govern­
ing structures (e.g., committees, productive communication,
transparency) with good conflict resolution: “People here have
Partnership
NP participants described partnerships as a way to level out a good sense of humor, we dedramatize when something
happens, deal with it right away, discuss it and solve it (. . .)
working relations, paying special attention to mutual assistance
Nothing drags on and on” (NP12, CHC).
and peers’ well-being.
To preserve cooperation, certain sites screened job candi­
Before the day starts, we can talk all together. It fosters good relation­ dates; accordingly, hires were not solely based on one’s experi­
ships. There’s no bitching. One has a problem, she arrives in tears, ence, but also on fit with the team. Those deemed to disturb the
everyone will go see her during the day (. . .) One got here this local culture of cooperation, even involuntarily, could be
morning, she brought food for everyone (. . .) There’s thoughtful
gestures you don’t find anywhere else, people look after each other.
assigned to different roles and even lose their job: “We had
(NP12, CHC). new employees, problematic employees who disturbed the
culture here (. . .) [The manager] made the decision; an
Participants believed that partnerships reflected peers’ com­ [employee] was laid off ” (NP9, FHT).
mitment to team cohesion and reciprocal support. They also
blurred the roles of “requester” and “requestee” by fostering
team members’ genuine and active interest in others. This Consultation
could eliminate the need to seek out assistance and put Participants described instances whereby a member, such as an
demands on others. For example, one FHT NP described her NP, requested another partner’s expertise in a brief interaction.
collaborating physician’s proactive stance as reflective of such Participants often used the term “consultation” to refer to
partnership, as he worked to understand her role expectations physician-NP or NP-NP exchanges activated by an NP’s per­
and expertise: “[Collaborative physician] sends me an e-mail ception of limitations in their competencies or scope of prac­
and says: « (. . .) What do you like? What are your strengths? » tice. Consultations occurred most often informally and
It’s good because it’s important to get to know each other. (. . .) spontaneously, and was deemed to increase both parties’
[He acts] based on what I tell him” (NP7, FHT). workloads:
Such partnerships were observed to be more common in [NP’s name] will come knock on my door or phone me nearly always
settings with more stable teams. Partnerships were also opti­ before [consulting with her collaborating physician] (laughs). (. . .)
mized with more conducive and convivial physical spaces. Few I totally don’t mind. I know how important it is to have somebody . . .
settings implemented team building activities to engage part­ But all those little extra things, they nearly all end up in my office, on
ners beyond their professional/clinical role. my lap, quite truthfully. So I’m swamped, often! (NP11, CHC)

Informal consultation was often difficult to achieve, yet it was

Cooperation necessary to meet NPs’ practice needs. In settings where NPs were
Participants described how, through sustained connections, expected to “assist” physicians, consultation was deemed poten­
team members had common goals and shared or delegated tially risky, as some physicians could feel “forced” into collabora­
tasks to meet care needs and system enhancement require­ tion – something NPs took issue with: “Physicians are supposed to
ments (i.e., optimization of individual, team, and model per­ agree to this collaborative role when they’re hired here!”
formance). We named this type of IPC cooperation, as being (NP18, CHC).
grounded in and primarily focused on exchanges, agreements, To lessen risks, participants sought to minimize disruptions
and consensus going beyond traditional teamwork, with by learning partners’ preferences and expectations. This
a particular focus on a common objective, geared toward involved considerable efforts through trial and error. NPs felt
patient care, and ensuring accountability. Cooperation was assertive and empowered to “impose” consultation activities
greater between non-medical workers across sites because of when institutional policies legitimizing consultation existed or
more sustained presence and availability. when multiple patient files were pending: “They [patient files]
536 A. RIOUX-DUBOIS AND A. PERRON

pile up! (. . .) there comes a time where you just have to go and Spatial configuration and meeting rooms, offices, kitchens,
knock on their door, otherwise it’s just you who’s collaborat­ break rooms, and other communal spaces were found to be
ing” (NP18, CHC). key to the development and sustaining of IPC.
Physician’s availability for consultation was interpreted
by many as kindness rather than stemming from their Meeting rooms
professional obligation toward patients and the care team. In some settings, meeting rooms were construed in ways that
Consultation practices were deemed to be jeopardized in led to divergent uses. In one FHT, rooms meant for interpro­
NPLCs due to decreased budgets for physician consultation, fessional and administrative meetings were taken over by some
which occurred after NPs saw their scope of practice physicians for their personal use rather than IPC. Such move
expand. was not challenged by anyone at the clinic, but some partici­
pants interpreted it as the privileging of physicians’ needs and
Delegation preferences over team-oriented activities.
A professional delegates an activity to another professional
who would otherwise be restricted by their scope of practice. Offices
Delegation underpinned medical directives directed at NPs In the two CHCs investigated, physicians’ offices were close to
and, in NPLCs, NP directives directed at nurses. The expansion those of other members, which CHC participants felt created
of NPs’ scope of practice reduced their use. a perception of proximity, inclusion, and availability. In FHTs,
Non-human actors were also delegators of activities, roles, physicians’ offices were often in remote sites, inducing a sense
and norms. For instance, the designation of MRP, entrenched of physical and symbolic distance between partners. Location
in organizational policies, positioned one member of the team of NPs’ offices was raised by several participants as an impor­
(typically a physician) in charge of care delivery for a group of tant feature of collaborative work environments which could in
patients, and therefore in authority over a group of profes­ turn impact NP integration in PHC settings:
sionals. A secondary provider (often an NP) was charged with
It [clinic design] makes a big difference! Yes, because I never see the
providing episodic care to patients under the responsibility of
physicians if I want to catch them in the hall, unless I have my door
the MRP. In FHTs, institutional mandates delegated chronic open [and see them] when they go to the bathroom. And then, it’s
care management to NPs. The extension of NPs’ scope of kind of awkward to be standing at the bathroom door like you’re
practice created a need for NPs to negotiate an expanded role waiting for them. But [another NP], because of where she is, she can be
reflective of their knowledge, expertise, and judgment. Scope aware all the time which doctors are free and when, whereas I often
don’t. (NP11, CHC).
expansion was often interpreted by clinics as an opportunity to
invest NPs’ full scope, whereas previously specific clinical con­ Three types of offices across research settings impacted IPC and
ditions mandated consultations with physicians. Participants care processes. First were private offices, used to chart, interview
shared that the change revealed difficulties in defining the patients, consult medical resources, or make calls. These were
scope of their practice as secondary providers, creating a need only attributed to physicians in one CHC, but to all profes­
to continuously negotiate professional territories: “Some phy­ sionals in one FHT and one NPLC. In CHCs, private offices
sicians trust us, they say: ‘If you need to see my patients, no bore physicians’ names only. Second were shared offices. NPs
problem, no need to ask.’ (. . .) Others, it’s a turf war, it’s saw these as facilitating IPC and strengthening communication,
ridiculous.” (NP9, FHT). friendships, peer support, resource sharing, and team cohesion.
Despite this, role expectations were often left undiscussed Third were rooms that served both as exam rooms and offices.
between MRPs and other team members leading participants In one CHC, these were assigned to NPs while physicians were
to look for signs for MRPs’ willingness to share responsibility provided with private offices. In one large FHT, NPs could use
for patients. For example, when MRPs referred their patients to exam rooms as offices while a large central area named the
NP-led chronic disease programs, this was interpreted as “bullpen” became reserved for physicians’ exclusive use even
acceptance of shared responsibility. However, some NP parti­ though it had originally been intended as an interprofessional
cipants still treaded carefully around physicians and limited space. In some sites, exam rooms were assigned daily on a “first
their scope of practice so as to not threaten the potential for come, first served” basis but at times this was thought to create
IPC: “I try not to encroach on their [physicians’] thing unless tensions regarding equitable use, which could in turn under­
it’s pressing (. . .) If the patient tells me something that’s not mine professionals’ disposition toward IPC.
urgent (. . .) I’ll direct them back to their family physician. I do
medication changes if it’s urgent” (NP12, CHC). Walls and doors
Participants often spoke about walls and doors as physical or
Physical spaces symbolic enablers, or barriers to IPC, depending on whether
they promoted exchanges or isolated members (especially NPs)
Physical spaces play a role in IPC. When optimal, they make it from others:
easier for healthcare providers to collaborate:
I don’t like being alone, I learn a lot from colleagues (. . .) As an NP
We never see each other unless really we make an effort to go over, in primary care anyways, I’ve lost that: that growth from colleagues.
but there’s never like this coincidental crossing paths. (. . .) [In (. . .) It’s so very isolated (. . .) geographically and even inside (. . .)
another FHT] we were grouped together to do our paperwork you’re very separated. Even the doors for me show things that, you
and I think if you’re sitting in the same room with someone, then come to the reception and there’s a big door that’s shut, like here
you would naturally make conversation.” (NP14, FHT) you must be all by yourself. (NP14, FHT)
 JOURNAL OF INTERPROFESSIONAL CARE 537

The effect of closed doors on members’ sense of belonging was institutional requirements (e.g., performance imperatives).
clearly identified in some settings, leading to informal open door Participants yearned instead for meetings to support their
policies: “They tell us, when we start: here, we encourage people to clinical and professional needs, support stronger relationships,
leave their doors open to facilitate communication” (NP12, CHC). and enhance proximity, communication, and problem-solving:
We have meetings but very few interdisciplinary meetings (. . .) The
Other collaboration tools disciplines are put in a certain hierarchy, and we don’t mix. (. . .)
There’s the clinical assistants, and the nurses and the NPs and the
NPLCs were the only sites that formally documented IPC- allied health, and then the physicians. And we don’t meet across the
related requirements. Team Charters were displayed in gather­ hierarchy. I’ve never met with the receptionists. We talked today
ing spaces; describing IPC-related norms, standards, and beha­ about all the bookings (. . .) Maybe they have really good ideas, but
I don’t know because we don’t interact. (NP14, FHT)
viors, thus facilitating IPC. In other sites, NP participants said
that employment status and schedules, sharing practices, inter­ Many NPs also expressed frustration at being excluded from
professional and administrative meetings, and virtual spaces meetings and decision-making processes, arguing they should
mediated IPC. This was meaningful in settings where IPC, be involved especially when these impacted them directly: “We
although promoted and encouraged, was rarely defined or learn the decisions and we’re not informed of the process.
formalized: “There’s nothing in writing. Oh, there’s some We’re told the rules and directives and our room to maneuver
nice theories about the principles of collaboration but in prac­ is limited. You can give your opinion, but the process will be
tice I think there’s a huge gap” (NP18, CHC). implemented regardless (NP9, FHT).”
NP intraprofessional meetings were deemed useful to help
Employment status and schedules smooth out scope of practice transitions, but these were rarely
Partners’ full or part time status and schedules influenced IPC. programmed as part of NPs’ regular workload. One FHT
Those with FTE positions described more opportunities to gathered NPs most often during their personal time (lunch
develop stronger IPC. NPs often monitored partners’ schedules break), which was interpreted as an inappropriate way to
to secure consultation times, but expressed disappointment maximize NPs’ time and performance and decrease costs: “It
seeing that physicians were often busy, unavailable, and over­ [FHT] is a business model, I mean we never met with [the
loaded: “You feel isolated because no one is 100% available. manager] during work time. It was always on our lunch hour”
Physicians’ schedules are so busy, that it makes everything (NP17, CHC). Such arrangements often led NPs to seek
difficult (. . .) they also do overtime, so collaboration is tough” employment elsewhere.
(NP18, CHC).
Beyond isolation, some NPs felt that heavy workloads also Virtual Spaces
negated opportunities to build alliances with physicians sup­ Participants identified electronic platforms and communica­
portive of NPs, especially in FHTs where some physicians tions as important collaborative tools. E-Mails, instant messa­
limited NPs’ influence in key committees: “Some physicians ging, and electronic health records created virtual spaces
don’t get involved enough. The strong headed ones do and they enabling geographically dispersed partners to connect and
tend to be against NPs. The others don’t really want to be collaborate. Yet they could also undermine collaboration as
involved, they’re overloaded, they have their personal life, they were often time consuming (e.g., writing up
they have other things” (NP7, FHT). a sufficiently detailed clinical case) and increased the likelihood
of delayed answers and miscommunication. These virtual
Sharing practices spaces also made it more difficult for NPs to ascertain physician
In some sites, daily debriefs were scheduled to discuss patient preferences regarding consultation processes and the sharing
care, possible conflicts, ethical dilemmas, and challenging care of patient care. Some participants felt this could lead to nega­
situations. In one CHC, the first daily activity was a morning tive judgments about NPs, and harm their overall integration
coffee break, described by NP participants as strengthening in clinical settings:
interpersonal and collaborative relationships.
All sites had designated charting time. Many identified this It [geographical distance] doesn’t help because they [physicians]
as a time for potential collaboration. In sites where charting might have preconceived ideas about us because they don’t see us
(. . .) Maybe if we worked together, I’d get to know them better and
moments were not shared, NPs’ attempts to consult colleagues we’d become real partners. And maybe they could support me
could be construed as inopportune and disruptive. against the others [physicians unsupportive of NP]. (NP7, FHT)
Finally, other shared tools, such as printers, mailboxes, and
coffee machines increased the likelihood of practitioner inter­
actions and thus IPC. Field notes described partners handing
Discussion
off printed documents, smiling at each other, and engaging in
clinical discussions around these devices, which became IPC IPC generates strong interest among researchers working to
facilitators. clarify its meaning, manifestations, and effects. Echoing other
researchers’ work (Goldman et al., 2010; Khan et al., 2021), we
Interprofessional and administrative meetings found that communal spaces (e.g., shared offices, kitchen)
All investigated sites had formal times set aside for clinical and/ facilitated planned and unplanned exchanges that strengthened
or administrative meetings. Most NP participants shared working relationships. Electronic medical records and commu­
a sense that these were designed first and foremost to meet nication technologies (e.g., e-mails, chats) opened up new
538 A. RIOUX-DUBOIS AND A. PERRON

collaborative spaces in lieu of face-to-face interactions; in some and supportive of the full expression of NPs’ (and other
settings, these became the main format for IPC, which could providers’) roles, expertise, and practices. Our findings
help overcome space and time constraints and link geographi­ show that NPs play a central role in developing and main­
cally dispersed or larger teams (particularly in FHTs). taining IPC and engage in various practices to meet the needs
However, their features (e.g., time consuming, rigid format) of patients, teams (Rioux-Dubois & Perron, 2021), and
could also hinder NPs’ ability to meaningfully connect with clinics’ organizational mandates. Such role multiplicity often
physicians and become familiar with their work method, some­ leads to inaccurate interpretations of NPs’ roles as lacking
times leading to misunderstandings and tensions. Similarly, clarity (Rioux-Dubois & Perron, 2016). IPC mediates one’s
administrative and interprofessional meetings engendered professional role(s) and ability to define/negotiate profes­
both opportunities for and barriers to IPC, depending on sional boundaries and identities, which Schot et al. (2020)
their format, purpose, and outcomes, which varied across described as bridging gaps, negotiating overlaps, and creating
PHC models. For instance, while CHCs enacted shared gov­ spaces.
ernance with flatter decision-making, NPLC participants Given recurrent instabilities impacting PHC settings, for­
reported both inclusionary and exclusionary decision- malization would help safeguard IPC. Protecting time in
making; FHT participants critiqued overall lack of transpar­ partners’ work schedules for collaborative activities (e.g., con­
ency, NP exclusion from decision-making, and entrenched sults, charting, meetings) would position IPC as a core feature
professional hierarchies. of clinical responsibilities. This would remove the need for
Our study highlights actants’ influence in IPC. Routine NPs to hunt for signs of partners’ willingness to engage
terminology such as MRP, often construed as a form of physi­ collaboratively and foster a collaborative organizational cul­
cian “ownership” creating a territory around certain patients, ture not subject to individual workloads and dispositions. In
which led secondary providers to enact deferent behaviors, those settings where IPC is achieved mostly virtually, enhan­
even when this undermined patient care. Our findings suggest cing partnerships through face-to-face meetings and team
that it can challenge some tenets of IPC including the flattening building activities should be strongly considered. Explicitly
of hierarchies and the meaningful and equitable distribution of defining IPC expectations in policies and procedures, job
work, resources, and responsibilities. Other common practices, descriptions and orientation, and performance appraisal
such as the labeling of offices for physicians but not NPs or the further supports IPC. Resource allocation (e.g., offices) should
appropriation of common areas for the exclusive use of physi­ be properly planned, guided by IPC principles around flat­
cians, revealed and perpetuated longstanding attitudes about tened hierarchies. Informal practices, such as open doors or
status and hierarchies despite organizational claims that such social events can also sustain collaborative engagement; they
hierarchies no longer prevailed. Simple objects such as offices need to be brought to light as a lever for IPC optimization in
and door signs powerfully organized social and professional these settings. Formalized and non-formalized practices have
relationships even in the absence of explicit direction to submit been identified as key to enhance IPC involving NPs
to such power structure, thus mediating IPC. (Contandriopoulos et al., 2015) and can challenge the idea
It is clear that IPC rests on the negotiation of professional that IPC is disruptive, an added burden, and too time-
role boundaries and their permeability in a team composed of consuming (Schot et al., 2020).
actors and actants. Negotiation becomes an unending collec­ We should expand our understanding of the relationships
tive responsibility referred to by Duner (2013) as an ongoing that make up interprofessional “things” (Latour, 2005) such as
boundary work, where others describe it as negotiating cultural, teams, networks, and collaboration. Our findings show that
social, or symbolic capital, or spaces (Schot et al., 2020). This IPC can be understood as a powerful, complex, and shifting
may explain why participants were more likely to construe IPC network of relationships between various agents, human and
as successful in PHC networks deemed more stable, well- non-human entities. NPs and physicians are readily acknowl­
defined, and predictable. However, such stability and durability edged as key contributors to IPC in PHC; other entities such as
of networks were difficult to achieve due to frequent changes in documents (e.g., policies, organigrams, NPs’ standards of prac­
quality imperatives, care targets, team compositions, NPs’ tice, job descriptions), medical records, schedules, coffee
scope of practice, and resource allocation, which disrupted
machines, and physical spaces also directly influence its enact­
participants’ view of IPC as a self-evident, and thus easy to
ment. This echoes Latour’s conceptualization of networks as
operationalize process.
heterogenous assemblages of actors and actants, allowing for
Several authors have proposed that NPs engaging with
the rightful consideration of actants as important, yet oft-
physicians either do so through a consultative or
a collaborative approach (see, Contandriopoulos et al., overlooked mediators of social processes such as IPC. As
2015). Our findings suggest that IPC transcends this binary “organizational arrangements” (Schot et al., 2020, p. 336),
view: it is “multifaceted” (Schot et al., 2020) and includes objects, rules, information structures, spaces, resources, and
mentorship, interprofessional education, partnerships, coop­ symbols hold power and thus shape IPC and associated socio-
eration, consultation, and delegation. Each enhanced NPs’ professional identities. IPC may therefore be better described
sense of integration and efficiency. We propose that diverse through team function, shared identity and responsibility, clear
forms of IPC may reflect settings that are more dynamic, roles/goals, interdependence, and network existence, size, and
adaptative, responsive to emerging needs, flexible, coherent, complexity.
 JOURNAL OF INTERPROFESSIONAL CARE 539

Limitations Amélie Perron, RN, PhD is a Full Professor at the School of Nursing at the
University of Ottawa. Her research interests include power relationships
Study limitations include participants experiencing possible between health care professionals, sociopolitical aspects of care and nur­
recall biases and acting and conversing differently during sing epistemology. Email address: [email protected]
observations, hence the importance of multiple data sources.
The sample also included mostly white, female NPs, whose
collaborative experiences do not necessarily reflect those of References
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