nursing research key terms

Research Terminology

Refer to this page for definitions and explanations of common terms used in research. This list is not exhaustive and is intended as a quick reference. Main menu | Comments/Suggestions

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NURSING RESEARCH

Chapter 4 NURSING RESEARCH OBJECTIVES • Define the key terms/concepts • Define nursing research • Explain the importance of research in nursing • Compare the various ways to acquire knowledge • Understand the basic differences between qualitative and quantitative approaches in research • Outline the steps in conducting research • Describe the way research, education and practice relate to each other • Identify the importance of critical thinking and critical reading when undertaking a research project • Discuss the importance of informed consent and ethics in relation to research • Define evidence-based practice • Explain how Enrolled Nurses (ENs) can participate in nursing research • Identify future trends in nursing research KEY TERMS/CONCEPTS data analysis data collection ethical principles hypothesis informed consent nursing research qualitative research quantitative research reliability research design research problem research question validity variables CHAPTER FOCUS Nursing theory and education are recognised as the main contributors to the development of an accountable and professional nurse in the health care environment. Research is also recognised by health care professionals as being equally important in influencing practice by informing decisions about the delivery of care to clients and their families. Today’s evidence-based nursing practice integrates education, theory, practice and the findings from research to provide quality health care. Nurses are also acknowledging the need to develop skills in critically appraising research literature to enable consideration of its application to clinical practice (Beanland et al 2004). The purpose of this chapter is to enable Enrolled Nurses (ENs) to develop an appreciation of the significance of research to them as nurse practitioners. It introduces the principles of nursing research, basic components of a research proposal, guidelines to critiquing a research article, and an overview of both qualitative and quantitative research. LIVED EXPERIENCE I always thought that research was something that academics did working in universities or laboratories. But I got excited when we started learning about evidence-based research in class, as I can now see how to use it in the clinical area and I also know that I will be giving the very latest nursing care to clients in my care. Melissa, Enrolled Nurse student NURSING RESEARCH The term ‘research’ refers to a systematic way of studying or examining issues so that the knowledge about that issue is validated. It requires an understanding of the existing knowledge about the issue so that new knowledge can be developed. There are many words and terms specifically related to research referred to in this chapter, which are covered in Table 4.1 (later in the chapter). TABLE 4.1 Common research terms Bias Any influence that may alter the outcomes of a research study Clinical nursing research Nursing research that has a direct impact on nursing interventions with clients Data Measurable bits of information collected for the purpose of analysis Data collection Gathering of information necessary to address the research problem Deductive reasoning Logical system of thinking that starts with the whole and breaks it down into its component parts Dependent variable A variable that is affected by the action of the independent variable Ethics committee Committee responsible for review of research proposals to ensure that human subjects are protected from harm Hypothesis Statement of a predicted relationship or difference between two or more variables. A hypothesis contains at least one independent and one dependent variable Independent variable A variable that causes a change in the dependent variable Inductive reasoning Logical system of thinking that begins with the component parts and builds them into a whole Informed consent An agreement by a research subject to participate voluntarily in a study after being fully informed about the study and the risks and benefits of participation Instrument Device or technique used to collect data in a research study, e.g., questionnaires or interviews Literature review A critical summary of available theoretical and research literature on the selected research topic. It places the research problem for a particular study in the context of what is currently known about the topic Nursing research Research usually conducted by nurses to generate knowledge that informs and develops the discipline and practice of nursing Population All known subjects that possess a common characteristic of interest to a researcher Problem statement A statement that describes the purpose of a research study, identifies key concepts and sets study limits Qualitative research Used to examine subjective human experiences by using non-statistical methods of analysis Quantitative research The systematic process used to gather and statistically analyse information that has been measured by an instrument and converted to numerical data Reliability Characteristic of a good instrument; the assessed degree of consistency and dependability Research A systematic process using both inductive and deductive reasoning to confirm and refine existing knowledge and to build new knowledge Research design The overall plan for collecting data in a research study Research process An orderly series of phrases identifying steps that allow the researcher to move from asking a question to finding an answer Research question Use of an interrogative format to identify the variables to be studied and possible relationships or differences between those variables Sample A subset of a population selected to participate in a research study Validity A characteristic of a good instrument; the extent of an instrument’s ability to measure what it states it will measure Variable A concept, characteristic or trait that varies within an identified population in a research study ( Borbasi et al 2008 ) Nursing research involves a systematic search for and validation of knowledge about issues important to the nursing profession and links theory, education and practice. Nursing research is important for: • Validating nursing as a profession • Documenting the effectiveness of nursing interventions • Providing a scientific knowledge base for practice • Demonstrating accountability for the profession. Research-based or evidence-based practice is essential if the nursing profession is to deliver safe, effective and efficient care. The ultimate goal of nursing is to provide evidence-based care that promotes quality outcomes for clients, families, health care providers and the health care system. Burns and Grove (2004) describe evidence-based practice as involving the use of collective research findings in: • Promoting the understanding of clients’ and families’ experiences with health and illness • Implementing effective nursing interventions to promote client health • Providing quality, cost-effective care within the health care system. EVIDENCE-BASED PRACTICE Evidence-based nursing is a clinical activity based on the belief that decisions about the delivery of care to clients should be informed by the best available and current scientific evidence (Beanland et al 2004). Another definition of evidence-based practice is that it is a process within which clinical decisions are made by practitioners using the best available research evidence, their clinical expertise and client preferences, with consideration also of available and finite resources (Schneider et al 2007). The five steps universally accepted as being necessary for evidence-based practice are presented in Clinical Interest Box 4.1 . Clinical Interest Box 4.2 explains evidence-based practice. CLINICAL INTEREST BOX 4.1 Steps in evidence-based practice 1. Ask a focused question. 2. Assess appropriate evidence. 3. Appraise evidence for validity, impact and precision. 4. Apply evidence accounting for patient values/preferences, clinical and policy issues. 5. Audit your practice/personal skills. (Source: Jackson et al 2006; Sackett et al 2000 as modified in Schneider et al 2007: 305) CLINICAL INTEREST BOX 4.2 Evidence-Based Practice What Is Evidence-Based Practice? A process of: • synthesising research evidence • designing clinical practice guidelines • implementing practice changes • evaluating outcomes Why Do We Need Evidence-Based Practice? • Rapid increase in amount of information • Rapid increase in healthcare costs • Determination of efficient and effective healthcare practices • Increased emphasis on performance and outcome standards Where Is Evidence Found? • Published research • Systematic reviews (e.g. Cochrane Collaboration; available: http://www.cochrane.org/ ) * • Special collections of EBP resources (e.g. The Joanna Briggs Institute; available: http://www.joannabriggs.edu.au ) * Descriptions can be found at this website, but access to systematic reviews is by subscription only. (Brown et al 2008: 13) THE EVOLUTION OF NURSING RESEARCH As early as 1854, Florence Nightingale demonstrated the importance of research in the delivery of nursing care. When Nightingale arrived in the Crimea in 1854, she found the military hospital barracks overcrowded, filthy and lacking in food, drugs and essential medical supplies. Men were dying from starvation and diseases such as cholera and typhus because of these conditions. By systematically collecting, organising and reporting data, Nightingale was able to implement sanitary reforms and prove a significant reduction in mortality rates. This is considered to be the first nursing research study (Kozier et al 2007). Research was slow to develop in nursing, with little formal research carried out by nurses until the late 1940s. Nursing schools evolved from military and religious roots and stressed order and obedience. Training was viewed as an apprenticeship, with long hours, and nurses had little say in their own training or work. Only when nursing began to move towards advanced education and affiliation with university settings did nursing research begin to emerge. This move began in the USA. In the 1960s and 1970s the number of nurses with advanced degrees and research skills increased and the push for doctoral preparation in nursing began. Nurses began to turn to nursing care and clinical practice to provide questions for research. Nursing theories evolved that attempted to describe and explain the practice of nursing and these theories began to be tested by nurse researchers. Practice-related research flourished and by the end of the 1970s two new research journals were launched in the USA to handle the nursing research explosion (Borbasi et al 2004). In Australia and New Zealand, nursing research awareness remained relatively low until nursing moved into the tertiary education sector in the 1970s and 1980s. This move was accompanied by a major increase in the level of research activity, which was directed at educational, disciplinary or professional issues, and research into other disciplinary areas of relevance to nursing. It is only recently that research education delivered to nurses in Australia and New Zealand has begun to prepare nurses to understand the relationship between research evidence and nursing practice, and how to go about incorporating research findings into practice (Crisp & Taylor 2005). Some ideas that have been tested and demonstrated to be useful in practice are: moist wound healing; pressure-relieving devices for the prevention of pressure ulcers; client information to improve self care and healthy lifestyles; communication with people who are dying; and nutritional support of older people in hospital (Brown et al 2008). THE FUTURE OF NURSING RESEARCH The value of research studies that increase understanding of clinical phenomena and provide direction for defining programs of research is well recognised and flourishing in Australia and New Zealand. Nurse researchers and nurse leaders are visibly involved at the national level, participating in policy making, representing nursing on expert panels and organisations such as the National Health and Medical Research Council (NHMRC) and lobbying for funding (Beanland et al 2004). Magnet Hospitals are emerging in both Australia and New Zealand. The concept of a ‘Magnet Hospital’ is to develop and sustain an environment where nursing- and midwifery-related evidence-based practice and practice change are more likely to occur. Magnet Hospitals aim to provide a commitment to staff development and training, effective systems for implementing and evaluating quality-based treatment and care, and sustainable long term resourcing (Schneider et al 2007). Borbasi et al (2004) state that, with the development of a national organisation for nursing research, research priorities in the 21st century are likely to be directed at nursing practice and that there will be an increased emphasis on building on the results of completed studies. They also believe that there will also be a greater emphasis on finding ways to utilise the results of nursing research in the course of day-to-day practice. RESEARCH METHODS Nursing research focuses on the full range of human experiences and responses and is directed towards helping well individuals improve their health status and stay healthy, as well as assisting clients who are sick or disabled by an illness to maintain or improve their health (Crisp & Taylor 2005). The major factor that affects whether a nursing researcher uses systematic, controlled methods for studying events or problems is the extent to which he or she wishes to study the way that characteristics or variables (see Table 4.1 ) are different, or the way that one variable is predictive of (causally associated with) another. These studies are well organised and follow a specific procedure to enable other researchers to reproduce the study or examine the evidence and achieve the same outcomes. To guide the design of a research study, nurse researchers may create a hypothesis or statement about what they expect to see before conducting the study (Crisp & Taylor 2005). Nurse researchers use many methods because nurses are interested in acquiring knowledge about a wide range of human needs and responses to health problems. For example, a different research method may be used by a nursing researcher interested in developing a deeper understanding of a phenomenon and how it may be experienced by clients, such as helping women deal with the consequences of incontinence after childbirth. Most methods used are either quantitative or qualitative in nature (Crisp & Taylor 2005). QUANTITATIVE METHODS Quantitative research methods involve the use of numbers and statistical analysis. This is a process used to gather and analyse information that has been measured by an ‘instrument’, such as a questionnaire, and converted to numerical data. Quantitative nursing research is the investigation of nursing phenomena that lend themselves to a precise measurement, such as pain severity, rate of wound healing, etc (Crisp & Taylor 2005). Box 4.1 describes different ways of using quantitative methods. Box 4.1 Types of research that use quantitative methods CORRELATIONAL RESEARCH Studies that explore the patterns of interrelationships among variables of interest, without any active intervention by the researcher. Correlational methods are used in testing predictive relationships among variables, for testing models or theories that seek to explain complex patterns of relationships, and for testing the most effective and efficient means of achieving positive health outcomes. DESCRIPTIVE RESEARCH Studies in which the aim is to accurately portray characteristics of individuals, situations or groups and the frequency with which certain events or characteristics occur. The major goal of this form of research is simply to describe what is seen in order to identify variables that may be of interest in future investigations. EXPERIMENTAL OR QUASI-EXPERIMENTAL RESEARCH Studies in which the investigator controls the independent variable and randomly assigns subjects to different conditions. The major goal of this research is to determine causal relationships among the variables through a controlled investigation in which only the independent variable can be the cause of changes in the dependent variable. EXPLORATORY RESEARCH Studies designed to develop or refine the dimensions of phenomena or to develop or refine a hypothesis about the relationships among phenomena. The major goal of this research is to explore what is seen in order to identify relationships among variables that might be of interest in future investigations. EVALUATION RESEARCH Studies that test how well a program, practice or policy is working. The major goal of this form of research is determining the success of a program. This type of research can determine specifically why a program was successful. When programs are unsuccessful, evaluation research can assist in identifying problems with the program, why it was not successful or even barriers to implementation of programs. SURVEY RESEARCH Studies designed to obtain information from populations regarding prevalence, distribution and interrelation of variables within the study population. They may be conducted for the general purposes of obtaining information about practices, opinions, attitudes and other characteristics of individuals. The major goal of this form of research is simple description or the accumulation of a large amount of data to describe the population being studied, as well as the topic of study. ( Crisp & Taylor 2005 ) In quantitative research, the researcher changes one set of variables and observes the outcome or its influence on other variables. Variables are changeable qualities, such as characteristics of people or situations that can change or vary for many reasons. Temperature, pulse, respiration, blood pressure, height and weight are examples of variables. The variable that the researcher controls or manipulates is called the independent variable. The variable that varies or changes because of this is called the dependent variable. For example, consider the statement: ‘Sitting upright in bed does not make breathing easy in a client with asthma’. The independent variable relates to sitting the client in different positions, such as lying flat, semi-recumbent, lateral and upright positions. This is the variable the researcher can manipulate to study its influence on the dependent variable. The dependent variable is the measurement of breathing. QUALITATIVE METHODS Qualitative research is used to describe information obtained in a non-numerical form, such as data obtained from interviews. Qualitative nursing research is the investigation of phenomena that are not easily quantified or categorised, in which inductive reasoning is used to develop generalisations or theories from specific observations or interviews (Crisp & Taylor 2005). See Box 4.2 for the different ways of using qualitative methods. Box 4.2 Types of research that use qualitative methods ( Crisp & Taylor 2005 ) ACTION RESEARCH Studies that attempt to make qualitative research more humanistic, holistic and relevant to the lives of human beings. The major goal of this research is working in collaboration with participants in a manner that brings about desired change(s). CRITICAL SOCIAL RESEARCH Studies that empower individuals involved in this research by attempting to confront unjust power structures within a specific context or society. The major goal of this research is the challenging of dominant constructions of reality and the societal structures that maintain the status quo and determine allocation of power and resources. DESCRIPTIVE RESEARCH Studies in which the objective is to accurately portray characteristics of individuals, situations or groups and the frequency with which certain events or characteristics occur. The major goal of this research is to describe what is seen in order to detect phenomena that might be of interest in future research. EXPLORATORY RESEARCH Studies designed to develop or refine the dimensions of phenomena or to develop or refine a hypothesis about the relationships among phenomena. The major goal of this research is to explore what is seen in order to identify relationships among phenomena that might be of interest in future research. HISTORICAL RESEARCH Systematic studies designed to establish facts and relationships concerning past events. The major goal of this research may be either a descriptive account of what occurred and the facts surrounding the event(s), or a critical approach may be taken in which the researchers challenge the dominant interpretations of facts. INTERPRETATIVE RESEARCH Studies in which human experience is investigated to generate deeper understanding of the phenomena of interest. The major goal of this research is the exploration of the numerous ways human beings experience the complex world in which they live. Qualitative researchers may wish to examine individual lives and their stories and behaviour, organisations and their functioning, or cultures and their interactions and social movement. As the study methodology embraces the examination of subjective phenomena, these findings are only considered to be representative of a particular person or group of people, and in a particular setting, and not reflective of other people or other settings (Borbasi et al 2004). There are strengths in both quantitative and qualitative approaches. The quantitative approach can support a theory or argue to disprove it, and can be very useful, for example, when hospitals or governments want to introduce policy changes. The qualitative approach, by contrast, has a human focus and allows researchers to know their subjects and collect information about attitudes and satisfaction levels that are vital to improve care provided by nurses. THE RESEARCH PROCESS There are several steps in conducting either quantitative or qualitative research. STEP 1. THE RESEARCH PROBLEM The research problem is refined through a process that proceeds from identifying a general idea of interest to defining a specific topic. A preliminary literature review reveals related factors that appear critical to the research topic. The significance of the research problem must be identified in terms of its potential contribution to clients, nurses and the medical community (Beanland et al 2004). Choosing the topic of interest may develop from: • Discussing an issue of common interest with a colleague • Reading about an issue in a journal, text or newspaper • An aspect of practice being introduced for the first time • An aspect of practice that may have been observed but needs to be validated • Areas of work that may need to change • Wanting to repeat a study that has already been conducted, to check the results. STEP 2. THE PURPOSE The purpose of the study states the aims or goals that the investigator hopes to achieve with the research. It also suggests the way in which the researcher sought to study the problem. STEP 3. LITERATURE REVIEW The overall purpose of conducting a review of the literature is to develop a strong knowledge base to carry out research and other consumer research activities in the educational and clinical practice settings. It is a broad, comprehensive, in-depth, systematic and critical review of scholarly publications, unpublished scholarly print materials, audiovisual materials and personal communications (Beanland et al 2004). The literature review provides a way of checking what has already been studied in relation to the proposed study. It can also provide an understanding of the procedures, methods of analysis and variables that can influence the study (see Box 4.3 ). Box 4.3 Overall purpose of a literature review • Determines what is known and not known about a subject, concept or problem. • Determines gaps, consistencies and inconsistencies in the literature about a subject, concept or problem. • Discovers unanswered questions about a subject, concept or problem. • Discovers conceptual traditions used to examine problems. • Uncovers a new practice intervention(s) or provides evidence for current practice intervention(s). • Generates useful research questions and hypotheses for the discipline. • Describes the strengths and weaknesses of designs or methods of enquiry and instruments used in earlier works. • Determines an appropriate research design or method (instruments, data collection and analysis methods) for answering the research question(s). • Determines the need for replication of a well-designed study or refinement of a study. • Promotes development of new or revised practice protocols, policies and projects or activities related to nursing practice and to the discipline. ( Schneider et al 2007 ) How to search successfully for information To conduct a successful search for information about a particular subject, the researcher needs to define the topic of interest, select appropriate search resources and selectively review and evaluate the materials produced by a search (Borbasi et al 2004). A search is conducted using indexes, abstracts and catalogues to find information about specific subjects. Books tend to give standard accepted information and practices. They provide good baseline data on a subject. Journals, however, provide more current information than books. They report changing trends and practices. Several electronic indexes are used for nursing journals ( Box 4.4 ), including the Cumulative Index to Nursing and Allied Health Literature (CINAHL), Index Medicus (a comprehensive index of peer-reviewed medical journals compiled by the US National Library of Medicine) and its online counterpart, MEDLINE (Medical Literature Analysis and Retrieval System [MEDLARS] online). Each index has a primary area of focus and advantages and limits. Electronic databases operate with a special vocabulary. However, the computer helps the researcher to define the preferred terms to use in a search. It is important to make the search as precise as possible; if there are several key terms, they should be used. Other limits such as gender, age and/or time factors, should also be set. Ask for assistance from the librarian if there is difficulty finding information. Many professional information sources are also available on the internet, where there is access to a wide variety of databases, client and nursing education resources, as well as some nursing journals (see Online Resources at the end of this chapter). Box 4.4 Examples of nursing research journals • Australian Journal of Advanced Nursing

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Nursing Research

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Snapshot:  This document provides an overview of nursing research, a summary of the research process, including discussion of the popular “Iowa Model,” in addition to research terminology and a library of links.

Nursing Research: Overview & Scope

• As is true for other healthcare professionals, many nurses rely upon custom, habit or institutional norms to guide nursing practice. One of the central goals of nursing research is to subject such practice to rigorous, scientific inquiry.
• An example of basic research would be investigating the way cancer cells use signaling pathways to multiply. The research might or might not subsequently yield insights into the pathophysiology of cancer, and to new cancer treatments.
• An example of EBP would be encouraging early ambulation as tolerated for post-surgical patients because a randomized control trial demonstrated that this practice led to a statistically significant reduction in rates of pneumonia and shorter hospital stays.
• An example of QI/PI would be formulating a set of clinically validated guidelines for reducing falls, such as mandating that RN’s complete a fall-risk assessment on admission, and then measuring and re-measuring over time the implementation and impacts of such a tool on fall rates within the organization.
• Nursing research – in all its various forms – comprises one ‘leg’ of the ‘three-legged stool’ of nursing education, nursing practice, and nursing research. Ideally, these three activities are interdependent: each is mutually dependent upon the other, and contributes to betterment of the profession.

The Research Process

Research is not simply a body of knowledge. It is a dynamic process with distinct steps and phases. Below is a broad overview of that process.

• Formulate the Question. The first step in any research project is to decide what will be investigated. The best research questions are clear, concise and focused. For example, the research question “what challenges do new nurses face?” is too broad, and would be very difficult to investigate. A better question might be, “what are the leading challenges to retaining bachelors-prepared nurses in their first year of practice in a major academic medical center?”
• Define the Purpose or Goal. Nursing research is an inherently applied discipline: its purpose is to improve the breadth and depth of nursing knowledge, and to thereby improve nursing practice. When you conduct research, keep in mind your intended audience, and what you hope to achieve with your research. If you cannot answer these questions, you should return to your research question and re-formulate it.
• Choose a Theoretical Framework & Research Design. While nursing research is typically ‘practice oriented,’ it is nonetheless important to be cognizant of how the themes and concepts in your research fit together, and to spell out how you will investigate your topic for your audience. Will you be investigating individuals’ feelings and narratives? Will you be measuring the statistical significance of a particular clinical intervention? Will you be synthesizing the results of previous studies, or conducting original research? Your answers to these questions will help determine the purpose, methods, assumptions and limits of your research.
• Perform a Literature Review. Research never exists in a vacuum, and any research project should survey existing research. A competent literature review, however, is not simply a dry recitation of past findings. Rather, it should be a dynamic summary and analysis of existing knowledge that points out the links between this past work and the new research being conducted. The literature review is a useful introduction for the research audience that both situates the author’s research in a broader context, and helps to justify the importance of and need for the research question the author investigates.
• Select the Population and Sample. Regardless of your research goals, framework or methodology, you will need to define who will be included in your study, and who will not. The population or sample you investigate needs to match your research question, and just as importantly, must be available for you to study. Populations may be defined by any number of variables, such as age, gender, clinical role/status, or professional setting.
• Perform Ethical Review & Obtain Approval. An essential part of the research process is to ensure that your research topic is ethically sound, and to obtain clearances from your organization or institution to conduct the research. This concern is always important, but perhaps especially so for nurses, who often deal with private and highly sensitive medical data, access to which may be restricted by HIPAA and other regulations. You will probably need to present your research proposal to an Institutional Review Board (IRB), or other similar institution for approval. Plan ahead, because review and approval can be a lengthy process, and the panel may require that you make revisions or otherwise alter your research design.
• Collect & Analyze Data. Once you know your research design and methodology, you’ll need to gather and interpret your data. This data may be qualitative or quantitative, or a mix of both. Before you do your collection, make sure you have the knowledge and means to make sense of your data. You may need to use statistical analysis for quantitative research, or determine your methodology for analyzing subjective feelings, values and narratives for qualitative research. Again, allow time: data collection and analysis is often challenging and time-consuming.
• Organize, Write & Edit. Your research question, methodology, and population sample should help you structure your write-up of the project. One way to structure your paper is to think in terms of broad categories: introduction, methods, results, discussion, and conclusions and recommendations. Using headings and sub-headings to ‘break up’ your research is often helpful to readers. Also be sure to acknowledge the limitations of your research and areas for further inquiry.
• Compose Citations, Sources & Bibliography. Every research study must clearly acknowledge sources and properly cite them. To do so is not only important for reasons of intellectual integrity, but also because readers should be able to reference your sources should they choose to do further reading and investigation. Follow your organization or institution’s accepted format; one commonly used format in nursing research is the American Psychological Association (APA) style.
• Communicate Findings. This final stage in the research process is a crucial one. After all, research that never finds its way to its intended audience is inert. Communicating your findings often includes publication; it may also include speaking about and presenting your research to professional audiences and to the public. However this communication occurs, be open to feedback. The questions and debates your research inspires may form the basis for your next investigation, or for research conducted by others in conversation with your own.

The Iowa Model

• The Iowa Model of Evidence-Based Practice to Promote Quality Care is a practice-driven research framework that has become a standard in professional nursing and nursing research.
• The topic should be aligned with an organizational priority. If it is not, the Model prompts the nurse researcher to consider a different “trigger,” or basis for the research.
• Once a topic has been selected, the next steps in the Model dictate forming a team, and then assembling, synthesizing, reviewing and critiquing the available research on the topic.
• Should the pilot project prove successful or encouraging, the practice change can then be ‘rolled out’ and gradually integrated within the organization on a larger scale.
• The team must continue to communicate and collaborate throughout this process to select evidence-based practice driven goals, collect data, monitor processes and outcomes, and modify the practice change as appropriate.
• The team is encouraged to communicate internally to implement the change, and externally with other organizations and stakeholders to expand nursing knowledge and to encourage the wider adoption of evidence-based practice driven changes in nursing.
• First, the team could choose to pursue the practice change on the basis of weaker forms of evidence, such as case reports and expert opinion. Alternately, the team could also choose to conduct its own research, and once further research has been completed, then return to the question of whether there exists a sufficient research basis for piloting and potentially implementing the proposed practice change.
• The Iowa Model integrates theory and practice to help professional nurses discover, formulate and advocate for evidence-based practice changes. It also possesses the great advantage of never leaving practitioners without a ‘next step.’ No matter what the professional nurse and his or her team encounter, the Model has clear recommendations and guidelines for a course of action.

Research Concepts & Terminology

• Research Hypothesis. The supposition or proposed explanation a researcher wishes to investigate or test. The hypothesis should propose a relationship between two or more variables.
• Null hypothesis. The supposition that there is no relationship between the variables or phenomena a researcher is investigating.
• Control group. The group of individuals in an experiment who are not subjected to the experimental intervention. The control group serves as a benchmark for measuring the effects of the experimental intervention on the treatment group.
• Independent vs. dependent variable. In experimental research, the independent variable is the “input” variable that is believed to influence or affect the dependent variable, or “output” variable. The independent variable is therefore unchanged by experimental manipulation, whereas the dependent variable is changed by such manipulation.
• Inductive vs. deductive reasoning. Inductive reasoning is the “bottom up” process of reasoning from specific examples or observations to formulate general principles. In contrast, deductive reasoning is a “top down” process of reasoning from the basis of one or more general principles to formulate more specific hypotheses, predictions, or explanations of phenomena.
• Qualitative vs. quantitative analysis. Qualitative analysis is a way of interpreting non-numerical data to draw out the themes, meanings and relationships between phenomena. In contrast, quantitative analysis is a way of interpreting numerical data, often using statistical analysis, to assess the significance and magnitude of the causal relationships among variables.
• Observational studies. An observational study is one in which the researcher observes the behaviors of a group of subjects without intervening in the group in order to draw inferences or conclusions. Observational studies stand in contrast with experiments, such as randomized control trials, which have treatment and control groups. Observational studies include panel studies, cohort studies and case-control studies.
• Cohort study. A cohort study is a type of forward-looking observational study in which a cohort (group) of individuals is followed over time. The cohort is usually investigated at regular intervals, and the characteristics or behaviors of the cohort are compared with the general population from which the cohort is drawn.
• Case-control study. A case-control study is a type of backward-looking observational study in which a group of individuals who share a common characteristic such as a disease or medical condition (“the cases”) are compared with one or more groups who do not possess the characteristic (“the controls”) in order to identify what caused the condition in “the cases”.
• Statistical vs. practical significance. In research, a statistically significant result is one that is not the result of chance or sampling error, thereby allowing the researcher to reject the null hypothesis. However, a statistically significant result may lack practical significance if the size or impact of the finding is not large or clinically significant.
• Type I vs. Type II error. In statistics, a Type I Error or “false positive result,” is defined as incorrectly rejecting a true null hypothesis. A Type II Error or “false negative result” is defined as failing to reject a false null hypothesis. Consequently, a Type I Error will lead a researcher to falsely conclude that a meaningful relationship or effect exists, whereas a Type II Error will lead a researcher to fail to detect a meaningful relationship or effect.
• Hierarchy of Evidence. A hierarchy of evidence is a way of grading the quality and relative authority of various types of research studies. Systematic reviews and meta-analyses are typically at the top of the hierarchy, followed by randomized control trials, cohort, case control and cross sectional studies; case studies, expert opinion and anecdotal observations are typically at the bottom. Many researchers believe clinical guidelines should be based on the highest possible level of evidence.
• Meta-Analysis. A meta-analysis is “review of reviews,” or an analysis of multiple research studies in order to draw out the studies’ most well-supported findings and conclusions. Meta-analysis is employed in many systemic reviews, and according to many researchers occupies the highest level of evidence in the hierarchy of evidence.
• Double-Blind Experiment. A double-blind experiment is one in which neither the person conducting the experiment (the researcher) or the subjects of the experiment know information about the experiment that could lead to conscious or unconscious bias. For example, if a researcher was evaluating whether a drug was more effective than a placebo, in a double-blind experiment neither the researcher nor the test subjects would know which group of patients received the drug under investigation, and which received the placebo.
• External vs. internal validity. In research, a study with findings that can be easily generalized to the general population is said to possess external validity. A study with high internal validity is one in which confounding variables have been successfully eliminated, and the causal relationship under investigation has been clearly established by the researcher. These forms of validity each exist on a continuum, and a study may be high in both kinds of validity, low in both, or high in one but not in the other.
• Reliability vs. validity. Reliability is concept in statistics and psychometrics that refers to the overall consistency of a given type or method of measurement. There are several different kinds or reliability, such as inter-method reliability (the degree to which different methods for measuring a given variable are consistent), inter-rater reliability (the degree to which the measurements or ratings made by different individuals of a given variable are consistent), and test-retest reliability (the degree to which a given test yields the same results when repeated over time). In contrast, validity measures the degree to which a given measurement is measuring what a researcher intends to measure.

Links & Resources

• NINR funds and promotes professional nursing research, and trains and educates current and future nurse research professionals.
• The website has a repository of video and audio resources for nurse researchers, provides news of interest to the nursing and broader medical research community, and offers summaries of the latest funded NINR research. Check out the website’s Grant Development and Management Resources page, which includes valuable information, links and resources for both research grant applicants and funded nurse researchers.
• The organization also offers both “intramural” (on-site) and “extramural” (off-site) research programs. Research encompasses a wide range of professional nursing and practice concerns, from health disparities to disease prevention to end of life care. NINR staff can also assist in each stage of the grant application process – from preparation, to review, to funding and post-grant management.
• The American Nursing Association (ANA) offers a Research Toolkit that offers a valuable overview of and introduction to nursing research and evidence based practice. The Toolkit offers links to numerous research resources, and access to a repository of reviews of research articles. You have register as a member on the site to get access.
• Essential Nursing Resources (ENR) provides a compilation of print and online resources of interest to nurse researchers. The Table of Contents clearly breaks down resources by category, and each resource is helpfully flagged as online or print, and fee- or no-free required for access.
• The National Database of Nursing Quality Indicators (NDNQI), part of the ANA’s National Center for Nursing Quality (NCNQ), is a national nursing quality measurement program that offers hospitals nursing unit-level performance data, benchmarked against state, regional and national averages. Such data is often valuable to nurse researchers. NDNQI currently has over 1,500 participating U.S. hospitals.
• The AHRQ supports research to subject clinical practice to critical, evidence-based standards, and to improve health outcomes. AHRQ is making a concerted effort to encourage contributions to nurse researchers to this broader mission of health research.
• Nursing research funded by AHRQ is summarized on the AHRQ Nursing Research web page. AHRQ provides extramural (off-site) funding for nursing-related health research, and follows the same peer-review process as NIH (the National Institutes of Health).
• The agency offers a Research Activities Online Newsletter that summarizes study findings of interest to professional nurses and nurse researchers.

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This award-winning nursing reference, meticulously researched by luminaries in the field, represents the state of the art in nursing science. Comprehensive and concise, entries provide the most relevant and current research perspectives and demonstrate the depth and breadth of nursing research today. This one-stop reference presents key terms and concepts and clarifies their application to practice.

The fourth edition has been substantially updated to contain the latest research for nurse scientists, educators, and students in all clinical specialties. With new information from the National Institute of Nursing Research, this reference is an essential compendium of nursing research for nursing students at any level and researchers in all clinical specialities.

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Joyce J. Fitzpatrick , PhD, MBA, RN, FAAN, is Elizabeth Brooks Ford Professor of Nursing, Frances Payne Bolton School of Nursing, Case Western Reserve University, Cleveland, OH, where she was Dean from 1982 through 1997. She is also Professor, Department of Geriatrics, Mount Sinai School of Medicine, New York, NY. In 1990, Dr. Fitzpatrick received an honorary doctorate, Doctor of Humane Letters, from her alma mater, Georgetown University. In 2011 she received an honorary doctorate, Doctor of Humane Letters, from the Frontier University of Nursing. She has received numerous honors and awards; she was elected a Fellow in the American Academy of Nursing in 1981 and a Fellow in the National Academies of Practice in 1996. She received the American Journal of Nursing Book of the Year Award 18 times. Dr. Fitzpatrick is widely published in nursing and health care literature with over 300 publications. She served as co-editor of the Annual Review of Nursing Research series , vols. 1-26; she edits the journals Applied Nursing Research, Archives in Psychiatric Nursing, and Nursing Education Perspectives , the official journal of the National League for Nursing. She edited three editions of the classic Encyclopedia of Nursing Research (ENR) , and a series of nursing research digests

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Demystifying nursing research terminology. Part 1

Affiliation.

• 1 School of Nursing and Midwifery, National University of Ireland, Galway, Ireland. [email protected]
• PMID: 21853892
• DOI: 10.7748/nr2011.07.18.4.38.c8635

Aim: This article aims to provide clear explanations of the research approaches available for nursing research.

Background: There are numerous research approaches available to the nurse researcher. There is also some ambiguity in the literature in relation to research terminology and this often leads to confusion about which approach to adopt.

Data sources: A review of the available and most up-to-date literature.

Discussion: The most commonly adopted approaches in nursing research are described and discussed.

Conclusion: This article explains the research paradigms and the rationales for choosing particular paradigms while part two will provide an explanation of the methodological options available to the researcher. A table is included that summarises the key information related to each paradigm.

Implications for practice/research: These articles will be particularly useful for the novice researcher or for the doctoral student.

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How Does Research Start?

Capili, Bernadette PhD, NP-C

Bernadette Capili is director of the Heilbrunn Family Center for Research Nursing, Rockefeller University, New York City. This manuscript was supported in part by grant No. UL1TR001866 from the National Institutes of Health's National Center for Advancing Translational Sciences Clinical and Translational Science Awards Program. Contact author: [email protected] . The author has disclosed no potential conflicts of interest, financial or otherwise. A podcast with the author is available at www.ajnonline.com .

Editor's note: This is the first article in a new series on clinical research by nurses. The series is designed to give nurses the knowledge and skills they need to participate in research, step by step. Each column will present the concepts that underpin evidence-based practice—from research design to data interpretation. The articles will also be accompanied by a podcast offering more insight and context from the author.

This article—the first in a new series on clinical research by nurses—focuses on how to start the research process by identifying a topic of interest and developing a well-defined research question.

Clinical research aims to deliver health care advancements that are “safe, beneficial, and cost-effective.” 1 It applies a methodical approach to developing studies that generate high-quality evidence to support changes in clinical practice. This is a stepwise process that attempts to limit the chances of errors, random or systematic, that can compromise conclusions and invalidate findings. 2 Nurses need to be well versed in the research in their field in order to find the best evidence to guide their clinical practice and to develop their own research. To effectively use the literature for these purposes, it is imperative to understand the principles of critical appraisal and basic study design.

There are many roles for nurses in research. Nurses can be consumers who stay abreast of current issues and trends in their specialty area, nurse champions who initiate quality improvement projects guided by the best clinical evidence, members of an interprofessional research team helping to address a complex health problem, or independent nurse scientists developing a line of scientific inquiry. Regardless of the nurse's role, a common goal of clinical research is to understand health and illness and to discover novel methods to detect, diagnose, treat, and prevent disease.

This column is the first in a series on the concepts of clinical research using a step-by-step approach. Each column will build on earlier columns to provide an overview of the essential components of clinical research. The focus of this inaugural column is how to start the research process, which involves the identification of the topic of interest and the development of a well-defined research question. This article also discusses how to formulate quantitative and qualitative research questions.

IDENTIFYING A TOPIC OF INTEREST

The motivation to explore an area of inquiry often starts with an observation that leads to questioning why something occurs or what would happen if we tried a different approach. Speaking to patients and hearing their concerns about how to manage specific conditions or symptoms is another way to be inspired. Exploring new technologies, examining successful techniques, and adapting the procedures of other fields or disciplines can be other sources for new insights and discoveries. 2 Nurses working in a cardiac setting, for example, may take an interest in using fitness watches to monitor adherence to a walking program to reduce blood pressure and body weight. Their ease of use, cost, and availability may be what draws nurses to exploring the potential uses of this technology. Since the goal of research is to improve patients' lives, it's vital that anyone engaging in clinical research be curious and willing to understand clinical issues and explore the problems that need solving.

Reviewing the literature . Developing a research project requires in-depth knowledge of the chosen area of inquiry (for example, the etiology and treatment of hypertension, which is the hypothetical area of inquiry in this article). Ways to become immersed in the topic include speaking to experts in the field and conducting a comprehensive literature review. Two main types of review found in the literature are narrative and systematic.

Narrative reviews present an overview of current issues and trends in the area of interest and can address clinical, background, or theoretical questions. They can summarize current findings, identify gaps in research, and provide suggestions for next steps. 3 On the downside, narrative reviews can be biased because they are based on the author's experience and interpretation of findings and lack systematic and objective selection criteria. 4

Systematic reviews differ from narrative reviews in that they use a systematic approach to select, appraise, and evaluate the literature. Systematic reviews start with a clinical question to be answered by the review. They use clearly defined criteria to determine which articles to include and which to exclude. Systematic reviews can help nurses understand what works and what doesn't in terms of intervention-based research, and they are excellent resources if an area of inquiry is an intervention-based project. (For the categories of interventional studies, see Table 1 .)

Reviewing citations from published papers is another way to find relevant publications. A frequently cited publication in a particular area may indicate a landmark paper in which the authors present an important discovery or identify a critical issue. An essential goal of the literature review is to ensure that previous studies in the area of interest are located and understood. Previous studies provide insight into recent discoveries in the field, as well as into the dilemmas and challenges others encountered in conducting the research.

DEVELOPING THE RESEARCH QUESTION

The two main branches of research methods are experimental and observational. Randomized controlled trials and non–randomized controlled trials belong in the experimental category, while analytical studies with control groups and descriptive studies without control groups belong in the observational category. Types of analytical studies include cohort and case–control studies; types of descriptive studies include ecological and cross-sectional studies, and case reports.

Despite their differences, the common thread among these research methods is the research question. This question helps guide the study design and is the foundation for developing the study. In the health sciences, the question needs to pass the “So what?” test. That is, is the issue relevant, is studying it feasible, and will it advance the field?

Cummings and colleagues use the mnemonic FINER ( F easible, I nteresting, N ovel, E thical, R elevant) to define the characteristics of a good research question. 2

Feasible . Feasibility is a critical element of research. Research questions must be answerable and focus on clear approaches to measuring or quantifying change or outcome. For example, assessing blood pressure for a study on the benefits of reducing hypertension is feasible because methods to measure blood pressure, the stages of hypertension, and the positive results associated with achieving normal blood pressure are established. For research requiring human participants, approaches to recruiting and enrolling them in the study require careful planning. Strategies must consider where and how to recruit the best participants to fit the study population under investigation. In addition, an adequate number of study participants is necessary in order to conduct the study. The allotted time frame to complete the study, the workforce to perform the study, and the budget to conduct the study must also be realistic. Research studies funded by private or public sponsors usually have defined time frames to completion, such as two or three years. Funders may also request a timeline showing when various aspects of the research will be achieved (institutional review board [IRB] approval, recruitment of participants, data analysis, and so on).

Interesting . Several factors may drive a researcher's interest in an area of inquiry. Cummings and colleagues use the term interesting to describe an area the investigator believes is important to examine. 2 For some investigators, an experience or an observation is the motivation for evaluating the underpinnings of a situation or condition. For some, the possibility of obtaining financial support, either through private or public funding, is an important consideration in choosing a research question or study subject. For others, pursuing a particular research question is the logical next step in their program of research.

Novel . Novel research implies that the study provides new information that contributes to or advances a field of inquiry. This may include research that confirms or refutes earlier study results or that replicates past research to validate scientific findings. When replicating studies, improving previously used research methods (for example, increasing sample size, outcome measures, or the follow-up period) can strengthen the project. A study replicating an earlier hypertension study may add a way to assess dietary sodium intake physiologically instead of only by collecting food records.

Ethical . It is mandatory that research proceed in an ethical manner, from the protection of human and animal subjects to data collection, data storage, and the reporting of research results. Research studies must obtain IRB approval before they can proceed. The IRB is an ethics committee that reviews the proposed research plan to ensure it has adequate safeguards for the well-being of the study participants. It also evaluates the potential risk versus benefit of the proposed study. If the level of risk posed by the study outweighs the benefits of the potential outcome, the IRB may require changes to the research plan to improve the safety profile, or it may reject the study. For example, an IRB may not approve a study proposing to use a placebo for comparison when well-established and effective treatments are available. The National Institutes of Health offers an excellent educational resource, Clinical Research Training ( https://ocr.od.nih.gov/clinical_research_training.html ), a free online tutorial on ethics, patient safety, protocol implementation, and regulatory research. Registration is required and each module takes 15 to 90 minutes to complete.

Relevant . Relevant research questions address critical issues. A relevant question will add to the current knowledge in the field. It may also change clinical practice or influence policy. The question must be timely and appropriate for the study population under investigation. For instance, to continue our hypothetical hypertension study example, for individuals diagnosed with hypertension, it is recognized that reducing the dietary intake of sodium and increasing potassium can lower blood pressure and reduce the risk of heart disease and stroke. Therefore, in conducting a dietary study to reduce blood pressure, an investigator might target the intakes of both sodium and potassium. Focusing solely on one and not the other ignores the best available evidence in the field.

GUIDELINES FOR QUESTION DEVELOPMENT: PICO, PEO

Guidelines are available to help frame the research question, and PICO and PEO are among the most common. PICO is best suited for quantitative studies, while PEO is appropriate for qualitative studies. Quantitative and qualitative methodologies approach research using different lenses. In quantitative research, numerical data is produced, necessitating statistical analysis. Qualitative research generates themes, and the outcome of interest is the understanding of phenomena and experiences. It's important to note that some topics may not fit the PICO or PEO frameworks. In those cases, novice researchers may want to consult with a mentor or academic research adviser for help in formulating the research question.

PICO questions incorporate the following components: P opulation, I ntervention, C omparison, and O utcome.

• Population is the people or community affected by a specific health condition or problem (for instance, middle-age adults ages 45 to 65 with stage 1 hypertension, or older adults ages 65 and older with stage 1 hypertension living in nursing homes).
• Intervention is the process or action under investigation. Interventions can be pharmaceutical agents, devices, or procedures; changes in a process; or patient education on diet and exercise. They can be either investigational or already available to consumers or health care professionals.
• Comparison means the group or intervention being compared with the intervention under investigation (for instance, those eating a vegan diet compared with those eating a Mediterranean-style diet).
• Outcome is the planned measure to determine the effect of an intervention on the population under study. For example, in the study comparing a vegan diet with a Mediterranean-style diet, the outcomes of interest could be the percent reductions in body weight and blood pressure.
• PEO questions incorporate the following components: P opulation, E xposure, and O utcome.
• Population centers on those affected and their problems (for example, middle-age adults who have hypertension and smoke).
• Exposure focuses on the area of interest (for example, experience with smoking cessation programs or triggers of smoking). Since qualitative studies can denote a broad area of research or specific subcategories of topics, the exposure viewpoint depends on the framing or wording of the research question and the goals of the project. 5
• Outcome might encompass a person's experience with smoking cessation and the themes associated with quitting and relapsing. Since the PEO model is best suited for qualitative studies, the outcome tends to include the definition of a person's experiences in certain areas or discover processes that happen in specific locations or contexts. 6

How to formulate a research question using the PICO and PEO frameworks is reviewed in Table 2 .

GOING FORWARD

This has been a brief review of how to find an area of interest for your research and how to form an effective research question. For some, the inspiration for research will come from observations and experiences in the work setting, colleagues, investigations in other fields, and past research. As has been noted, before delving into developing a research protocol it's important to master the subject of interest by speaking with experts and gaining a firm understanding of the literature in the field. Then, consider using the FINER mnemonic as a guide to determine if your research question can pass the “So what?” test and the PICO or PEO model to structure the question. Formulating the appropriate research question is vital to conducting your research because the question is the starting point to selecting the study design, population of interest, interventions or exposure, and outcomes. The next column will discuss the process for selecting the study participants.

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Nursing Research

• First Online: 24 January 2019

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Nurses play an increasingly active role in clinical research in IBD. By reviewing existing literature on the topic, this chapter provides a brief overview of some main concepts related to research in nursing. In addition, the chapter provides some general advice in relation to implementing evidence-based practice, as well as carrying out independent research.

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Jelsness-Jørgensen, LP. (2019). Nursing Research. In: Sturm, A., White, L. (eds) Inflammatory Bowel Disease Nursing Manual. Springer, Cham. https://doi.org/10.1007/978-3-319-75022-4_42

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Nursing Research

Nursing research worldwide is committed to rigorous scientific inquiry that provides a significant body of knowledge to advance nursing practice, shape health policy, and impact the health of people in all countries. The vision for nursing research is driven by the profession's mandate to society to optimize the health and well-being of populations (American Nurses Association, 2003; International Council of Nurses, 1999). Nurse researchers bring a holistic perspective to studying individuals, families, and communities involving a biobehavioral, interdisciplinary, and translational approach to science. The priorities for nursing research reflect nursing's commitment to the promotion of health and healthy lifestyles, the advancement of quality and excellence in health care, and the critical importance of basing professional nursing practice on research.

As one of the world leaders in nursing research, it is important to delineate the position of the academic leaders in the U.S. on research advancement and facilitation, as signified by the membership of the American Association of Colleges of Nursing (AACN). In order to enhance the science of the discipline and facilitate nursing research, several factors need to be understood separately and in interaction: the vision and importance of nursing research as a scientific basis for the health of the public; the scope of nursing research; the cultural environment and workforce required for cutting edge and high-impact nursing research; the importance of a research intensive environment for faculty and students; and the challenges and opportunities impacting the research mission of the discipline and profession.

Approved by AACN Membership: October 26, 1998 Revisions Approved by the Membership: March 15, 1999 and March 13, 2006

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6 Nursing Research

Research training in nursing prepares investigators who are a part of the larger health sciences workforce. Study questions are raised from the nursing perspective but contribute to knowledge in general. For scientists in the discipline of nursing, the ultimate intent of the knowledge generated through research is to provide information for guiding nursing practice; assessing the health care environment, enhancing patient, family, and community outcomes; and shaping health policy.

The science of nursing is characterized by three themes of inquiry that relate to the function of intact humans: (1) principles and laws that govern life processes, well-being, and optimum function during illness and health; (2) patterns of human behavior in interaction with the environment in critical life situations; and (3) processes by which positive changes in health status are affected. 1 Thus, within the health sciences, nursing studies integrate biobehavioral responses of humans. The science of nursing can also be classified as translational research because it advances clinical knowledge and has the directional aims of improved health care and human health status. 2 As stated in a classic policy paper, research for nursing focuses on ameliorating the consequences of disease, managing the symptoms of illnesses and treatments of disease, facilitating individuals and families coping or adapting to their disease, and dealing in large part with promoting healthy lifestyles for individuals of all ages and under different backgrounds and disease conditions. 3 In addition, nursing research focuses on enhancing or redesigning the environment in which health care occurs in terms of the factors that influence patient, family, and community outcomes.

Focusing on ameliorating the consequences of illnesses or their treatment is the intent of many research programs conducted in nursing. For example, a new protocol for endotracheal suctioning has been tested and implemented in a number of hospital critical care units. Endotracheal suctioning is a frequently performed procedure that can have serious consequences if not done correctly. Another example in the area of symptom management is understanding the factors that influence common problems such as pain. In one study that focused on developing a longer-acting pain medication, investigators found that gender is a major factor in whether drugs are effective, with women responding well to seldom-used kappa-opioid drugs while men have little benefit from such drugs.

Another major area for research in nursing is facilitating individuals and families as they cope or adapt to long-term chronic disease. An excellent example of this area of study is a self-help program developed for Spanish-speaking people with arthritis. For many years, Hispanics with arthritis did not have many educational resources for how to cope with or adapt to their illness. Two investigators at Stanford University's medical center have now developed and tested for effectiveness a self-management program with accompanying exercise and relaxation tapes. This self-help program is being considered for nationwide dissemination by the National Arthritis Foundation.

Research in nursing also has a strong focus on health promotion and risk reduction. The intent is to promote healthy lifestyles for individuals of all ages and backgrounds and with various disease conditions. One example is a school-based program now adapted by most North Carolina schools that is a tested health promotion program in exercise and diet for young children at risk for cardiovascular disease. The research results from this school-based intervention program are impressive; the young people's total cholesterol levels and measurements of body fat were significantly reduced following the education and exercise interventions, and their fitness levels, physical activity, and knowledge about cardiovascular disease risk factors improved. 4

Together, influencing, redesigning, and shaping the environment for patients, families, and communities is another major area of study in nursing. For example, over 80 studies have shown the influence of nursing surveillance and presence on positive patient outcomes. 5 The shortage of nurses, a critical factor, in a health care environment has been demonstrated to increase patient mortality and morbidity. 6 Other studies show the benefit of home visits by nurses in improving the health and quality of life of low-income mothers and children. 7

Research in nursing is often referred to as “nursing science” or “nursing research,” which has led some to confuse it with the nursing profession. This terminology exists at the National Institutes of Health (NIH) in the name of the National Institute for Nursing Research (NINR); however, the funding from NINR supports scientific research relevant to the science of nursing, and the investigators may be nurses or nonnurses. Nursing science is a knowledge structure that is separate from the profession and clinical practice of nursing. 8 Furthermore, the term “nurse-scientist” is not reserved for graduates of Ph.D. programs in nursing; it refers to any scientist conducting research in the disciplinary field of nursing. For example, highly trained nurses under the supervision of a principal investigator could conduct the bulk of the work in a clinical trial.

Research training for nurses, as for other biomedical and behavioral researchers, needs to occur within strong research-intensive universities and schools of nursing. Important characteristics of these training environments include an interdisciplinary cadre of researchers and a strong group of nursing research colleagues who are senior scientists in the sense of consistent extramural review and funding of their investigative programs and obvious productivity in terms of publications and presentations. These elements are essential to the environment required for excellence in research training.

The NINR has traditionally placed a greater emphasis on research training in relationship to the relative size of the institute's budget than is evident with NIH in general. This is due to the current stage of development of nursing research and the need for greater numbers both as investigators and academic faculty. At least 8 percent of NINR funds go to research training, which is roughly twice the percentage invested by other institutes. 9 This commitment has been consistent for a number of years. This committee's Nursing Research Panel members commend the wisdom of this tradition and encourage its continuation.

This chapter focuses on the following two areas that are of major concern to the discipline: (1) changing the career trajectory of research training for nurse-scientists to include earlier and more rapid progression through the educational programs to and through doctoral and postdoctoral study as well as increasing the number of individuals seeking doctoral education and faculty roles, and (2) enhancing postdoctoral and career development opportunities in creative ways.

• CHANGING THE CAREER TRAJECTORY FOR NURSE-SCIENTISTS

The following three major factors motivate the critical need to change the career trajectory for nurse-researchers: (1) enhancing the productivity of nurse-researchers to build strong, sustained research programs generating knowledge for nursing and health practice as well as shaping health policy; (2) responding to the shortage of nursing faculty and the advancing age of current nurse-investigators, and (3) emphasizing the need for strong research training of nurse-investigators in research-extensive and research-intensive universities with equally strong interdisciplinary research opportunities.

• ENHANCING SUSTAINED PRODUCTIVITY FOR NURSE-SCIENTISTS

Nurse-scientists play a critical role in the conduct of research and the generation of new knowledge that can serve as the evidence base for practice and improvement of patient health outcomes. However, nurses delay entering Ph.D. programs. There is particular concern because of inherent limitations in the number of years of potential scientific productivity. Starting assistant professors in other scientific fields typically have a research career trajectory of 30 to 40 years in duration. The average age of an assistant professor in nursing is 50.2 years. Hinshaw reasons that for a faculty member who enters the nursing academic workforce at the age of 50 and retires at 65, this productive period will be only 15 years for developing research programs and contributing to science for nursing and health practice in general. 10 Thus, nurse-investigators tend to have a short career span. This limitation severely constrains the growth of nursing research and thus knowledge for nursing practice.

The median time elapsed between entry into a master's program to completion of a doctorate in nursing is approximately 15.9 years compared to 8.5 years in other disciplines. 11 In addition to having a long period of graduate training, the time has increased by 3 years since 1990, and there are no signs of the trend being reversed. Because there are many factors that reinforce the late entry of nurses into Ph.D. programs, there is a need to create incentives to change the career path. The challenge of promoting earlier entry into science careers was discussed by this panel. Of several proposals considered, there was strong support for one that would encourage and support education trajectories with fewer interruptions. To facilitate this, there needs to be greater awareness of nursing as a scientific discipline. Once students enter undergraduate programs in nursing, those students with interests in science should be identified early and encouraged to consider doctoral education. Exposure to nurse-scientists during the undergraduate program would also entice students to consider research as a primary focus in nursing. A few programs of this type exist, such as the Early-Entry Option in the school of nursing at the University of Wisconsin, Madison. In this program highly talented undergraduates are moved directly into the Ph.D. program.

A “fast tracking” of undergraduates into doctoral programs also necessitates dispelling myths related to the need for clinical practice prior to graduate school entry. There is a need to evaluate the requirement of the master's degree for individuals interested in an academic career with an emphasis on research. The lengthening of most master's programs due to certification requirements for advanced-practice roles has resulted in two plus years for master's program completion, which further delays entry into doctoral education.

In addition, the average number of years registered in a doctoral program is longer for nursing than for other fields. On average, it takes 8.3 years for nursing Ph.D. students to complete their degrees compared to 6.8 years for all research program doctoral students. 12 This is due in part to the fact that the majority of doctoral nursing students are part-time students. As of 2002, there were 81 research-focused doctoral programs in nursing with a total of 3,168 enrollees; 55 percent of enrollees were part-time students. This accounts for the low percentage of graduates; 12.8 percent of enrollees graduate each year. 13

Nursing developed both its Ph.D. and its D.N.Sc. 14 programs to build on the master's degree in nursing as well as to accommodate breaks between degrees for clinical practice. Early reliance on the master's degree is understandable in that it was nursing's highest degree for many years before the establishment of a significant number of research doctoral programs. As doctoral programs were developed, they built on the master's content, which at the time was predominantly research and theory focused. Over time the master's programs have changed to become primarily preparation for advanced clinical practice, yet nursing continues to require the master's degree for entry into doctoral study in most programs. Currently, very few doctoral programs in nursing admit baccalaureate graduates directly into the program, and for those that do, the master's degree is usually required as a progression step. This requirement for entry into the Ph.D. program makes the group of advanced nurse-practitioners, rather than baccalaureate students, the major pool from which applicants are recruited into research. This is problematic in that this practitioner pool has the same demographic characteristics as the profession and thus is older in average age and more limited in diversity compared to applicants for science Ph.D. programs in general. Incorporation of the clinical/professional content from the master's degree as foundational to the Ph.D. in nursing also encourages faculty to recruit and teach only nurses. Currently there are only a few doctorate programs in nursing that admit nonnurses.

Even though there are other fields that require a master's degree as a requirement for earning the professional research doctorate, such as the M.P.H. for the Dr.P.H., the master's degree has a completely different meaning relative to the science Ph.D. degree. The master's degree is usually awarded as a “consolation prize” for students who are unable to complete the requirements for the science Ph.D. By making the master's degree a requirement for its Ph.D. program, nursing has created confusion as to the meaning of the degree outside the nursing profession.

In considering strategies for increasing the number and length of productive research years for scientists in nursing, it is important to distinguish between the educational needs and goals of nursing as a practice profession that requires practitioners with clinical expertise from nursing as an academic discipline and science that requires independent researchers and scientists to build the body of knowledge. 15 To improve the productivity and research focus of the Ph.D. in nursing, doctoral programs need to be reengineered to admit directly from baccalaureate programs, to admit nonnurses, to decrease the number of years from high school to Ph.D. graduation, and to expand the interdisciplinary scope of the program and the research. The need for doctorally prepared practitioners and clinical faculty would be met if nursing could develop a new nonresearch clinical doctorate, similar to the M.D. and Pharm.D. in medicine and pharmacy, respectively. The concept of a nonresearch clinical doctorate in nursing is controversial, but some programs of this type exist.

Nursing should be encouraged to reengineer some of its doctorate programs to exclusively meet the goal of producing scientists and researchers who are the most capable in terms of skills and projected career life, to meet the needs of nursing as a science and for the development of its research-based disciplinary knowledge. Doctorate programs currently require core coursework in theoretical systems, philosophy of science, qualitative and quantitative methods, and statistical/data analysis techniques. What is different from other science degrees is the amount of advanced practice usually required prior to the doctoral program. Some educational depth in a clinical area or in practice is important for the study of clinical questions, but how much is the issue.

There is no clear research career trajectory evident among scientists in nursing today. The common thread is that they entered their doctoral programs later than most other scientists and have not benefited from postdoctoral education. This is because most nurses enter doctoral programs following receipt of the clinical master's degree, also often with many years of clinical experience, and their primary socialization has been as practitioners. As such, they bring with them rich experiences that may help shape the focus of their inquiry. However, they also carry with them enormous burdens relating to their readiness for entering rigorous science training, their interest in continuing training following their predoctoral experience, and their long-term capacity for developing a research career. In addition, when nurses complete their doctoral training, most move directly into an academic career. There they frequently encounter settings in which the demands for teaching and lack of pervasive research programs, socialization, and further mentoring make continuing progress as a scientist difficult.

There is evidence to suggest that a successful career in science is the result of a number of key factors across the life span. These factors include inspiration and “connection” to science and the field; involvement in the enterprise of discovery and science; knowledge, skill, and leadership development; opportunities for coaching, role modeling, and mentoring; a scientific community with peer engagement, assessment, support, and critique; an intensive research environment; and adequate support for research in all of its phases. With these factors in mind, each stage of nursing from precollege, undergraduate, predoctoral, and postdoctoral to the career scientist can build strategies to enhance the career path.

The development of future scientists begins very early in the educational experiences of young people. These include education in school but also beyond. This begins with exposing students interested in nursing at the precollege level to both the profession and nursing science. Undergraduate development of scientists moves individuals from a more general interest in and connection to science to actually beginning to embark on a career in science. The context should be designed to support both the acquisition of a solid academic foundation for further study, a clear notion of pathways for becoming a scientist, and educational experiences that move the student into actual conduct of research. Predoctoral training should begin before the doctoral student starts a course of study. The student's program should assure a very strong match between the research interests of the student and the capacity of the program and faculty. Programs should be fundamentally grounded in a commitment to and processes that support the development of scientists. The postdoctoral phase is the point at which one's own science career should begin to take hold and the intrinsic rewards of science and discovery drive the work of the postdoctoral fellow. Ultimately, the career scientist is at the stage of developing and maintaining his/her program of research. For academic scientists this is the point at which mentoree becomes mentor and teacher, based on the program of research. It is also the point at which the scientist should become an active member of the academic community.

• RESPONDING TO THE SHORTAGE OF NURSE-INVESTIGATORS

It has been well established that there is both a current shortage and a projected continued shortage of nursing faculty, especially those who are scientists and researchers. At this time, approximately 50 percent of faculty that teach in nursing baccalaureate programs are doctorally prepared. This represents a marked increase from the late 1970s, when only 15 percent were. This 50 percent level was achieved in 1999 but has not increased since then despite a large increase in the number of doctoral degree programs available to nurses during the same time period (e.g., in 2002 there were 81 research-focused programs). Two factors that likely contribute to this stalemate are (1) the relatively constant number of doctoral degrees earned each year, despite the increase in the number of programs, as shown in Table 6-1 , and (2) the older age of graduates, as evidenced by an increase in the average age of assistant professors from 45 to 49.6 years for the period 1996 to 1999. In 2002 the average age of doctorally prepared faculty was 53.3, compared to 50.2 in 1999 and 2000. 16 These statistics suggest that the doctorally prepared faculty is aging, and because the percentage of faculty members with doctorates is not increasing, it does not appear that younger replacements are being put in place. Thus, this older group of doctorally prepared faculty members in nursing is likely to retire from the academic workforce over the next few years, leaving nursing programs with too few faculty members to conduct research and educate the next generation of scientists.

Nursing Doctorates from U.S. Institutions, 1991–2003 .

The need to dramatically increase, even double, the number of nurse-scientists is acute, especially at earlier points in their careers. A recent Special Survey of Vacant Faculty Positions conducted by the American Association of Colleges of Nursing indicated that 59.8 percent of the vacancies require an earned doctoral degree. 17 Training opportunities are available, including predoctoral and postdoctoral fellowship programs offered primarily by the NINR. The number of applicants for these awards has remained relatively stable over time, consistent with the flat doctoral graduation rate for nursing. It is important to provide research training incentives that increase the number of nurses selecting a research career and at a much earlier point in their professional development.

• EMPHASIZING RESEARCH-INTENSIVE TRAINING ENVIRONMENTS

Strong, research-intensive environments are critical in both the general universities and the schools of nursing for doctoral, postdoctoral, and career development preparation. Such environments provide the experience of being immersed in scientific inquiry with mentors and the intellectual cohort of investigators required for the preparation of nurse-researchers. Research-intensive environments also promote crucial interdisciplinary research opportunities. Nursing research confronts complex questions. Thus it needs to involve multiple perspectives and bodies of interdisciplinary expertise.

To date, scientific training for nurses and others committed to nursing research has utilized a variety of National Research Service Awards (NRSAs) and Career Development K awards. These research training awards are funded by the NINR. The individual predoctoral awards (F31) have been slowly increasing, with very limited numbers of individual postdoctoral awards (F32) evident. The NRSA institutional awards (T32) have grown considerably over time, with 43 such awards made between 1986 and 2002 and 27 operational in 2003. Within the T32s, 65 postdoctoral trainees and 93 predoctoral awards were anticipated for 2003. For the individual NRSA awards there were five postdoctoral awards (F32) and 100 predoctoral awards (F31) for 2003 (see Figure 6-1 ).

Training positions at the postdoctoral and predoctoral levels. SOURCE: National Institute for Nursing Research Budget Office.

The level of scientific productivity differs among the NRSA mechanisms for the individuals and institutions funded by the NINR. Analysis of the funding record for successfully acquiring either research (R) or career (K) development awards later in the career shows a pattern similar to that of the total NIH research training programs. NINR trainees and fellows funded on individual NRSAs are more apt to successfully acquire R and K awards (see Table 6-2 ) at a later date.

Analysis of Pre- and Postdoctoral Fellows with Subsequent Funding .

The difference is sizable, with predoctoral awards being 17 percent of the individual awards (F31) and 5 percent of the T32 predoctoral positions. The pattern is similar with a greater difference for the postdoctoral fellows—38 percent for the F32 and 18 percent of the T32 positions. However, productivity in terms of publications shows the opposite pattern (see Figure 6-2 ).

Publications, T32 versus non-T32. SOURCE: Outcome analysis by National Institute for Nursing Research at NIH.

The 2 years 1997 and 1999 illustrate a consistent pattern of higher publications for trainees and fellows on the T32 awards. In 1997 and 1999, 158 and 154 publications resulted from trainees and fellows on the institutional T32 awards versus 66 and 23, respectively, for doctoral students holding the individual F awards.

Both institutional and individual research training awards under the NRSA program should continue. The individual awards build strong scientific capability and independence when working with a research-active mentor. With the T32 institutional awards, the cadre of strong senior researchers forming a scientific community is valuable in terms of mentoring and publications. The individual predoctoral awards (F31) can be used for a variable length of study. The NINR/NIH is encouraged to allocate three to four years per award in order to support full-time, consistent progression for research training.

The lower productivity of trainers and fellows, who have been funded on the institutional NRSAs (T32) and later obtain R01 and K awards, is of concern. The research training offered through T32 mechanisms needs to be strengthened in the following manner:

• T32 awards should be placed in research-intensive universities with strong interdisciplinary opportunities and research funding, and research interdisciplinary activities should be a critical aspect of the initial NRSA application and annual reports.
• The T32 awards should be allocated only to schools with research-intensive environments, including a cadre of senior investigators with extramurally funded research or research track records and research infrastructures that support research and research training.
• The application process for T32 positions as predoctoral trainees or postdoctoral fellows should be more formalized, with specific proposals submitted in relationship to their research and the match with faculty at the institution made explicit.
• Trainees and fellows on a T32 award position should provide evidence of the interdisciplinary strength that is part of their program of study.
• Criteria for selection of T32 fellows and trainees should be based on a consistent, full-time plan for research training and long-term potential for contribution to science and nursing.
• The monitoring and tracking of trainees and fellows should be formalized, with changes in research plans or mentor(s) filed as part of the annual report.

A small but growing cadre of nurse-investigators is supported in their research development by K awards. In addition to the awards from NINR, other institutes and centers also support nursing research through the K mechanisms, since elements of nursing research are intrinsic to other fields. These awards are usually awarded to nurse-scientists in their early or midcareer stages when they are shifting the substantive or methodological focus of their research. NINR has primarily used the following four types of career awards: K01, Mentored Research Scientist Development Award; Minority K01, Mentored Research Scientist Development Award for Minority Investigators; K22, Career Transition Award, and K23, Mentored Patient-Oriented Research Career Development Award; and K24, Mid-Career Investigator Award in Patient-Oriented Research. 18

These awards could be important in advancing both career development and science development. Unfortunately, there is limited information regarding the outcomes of these awards, including successful research grants and publications by awardees.

In summary, three major factors influence the recommendation to change the research training career trajectory pattern for nurse-scientists: the need to enhance the productivity of each investigator's study for nursing practice and for shaping health policy; increasing the numbers of nurse-investigators to respond to the investigator and faculty shortage; and emphasizing the need for research training within strong research-intensive environments.

• RECOMMENDATION

Recommendation 6-1: The committee recommends that a new T32 program be established that focuses on rapid progression into research careers. Criteria might include predoctoral trainees who are within 8 years of high school graduation, not requiring a master's degree before commencing with a Ph.D., and postdoctoral trainees who are within 2 years of their Ph.D.

This new program would produce strong research personnel and lengthen the research careers of the trainees. These grants should be placed in research-intensive universities with strong interdisciplinary opportunities and research funding, including a cadre of well-established senior investigators.

Donaldson, S. K. and D. M. Crowley. 1978 .

Sung, N. S., et al. 2003 .

American Nurses Association. 1985 .

National Institute for Nursing Research. 2003 .

Aiken, L. H., et al. 2002 .

National Institute of Nursing Research. 2003 . op. cit.

Donaldson and Crowley. 1978 . op. cit.

Grady, P. A. 2003 .

Hinshaw, A. S. 2001 .

National Opinion Research Center. 2001 .

American Association of Colleges of Nursing. 2003b .

American Association of Colleges of Nursing. 2003a .

McEwen, M., and G. Bechtel. 2000 .

Donaldson and Crowley. 1973. op. cit.

American Association on Colleges of Nursing. 2004 .

Grady. 2003 . op. cit.

See Appendix B for a complete explanation of awards.

• Cite this Page National Research Council (US) Committee for Monitoring the Nation's Changing Needs for Biomedical, Behavioral, and Clinical Personnel. Advancing the Nation's Health Needs: NIH Research Training Programs. Washington (DC): National Academies Press (US); 2005. 6, Nursing Research.
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Facilitators and barriers to interprofessional collaboration among health professionals in primary healthcare centers in Qatar: a qualitative exploration using the “Gears” model

• Alla El-Awaisi 1 ,
• Ola Hasan Yakti 2 ,
• Abier Mohamed Elboshra 1 ,
• Kawthar Hasan Jasim 1 ,
• Alzahraa Fathi AboAlward 1 ,
• Raghad Walid Shalfawi 3 ,
• Ahmed Awaisu 1 ,
• Daniel Rainkie 4 ,
• Noora Al Mutawa 3 , 5 &
• Stella Major 6  

BMC Primary Care volume  25 , Article number:  316 ( 2024 ) Cite this article

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The number of patients seeking medical care is increasing, necessitating more access to primary healthcare services. As several of these patients usually present with complex medical conditions, the need for interprofessional collaboration (IPC) among health professionals in primary care is necessary. IPC is essential for facing the increasing and challenging healthcare demands. Therefore, the facilitators of and the barriers to IPC should be studied in the hope that the results will be used to promote such endeavors.

This study aimed to explore the perspectives of different health professionals regarding the facilitators of and the barriers to IPC in the primary healthcare settings in Qatar.

A qualitative study using focus groups was conducted within the Primary Health Care Corporation (PHCC) in Qatar. Several health professionals were invited to participate in the focus groups. The focus groups were uniprofessional for general practitioners (GPs), nurses, and dentists, while they were interprofessional for the other health professionals. Focus groups were audio-recorded and transcribed verbatim and validated by the research team. The data were analyzed by deductive thematic analysis using the “Gears” Conceptual Model as a coding framework.

Fourteen focus groups were conducted involving 58 participants (including 17 GPs, 12 nurses, 15 pharmacists, 3 dentists, and 11 allied health professionals) working in PHCC in Qatar. The findings revealed a spectrum of factors influencing IPC, categorized into four main domains: Macro, Meso, Micro, and individual levels, with each accompanied by relevant barriers and facilitators. Key challenges identified included a lack of communication skills, insufficient professional competencies, and power imbalances, among others. To address these challenges, recommendations were made to implement dedicated training sessions on IPC, reduce hierarchical barriers among different health professionals, and enhance the effectiveness of existing systems. Conversely, it was emphasized that projects and campaigns focused on IPC, alongside the development of enhanced communication skills and the presence of supportive leadership, as essential for facilitating effective IPC in PHCCs.

The interplay between the meso, macro, micro, and individual levels highlight the significance of a multifaceted approach to interventions, aiming to enhance the successes of IPC. While initiatives like interprofessional education training are underway, numerous challenges persist before achieving improved collaboration and more efficient integration of IPC in the PHCC setting.

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Introduction

The World Health Organization (WHO) projects a global deficit of health professionals in comparison to the needs, expected to exceed 18 million by 2030, which will impede the provision of optimal healthcare services. In their “Global strategy on human resources for health: Workforce 2030”, they highlighted the need to equip health professionals with the skills needed to practice collaboratively in interprofessional teams [ 1 ]. One of the best solutions to face this strain on the healthcare system and to provide better management of the complex health challenges is to implement and promote the concept of interprofessional collaboration (IPC) as these demands often are beyond the expertise of any single profession [ 2 , 3 , 4 ]. According to the WHO, IPC occurs when “multiple healthcare workers from different professional backgrounds provide comprehensive services by working with patients, their families, caregivers, and communities to deliver the highest quality of care across settings” [ 2 ]. IPC recently has become one of the core demands of accreditors, funding institutions, policymakers, and practicing health professionals, recognizing its potential to improve the quality of care and address the increasing demand for healthcare services [ 5 , 6 , 7 , 8 ].

Research has consistently highlighted the positive impact of IPC on healthcare work processes, patient safety, and patient outcomes across various disease states such as diabetes, heart failure and asthma, which were treated in hospital, primary care, and community settings [ 9 , 10 , 11 ]. Research has concluded that a high degree of IPC has led to better subjective outcomes, including overall satisfaction, treatment success, and willingness to recommend the healthcare institution to others. Additionally, objective outcomes such as reduced mortality rate, readmissions, and hospital length of stay have been noted. Furthermore, collaboration has been associated with improved decision-making and increased innovation [ 12 , 13 ]. It has also been demonstrated that as the relationship and level of connectedness between physicians and other health professionals increase; hospitalization costs and readmission rates decrease [ 14 ].

Primary healthcare is the foundation of any country’s healthcare system. It is not only considered the primary point of contact with the healthcare system, but it also serves as the vehicle for ensuring continuity of care across settings. The increase in the number of people with multiple chronic diseases that are associated with considerable social, functional, and emotional impairment and an increase in the healthcare demand, leading to an increase in the needed services [ 15 , 16 , 17 , 18 ]. Consequently, policymakers on an international scale have persistently advocated for the greater integration of interprofessional team-based care in primary healthcare settings and the development of influencing factors that explicitly acknowledge the value of this collaborative approach [ 19 , 20 ]. Several studies in the literature have highlighted the positive outcomes associated with effective collaboration within primary healthcare settings [ 21 , 22 , 23 ]. This has led to an internationally movement towards team-based primary healthcare, to enhance the integration of services and to emphasize health promotion and chronic disease management [ 19 ]. Ineffective collaboration leads to an increased risk of preventable errors, lack of efficiency, and loss of motivation, resulting in suboptimal patient care based on nurses’ opinions [ 24 ].

While IPC efforts are usually initiated by policymakers, research have demonstrated that health professionals’ play a vital role in providing high-quality IPC. Therefore, it is of crucial importance to consider the perspectives of health professionals working in primary healthcare settings regarding IPC when designing and implementing IPC projects [ 25 ]. Numerous studies have examined IPC across various countries. For example, a systematic review was conducted to explore facilitators and barriers to IPC implementation in primary healthcare settings. This review included studies conducted in Great Britain, the United States, the Netherlands, Australia, Spain, Brazil, Canada, and New Zealand. The findings of this review indicated that allied health professionals generally hold positive perceptions of IPC within primary healthcare contexts [ 26 , 27 ]. However, limited research has been conducted to investigate healthcare IPC practice in Qatar, particularly in primary healthcare settings. Given the recent expansion of scope of practice in primary care in Qatar [ 28 ], it is essential to explore the current practices in primary healthcare in Qatar in terms of IPC facilitators and barriers, and determining the necessary steps to achieve optimal collaboration within the Qatari healthcare system.

This study is a continuation of a previous study that explored the perspective of 1415 health professionals in primary healthcare settings through a self-administered questionnaire [ 28 ]. Results of the study showed that health professionals generally have a positive attitude and readiness toward IPC. Interprofessional differences were noted regarding their readiness to be involved in IPC, where physicians had slightly more positive readiness towards understanding their professional identity compared to other health professionals. Health professionals with previous IPC or interprofessional education (IPE) experiences revealed greater, but non-significant positive attitudes toward IPC compared to those without previous experiences. Participants suggested that facilitators and barriers for IPC in primary healthcare settings are conceptual rather than physical. Facilitators included personal belief in IPC benefit, higher professional satisfaction, interprofessional respect, appreciation of other health professionals’ role, institutional support, and leadership. Barriers identified included lack of time, leadership, support, and limited resources.

In an effort to understand the health professionals’ perception of the facilitators and barriers for IPC in primary healthcare in Qatar, the current study will explore the factors affecting the IPC in primary healthcare in Qatar using the “Gears” conceptual model [ 7 ]. The Gears model offers a taxonomy of factors influencing IPC within Interprofessional Primary Care Teams (IPCTs). These factors are categorized into levels: policymakers (macro gear), organizational managers (meso gear), healthcare teams (micro gear), and health professionals (individual gear). Most of the factors identified by the “Gears model” are within the micro gear, or those affecting the individual. These involve formal processes such as quality audits and group problem-solving; social processes pertained to open communication and supportive colleagues; team attitudes such as feeling part of the team; and team structure such as team size and having a collaboration champion or facilitator. Macro gears/policy factors are those that change less frequently and are pertained to regulations regarding the general scope of practice, funding, etc. Meso gears/ organizational factors are those that change more often and affect more than one team in the organization, those are concerned with the information systems, organizational culture, etc. Individual factors include the individual health professional characteristics such as belief in IPC care and personal flexibility.

The aim of this study is to identify factors facilitating or impeding IPC in primary healthcare in Qatar by exploring the perspectives of health professionals working in primary healthcare qualitatively. These include GPs, nurses, pharmacists, dentists, and allied health professionals (lab technicians, physiotherapists, dieticians, and radiographers). Findings from this study will be used to find ways to enhance and promote collaborative practice in primary healthcare in Qatar.

Study design

In this qualitative study design, data were collected through semi-structured focus groups. A qualitative approach was used to explore comprehensively the lived experiences of health professional’s perspective as it allows for investigating a phenomenon from the people who have experienced it. It gives a deeper insight and answers to what, how, and why questions [ 12 ].

Study setting

The study was conducted among health professionals working in the Primary Health Care Corporation (PHCC) in Qatar. PHCC was established in 1978 to provide comprehensive primary healthcare services and became an independent body in 2012 with full administrative and financial autonomy. At the present time, the PHCC provides PHC through 27 PHC centers distributed across the country. Each center is staffed with health professionals who provide a broad range of services, focusing on health promotion and disease prevention. PHCC has adopted and implemented family medicine model of care and offers a wide range of services, including general medicine, dentistry, ophthalmology, optometry, ENT, dermatology, mental health, preventive and lifestyle services such as wellness, premarital care, cancer screening, gym and geriatric, physiotherapy and radiology services [ 29 ]. In February 2018, a local continuous professional development (CPD) program was initiated by PHCC Workforce Training Department (WFTD) for implementing learning activities across the 27 PHCC health centers using interprofessional and collaborative approaches.

Study participants and sampling

The study comprised 58 participants, including 17 general practitioners, 12 nurses, 3 dentists, 15 pharmacists, and 11 allied health professionals (e.g., laboratory technologists, radiologists, optometrists, and audiologists) working in PHCC in Qatar. A purposive sampling strategy was employed to select health professionals with experience or understanding of IPC, aiming to maximize participant recruitment and ensure representation of the study population’s views [ 16 ]. Sampling continued until thematic saturation was reached, indicating no further emergent ideas from discussions [ 17 ].

Participants’ recruitment

Emails were sent to the health professionals working at PHCC in Qatar inviting them to participate in the study focus groups that were planned to be conducted at Qatar University or PHCC headquarters. Recruitment of participants was facilitated through WFTD which took the responsibility of recruiting and arranging appropriate focus group schedule that can suit study participants. An invitation email was sent with consent form and participant information sheet to participants prior to the focus groups.

Data collection

The topic guide was developed through discussions with the research team, a review of previous literature, and based on phase 1 quantitative results [ 28 ] (please see supplementary file). A pilot interview was conducted with minor adjustments and included a few health professionals working in PHCC. Because no significant changes were made it was included in the final analysis. The focus group were uniprofessional (i.e. homogenous groups) for GPs, nurses and dentist and interprofessional (i.e. heterogeneous groups) for the remaining health professionals and varied in duration between 90 and 120 min. The discussions were audio-recorded and transcribed verbatim.

Data analysis

A deductive thematic analysis was conducted of data, which is an analytical method in which authors use existing themes, categories, or domains to categorize new data under such categories [ 30 ]. Participants’ ideas were categorized under four main domains adapted from the “Gears model” [ 7 ]. The gears model outlines the factors affecting IPC within IPCTs under four main factor domains: macro, meso, micro, and individual factors. AME, AA, KJ, RS reviewed and validated the transcripts. They then independently reviewed couple of transcripts to generate codes in discussion with the lead author (AE). Coding for the rest of the transcripts was validated by one faculty member from the research team. A final discussion took place with all authors to agree on themes and subthemes.

Reflexivity

During the data collection and analysis process, the research team engaged in reflexive practices to mitigate potential biases. The team consisted of various individuals with diverse backgrounds, including faculty members with pharmacy, nursing and medical backgrounds, three of whom were practicing health professionals, along with four pharmacy students and one alumna. The team offered a broad spectrum of perspectives and insights for data generation and analysis. These faculty members had an understanding of IPE and had previously conducted workshops on interprofessional collaboration for health professionals at PHCC. With a background in IPC, participants’ ideas were more easily understood, facilitating deeper engagement, and enabling the comprehension of their perspectives more readily, thus ensuring a comprehensive interpretation of the data. Throughout the research process, attention was paid to the potential influence of professional backgrounds, with reflexive practices employed to mitigate biases and ensure the integrity of the findings.

Data collection were mostly led by the principal investigator, with support from students adhering to a pre-defined topic guide to minimize personal biases. To further enhance trustworthiness of the study, students independently coded the data, which was validated by a faculty member of the research team. The team met several times to review and compare codes and themes, refining the analysis iteratively until consensus was reached. Each stage of the research process was overseen by the principal investigator, ensuring the rigor and robustness of the study.

Fourteen focus groups were conducted between September 2019 and February 2020, involving 58 health professionals working in primary healthcare centers in Qatar (17 general practitioners, 12 nurses 15 pharmacists, 3 dentists, and 11 allied health professionals). The baseline characteristics of the participants are summarized in Table  1 . Four domains, 10 themes, and 14 sub-themes were identified from the focus groups. The domains, themes, and sub-themes are summarized in Table  2 .

Gears domain 1: macro factors

Facilitators, theme 1: the influence of organizational policies on ipc.

Several factors were identified by health professionals pertaining to the policies that can affect IPC. These factors were mainly related to the rules and regulations set by the organization’s managers or government bodies, which typically influence the general scopes of practice, funding mechanisms, and remuneration of providers. Consensus was reached that these regulations play a significant role in fostering IPC among health professionals.

“Actually , we have very well prepared and organized policies. Policies related to teamwork , which align with best-practices and international guidelines. The policies at our PHCC facilitate collaboration… but how to use it? Is everybody aware of its use?” [Laboratory technologist 1].

No major barriers were identified under the macro factors.

Gear’s domain 2: meso factors

Theme 2.1: leveraging technology for enhanced communication.

Participants unanimously agreed that the current health information system, specifically CERNER, serve as a strong facilitator for enhancing communication among health professionals. It enables seamless sharing of patients’ details documented by other health professionals.

“I find the CERNER system software amazing , because you can get to see the history of the patients and previous appointments records. Everything is well documented” [Dentist 3].

Theme 2.2: communication hindered by limitations in healthcare information system utilization

Several participants noted that current system (CERNER) is not fully utilized for documenting and reporting of medical or medication errors which can serve as a barrier. As an example, one participant expressed reluctance to utilize the system and filing an OVA (incidental report) for fear of retaliation in case the reporter is identified.

“If I were to write OVA (incidental report) for him/her , he/she will get angry at me. So , there’s no use. Actually , the purpose is to report in order for others to learn from them , but there is no clear pathway that there will be no consequences for us reporters” [Nurse 2].

Furthermore, another HCP mentioned that the current information system might be a barrier, as not all health professionals have equal access to the system.

“The pharmacist is not allowed to enter a recommendation into the system; they have their own system” [GP 5].

Theme 2.3: barriers in organizational dynamics hindering IPC

Sub-theme 2.3.1: hierarchy hinders collaborative spirit.

One of the primary obstacles to collaboration within the institution is perceived to be the presence of a hierarchical structure. This perception is based not only in the observable existence of a grading system that categorizes health professionals according to their profession and seniority, but also in the benefits associated with higher hierarchical positions.

“The hierarchy is influenced by salary differences” [GP 4].

Participants in the study observed that this hierarchical system leads to disparities, which undermine their willingness to collaborate. As an example, pharmacists expressed feeling of being treated differently compared to GPs, who are routinely offered opportunities to attend international conferences. The lack of such opportunities for pharmacists and other health professionals further reinforces the perception of hierarchy within the institution.

“I have tried to attend a conference; I have a right to enhance my education. Why does this apply to the GP and not to the pharmacist?” [Pharmacist 8]. “He -the GP- thinks that the pharmacist as being of lower status , and he is the only one to have the authority to write and make decisions” [Pharmacist 9].

Sub-theme 2.3.2: blame culture instils apprehension among health professionals

Another significant factor that had a considerable impact on collaborative efforts was the existence of a culture of blame within the PHCC organization. This culture of blame surfaced frequently during discussions among health professionals and was found to hinder effective collaboration among team members. Some perceived the level of blame not to be equitable.

“What if I did a mistake? And what if the mistake was done by the GP? The blame wouldn’t be equal. We would receive more blame” [Nurse 3]. “I still believe that some of us should refrain from perpetuating a blame culture or name-calling. After all , all of us are human beings. We are prone to making errors” [GP 10]. “We need to promote a culture of no blame. When things go wrong or mistakes occur , we should view them as collective challenges rather than assigning fault to individuals and subjecting them to humiliation. This approach will significantly transform the overall attitude within the environment” [GP 2].

Sub-theme 2.3.3: Lack of feedback contributes to the perception that health professionals’ efforts are undervalued

Some health professionals have expressed concerns regarding the lack of feedback on their performance, interventions, and error reports, particularly within Datix, a patient safety software utilized for healthcare risk reporting. This absence of feedback is perceived as a significant impediment to IPC, as it fosters the perception that the efforts of health professionals are not adequately acknowledged or valued.

“The risk management team should gather data and determine the significance of incidents reported through Datix , which is serious or recurring. If a mistake is repeated , they will ask or make an investigation about this issue. However , aside from these instances , no action is taken. No feedback is provided” [Pharmacist 1].

Gears domain 3: micro factor

Theme 3.1: expanding the scope of practice of team members enhances collaboration.

Given that IPC heavily relies on teamwork, the topic of collaborative efforts and teamwork surfaced frequently during focus groups.

“ The most important thing in primary healthcare practice is the teamwork. We underscore its importance , as it permeates our daily operations” [GP 6].

Expanding the scope of practice of healthcare team members has the potential to foster enhanced collaboration between team members. For example, pharmacists who participated in the discussions expressed that the inclusion of a clinical pharmacist within PHCC would enhance collaboration. This is attributed to the direct involvement of the clinical pharmacist with the interprofessional team, which obviates the need for external prompting to initiate collaborative efforts.

Theme 3.2: effective communication channels foster collaboration

Effective collaboration among participants was found to significantly hinge on the establishment of robust communication channels. This encompasses both formal features and tools, ranging from cordial and conversational telephonic exchanges to more structured modes of communication, such as the sharing of electronic patient records. Several participants cited instances of proficient communication that had led to successful collaboration outcomes.

“Every colleague should be encouraged to express their concerns , whether in written form or verbally , as it facilitates communication” [Dentist 3]. “Many doctors respect our opinion and express gratitude , acknowledging that we draw their attention to certain points“ [Pharmacist 9].

The majority of participants highlighted the importance of communication tools provided by the institution, including telephones, the CERNER system, and email platforms. Participants expressed their appreciation for these communication channels, noting that they effectively save time and enable seamless collaboration, even when they are attending to patients in different locations.

“It’s not difficult because we have our colleagues , whom we can contact directly by phone” [Dentist 1].

Theme 3.3: formal team processes have a significant role in facilitating collaboration

Sub-theme 3.3.1: supportive leaders empower team members to collaborate.

Leaders who demonstrate appreciation and dedication play a crucial role in fostering positive experiences of IPC. Regular interprofessional meetings organized by these leaders ensure that the environment is conducive to collaboration, and support empowering health professionals to initiate and engage in collaborative endeavor.

“So , if we have any issues , we talk to our supervisor , who then reports it to the health center manager. She is really supportive” [Pharmacist 3].

Sub-theme 3.3.2: engagement in interprofessional initiatives enhances collaboration among team members

Participants emphasized that their involvement in workplace initiatives, such as projects, campaigns, seminars, and workshops, played a crucial role in promoting IPC. According to health professionals, these initiatives were beneficial as they provided them with diverse professional perspectives, opinions, and ideas, which in turn enhanced their chances of success in their collaborative efforts.

“In our health center , we initiated a project to improve the practice of antibiotic prescribing. We were collaborating with GPs to know from them how to write and put a protocol to lessen the misuse of antibiotic” [Pharmacist 2].

Participants also recognized that engaging in collaborative research activities involving multiple team members was an effective facilitator for enhancing patient safety.

“I conducted research on medication use reviews , actively engaging with general practitioners’ clinics. I would regularly visit these clinics to share information about the study. During these interactions , I explained my criteria , encouraging them to refer eligible patients to the pharmacy” [Pharmacist 6].

Furthermore, vaccination campaigns were considered essential by several pharmacists as they provided opportunities for collaboration with other disciplines including educational outreach events. Several pharmacists reported on their involvement in these campaigns and the subsequent positive impact on collaboration dynamics. Specifically, one pharmacist highlighted a reduction in the uptake of pneumococcal vaccine among eligible patients and assumed a proactive role by gathering information from various GPs regarding the decreased prescription of such vaccines.

“We did a project in collaboration with GPs , regarding vaccinating high risk patients with pneumococcal vaccine” [Pharmacist 4]. “During the immunization week , I held a seminar about immunization. I taught them -nurses- individually how to use each vaccine properly and why we are using it” [Pharmacist 2].

Moreover, participants found case-based discussions and interprofessional training sessions with other health professionals valuable for collaboration. These sessions allowed discussion of each profession’s role and facilitated idea exchange.

“ As part of our interprofessional education efforts , we conduct weekly lectures and brief discussions for an hour… sometimes , new nurses and physiotherapists attend these lectures…… We discuss how we can help promote the collaboration between all of us for better care for the patients” [GP 9].

Sub-theme 3.3.3: optimizing accessible healthcare environments

Experiences related to the impact of the environment on collaboration were generally positively perceived. For instance, the close proximity of a nurse diabetic educator to the pharmacy facilitated direct communication between pharmacists and educators, enabling them to address any concerns more efficiently. Moreover, having practitioners co-located in a single setting, rather than dispersed in various locations within the center, was deemed more advantageous.

“We have it , diabetic educator , clinical pharmacist , and GP all in one place , so they all work together for assessment of patient and education , particularly high-risk patient” [Pharmacist 4].

Theme 3.4: time constraints impede collaboration and affect patient outcomes

Participants identified time constraints as a significant challenge to collaboration, with health professionals struggling to allocate sufficient time for documentation, communication, and knowledge-sharing, potentially impacting patient outcomes.

“We can’t afford the luxury of opening CERNER each time since we are already occupied with other tasks” [Pharmacist 5]. “Even when there is an issue …. we should learn from it. We are not learning. We just want to finish this issue and just move on because there is no time. There is too much work” [Laboratory technologist 1].

Theme: 3.5: lack of clarity in scope of practice leads to misunderstandings and hinders collaboration

A number of health professionals expressed concerns regarding the potential misunderstanding of their scope of practice, leading to requests to perform tasks beyond their designated role which impact the collaborative culture leading to frustration.

“Nurses are responsible for taking vital signs , following the patient’s care plan , and managing medications , but cleaning is not part of their role although some doctors mistakenly believe it to be so” [Nurse 3]. “At times , we notice that some GPs are unaware of the difference between a technician and a radiologist” [Laboratory technologist 1].

Gears domain 4: individual factors

Theme 4.1: prior exposure to ipe enhances appreciation for ipc.

The study observed that health professionals who had prior experience with IPE exhibited a greater appreciation towards collaborative work.

“We learned and practiced IPE during our education. However , in practical settings , there is still a need for a comprehensive understanding of IPE and its implementation. While there are individual efforts to apply it , full implementation has not been achieved yet” [Pharmacist 3].

Theme 4.2: health professionals’ factors

Subtheme 4.2.1: effective communication skills drive enhanced collaboration among health professionals.

Effective communication was deemed crucial by participants in healthcare settings. Nurses felt valued and integral to the team when equipped with proper communication skills, while GPs found direct communication with other health professionals to be advantageous, enhancing their practice.

“Quite a few times , I’ve reached out to the on-site ophthalmologist by phone. When there’s a concern about a patient , whether its suspected cornea issues or the need to rule out certain conditions , a simple phone call often results in them accommodating the patient. The ophthalmologist has consistently been responsive and helpful in these interactions” [GP 6].

Subtheme 4.2.2: positive interpersonal qualities among health professionals enhance collaboration

The collaboration within the team is influenced by health professionals’ interpersonal qualities which was identified as a significant factor, with approachability and friendliness being crucial in facilitating collaboration.

“The difference here is that I find everybody to be approachable and friendly [GP 6]. Very friendly environment. You can approach the nurses , the doctors—everyone is accessible” [GP 10].

Furthermore, respect and trust were highly valued facilitators of IPC and were discussed in conjunction with other facilitators.

“Mutual respect among all health professionals will facilitate smoother and more effective collaboration” [Nurse 3]. “We must respect each other. Just because I am a GP , it doesn’t mean my opinion is the only opinion or the correct one” [GP 3].

Theme 4.3: patient perceptions impact IPC

Patient perceptions were found to exert a considerable impact on the dynamics of collaboration between nurses, GPs, and other health professionals. Participants reported that patients tended to perceive nurses as occupying a subordinate position relative to GPs, and consequently, were less forthcoming in discussing healthcare concerns with them.

“ You are the nurse; you know less than the doctor” [Nurse 4]. “ Patients typically highly value recommendations from physicians. However , when they seek advice or education from nurses or pharmacists , they sometimes may not value it as much as they would if it came from a physician ” [Pharmacist 7].

Additionally, participants believe patients regard GPs as the key health professionals, and preferred to communicate exclusively with them. This perception placed an additional workload on GPs, leading to potential consequences on their capacity to collaborate effectively with other health professionals.

“We need to educate patients more about the roles each team member plays and how we all work together as a team. When a patient comes in , they often see the doctor as the leader but it’s important for them to understand the contributions of all team members” [GP 5].

Theme 4.4: impact of of perceived approachability and ego on IPC

On the other hand, encountered challenges in communicating with GPs, including when they perceived a sense of ego, or if they were less approachable. Nurses expressed reluctancy to approach pharmacists or GPs whom they felt would not respect them.

“ Being approachable is one of the most important things especially when it comes to the team. For example , some of the nurses would know a lot of information about the patient but if you’re not an approachable GP , they will not come and voluntarily divulge the information” [GP 6]. “Ego. When you are dealing with people these things are barriers and the best solution is always communication” [Nurse 6].

Similarly, GPs encountered similar challenges in communicating with other health professionals if they perceived them as unfriendly or unapproachable. However, they differed from the nurses in that they seemed to encounter these challenges within their own field of practice rather than in interactions with other health professionals.

Theme 5: enhancing IPC through equity, training, and support

The study participants put forth several proposals to enhance IPC in their workplace. A key recommendation was to ensure equity among health professionals, such that all members had full and equal access to patient files. This would enable effective IPC by keeping all team members abreast of the patient’s evolving health status and treatment plan. Participants recognized that institutional and leadership support would be necessary to achieve this equity. Additionally, due to the acknowledged limitations posed by workload and time constraints, many participants suggested that the recruitment of additional staff could facilitate IPC processes. Further, the participants proposed the need for more frequent training sessions to improve communication skills, enhance system and documentation writing, and provide IPC disease management, role clarification, and professional competencies education.

“When they send you for training you will be empowered” [Nurse 2].

Finally, health professionals emphasized the importance of a supportive system that offers constructive feedback to identify weaknesses and facilitate continuous improvement of practice. In addition, health professionals remarked on the impact of managerial support on collaboration and performance.

“When we receive support from the health center manager during our practice , we find that collaboration improves , leading to better outcomes” [Pharmacist 2].

This qualitative focus group study explored facilitators of and barriers to IPC as perceived by health professionals (including GPs, nurses, pharmacists, dentists, and allied health professionals) from various backgrounds in primary healthcare in Qatar using the “Gears” conceptual model. Overall, the majority of health professionals who participated in this study have acknowledged and appreciated the importance of IPC work within their institutions, which is consistent with other published studies [ 27 , 31 , 32 ].

Facilitators under the micro-gear domain focused on healthcare teams. Participants agreed that the diversity of health professionals within the same PHCC is a major facilitator for better collaboration. They also agreed that the presence of different communication channels (e.g. telephones, CERNER, etc.) is another facilitator. Supportive leaders in the team were acknowledged to have a positive influence on attitudes toward IPC. IPE activities were identified as positively influencing attitudes towards toward IPE and IPC. These findings are consistent with those of other studies. There was an agreement among several studies regarding the importance of open communication and various communication strategies and tools in facilitating IPC [ 33 , 34 ]. For example, Müller et al. [ 33 ], in their study where authors interviewed several clinical executive managers, found that participants agreed that multilateral communication is one of the enablers for effective IPC. Facilitators within the individual-gear, includes Individual contextual factors contributing to IPC such as previous exposure to IPC, patient related factors, and characteristics of health professionals. Previous exposure to IPC emerged as a significant facilitator for both health professionals and patients. Communication skills were identified as crucial in supporting exposure to IPC. Participants highlighted the importance of accessible communication methods, such as availability by phone or in person conversations, eliminating roadblocks to IPC. Furthermore, the approachability of health professionals, characterized by their openness to information sharing and their trust and respect for the competency, knowledge, and skills of other health professionals was a key facilitator to IPC.

Regarding the meso-gear facilitators, participants valued the importance of receiving ongoing, and timely feedback based on practice experiences to consolidate learning and minimize recurrence of errors. They advocated for utilizing data from platforms such as Datix; an Incident Reporting System (IRS), which is a valuable resource among all team members involved in patient care. Participants recommend a wider use of such data for learning, in interprofessional team meetings. This aligns with evidence from the literature which suggests that critical to the success of any IRS is the quality of the feedback given to reporters to enable learning, encourage reporting, and give reporters evidence that the information they are providing is being used appropriately [ 35 , 36 ]. Space and proximity are reported as excellent opportunity for teams to work together and share perspectives in the care for the patient [ 37 ]. As new PHCC centers are created to serve the growing needs of Qatar’s population, leaders can benefit from including members of the care teams, in the final design discussions, so that space and proximity can continue to remain optimal and facilitate interprofessional practice and team centered patient care.

The least number of factors were identified under the macro-gears. These relate to governance and regulations, which were considered as a major facilitator for better IPC in the primary healthcare setting in Qatar. The participants in this study had reflected on the existing policy and regulatory facilitators that foster collaborative practice in PHC setting in Qatar, but did not discuss barriers to policies and regulations. The study findings reaffirm the potential role and influence of government policies and regulations in facilitating IPC in primary care settings from the perspective of the health professionals. Additionally, organizational-level policies were also perceived as key facilitators. This aligns with the macro-level factors of the Gears conceptual model, which allows the conceptualization of the intricate relationships between this and the other domains of the model from the perspective of the health professionals. Previous studies have documented the influence of policy and regulation in promoting collaborative practice and IPE. One international review has summarized the global policies and legal factors influencing the behaviors of health professionals towards successful implementation of collaborative practice [ 38 ]. These factors largely influence the scope of practice of various health professions and how the different professions work collaboratively, funding mechanisms, and reimbursement systems for health services.

In Qatar, health professions and practices are regulated by the Department of Healthcare Professions under the Ministry of Public Health (MoPH) [ 39 ], which is considered a key aspect of professional practice [ 38 ]. Although there are no umbrella laws to regulate multiple health professions under a single statute, which is a major drawback to an effective and conducive implementation of collaborative practice in various settings, having a unified regulatory and legal structure has been shown to foster a culture of equity among different health professionals [ 40 ]. An important aspect of policy and professional regulation is the scope of practice, which should typically clarify roles and represent specific areas of competence for each particular health profession. Participants indicated the presence of scope of practice for various professions in the State of Qatar. Previous studies and reports have highlighted the importance of restructuring the scope of practice of health professions towards effective IPC and to remove barriers to healthcare provision. This will allow health professionals to practice within the scope of their practices and to the full extent of their professional competence without encroaching other professions’ scope of practice, which will ultimately lead to effective collaborative practice [ 41 , 42 ]. In addition, funding and reimbursement are macro-level aspects that can significantly impact IPC [ 40 , 43 ]. In the present study, there was a consensus that these regulatory factors play a key role in facilitating the IPC among the health professionals in primary care settings in Qatar.

Barriers pertaining to the healthcare teams, or the micro-gear, are the lack of understanding of other professionals’ scope of practice, and the lack of time. This is not different from what is reported in the literature, where lack of time and poor understanding of other health professionals ' roles were considered, besides other barriers, major hinderers for IPC in one review paper that collected multiple articles that studied the enablers and hinderers of IPC [ 34 ]. For the individual-gear barriers, health professionals identified that the hierarchy entrenched within the healthcare system contributed a major barrier to collaboration. Within the studied context, GPs are seen as the pinnacle health professional by patients. Therefore, patients are reluctant to provide information to health professionals other than the GP. This ultimately reduces the effectiveness of the healthcare system as the scope of practice of the remainder of the interprofessional team are constrained to meet patient needs. This might limit other health professionals’ roles, and hence they might be less able to exchange care. This idea might go with the concept of the “patient-doctor dyad” that has been reported in the literature, where authors described that one of the hinderers of IPC is the patient’s desire to be mainly seen and examined by GPs, which is often prioritized over collaborative care [ 44 , 45 , 46 ]. Pharmacists, in this study, described that patients also might ignore pharmacists’ recommendations if it was not aligned with the GPs’ recommendations. While IPC may beget IPC, participants remarked that there was difficulty bringing IPC to life in their PHCC context. Knowledge of IPC must be accompanied by a shift in organizational culture, supported by policies and performance review, led by champions, and guided by exemplars of IPC.

Two subthemes were considered under the meso-factors, which are mainly regarding the information system and the organizational culture. Our results indicate that although a health information system (HIS) is operating within the primary healthcare center (PHCC) system, however, not all members of the team use nor rely on it, to complete their duties in patient care. This fragmentation of data systems poses a threat to team unity and excludes some team members (in this context the pharmacists) from being on the same page as the rest. Efforts to merge all data subunits and enable all team members to access the HIS, can enhance work time efficiency (a micro challenge) that participants reported for pharmacists to require in order to be on the same page as the other care providers in the team and is supported by research which stresses the benefits of a health information system which enables the participation of all staff who are directly concerned with patient care in that setting [ 47 , 48 ].

In the interest of optimizing patient safety, whilst participants in this study valued the opportunity for a shared HIS to serve as a platform where errors could be recorded, our data indicates that health care team members did not feel safe enough to do so. According to Smiley and colleagues [ 49 ] the fear of being fired and subjected to judicial inquiry and prosecution make many nurses conceal errors. This aligns with our participants’ reported concerns about the prevalence of “blame culture” and how this results in individuals feeling personally and professionally vulnerable. Blame culture in health care organizations is mainly associated with the approach used by management when dealing with medical errors and accidents [ 50 , 51 ]. Efforts to embrace a culture that promotes transparency and accountability, and management approach which as described by Catino [ 52 ] relates the causal factors of a given event to the whole organization rather than the individual, are priorities for the PHCC organizational leadership to consider.

Furthermore, hierarchy in privileges, such as varied levels of access to professional development opportunities, threatens team unity, and in turn generates a sense where some professions feel less valued for working in their roles. Educators postulate that if individuals from different professions learn together, they will be able to more effectively work together in teams to achieve desired outcomes [ 53 ]. Integrating CPD in interprofessional decision support with quality improvement and patient safety initiatives will likely enhance the uptake and ability to sustain these educational initiatives [ 54 ]. For instance, the “Schwartz Center Rounds” in the US and UK provide a forum in which professional and nonprofessional staff across healthcare disciplines can discuss challenging psychosocial and emotional aspects of a patient’s care and the impact of these challenges on the care team. These rounds do not focus solely on decision-making, but attendees report significantly enhanced appreciation of colleagues’ roles and contributions, communication, and teamwork [ 55 ]. In this way, the professional learning needs can meet not only the individual profession, but also translate into opportunities for teams to problem solve together and in turn improve safer patient care.

In general, the current study results on facilitators and barriers to IPC align well with those identified by a review study by [ 34 ] that summarized the facilitators and barriers for interprofessional care in primary healthcare. Common facilitators in both studies are the lack of time and training for the health professionals, lack of understanding of others’ roles, and poor communication. It is interesting to note that fears relating to professional identity were identified as a hinderer in the review; however, it was not mentioned by any HCP in the current study. This could be due to the proper understanding of the self-role of the HCP in this study. IPC enablers identified by the review were all reported in this study (i.e. communication tools, co-location of HCP, and recognition of other professionals’ roles and contributions).

Strengths and limitations

One strength of this study is the use of the “Gears model” to understand facilitators and barriers at each level within the IPCTs. Identifying the facilitators and barriers at each level of the work environment makes it easier for decision-makers to identify the gaps and the points that need improvement specific for each level, and hence will help implement appropriate, and probably more efficient, interventions suitable for each level to improve IPC within the PHCC settings. The current study included a high diversity of health professionals and did not focus on certain professions, which aligns with what interprofessional work is all about. This study, as mentioned before, is a continuation of a previous quantitative study done on more than 1400 health professionals to assess their attitude toward IPC. Although the previous study showed that health professionals have a positive attitude toward IPC, which was evident by the survey, the current study examined these quantitative findings from a qualitative lens. This provided a clearer insight to ensure a comprehensive understanding of what shapes these perspectives.

Limitations of the study might include the lack of anonymity in focus groups, which might increase the social desirability. Second, although the study included multiple professions, most participants were GPs, pharmacists, or nurses. Moreover, some HCP were not present (e.g. pharmacy technicians, and physiotherapists), which could limit the generalizability of the current study to these professions.

The interplay between the meso, macro, micro, and individual gears showcases the importance of a multifaceted approach to interventions to amplify the successes of IPC. Policies such as data sharing and collaborative key performance indicators support the interaction between the meso and individual gears. The individual assists the macro and meso gears through communication and trust in the scope of practice of the other team members. Simultaneously, health professionals must advocate for their colleagues to patients. Patients have a direct connection to the micro and individual gears which ultimately affect the care being provided to them.

Data availability

No datasets were generated or analysed during the current study.

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Acknowledgements

Thanks to Dr. Jessie Johnson from the University of Calgary-Qatar for her initial support with this project. Also, we would like to thank all health professionals from primary health care who volunteered to participate in this study.

This publication was supported by Qatar University Student Grant [QUST-1-CPH-2020-25]/ [QUST-2-CPH-2019-3]. The findings achieved herein are solely the responsibility of the author[s].

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Department of Clinical Pharmacy and Practice, College of Pharmacy, QU Health, Qatar University, Doha, Qatar

Alla El-Awaisi, Abier Mohamed Elboshra, Kawthar Hasan Jasim, Alzahraa Fathi AboAlward & Ahmed Awaisu

Hamad Medical Cooperation, Doha, Qatar

Ola Hasan Yakti

Primary Health Care Corporation, Doha, Qatar

Raghad Walid Shalfawi & Noora Al Mutawa

College of Pharmacy, Dalhousie University, Halifax, Canada

Daniel Rainkie

Department of Clinical Academic Education, College of Medicine, QU Health, Qatar University, Doha, Qatar

Noora Al Mutawa

Division of Medical Education, Weill Cornell Medicine – Qatar, Doha, Qatar

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Contributions

AE contributed to the conception of this research idea, study design, data collection, data analysis, and including supporting all stages of this paper. AME, KJ, AAZ, RS accompanied AE in the focus groups. AME, KJ, AAZ, RS, AA, DR, NA, SM supported with the study design, study conceptualization, analysis, and interpretation of findings. OY supported with the data validation, analysis, and interpretation of findings. All authors contributed to drafting the manuscript and reviewed and approved the final version of the manuscript.

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Correspondence to Alla El-Awaisi .

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Ethics approval was obtained from the PHCC Research Committee (PHCC/RC/18/12/001) and the Qatar University Institutional Review Board (QU-IRB 1084-EA/19). All participants received information leaflet about the study and that their participation in the qualitative study would be voluntarily and will be treated confidentially. All participants signed and dated the written informed consent form. The study was carried out in accordance to the relevant guidelines and regulations.

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El-Awaisi, A., Yakti, O.H., Elboshra, A.M. et al. Facilitators and barriers to interprofessional collaboration among health professionals in primary healthcare centers in Qatar: a qualitative exploration using the “Gears” model. BMC Prim. Care 25 , 316 (2024). https://doi.org/10.1186/s12875-024-02537-8

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Received : 08 December 2023

Accepted : 22 July 2024

Published : 27 August 2024

DOI : https://doi.org/10.1186/s12875-024-02537-8

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