Research design
This research sought to make explicit the nature of allied health collaborative practice to inform student preparation through two interpretive studies, one based on literature and the other drawn from participant experiences. Moving away from more traditional research approaches, this research disrupts typical allied health research (Denniston, 2023). The literature study dialogued with established and accepted concepts as published in literature to make explicit the often-implicit underpinnings of collaboration and collaborative practice. Studying professional preparation or professional ‘nurseries’ opens-up understandings of why professions develop the way they do (Shulman, 2005). Thus, the second study explored allied health academics’ and allied health students’ experiences through semi-structured interviews and focus groups.
Located in the interpretive paradigm this qualitative research used a Gadamerian philosophical hermeneutic approach to open-up possibilities of new knowledge development (see Smythe & Spence, 2012). Philosophical hermeneutics focuses on understanding how people interpret the world around them and how this affects the way they think and act (Lawless, Constantineau, & Dizboni, 2017). Hermeneutic concepts of fusion of horizons, hermeneutic circle and dialogue of question and answer enabled deep dialogue with texts and generation of new understandings (Boell & Cecez-Kecmanovic, 2014; Gadamer, 1975). A multi-faceted approach to quality considerations, informed by guidelines for good qualitative research was used to ensure trustworthiness, rigour and transparency (see Silverman, 2001). The rigour of the research was enhanced by inclusion of two text studies (see Barbour, 2001), each exploring the phenomenon from a different but interrelated angle. Rich discussion around assumptions, biases and decision making underpins researcher reflexivity (Denniston, 2023). Reflexivity was facilitated through journaling and regular research meetings.
Research transparency involved the researchers articulating their beginning horizons of understandings and the dialogue questions involved in the iterative process of reaching a fused horizon of understanding with the text sets. The experiential study was conducted with ethical approval from the xxx University Ethics in Human Research Committee (protocol number 2014/219) with the xxx University Ethics in Human Research Committee accepting this approval for the research to commence. During this research, the broad ethical principles of participant confidentiality, safety, wellbeing and anonymity were applied.
Text construction (Data collection)
Two text sets were constructed, one for each study. In the first study, the literature text set was constructed from published and accepted understandings of the concept of collaboration or collaborative practice in general and in relation to allied health. Texts were sourced from over 100 journal articles, research reports, books, eBooks and reputable websites (such as the Australian Bureau of Statistics and Word Health Organisation). Database searches were used (Primo Search, CINAHL, OVID, ERIC, EBSCOhost, ProQuest, MEDLINE) via a range of key search terms (including, allied health, collaborative practice and collaboration). This text set provided a diverse range of literature to dialogue with and subsequently deepen understandings of allied health collaborative practice.
In the second study, the experiential text set was constructed from the transcripts of semi-structured interviews and focus groups undertaken with 24 participants, 12 academics and 12 students (See Table 1). Student voices are often less heard and considered, and their perspectives important to the learning and teaching community (Kagawa, Selby, & Trier, 2006; Peimani & Kamalipour, 2021). Shulman (2005) also highlights the value of studying professional ‘nurseries’ to understand why professions develop the way they do. Thus, academic and student perspectives provided a unique insight into nature of allied health collaborative practice to inform student preparation.
Academics participated in semi-structured interviews. Six academics accepted the invitation to use photographic elicitation to enhance their engagement. Photographic elicitation enables the researcher and participant to examine and discuss photographs (Collier & Collier, 1986), uncovering and including previously unknown or unconsidered dimensions of phenomena (Banks, 2007). Students provided their perspectives through three focus groups. A focus group is a useful strategy to gather people from similar backgrounds or with similar experiences to discuss a specific topic of interest, generating rich information on collective views and experiences, and the meanings that lie behind those views (Mishra, 2016). Focus groups were specifically chosen for the student participants as focus groups that allow participants to tell their own stories and express their opinions and are highly suitable for collecting perspectives from young adults (Adler, Slantera, & Zumstein-Shaha, 2019). The text set of 12 semi-structured interviews and three focus groups provided a rich source of experiential material. This richness is supported by Hennick & Kaisers’ (2022) proposition that saturation can be achieved in qualitative research through a narrow range of interviews (9–17) or focus groups (4–8).
Table 1
Summary of participant characteristics
|
Students*
|
Student year level
|
Academics**
|
Allied Health Profession
|
|
|
|
Paramedicine
|
0
|
NA
|
2
|
Physiotherapy
|
2
|
3
|
3
|
Podiatry
|
8
|
2–4
|
2
|
Occupational therapy
|
0
|
NA
|
3
|
Speech pathology
|
2
|
4
|
2
|
TOTAL
|
12
|
|
12
|
* Students participated in three discipline specific focus groups and had all undertaken some form of clinical placement
All interviews and focus group were audio-recorded with participants’ consent and transcribed verbatim to form texts for interpretation. To assist differentiation between academic and student participants’ voices for interpretation and dissemination, academic participants were assigned pseudonyms beginning with “A” and student participants were assigned pseudonyms beginning with “S”.
Two Australian universities provided the context for the experiential text set. Participants were recruited from undergraduate (Bachelor degree) physiotherapy, occupational therapy, speech pathology, paramedicine and podiatry programs. These allied health professions have scope to work together in various forms (see Graham, Doherty, Wilson, Wilson, & Currie, 2019; Singh, Küçükdeveci, Grabljevec, & Gray, 2018). Invitations to participate were emailed by Heads of relevant Schools to all allied health students and academics within in the schools. All allied health students and academics who responded participated in the research.
Text interpretation (Data analysis)
Interpretation, informed by philosophical hermeneutics, was guided by the concepts of fusion of horizons, hermeneutic circle and dialogue of question and answer. These concepts enabled deep dialogue with the text sets of both studies, and generated new understandings (Boell & Cecez-Kecmanovic, 2014; Gadamer, 1975). See Text box 1 for a description of the concepts guiding interpretation (informed by Gadamer, 1975).
The process of interpretation of the literature and experiential texts was not a linear and prescriptive process. Interpretation was fluid and interwoven, guided by a set of research questions that looked to explore allied health collaborative practice and the development of allied health collaborative practice capability in higher education. The researchers commenced interpretation of the literature text sets whilst constructing the experiential text sets, moving to interpretation of the experiential text before completing the literature interpretation. This represented movement between the parts (literature and experiential text sets) and the whole (emerging understandings). Through the use of fusion of horizons, hermeneutic circle and dialogue of question and answer, a whole conceptualisation was developed. This conceptualisation is a structure of understanding that integrates our interpretation of both the literature and experiential studies. This structure of understanding is presented in the findings.
Findings
Our research highlights the shapers of allied health collaborative practice across contextual, social and individual domains. The shapers are: in-situ standards and physical environments (contextual domain); interpersonal transactions and reciprocal exchanges (social domain); individual contributions and engagement activities (individual domain). These shapers interplay in dynamic and unequal ways, contributing to the nuanced nature of allied health collaborative practice and put forward key considerations for allied health student education.
Shapers within the contextual domain
Contextual shapers of allied health collaborative practice were interpreted to be in-situ standards and physical environments. In-situ standards reflect the way collaborative practice is grounded in health service frameworks and patient needs (Schadewaldt, McInnes, Hiller, & Gardner, 2016; WHO, 2010). Frameworks include practitioner registration requirements, codes of conduct and clinical policies and pathways. Practitioner registration and codes of conduct establish the professional norms (Jennings, 2020) and legal conditions that explicitly shape expectations for and requirements of allied health collaborative practice. For example, registration and professional bodies such as Speech Pathology Australia [SPA] and the Australian Health Practitioners Registration Authority [AHPRA] mandate codes of conduct and provide practice guidelines for allied health professionals. Codes of conduct and practitioner registration significantly shape practice because of their legal implications and the way health professionals are obliged to enact these codes.
Clinical needs arising from patient circumstances also shape allied health collaborative practice as in-situ standards in the form of clinical guidelines may guide who is involved and their role in collaborative practice (see Allied Health Professions Australia, 2022; WHO, 2010). For example, some clinical guidelines provide explicit guidance in relation to stroke and diabetes (Hillier et al., 2011; Shaughnessy, Cosgrove, & Lexchin, 2016). However, patient circumstances can change over time as a condition worsens or improves (Bleakly, 2011), adding a dynamic dimension to allied health collaborative practice as different health professions can be required for patient care at particular times. This showcases that health professionals may need to navigate tensions arising from complying with clinical guidelines while at the same time responding to the changing circumstances of clients and patients at any given time.
Physical environments as a key shaper of allied health collaborative practice were identified through participants highlighting the important contribution of spaces and locations. For example, being in the same physical space with other health professionals opened up opportunities for allied health collaborative practice. Amber described how being physically located with colleagues provided informal (e.g., socialising and getting to know colleagues) opportunities for allied health collaborative practice. While for Agnes, the prospect of being in the same space with other health professionals in the gym emphasised the importance of opportunities for interactions between a range of people:
“[Collaborative practice could be] just informal chats over coffee about that sort of stuff”- Amber.
“[Collaborative practice is where you] have the OTs and the speechies [speech pathologists] and the physios [physiotherapists] and the allied health assistants and the porters and the nurses all hanging around the gym… So you often have a lot of discussion about transfers and optimal care for the patient” - Agnes.
Amanda’s description of collaborative practice also highlighted how physical environments can shape the way people work together. Amanda described why it was important for different health professionals to be together to enable discussions and problem-solving, which to her were key in collaborative practice. These thoughts were raised in relation to her photograph of a hospital gym, further highlighting the importance of physical colocation:
“Sometimes it [collaborative practice] can be really practical stuff like working with a physiotherapist and OT [occupational therapist], for us [speech therapists] it’s always around positioning and, and getting people into the right position so having to work really closely with them [physiotherapists and occupational therapists] to understand what the client’s capable of and then kind-of optimising what that client can do so that we can then work with them a little bit more so that could sometimes be very hands-on together” - Amanda.
Sawyer emphasised how workplace environments significantly shape attitudes towards collaborative practice, depending on the nature of those workplace learning experiences and attitudes of supervisors:
“I think clinical experiences definitely influence it [how student’s feel about different practice areas]” - Sawyer.
Shapers within the social domain
Social shapers of allied health collaborative practice are interpersonal transactions and reciprocal exchanges. The social shapers were found to help foster and sustain the relationships fundamental to collaborative practice.
Interpersonal transactions encompass negotiating, sharing and cooperating and enable allied health professionals to nurture relationships which are core to allied health collaborative practice. Interpersonal transactions assist allied health professionals to coalesce individual perspectives regarding patient management to form common goals and objectives (see Aarons et al., 2014; Braithwaite et al., 2017; Cigarini, Vicens, Duch, Sánchez, & Perelló, 2018), which underpin collaborative practice (Greidanus Warren, Harris & Umetsubo, 2020). Negotiating, sharing and cooperating are also embedded within allied health professional registration standards and thresholds (for example see Occupational Therapy Board of Australia, 2020; Physiotherapy Board of Australia, 2015; Speech Pathology Australia, 2019).
The importance of interpersonal transactions is further evidenced by social language commonly associated with collaborative practice such as ‘together’ and ‘team’ (see Croker, Higgs, & Trede, 2009; Hojat & Gonnella, 2011; Massey, Fisher, Croker, & Smith, 2013; Reeves, Pelone, Harrison, Goldman, & Zwarenstein, 2017) and the use of words such as ‘teamwork’ and ‘groups’ to describe common forms of collaboration (see Croker, Trede, & Higgs, 2012). This language highlights the way allied health collaborative practice is comprised two or more people, and the importance of interpersonal transactions in bringing these people together and thus shaping the dynamic nature of allied health collaborative practice in particular places and times.
Reciprocal exchanges refers to the importance of requited interactions in allied health collaborative practice. The importance of reciprocity was particularly evident during conversations with academic participants. For example, Andrea identified correspondence with other health professionals (via letters) as collaborative practice but emphasised that in order for it to be collaborative practice, there needed to be a level of reciprocity. Reciprocity was in this instance, in the form of a response from the recipient. For Andrea a response to a letter transformed letter writing into a form of collaborative practice:
“I probably bring it [collaborative practice) into every day. It might be a shoot-off to the doctor, it might be a shoot-off letter to the physio… It [a reply] reaffirms what we have been doing…” - Andrea.
Sammy also highlighted the importance of interaction and doing things with other health professionals:
“My neuro placement was a lot more teamwork, doing things together, especially with going on home visits with the OT” - Sunny.
The importance of reciprocal exchanges was further highlighted when participants described what collaborative practice ‘is not’, tending to provide examples lacking reciprocal exchanges between people. For example, Angus described an experience of working with a group of people where one team member was dominant to indicate what collaborative practice ‘isn’t’. Angus felt that collaborative practice didn’t occur when individual team members dominated decision-making, and referred patients to other health professionals with no discussion, highlighting a lack of reciprocal exchanges:
“So very much a traditional team, and they thought they were doing great, getting everyone’s opinions and go round and hear the psychologist and the OT [occupational therapist] and the decision would be made but really the consultant would over-rule or would make that final decision” - Angus.
Shapers within the individual domain
Individual shapers of allied health collaborative practice are individual contributions and engagement activities. These shapers demonstrate the way health professionals draw on their own skills and knowledge, and actively insert themselves into particular activities as part of collaborative practice.
Individual contributions in allied health collaborative practice are based on the health professional’s ethical stance and meaningful application of particular skills and knowledge. The ethical stance of health professional’s forms part of their individual contribution, as collaborative practice can present various ethical challenges which individuals must address (Machin et al., 2019). A person’s ethical stance guides practice and helps determine what is what they perceive is ‘best’ for patients (Kurtz & Starbird, 2016). Importantly, individual practitioners interpret and apply ethical standards depending on their own unique circumstances and beliefs.
Meaningful application of individual contributions requires people to draw on individual skills, knowledge and capabilities whilst working together (Croker, Higgs, & Trede, 2009). Frameworks for collaborative practice tend to emphasise the importance of individual skills and knowledge within multiple competencies (see Barr, 1998; Suter, Arndt, Arthur, Parboosingh, Taylor, & Deutschlander, 2009; Brewer & Jones, 2013; Canadian Interprofessional Health Collaborative, 2019; Centre for the Advancement of Interprofessional Education, 2022).
Engagement activities refer to the embodied endeavours integral to allied health collaborative practice including case conferences, team meetings, hallway and staff room discussions, as well as clinical activities like joint assessment and treatment sessions. Sharon captured collaborative practice in hospital settings through examples of scheduled clinical sessions with other health professionals:
“One of my placements was in hospital so [collaborative practice consisted of] case conferences all the time, joint assessments and everything like that” - Sharon.
In describing the importance of unscheduled opportunities for health professional interactions, Anna highlighted the influence of physical environments:
“If physically you’re located away from each other so that opportunities to even informally socialise together, to actually know something about your colleagues other than what they do with their patients then like all of those informal opportunities are taken away as well as the more formal opportunities of actually being able to do things like joint treatments together” – Anna.
The way allied health collaborative practice is shaped by engagement activities was also portrayed by Agnes in her description of staff discussions as an important part of allied health collaborative practice. Agnes described allied health collaborative practice as centred on discussing patient needs, informally and formally, as a way of opening up opportunities to address client needs:
“… often you discuss clients [in staff tea rooms], not so much a case conference… around what the patient needs and sometimes I think you can discover opportunities [to address those needs]” - Agnes.
Shapers acting in dynamic and unequal ways
The interplay between shapers can be dynamic and unequal. This dynamic interplay clearly occurs within the domains, for example within the social domain, interpersonal transactions rely on reciprocal exchanges if the practice is to be shaped as collaborative. The dynamic interplay also occurs between domains. For example, communication as an individual contribution establishes and nurtures the relationships necessary for interpersonal transactions and reciprocal exchanges (Seaton, Jones, Johnston, & Francis, 2020). This dynamic interplay potentially accounts for differences in collaborative practice across different clinical settings and patient circumstances.
Shapers also act in unequal ways. The dynamic interplay renders some shapers more dominant than others. For example, in the contextual domain, a hospital setting that has standardised procedural guidelines may have a significant influence on collaborative practice. This is based on the way the guidelines (in-situ standards) provide direct instruction to clinical staff in relation to patient care approaches and interactions (Hillier, 2011; Shaughnessy, Cosgrove, & Lexchin, 2016). In this instance, in-situ standards is a predominant shaper of allied health collaborative practice.