The aim of this research was to review the standardization process of AHPQ in Iran in order to study the attitude towards health care professions.
Validity and reliability of AHPQ were confirmed in two fields of medicine and nursing. Also, the participants were selected from main and referral hospitals; therefore, the results may be different in other parts of Iran.
In the first phase, the questionnaire included 20 semantic differential questions ranged between 1–10 point scales. As to the results, extent of scale has caused unnecessary dispersion in responses, also larger sample size is necessary. Decreasing the extent of scale from 10 to 5 points and increasing sample size in the second phase, led to revealing three underlying constructs of professional ethics, professional autonomy and patient-centered care in the questionnaire.
The validity of AHPQ is also evaluated in Danish. The questionnaire in Danish has been valid in its original form; contains 20 items, each consisting of two opposite attributes, serves as verbal anchors for each end of a 10 cm visual scale. The word "Assertive" is unclear in Danish, so for a better understanding the short explanation has been presented in Danish in brackets in front of the word. (25) In our study, according to Delphi it was suggested that the words caring and empathetic should be explained too.
The triple constructs are not necessarily in disagreement with each other. In other words, the individuals with attitudes towards professional ethics or professional autonomy are not necessarily opposed to patient-centered care and vice-versa; but it reveals that they preferred the relevant items. This finding is consistent with the original questionnaire. According to the original questionnaire, the relationship between the two components has remained constant during the AHPQ tool development process. The components are in direct relationship with each other so that the lower score in the caring Component has a lower score in the subservient component and vice versa. Therefore, professions that are less caring, seems to have less activity than other colleagues in equal positions in the health team and, instead, are more dominant. (26)
For example, most participants believed in respecting ethical principles in communication skills (first factor) such as Caring, Empathy, Approachability, Values team work, Sympathy, Thoughtfulness, Flexibility, Gently, Not arrogantly, Practicality, Conciliatory, Not confrontationally, are the key fundamentals for inter professional collaboration.
The others preferred expertise and professional autonomy of members (second factor) manifested by indicators such as confidence, assertiveness, values autonomy, technically focus, independency and observe economic value of professional services in inter professional collaboration.
At the same time, for the other participants, the patient-centered care and respect for patient rights and conditions (third factor) is the most important basis for inter professional collaboration. Patient-centered care directs the basis of inter professional collaboration, health care team and their relationships in the first two factors, towards patient, and in fact, it encourages the health care member to sacrifice and self-devotion in favor of the patient. The third factor in factor analysis is confirmed weekly but based on maximum difference it is confirmed in a clearly.
Thus, the present study improves the concept of attitude towards inter professional collaboration in health care team compared with the idea suggested by Lindquist et al. (11). In Lindquist study, three underlying constructs has been identified by factor analysis through underlying construct method with factor value higher than 1; but, just two constructs of care and service have been analyzed. Ignoring the third valuable factor has leaded that this study covers only 43% population variance and identifies construct by 18 out of 20 items of the questionnaire.
In this study, two methods of underlying constructs and maximum difference in factor analysis, have been applied, therefore, the constructs of all questionnaire’s items have been determined and the variance coverage of the population exceeds up to 58%, but also the third factor has been analyzed and finally, all constructs of the questionnaire have been analyzed more appropriately; patient care and providing health care services are of the health care team responsibilities, however, the questionnaire seeks to identify the attitude of health team during such inter professional duties.
Job stress is normally reported by health care professionals, such as nurses. Studies suggest that problems due to work load, inadequate time off from work scheduled and job independency limitations could lead to emotional exhaustion and even hatred toward patients. (27) In contrast, nurses' satisfaction increases, when they feel independency and make good working relationship with their managers and peers. (28) Wageman (2005) and Campion (1993) are the most comprehensive instruments, measure enabling conditions and cover aspects of task design (e.g., interdependence, autonomy), team composition (e.g., competencies, diversity), as well as organizational climate (e.g., recognition, training). Neither instrument was developed in healthcare, nor have they had much prior use in healthcare contexts. (29) The dominance of the attitude of inter professional autonomy (second factor) in a health care team means that the members of the team do not interfere in the specialized tasks of one another. Therefore, each member, after independently carrying out the relevant duties to his/her own profession, will refer the patient to other team member with the results of his/her work. In this type of attitude, official interaction governs the activity of health care team, and any action by any member has been regarded as interference in his/her own expertise and could result in conflict and in severe cases can conducive to team disjoint.
Whereas, a health care team, in which the attitude of inter professional ethics prevails, the team members’ interaction goes beyond official relationships of technical professions, but rather respect and friendly cooperation among team members makes the basis of their interaction. This way, team members may perform organizational tasks of each other with resilience, empathy and compassion, and defend their colleagues’ performance before the non-team elements. Patient care is always high on healthcare delivery agenda. Team work is essential.
As a doctor, key player in a team, is trying to improve patient’s health. The first priority must be optimal collaboration in order to help patients. Multi-disciplinary care as a team approach is not restricted to some hospitals rich in resources, but when there is challenging environments with limited resources, multi-disciplinary care approach could be included as a clinical performance in a developing country. A team consists of trainees, colleagues and advisors, nurses, medical assistants, managers, social workers, technicians and secretaries. Thus, it is necessary to learn how to work with others members properly. If a member had a hard day, he should be helped, ethics is a topic in WHO. (30) Facilitating team performance behaviors, need to distinguished personal values based on merits or ethics for team members. (31)
Although this attitude increases group cohesion, it should be taken into account that the concepts of flexibility, courtesy, tranquility, sobriety and pacifism in group interactions should not cause to rot patients' rights which could be eliminated by overcoming the attitude towards patient-centered care in inter professional collaborations. In this attitude patients’ rights and their health overweight pseudo respect to colleagues and their professional independency. The way of interaction and inter professional collaboration of team could be linked with the missions and visions of forming team. In such a team, the concept of specialized tasks of team members and common ceremonies cause no mental and social barrier for patient care and health services provision. The representative characteristic of high quality health care system is providing health care based on patients’ needs and expectations. Most systems where physicians have been supported, benefit of the modified redesign models in which health care is fully adjusted with patients’ needs. Planning a medical examination in a clinic, specific for patient’s anxiety, encourages them to participate in care control process. (32)
The results of this study suggest that major part of the statistical population, both physicians and nurses, have crossed the mental barrier caused by administrative structure based on specialization and independence of activities and duties of each profession to a great extent, and have undertaken responsibilities based on inter professional human relationship in health team. In such a society, team work needs to be promoted based on professional ethics and mutual respect among co-workers; besides, prioritizing patient-centered care and sense of responsibility for patient to interpersonal ceremonies and interests of health team members should also be taught.