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\title{Interprofessional Working: Perceptions of Healthcare Professionals in Nepalese Hospitals}
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             \author[1]{Bachchu Kailash  Kaini}

             \author[2]{Kaini  Bachchu}

             \affil[1]{  University of Greenwich, London, UK}

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\date{\small \em Received: 10 December 2015 Accepted: 2 January 2016 Published: 15 January 2016}

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\begin{abstract}
        


Interprofessional working (IPW) is an essential part of the health service delivery system. Effective delivery of health services relies on the contribution of healthcare professionals (HCPs) from all groups. The aim of the study is to examine how HCPs collaborate and to assess their perceptions of IPW on healthcare delivery. This study follows a qualitative research approach. It was conducted in three hospitals in Nepal using semi-structured interview schedule. Purposive sampling method was used to select the hospitals and the participants. All together thirty-eight HCPs participated in the research. This study suggests that IPW is an integral part of HCPs? life and they viewed it as a booster to support them to deliver the optimal and desired health outcomes. HCPs perceived that organisational support and involvement of service users are important for the successful delivery IPW. Verbal means of communication are mostly used during IPW. Nursing and allied health professionals (AHPs) are more critical to the medical professionals because they feel domination and professional isolation from the medical professionals. This study recognises factors that support IPW and also identifies various barriers to IPW in Nepalese hospitals.

\end{abstract}


\keywords{interprofessional working, healthcare professionals, perceptions, medical dominance.}

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\let\tabcellsep& 	 	 		 
\section[{I. Introduction}]{I. Introduction}\par
arious HCPs and organisations contribute to health and social care. Every profession and healthcare organisation has its own purpose, interest and field of specialisation. Healthcare system across the world 'depends on health workers working together across professional groups and system boundaries'  {\ref (Mickan et al., 2010, p.493)}. The structure and nature of healthcare team is varied and it depends on various factors such as types of service users, specialties, organisational strategies, and so on. The way interprofessional care (IPC) team is managed and structured may have great impact upon the success or failure of the team. The main objective of IPW is to bring a broader scope of knowledge, skill and expertise of HCPs in the efforts to improve the quality of care and clinical outcomes related to health problems and issues of service users \hyperref[b1]{(Bope and Jost, 1994)}.\par
Empirical researches have demonstrated that more positive healthcare outcomes are achieved by collaborating interprofessional teams \hyperref[b31]{(Pollard et al, 2005;}\hyperref[b9]{Dow and Evans, 2005;}\hyperref[b35]{Ritter, 1983;}\hyperref[b0]{Biggs, 1997;}\hyperref[b25]{Miller et al, 2001;}\hyperref[b21]{Leathard, 2003;} {\ref CHSRF, 2006;}\hyperref[b3]{Byrnes et al, 2009;}\hyperref[b17]{Holland et al, 2005;}\hyperref[b22]{McAlister et al, 2004}). These researches were carried out on IPW in developed health economies. However, it is observed that there were no comprehensive researches carried out and reported in underdeveloped countries to investigate the benefits of IPW and collaborative practice to service users and to assess the perceptions of IPW among HCPs. This study was designed to answer three research questions: (1) how do various HCPs interact and collaborate in Nepalese hospitals? (2) how do HCPs perceive the impact of IPW within teams on the delivery of healthcare? (3) which factors support and hinder IPW between various professionals in teams providing healthcare services?\par
Nepal is a small landlocked and underdeveloped country situated in South East Asia between India and China. There is a multi-tier health delivery system in Nepal based on the different levels of care -tertiary, secondary and primary care. Health services within the public sector are centrally financed in Nepal with differing degrees of local autonomy and the control of service delivery rests largely in the hands of the relevant professions. Apart from government healthcare facilities, number of private hospitals, nursing homes, medical colleges and voluntary hospitals (hospitals run by charitable or not-for-the profit organisations) are established in Nepal. Public and private educational institutions run various academic and vocational healthcare courses in Nepal at undergraduate and post graduate levels. Professional councils regulate healthcare professionals and all HCPs are required to register with their respective council to be a qualified member of their profession and to practice legally in Nepal.\par
The health service in Nepal is the biggest employer group and it has more than 50 careers, most of which are qualified, registered or regulated professionals  {\ref (MOHP, 2012)}. With such a diversity of professions, it is obvious that co-ordinated patient care requires communication, interaction and joint decision making between HCPs  {\ref (Reel and Hutchings, 2007, p.138)}. In this context, this study was carried out to assess how HCPs collaborate and to assess their perceptions of IPW on healthcare delivery in Nepal. 
\section[{II. Methods}]{II. Methods}\par
This research is carried out by using qualitative method and by employing a case study approach. This study mainly focuses on assessing the participants' own experiences and understanding of the subject they are involved in or have experienced. Therefore, qualitative approach is considered as a more appropriate approach.\par
The 'healthcare professional' is a broad term which covers all professionals working in the health services. Based on the nature of their work, identity, registration requirements with professional councils, established norms and practices; in this study the HCPs were divided into three groups -medical, nursing and AHPs. Data for this study is collected by using semistructured interview schedule from these three groups of HCPs from three hospitals in Kathmandu, the capital city of Nepal. AHPs include all professionals (excluding medical and nursing) such as-physiotherapists, biomedical scientists, pharmacists, radiographers, pathology technicians, language and speech therapists, occupational therapists, etc. 
\section[{a) Sampling and data collection}]{a) Sampling and data collection}\par
This study followed non-probability and purposive sampling and identified the cases of interest from people or organisations which were 'information rich' \hyperref[b27]{(Patton, 2002)}. Identifying and negotiating access to research sites, subjects and population are critical parts of the research process especially in qualitative research \hyperref[b8]{(Devers and Frankel, 2000)}. A list of hospitals in Kathmandu was searched and their capacity, nature of work and year of establishment was then compared. One hospital from each group of public, private and voluntary (not-for-the profit) hospital was selected for this study. There were three inclusion criteria for all participants for the study. Firstly, all participants should be professionally qualified. Secondly, the participants should be registered with their professional councils and should be eligible to practise in their healthcare or clinical field. Finally, all HCPs should be working with an IPC team.\par
A total of 38 HCPs participated from the three hospitals. Of the total participants, 13 were medical professionals, 15 were nursing professionals and 10 were AHPs. Similarly, 13 participants were from the public hospital, 14 were from the private hospital and 11 were from the voluntary hospital. All interviews were conducted in the hospital at the time and date of their choice. The duration of each interview was between approximately 45 minutes to an hour. All interviews were recorded in a digital format with the informed and written consent of the participants. The interviews were transcribed, saved in the digital format and were anonymised to protect confidentiality. 
\section[{b) Data analysis}]{b) Data analysis}\par
This study followed multiple case study approach for data analysis. Qualitative content analysis approach was followed for this study, which identified certain patterns and themes. Inductive approach; by grounding the assessment of categories, patterns and themes, and by drawing inferences; was followed. This study used interpretive thematic approach to analyse the interview data. A combination of paper, post-it divider, highlighters and coloured markers to mark hard copies of transcripts was used to interpret and analyse data. Apart from the data from the interviews, various other hospital documents and policies were also reviewed and analysed for this study. 
\section[{c) Ethical considerations}]{c) Ethical considerations}\par
Ethical approval was received from the University Research Ethics Committee, University of Greenwich and Nepal Health Research Council (a national regulatory body to oversee and regulate health researches in Nepal). Moreover, approval from three hospitals, where the study was carried out, was obtained.  
\section[{Volume XVI Issue 1 Version I}]{Volume XVI Issue 1 Version I} 
\section[{III. Results}]{III. Results}\par
The findings of the study are divided into various sections based on major themes and categories derived from the analysis of interview data and review of hospital procedural documents related to IPW. Interview quotes are presented by professions and hospitals, coded and anonymised (e.g. A1-N, B5-M, C8-A) to maintain confidentiality. First alphabets A, B and C represent the types of hospital (i.e. public, private and voluntary hospital respectively) participants belong to, whereas the last alphabets N, M and C represent nursing, medical and AHPs respectively. 
\section[{a) Medical dominance}]{a) Medical dominance}\par
Nursing and AHPs from all hospitals perceived that medical professionals dominate overall service delivery aspects in healthcare and they perceived that it as detrimental for IPW relationships. They mentioned various reasons why the medical professionals dominate the healthcare sector. A nurse from the private hospital states: Participants stated that medical professionals are seen as highly recognised, respected and competent compared to other professionals. They stated this was due to their education, expertise, high recognition of their professions from the public and other HCPs, and specialised roles. Few nursing and AHPs highlighted that medical professionals' degree and specialised knowledge put them on top of the 
\section[{Doctors are seen as the dominant profession in the hospital. There are many reasons for this; it is mainly because of their education and expertise. (B11-N)}]{Doctors are seen as the dominant profession in the hospital. There are many reasons for this; it is mainly because of their education and expertise. (B11-N)}\par
professional, organisational and team hierarchy in healthcare organisations and hospitals.\par
A nurse from the public hospital comments how medical professionals feel superior than other professionals:\par
Sometimes we try and suggest the doctors to carry out something for patient care, but they do not easily accept our suggestions and they feel we are doubting them or they feel they are superior than us. (A10-N) One AHP from the private hospital highlights the need of equal recognition of all professionals:\par
Even though all professions have to be equally recognised and given equal importance, the doctors completely dominate our profession due to their attitude, social recognition and roles. (B6-A) An AHP feels sidelined by medical professionals:\par
We have not been given the authority to produce report and our signature here is nearly invalid. We (AHPs) are seen as helpers by medical professions rather than a secular profession. Therefore, we always feel dominated. (C5-A) Medical professionals agreed that dominance of medial professions exists in Nepalese hospitals. One medical professional stated that they get more respect than any other professionals and this may be one of the reasons why they seem more dominant amongst all professions in healthcare. He states:\par
I think the respect and recognition to a doctor is more than that is required and that's why doctors feel more proud and empowered than they should be at times. I think people are more esteemed than they should be. So, we are having more respect than we want. People think a doctor is the God which is not correct. (A2-M) b) Organisational support and structures Participants felt that the healthcare organisations defines roles of clinical leaders and delegates them authority to ensure safe and effective delivery of health services. Participants felt that organisational support was essential for the development of clinical leadership and for successful IPW. One nurse from the public hospital states:\par
I have seen my team leader, a medical professional, has resolved conflicts between two different professionals and driven the team for achieving common goals of our team. (A4-N) Participants believed that the initiatives taken by a leader of IPC team helped to enhance skills and competency of HCPs. One AHP from the voluntary hospital states: 
\section[{I feel my team in-charge (medical professional) takes necessary steps to facilitate IPW. He takes actions to promote IPW across the hospital through team meetings, training, education and conferences. (C6-A)}]{I feel my team in-charge (medical professional) takes necessary steps to facilitate IPW. He takes actions to promote IPW across the hospital through team meetings, training, education and conferences. (C6-A)}\par
All professionals from all hospitals stated that medical professionals lead the team and they felt that team leaders were competent and supportive. One nurse from the public hospital states:\par
For now the doctors lead the team. ..... They support us and they are competent but there are still things to improve. (A1-N)\par
From the interviews, it is noted that there were no such ground rules, organisational policies or protocols for IPW. One medical professional pointed out that lack of organisational policies for IPW is not helpful for them to deliver IPC:\par
We have no practice to set up rules or policies for IPW to make sound and appropriate decisions for the delivery of IPC. This does not help to improve IPW relations. (A7-M) One nurse from the private hospital stated that there were inconsistent approaches due to the lack of protocols for IPW. She states:\par
There are no written protocols for IPW in this hospital. The rules are used according to the situation. (B11-N)\par
One AHP from the voluntary hospital comments that there were no guidance or protocols for IPW at any levels. She adds: 
\section[{I have never seen any guidance or protocols for IPW, not only in this hospital, but also in other hospitals, at national or regional levels. (C6-A)}]{I have never seen any guidance or protocols for IPW, not only in this hospital, but also in other hospitals, at national or regional levels. (C6-A)}\par
From the analysis of hospital documents, strategies and policies of participating hospitals, it was noted that hospitals did not have protocols or guidance for IPW. During the research, job descriptions of ward managers, in-charges and department heads were reviewed. The job descriptions of healthcare did not have any components or roles specified for IPW or collaborative practice between HCPs. 
\section[{c) Communication and interaction}]{c) Communication and interaction}\par
Participants mentioned that they used different means of communication to communicate with service users and other professionals while they deliver health services. It is apparent from the interviews that most of the time HCPs used verbal means of communication. Participants mentioned face to face meetings or discussions, telephone conversations, continuous medical education (CME) and clinical conferences are widely used to communicate with other colleagues at work. One medical professional from the public hospital states that they conduct a medical conference every morning to communicate between all professional groups in the hospital: 
\section[{There is a morning conference. That is one of the most important ways of communication. And, we communicate about patient's health both formally and informally, I mean verbally and by phone. (A7-M)}]{There is a morning conference. That is one of the most important ways of communication. And, we communicate about patient's health both formally and informally, I mean verbally and by phone. (A7-M)}\par
One nursing professional from the private hospital experienced that the verbal means of communication is used mostly:\par
There are various means used for communication between the team members. For example, proper job description and tasks are studied and then jobs are assigned to the individuals. Mostly, verbal communication is carried out. (C11-N) Participants from all hospitals stated that they used medical notes, documents or forms to note their clinical assessment, management, findings, observations and treatment plan apart from fact to face meetings and verbal communication. One medical professional from the public hospital states:\par
We have a mechanism where the doctors write on the form or medical notes. 
\section[{That is a means of communication (A2-M) d) Involvement of service users}]{That is a means of communication (A2-M) d) Involvement of service users}\par
All participants from all hospitals pointed out that service users' awareness of their problems and understanding from their perspectives are equally important to both sides -HCPs and service users for the successful delivery of IPC. One nurse from the private hospital states: 
\section[{Whenever you are going to conduct a procedure relating the patient, the patient should have a good idea of what is happening around him/her and should give consent on whether it should be carried out or not. (B1-N)}]{Whenever you are going to conduct a procedure relating the patient, the patient should have a good idea of what is happening around him/her and should give consent on whether it should be carried out or not. (B1-N)}\par
The importance of understanding service user is highlighted by an AHP from the voluntary hospital:\par
The most important thing is the understanding of the patient. (C8-A) Participants expressed that involvement of service users for their care planning and management is valued by service users. One doctor states:\par
When I speak to patients and explain the problems, issues, pros and cons of the treatment; they always feel great. They feel that they are valued. (A13-M) One AHP from the voluntary hospital experienced that service users always feel great when they are fully informed of the issues, diagnosis and treatment. He comments: 
\section[{It is our responsibility to give them (patients) full information of their diagnosis and treatment. I have seen how patients are thankful to us for giving them detail information. It is also a matter of satisfaction for us. (C5-A) e) Perceived benefits and challenges of IPW}]{It is our responsibility to give them (patients) full information of their diagnosis and treatment. I have seen how patients are thankful to us for giving them detail information. It is also a matter of satisfaction for us. (C5-A) e) Perceived benefits and challenges of IPW}\par
Participants believed that IPW is beneficial to them, service users and healthcare organisations; and they believed that IPW helped to improve quality of care, improve staff satisfaction, better team performance, better communication and interaction.\par
Due  
\section[{. working in the interprofessional team can bring advantage to the institute. The reputation of the hospital can increase due to this. (C5-A)}]{. working in the interprofessional team can bring advantage to the institute. The reputation of the hospital can increase due to this. (C5-A)}\par
All participants from all hospitals in this research pointed out obstacles, barriers and challenges of IPW. These barriers and challenges are related to personal, professional and organisational depending on the nature of IPW. HCPs professionals point out various barriers and challenges of IPW: 
\section[{We do not understand each others' roles and responsibilities in terms of working together and it can be an obstacle. ... egoism is another obstacle for interprofessional team working and it should be stopped. (A11-M) Lack of proper communication is also a barrier between the professionals in a team. (C3-M) If there is no mutual respect between the professions, problems arise. Another barrier we can find is the communication barrier i.e. low level of communication. ... medical dominance also plays as a barrier for IPW. (B3-N) Negative attitude, knowledge, education, lack of communication, lack of training, medical dominance can be mentioned as some of the barriers in the IPC team. (C5-A)}]{We do not understand each others' roles and responsibilities in terms of working together and it can be an obstacle. ... egoism is another obstacle for interprofessional team working and it should be stopped. (A11-M) Lack of proper communication is also a barrier between the professionals in a team. (C3-M) If there is no mutual respect between the professions, problems arise. Another barrier we can find is the communication barrier i.e. low level of communication. ... medical dominance also plays as a barrier for IPW. (B3-N) Negative attitude, knowledge, education, lack of communication, lack of training, medical dominance can be mentioned as some of the barriers in the IPC team. (C5-A)} 
\section[{IV. Discussion}]{IV. Discussion}\par
This study concludes that medicine is the most established and dominant profession amongst all professions in the context of Nepalese healthcare due to their education, knowledge and expertise; and the respect and recognition they receive from the public and other professionals in Nepal. This may have been linked to the education and training system for HCPs in Nepal. There is tough competition to get entry into the medical courses compared to nursing and other healthcare professional courses. Medical graduates go through very extensive training during their university courses, in comparison to nursing and AHP. Medical dominance is widely discussed by various authors and research scholars \hyperref[b13]{(Freidson, 1970}\hyperref[b14]{(Freidson, \& 1986;;}\hyperref[b20]{Larson, 1977;}\hyperref[b19]{Larkin;}\hyperref[b18]{Kenny and Adamson, 1992)}. Nursing and AHPs lack specialist body of knowledge and have no monopoly in the healthcare field and dominated by medicine \hyperref[b32]{(Rawson, 1994;} {\ref pp.47)}. \hyperref[b36]{Wall (2003)} asserts that doctors have been dominant and the law accepted that 'what was done to patients was the doctor's responsibility even if they had not administered the particular treatment'  {\ref (Wall, 2003, pp.73}).\par
This research highlights the importance of organisational support for the development and implementation of IPW agenda in hospitals. Formal structures and processes are required in healthcare organisations to use the talents of different HCPs. This becomes important in Nepalese healthcare context as this research confirms that there were no organisational policies and guidance for IPW in any of the hospitals under study. HCPs in Nepalese hospitals believed that organisational policies give them a direction to deliver successful IPC and help them to improve the quality of care.\par
It is also important to highlight that healthcare organisations have to play active roles and need to allocate enough resources to support and encourage their employees to practice IPW, which ultimately helps to deliver effective health services and benefits service users, healthcare providers, HCPs and health system across the board. Literature also suggest that IPW is influenced by organisational factors, such as organisational culture, policies and regulations \hyperref[b10]{(Drinka and Clark, 2000}\hyperref[b28]{, Payne, 2000}\hyperref[b33]{and Reel and Hutchings, 2007)}.\par
Most senior doctors in the interprofessional care team take the leadership roles and responsibilities for IPC in Nepalese hospitals. It is agreed as a common and accepted practice in Nepalese hospitals; and it is practised in a less formalised or less structured basis. The authority that medical professionals get through the licensing process gives them the power, privilege and exclusive rights. Most of clinical teams and professional groups in healthcare are led by senior clinicians \hyperref[b11]{(Fagin, 1992;}\hyperref[b1]{Bope and Jost, 1994;} {\ref Hammeman, 1995;}\hyperref[b23]{McWilliam et al, 2003;}\hyperref[b34]{Richardson and Storr, 2010)}, who are responsible for care given by the healthcare team.\par
This research suggests that many forms of communication and interaction; such as mainly cooperation, consultation, multiple entry and teamwork; occur during IPW in Nepalese hospitals. This study highlights that healthcare professionals also use informal means of communication; such as face-to-face discussion and phone consultation; in many situations in Nepalese hospitals. The CIHC (2010) states that communication in an IPC environment is demonstrated through listening and other non verbal and verbal means through negotiating, consulting, interacting, discussing or debating. This research confirms that team meetings in Nepalese hospitals were regularly held for various reasons; such as clinical decision, information sharing and team management. Team meeting is considered as one of the main forms of IPW and a way of communication. However, the effectiveness of team meetings depends on how decisions of the team meetings were communicated to all members and stakeholders. \hyperref[b2]{Borril et al (2002)} highlight the importance of group discussions and role play for IPW.\par
Involvement of service users in IPW and clinical decision making was another important finding of this study. IPC is delivered to service users and one of the objectives of IPW practice is to deliver effective and improved health services to service users. Empirical researches have demonstrated that more positive healthcare outcomes are achieved by engaging service users in clinical decision making \hyperref[b7]{(Colyer, 2012}; CIHC; 2010; WHO, 2010; \hyperref[b29]{Pecukonis, et al, 2008)}. This study confirms that HCPs perceived consensual decision making was good for service users, even though all HCPs did not have equal involvement in clinical decision making. It is important that medical professionals are authorised legally for admitting patients, ordering tests and procedures, prescribing medications, making clinical decisions, carrying out interventions and procedures; which are restricted to nursing and AHPs. One of the attributes of IPW is consensual clinical decision making for the benefits of patients \hyperref[b4]{(Carnwell and Buchanan, 2005;}\hyperref[b38]{Wells et al, 1998)}.\par
The findings of this study established that HCPs perceived interprofessional practices positively and they were aware of the importance of IPW for the effective delivery of health services even though they thought IPW was relatively a new concept in the Nepalese context. Literature (CIHC, 2010; Petri, 2010;  {\ref Way et al, 2005)} suggest that interprofessional practices influence the way healthcare organisations are run, managed and now the healthcare system are developed. This study highlights that many organisational factors such as training and education; organisational protocols and guidance for IPW; strong leadership; support from organisation, flexible rules, competent and confident workforce, clear job description and supervision are important for successful IPW in Nepalese hospitals.\par
IPW does not occur smoothly all the time without any obstacles. Several barriers to interprofessional practices perceived by HCPs within the structure of Nepalese hospitals, between and among HCPs. This study points out that funding and resource issues, organisational guidance and protocols for IPW and lack of education and training are the main challenges of IPW. Any move towards a greater integration and co-operation between agencies and practitioners may bring benefits, but also create tensions that need to be recognised and resolved for successful working relationships to be maintained \hyperref[b12]{(Fitzsimmons and White, 1997)}. IPW is recognised as the best practice in healthcare. However, the implementation and operationalisation of the concept of interprofessional collaboration in health and social care has been a challenge \hyperref[b30]{(Petri, 2010)}. 
\section[{V. Conclusion}]{V. Conclusion}\par
This study assesses HCPs' perceptions of IPW in the delivery of health services in Nepalese hospitals. HCPs in Nepalese hospitals perceived that IPW is beneficial to HCPs, service users and healthcare delivery; and they thought it as a booster for effective delivery of health services and improving quality of care. This study confirms that the core concept of IPW is equally applicable in the context of Nepalese healthcare. This study confirms that dominance of medical professionals exists in Nepalese hospitals. HCPs perceived that IPW is not sufficiently motivated amongst HCPs and adequate support is lacking from all stakeholders in Nepalese hospitals. This study highlights the importance of organisations support and involvement of service users for the successful delivery of IPC. This study recognises factors that support IPW and identifies various organisational, professional and interpersonal barriers to IPW in Nepalese hospitals. \begin{figure}[htbp]
\noindent\textbf{}\includegraphics[]{image-2.png}
\caption{\label{fig_0}}\end{figure}
 \begin{figure}[htbp]
\noindent\textbf{} \par 
\begin{longtable}{P{0.85\textwidth}}
But, it has to be properly supported by leadership,\\
supervision, guidance, training, education etc. (C1-N)\\
IPW is the most important factor while working in the\\
hospital. You can do nothing at all just by yourself.\\
Doctors, nurses and other supporting staffs make a\\
team capable of working for the welfare of the patient.\\
(B8-N)\\
IPW is very much important. Without teamwork,\\
patients cannot receive authentic treatment. ..\end{longtable} \par
 
\caption{\label{tab_0}}\end{figure}
 			\footnote{© 2016 Global Journals Inc. (US)} 			\footnote{Interprofessional Working: Perceptions of Healthcare Professionals in Nepalese Hospitals} 		 		\backmatter   			 
\subsection[{Declaration of interest}]{Declaration of interest}\par
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\end{document}
