Abstract
Objective
To develop a framework for professional practice for a large urban public health unit in Canada.
Methods
The project involved a literature search, key informant interviews, an environmental scan and focus groups.
Results
Analysis and synthesis led to recommendations for the development of discipline-specific Professional Practice Leaders (PPL) and an Interprofessional Practice Leaders Network. The latter meets to discuss cross-cutting practice issues and is chaired by the chief executive officer of the health unit, the Medical Officer of Health. The one-year evaluation has demonstrated that this initiative has worked well in practice. It is a flexible framework which provides new leadership opportunities and gives staff valuable input into decisionmaking on practice issues. It is also a more efficient use of staff resources, including a comprehensive approach to solving problems and in breaking down silos between programs. Communication and collaboration between disciplines has increased.
Conclusion
The initiative was evaluated successfully after the pilot year. In going forward areas to review include the time allotment for the PPL, communication between the PPL, the respective Program Director and the entire department, and expanding professional development opportunities for the PPL.
Introduction
Professional practice issues are those that affect the practice of professionals as they conduct their day-to-day work. These can include such issues as: the application of knowledge, skill and judgement for practice; ethical behaviour to promote excellence in practice; the domains of practice, education, leadership, research/quality assurance, professional development, legislative standards/regulations; and student activities. Toronto Public Health Department employs about 1200 professionals representing the mosaic of health disciplines including 700 full-time public health nurses, 200 environmental inspectors, 50 dieticians/nutritionists, 100 dentists and dental hygienists/assistants, 15 public health physicians and 250 allied health professionals representing program evaluators, epidemiologists, family home visitors, research consultants and health promotion specialists.
Creating an environment for defining and promoting high standards of practice and supporting professionals to exercise their specialized expertise and competence aligns well with two of the strategic directions in the department's 2005–09 strategic plan: 1
to be an innovative and effective public health organization;
to be the public health workplace of choice.
As an important backdrop, there is a move at a national level under the Public Health Agency of Canada to create structures that embody all of professional practice. Development of a framework for professional practice will maintain the health departments' reputation as a leader in innovative public health practice. Employers share responsibility with professionals, professional associations and others for promoting environments that support high quality professional practice. 2 Organizations that promote collaboration in professional practice benefit as productivity and effective use of personnel is maximized because professionals use their talents and skills in a cooperative and non-competitive way. 3 Staff at all levels need development opportunities for them to change paradigms, adopt new approaches, think creatively and proactively to address the challenges ahead. This could lead to consistency in client care, better quality across the system and using best practices in the organization. 4
The department management team is the central decisionmaking body. One of the main elements that can result from hierarchical decisionmaking is that many front line staff are excluded. Processes are not always transparent, and understanding and communication are often fragmented. The management team has only limited opportunities to connect with staff on issues that affect their practice and these are often only brief interactions at town hall meetings twice a year.
Public health nurses had identified a need to have a voice in decisionmaking in relation to nursing practice issues, and a structure; the Nursing Practice Council was established in 2002 to meet this need. As the Council began to meet and hear from nurses they found that several of the issues that were raised were not specific to nurses. The council strongly encouraged the management team to look for a better mechanism whereby the practice needs and requests of other professional staff could be dealt with in an effective and efficient way. Dieticians also identified a need to meet with their members and so a Dietetic Practice Council was established in 2005, giving them a formal mechanism for providing input into the issues that affect dietetic practice. Environmental health inspectors already had a quality assurance team with a mandate to promote safe and excellent practice. Other professional groups had no formal mechanism to provide input into decisionmaking as it affected their practices. In order to make the processes fair and somewhat equitable across professional groups it was necessary to determine how other professional staff could be involved. The objective was to define the key elements of a framework for an integrated collaborative approach to decisionmaking on practice issues for professionals from different disciplines.
The aim was to work with professionals to develop transparent structures or processes by which all professional groups could feel a sense of participation and empowerment, make decisions based on information from an interdisciplinary perspective, share professional goals and views that are unique to a discipline and increase personal accountability for care. 5 Further to this, the aim was to improve staff satisfaction and facilitate the development and growth of engaged, creative and productive individuals and teams. 6 Establishment of structures or processes for professional practice would allow clinicians to bring their perspectives to the table and clearly articulate their contribution. If structures and processes were defined that enable staff to participate in decisionmaking for practice issues, the results would, in the long term, translate to client satisfaction. The departmental management team could potentially divest of some of the practice issues that sometimes bog down their agenda, freeing them to deal with more strategic issues that affect public health across Ontario and Canada.
Methods
The project had several phases including a review of the literature, key informant interviews, an environmental scan and focus groups.
Literature review
Relevant articles were searched for in CINAHL, Medline, Psyc INFO, CDSR, ACP Journal Club, DARE and CCTR databases using the search terms: professional practice, professional practice models, interdisciplinary practice models, interprofessional practice, collaboration, shared governance, accountability, practice leaders, leadership and professionalism. The reference lists of key articles were assessed for additional potentially relevant titles. Selected journals were hand searched from 2000–04. A total of 291 articles were found, of which 103 were deemed relevant for inclusion in the project. Excluded articles were from acute hospital settings, addressed interdisciplinary teams related to patient care or discussed the role of the advanced practitioner in a clinical setting. The majority of the literature in this area is theoretical or descriptive in nature. However, where empirical studies were available, they were included. The articles were reviewed to identify issues in relation to professional practice structures, processes or values. Once all articles were reviewed common issues that had emerged were summarized.
Key informant interviews and environmental scan
Key informant interviews were conducted with the public health directors in the Department from the five main professions of nursing, medicine, environmental health, dentistry/dental hygiene and dietetics.
In addition, telephone or face-to-face interviews took place with key public health professionals from a variety of professions across Canada to elicit their opinions on professional practice structures and interprofessional collaboration, based on their experience in public health or health care. Respondents were asked what types of professional practice structures existed in their health unit or hospital and if they could forward any written information about these structures. Relevant organizations such as the Professional Practice Network of Ontario, and the Community Health Nurses Interest Group were also contacted.
An environmental scan of public health units and acute health care settings across Canada was conducted. Many hospitals have professional practice structures, primarily with a focus on nurses. This resulted in an accumulation of grey literature that was reviewed for information and overlap with the research literature for structure and implementation options.
Focus groups
Six focus groups, comprising approximately 60 clinical and managerial staff (regulated and non-regulated) from all professions, were conducted to gain a perspective of professionals' views on how best to deal effectively with practice issues that have cross-cutting implications. The focus groups were audio taped and the transcripts were then reviewed for themes. Similar themes emerged from all six groups, thus confirming the themes. The themes were consistent with what had been reported in the literature with respect to practice issues and professional practice structures.
Results
Literature review
The literature review enabled the synthesis of the best available evidence for professional practice structures and processes, and the identification of strategies for implementation and evaluation.
Davis and colleagues emphasized the need for organizational support as a necessary element in a professional practice structure. 7 A professional practice model delineates the organizational structure and process elements that enhance a disciplines' control over the delivery of services and the environment in which services are delivered. 8 Professional practice models are a key element in recruitment and retention of professional staff. They address many issues such as accountability, role clarity and overlapping scopes of practice. 9
Clearly defined and appropriate levels of authority regarding professional practice issues are essential.9–11 The primary customer of professional practice structures is the practitioner, yet the formal authority may reside with operational areas of the organization.
Studies of magnet hospitals illuminated the leadership characteristics and professional practice attributes of nurses within these organizations. Among the most important elements of clinical nursing practice were autonomy within clinical practice, status within the organization and collaboration. Participative management and support of professional development were traits shared in magnet hospitals. These findings describe the essential characteristics of professional nursing and the impact of nursing on patient and organizational outcomes. 12
The literature describes the emergence of new non-management leadership positions to support professional practice in health care organizations. These positions create roles that are reflective of the mission, practice type and setting of different types of health care organizations. 13 Such leadership positions were found in both academic and community facilities but were significantly more prevalent in academic than community hospitals. Often called Professional Practice Leaders, their role is to promote competent professional practice. They are seen as a resource, advocate, mentor and responsible for professional development and monitoring evidence-based practice. They represent their program's interests on organization-wide education and research committees. 14
The Canadian first ministers' meetings have stressed the importance of teamwork and collaboration in health care delivery and indicate that these ideas are at the forefront for many Canadians and their decision-makers. Health Canada has also been involved in many recent initiatives that have called for improved interprofessional collaboration in health care.15,16 The practice area also needs to change its philosophy about how professionals can work together given the resistance to change and the attitudes toward scopes of practice.
Collaborative care and improved teamwork have been shown to improve many aspects of the health care system in both public health and primary care. 17 Oandasan states that in order for effective teamwork to enhance health care all levels with the system need to work in sync. For health care professionals to practice collaboratively in teams they must share a common understanding of team and teamwork and understand the processes that are needed for collaboration to occur. In addition, management and organizational structures need to support teamwork. Policies and infrastructures must be developed which enable organizations to make teamwork in all health care settings a reality. The specific outcome of effective health care teams which are supported by a health care system can optimize the health of Canadians. 18
Many recommendations are cited in the Oandasan synthesis document in relation to promoting effective teamwork. Those that are directly related to the development of a professional practice framework are: facilitating communication, cooperation and teamwork across and within all levels of government, organizations and health care providers at the practice level; creating leaders to foster collaborative practice in health care settings; developing leadership training opportunities to help organizational leaders create a culture that supports teamwork and builds capacity for team members to practice collaboratively; and developing policies on the necessary resources and tools to facilitate teamwork. 18
In 2001, the Canadian Health Services Research Foundation (CHSRF) sponsored Listening for Directions, a priority-setting exercise on health services and policy issues. One of the themes which emerged was teamwork but primarily for clinical organizations. However, in 2004, in a similar Listening for Directions process there was a separation between the workplace and workforce aspects of teamwork. In the workplace aspect there was an interest in the role of occupational hierarchies, organizational structures and management processes toward stress and productivity. The workforce aspect concerns were with respect to the best ways to facilitate interprofessional teamwork and approaches. 19
As Clements et al. state, one of the greatest challenges to implementing effective teamwork is the hierarchical structure of health care. 20 There are professional silos and territories as well as entrenched attitudes about scopes of practice which, unless broken down, will sabotage teamwork. Health care professionals need to adopt common goals, break down the silos and hierarchies, and educate each other and their patients as how each team member contributes to the outcomes of better patient health.
In 2005 CHSRF brought together a large group of researchers and decision-makers to discuss effective teamwork. This group identified some key factors that contribute to success of teams which include: leadership and having change management champions; clear role expectations for all team members; respect, trust and being valued within the teamwork setting; and, finally, readiness of the organization to create a culture of acceptance for teamwork.
Stelioff states that in order for the Canadian health care system to ensure more effective and focused activity it is necessary to improve the quality of the working life of staff. In 2005, 11 major health care organizatons decided to work together to build healthier workplaces. In 2007 their report, Within Our Grasp: A Healthy Workplace Action Strategy for Success and Sustainability in Canada's Healthcare System, several priorities for action to develop professional practice environments were highlighted. These included: promote latitude in decisionmaking related to professional practice; create autonomy for appropriate decisions at the unit level and empower leaders to ensure the system can respond to and support front line decisionmaking; promote inclusiveness for all health care providers and create working conditions and positive working relationships that support collaborative practice very broadly; develop collaborative teams and provide dedicated time for dialogue to address factors that influence team function and increase effectiveness; and optimize staff participation in clinical decisionmaking within and across disciplines. 21
Interviews and environmental scan
Professional practice issues were seen as important by directors in the Department and there was support for resources to be made available. The value of addressing practice issues that were cross-cutting included increased communication, decreased silos and an understanding and synergy among professionals (both regulated and non-regulated). The respondents felt that any professional practice structure should include both front line and management staff as this would increase buy-in. The value added in terms of interaction among professionals was seen in relation to professional development, research and students. They also identified a need for clear terms of reference and an understanding of role and structure to support professional practice issues.
The external informants all identified professional practice as an important area for public health to focus on given the benefits that these structures have had in hospitals. As public health professionals have a long history of working collaboratively, it appeared to be a natural evolution. They also shared similar views to those identified by the directors in the Department including professional development, particularly as is it relates to larger system changes (i.e. public health competencies and changes to the Regulated Health Professions Act).
The environmental scan showed that few public health units in Canada have professional practice structures. One mid-size mainly rural health unit has Senior Discipline Leadership roles at the management level. Their roles include identifying and accessing cross program/discipline educational opportunities; exposing students to all disciplines in public health; new staff orientation; and increasing cross-agency understanding of the preparation and skill of the various professions.
A western Canadian province established a regional professional practice council in the fall of 2004. It is a council made up of professionals covered under their regulated Health Professions Act. This council will work with the Nursing Practice Council and the Medical Advisory Board to address interprofessional practice issues and policies that arise from all the regions, operational departments and service areas, including public health services. Responsibilities of the members include providing ongoing communication to their staff, ensuring colleagues are consulted on issues and concerns, and bringing issues forward to meetings.
Focus groups
The issues that emerged from the focus groups were not explicit to one professional group but were common among all groups represented. Each of the focus groups had representation from at least seven of the main disciplines.
Communication problems were strongly identified as an important professional practice issue in all focus groups. A lack of knowledge of roles and responsibilities of other professions and a lack of contact exists. Other issues identified included students (how we manage them and how we organize their learning about other professions), professional development and consistent policies:
‘You would get to see the bigger picture instead of working in your own silo… helps you understand gaps and adjust service delivery to fill the gaps. It helps with policy and procedure development. There would be more alignment and clearer messages to the community. Cross-fertilization of ideas makes people get pumped up, think beyond silos.'’
‘We need a structured approach – what are the issues that are out there? Have a process to identify the issue. Tell us what the practice issues are that affect practice and that they would like to discuss with other disciplines.'’
‘Front line staff needs to be involved at the table where they can bring issues in confidence and put them forward. Their perspective is important.'’
‘Transparency is important. If we are supposed to be representing people, they need to be able to see why decisions are made.'’
Focus group members felt that addressing cross-cutting practice issues would improve efficiency, provide better care, increase knowledge about other professions and programs, and improve job satisfaction. They also recognized that resources would need to be allocated to this collaboration. They identified that the key elements of any structure should be: inclusive of all professions and all levels of staff; transparent; flexible; supported by the department management team in vision and resources; and able to be evaluated in terms of value to the organization and the professionals.
Discussion
Fundamental elements were identified that should be included in a framework to address practice issues. These included authority, transparency flexibility, organizational support, inclusivity and evaluation. Structural elements such as resource implications and staffing were highlighted in the literature and were highly dependent on the size of the organization and the numbers of professionals employed who were regulated or non-regulated.
The synthesis and examination of the evidence resulted in the development of a conceptual model for professional practice within the health unit. The model should be supported by the senior organizational leaders, inclusive of all disciplines, transparent, resourced adequately and given some lines of authority.
Five models were presented to the department management team as a starting point for decisionmaking. A final professional practice framework was endorsed by the team and included the development of seven Professional Practice Leaders (PPL) and the formation of an Interprofessional Practice Leaders Network to be chaired by the chief operating officer of the health department, the Medical Officer of Health. Implementation plans commenced in November 2005 with expression of interests for the leadership positions from dietetics, allied health and inspection. Those for nursing, medicine, dentistry and dental hygiene were appointed. Implementation commenced in January 2006.
Evaluation
An evaluation of the professional practice model was challenging as Professional Practice Leaders were still defining and learning their roles, and many public health department staff were not familiar with the initiative. Overall from a performance perspective, there have been many successes and some challenges.
The interprofessional nature of the Network has worked very well, both in principle and practice. Having a designated PPL has given some professions a new leadership role and a sense of organizational support. The initiative is flexible enough to accommodate a variety of implementation strategies aimed at helping achieve the goals and objectives. This was reflected in the development and implementation of a number of key documents including the Network terms of reference, issue prioritization tool, evaluation framework (including logic model, data collection forms), professional practice tools (including decision tree, flow chart, confirming and defining a professional practice issue) and the briefing note format for decisionmaking.
The key indicators that were measured for the evaluation included: number of PPLs selected; Network and PPL meetings; practice issues raised; strategies initiated; communication about the initiative; and the degree of staff satisfaction with the initiative.
Overall during the pilot year, eight Network and 17 PPL meetings took place. There were a range of issues (1–36) that came forward to individual PPLs. Of these, 30 were resolved. PPLs referred six issues to be dealt with by other mechanisms. Twelve issues came to the Network and, of these, 10 were effectively resolved. Several policies, guidelines and standards were reviewed, developed or initiated by the PPLs. These included documentation, complementary therapy and the dress guideline. The Network was a key partner in a large research survey on public health core competencies. In general staff satisfaction with resolution of practice issues was high. The satisfaction of PPLs with their role was medium to high. There have been a number of communication strategies that have been implemented to talk about this initiative including several articles in newsletters and emails, as well as presentations at staff and manager meetings.
Having the Medical Officer of Health as the chair of the Network has added credibility to the initiative and has helped to resolve practice issues. The role of the PPL has been instrumental in coordinating activities as well as being the first contact for staff in relation to practice issues. The role of the Professional Practice Consultant who is essentially the coordinator of the initiative has been instrumental in moving the role of the PPL and the Network forward. She coordinates all meetings, as well as consults and supports all PPLs in their new roles.
The Network has been successful in dealing with cross-cutting practice issues such as core competencies, professional development and corporate policies and guidelines. There has been the establishment of a standard process for consultation and conducting research, as facilitated by the research on core competencies. PPLs can monitor external changes that not only affect professional practice but also the future of public health. In addition, many issues raised by staff that may not have been addressed otherwise were referred to the appropriate structure. Having PPLs and a Network seems to be helping in breaking down some of the silos between professional groups and programs. In effect, successful linkages have been established with internal stakeholders such as the councils in nursing and dietetics, and external organizations such as the Public Health Agency of Canada.
Some challenges remain. In terms of PPL representation, some see the structure as problematic due to the disproportionate numbers and diversity of staff in each of the disciplines. This creates differences in the effectiveness and efficiency of undertaking the PPL role. For some of the PPLs, a practice council exists which takes up a considerable amount of their time. For other PPLs, where there are smaller numbers of staff (i.e. medicine, dental hygiene) and where there are a wide range of types of staff (i.e. allied health), this makes the challenge of communication and implementing the role much more difficult.
The size of the public health department also contributes to the challenges that PPLs face. There are 35 offices and PPLs have found difficulties in meeting with their respective colleagues in a timely and effective way. The role of PPL is an assignment rather than a formal position and many are balancing their other work, depending on the assignment time commitment. Many of the PPLs have not been able to fully undertake their PPL time allotment to do the professional practice work. This means that there may be an inability to address comprehensively practice issues and meet the objectives of the Network and the PPL role. This creates reactive rather than proactive action. PPLs also need time for skill development and learning about professional practice issues. With an increase in the complexity and numbers of issues anticipated, time pressures could become more prominent. The allocation of resources and the necessity to review these PPL roles as assignments or permanent positions needs to be considered.
In some professions there seems to be a lack of willingness to bring practice issues forward, especially in the non-regulated professions. There are divergent views between the PPLs on why this is occurring. Some feel the perception of an over-arching management role may be limiting staff interest and participation. Two PPLs currently hold management positions in the organization and the staff who raise practice issues to them are also in management positions, and so this hasn't posed any problems. It is, however, interesting that the PPLs of nursing, dietetics and inspection are all front line staff and have issues brought forward by both front line and management staff.
Moving forward
The PPLs and the Network formulated four recommendations to the Departmental Management Team after the one-year pilot:
Continue with the PPL and Network structure – The initiative addresses collaboration, communication, core competencies and other key issues among and between various professional disciplines. The efforts of the PPLs in identifying and addressing practice issues, with the support of senior management and the direction of the Medical Office of Health, have shown that the Network is an important component of providing effective service delivery.
Maintain the previously established time allotments for PPLs – Given the part-time commitment for PPLs, there is difficulty in balancing the time for their different roles, especially when there are competing program priorities. As a result, some PPLs are not able to fully utilize their allotted time to do the PPL work. In addition, given the increasing breadth of the role and considering the added dimensions of practice council responsibilities, some PPLs feel the position should be full-time. Reassess time requirements in six months after PPLs have been able to fully utilize time allotments.
Institute direct communication links between the PPL and their respective program Director – Some PPLs have not been able to adequately identify, address or resolve profession specific issues with their program manager(s). Allowing PPLs to channel practice issues through senior management, in consultation with the program manager(s), would improve this.
Support PPLs' professional development opportunities – PPL program managers give priority to PPLs for professional development opportunities as it relates to professional practice.
Implications for practice
The endorsement of a professional practice framework can add value in terms of efficiency, better client care, increased knowledge about discipline roles, job satisfaction and better communication among disciplines. An open, transparent process for decisionmaking will enable all professionals to give voice to issues that affect their practice and allow them to offer creative strategies and solutions. The creation of new PPL roles was a method of supporting leadership opportunities for staff. Having staff develop the skills of collaboration, facilitation, system and critical thinking, are important prerequisites in order to assume more senior managerial positions in the organization. Public health administrators can also benefit from the role of the PPL to foster collaboration and a two way dialogue about issues that may require an interprofessional opinion. The trust that can develop in the organization can ultimately lead to systematic changes in the workplace. Over time, a shift in thinking may occur to enable both senior managers and front line staff to be involved jointly as decision-makers and problem solvers for practice issues.
Conclusion
The evaluation of this initiative was helpful in achieving endorsement for all the recommendations and continuing with the model. The management team was satisfied with how practice issues had been dealt with and saw opportunities and benefits of continuing. There are some issues that will need to be reviewed by the Network as they continue to move forward. These include the time allocation for the PPL role, the job assignment nature of the role, ensuring staff understand the role of the PPL and the Network, communicating the benefits and successes, and finally continuing to monitor the effectiveness of the initiative and make modifications and improvements as necessary.