Introduction

There are challenges associated with collaboration among health professionals in resource-limited settings and current continuing professional development (CPD) programmes seem not to address specific issues related to collaboration. Popular CPD programmes for health professionals, driven by employers or professional bodies, are usually provided for specific professions and aimed at the transfer of knowledge and skills from experts and are seldom delivered in the workplace [1–3]. Zwarenstein et al. [4] demonstrated the potential value to healthcare outcomes of practice based interprofessional education interventions through a systematic review of studies from high-come countries. Practice based CPD activities integrate and account for the complex workplace environment which is often missed in pervasive CPD activities in low-resource settings [5].

The workplace environment for health professionals is inherently complex, dynamic, non-linear and often difficult to predict [6]. The ageing population, changes in population healthcare needs, epidemiological transitions, resource limitations, and the protracted health workforce shortage contribute to the labyrinth of the workplace environment, which often compromises healthcare [7]. The absence of true collaboration among health professionals, especially in resource-limited workplace settings, worsens the situation [8]. Various scholars and organisations advocate for collaboration among health professionals to enhance person-centered care, improve health professional job-satisfaction and improve systems for health [9].

Collaboration among health professionals in the workplace may not occur spontaneously, especially in cases where their initial training was through uni-professional programmes [10]. Key strategic elements such as careful planning, leadership, and education, need to inform workplace initiatives that foster the development of collaboration among health professionals. Continuing Interprofessional Education (CIPE) reflects deliberate initiatives aimed at improving collaboration among health professionals and enhancing the quality of healthcare within the complex workplace environments through engaging two or more health professionals from different professional backgrounds in learning with, from and about each other [11]. The CIPE initiatives are primarily appropriate for health professionals after their initial qualification and may be an alternative to traditional CPD programmes in fostering collaboration among health professionals [12, 13].

Veerapen et al. [14] emphasise that the CIPE initiatives should be developed with a clear understanding of workplace dynamics, structure and the prevailing attitudes and biases of targeted health professionals underpinned by sound theoretical frameworks. The social identity theory, reflective and experiential learning theory, and learning within communities of practice are proximal theories that can be infused in the design and delivery of the CIPE initiatives [15]. In applying these theories in practice, Owen et al. [15] describes that the CIPE initiatives should have a clear focus on hands-on interprofessional exchange situated in the workplace through interaction and co-participation of all health professionals. The unique aspects of each workplace and associated behaviours of health professionals influence the effectiveness of the CIPE initiatives [2, 15].

Resource-limited settings present unique workplace environments for health professionals. Such workplace environments are generally characterised by limited numbers and types of health professionals, heavy disease burden, and limited operational resources which affect the delivery of healthcare [16]. Collaboration among health professionals, especially in resource-limited settings, would significantly contribute to improved healthcare and health outcomes. Collaboration is valued as essential in such healthcare crises situations such as the COVID-19 pandemic, where healthcare workers could collaboratively support each other and become each other’s buffer to burn out. The CIPE initiatives are therefore essential in these settings and such initiatives may be different from those developed in well-resourced settings. As established, the CIPE initiatives need to be informed by the workplace dynamics, structure and the prevailing attitudes and biases of targeted health professionals which are revealed as health professionals interact within the workplace [14]. The interaction patterns of health professionals in resource-limited settings are not known. The majority of the literature from the African context reports interprofessional education for pre-registration programmes and there are limited reports that focus on Continuing Interprofessional Education. We argue that insights into the interaction patterns of health professionals in the workplace could provide guidance for improving the design and value of CIPE initiatives as a vehicle towards collaboration among health professionals in resource-limited settings. Resource limited settings lack funds that affect individuals, the society and/or institutions to access healthcare. In resource limited settings, there is limited access to medication, less-developed infrastructure, few-numbers of trained health professionals and poorly maintained infrastructure. Therefore, this article aims to describe the interprofessional interaction patterns of health professionals in the workplace in a resource-limited setting.

Methods

This study was approved by the Health Sciences Research Ethics committee of the University of the Free State (HSD2018/0055/3007) and the Department of Health (Free State Province) in South Africa. All participants provided written consent to be part of the study.

Findings

The interaction patterns of health professionals at a central hospital in South Africa are presented as three themes namely: Formed professional identity, Communication networks and approaches; and Professional practice and care. The themes of the study are discussed and supported with evidence from the data.

Discussion

The purpose of this study was to describe the interprofessional interaction patterns of health professionals in a resource-limited setting. Understanding the interprofessional interaction patterns of health professionals would support the development of CIPE initiatives that are influenced by the workplace dynamics, structure and prevailing attitudes and biases of targeted health professionals. This study provides a glimpse of how health professionals in a typical low-resource setting in South Africa seemed to interact. The study outcomes seem not to be unique to low-resource settings, as earlier studies in higher income countries have demonstrated similar outcomes [25, 26]. Contextual, processual, relational and organisational factors seem to heavily influence the interprofessional interaction patterns in this setting [27].

Professional identity is a concept associated with how professionals perceive themselves within an occupational context and in what way such a perception is revealed to others [28]. The infrastructure, education, socialisation, and society, contribute to professional identity formation and such identities may not be aligned to the professional roles and scope as described by regulators. The professional identity of the health professionals in this study seemed to mirror professional hierarchy, with Doctors at the apex of this hierarchy and the other health professional fitting at its base. It appeared as if Doctors were expected to naturally lead patient care and give directives to all other health professionals who seemed to have a reporting role. Professional hierarchy in the workplace for health professionals has been reported in various settings [29] with debilitating patient outcomes, poor job satisfaction and tardy decision-making processes [30]. The omnipresent patriarchal culture, wide salary variation, and difference in the level of education of the health professionals in this setting, which are described by Reeves et al. as contextual factors [27], seem to rivet professional hierarchy among health professionals.

CIPE initiatives underpinned by transformative learning would be valuable for this setting. The patterns of interprofessional interaction seem to be influenced by deeply seated world-views originating from the “habits of the mind” influenced by family, culture and the community [31]. Mezirow describes transformative learning as aimed at influencing the world views of adult learners through critical reflection on own beliefs, assumptions and perspectives [20, 32]. Initially, health professionals would benefit from facilitated learning on self-reflection and self-knowledge. Self-reflection is fundamental to transformative learning, as it empowers an individuals to question the “habits of the mind”. Understanding the professional roles of other health professionals nested within the social identity theory, would support health professionals in recognising their identities and roles within an occupational group that has shared knowledge and values [15]. Case studies, simulations, and practical interprofessional exchanges underpinned by experiential learning principles would allow health professionals as a team to engage and reflect on their various professional roles within patient care. Sweeny et al. [33] further explain that the flattening of professional hierarchies should be aligned with a leadership approach that encourages shared decision making, value clarification, professional autonomy and professional accountability. Such a leadership approach when executed in the workplace may steer the focus of decision making to rest on all health professionals instead of the Doctor [34].

Nurses and Doctors seemed to be the key role players with the communication networks recognised in this study, with caregivers and the other health professionals peripherally engaged. The chronic shortage of health professionals, especially the allied health professionals in resource-limited settings, justifies the predominant role players in patient care in this study. This chronic shortage of allied health professionals has been attributed to various factors including limited training opportunities, poor regulation and limited utilisation in resource-limited settings [35]. The shortage of health workers may not necessarily justify the observed interprofessional interaction patterns, however CIPE initiatives in such settings must be sensitive to the shortage of health professionals through integrating trans-professional models of care. Trans-professional models of care are aimed at increasing the range of services offered by health professionals through flexibility in professional boundaries, workload distribution and support during problem-solving [36, 37]. Trans-professional models of care may need to be carefully applied and be within the remit of professional regulation. Trans-professional models of care must be driven by patient needs and aimed at improving patient outcomes through engaging patients and their caregivers in their own care [37]. Trans-professional care could enhance efficiency in the utilisation of health professionals, creating high performing teams that would stretch the limited resources. Such a model of care will enhance health professionals to support each other within a resource-limited context.

In multi-professional models of care, health professionals from different professional backgrounds work in parallel to perform professional specific care such as conducting a profession-specific assessment, planning, and care [37]. Caregivers in this study were exposed to this model of care, which seemed iterative and irritating, as similar questions for example during history taking were asked by different health professionals. The CIPE initiatives should emphasise the development of a common language of communication among the health professionals, which would lead to interdependence in health interventions. The International Classification of Function, Disability and Health (ICF) framework proposed by the World Health Organisation (WHO) may be used in structuring approaches towards a common language of communication among health professions. The ICF has been reported to catalyse interprofessional exchange, further improving collaboration among health professionals, especially in resource-limited settings, where multi-professional models of care may be expensive and resource-intensive [38].

True collaboration among health professionals as an outcome of the CIPE initiatives needs to involve the patients and caregivers in decisions regarding their own care. Patients and caregivers in this setting seemed to have limited roles in their own care and this may have been a result of the pervasive culture of traditional authority, with patients and caregivers subservient to health professionals. Ward et al. [39] explained that involving patients in decision making regarding their own care has direct benefits which include improved compliance to management approaches. Dismantling subservience of patients and caregivers may be a challenge as such cultures are part of social structures which expect authority to be respected. The CIPE initiatives should aim at the collaboration of health professionals towards person-centered respectful care that acknowledges the context of the patients and caregivers.

Typical of resource-limited settings is the physical environment of the workplace of health professionals which presents a challenge for engaging in true collaboration and the provision of quality care. This study revealed how the environment influenced fundamental patient care issues such as confidentiality due to the absence of individualised compartments for patient care. Some workplace environments in these resource-limited settings may not accommodate a large interprofessional team to provide direct care to patients while in some case there may not be space for meetings and dialogue which are necessary for collaboration. The use of shared documents, which allow health professionals to communicate in a common language may be an alternative to resource-limitations that arise to the challenges of space.

Conclusion

The collaboration of health professionals within the workplace has been linked to improved patient care, patient outcomes and improved healthcare worker satisfaction [9]. Health professionals in resource-limited settings are not trained to work collaboratively as the majority of undergraduate training is provided in uni-professional programmes. Current CPD activities for health professionals usually do not address the collaboration of health professionals and are conducted away from the complex workplace environments.

CIPE initiatives situated within the complex workplace environment may be engaged in developing collaboration among health professionals. These initiatives need to be designed based on the contextual underpinnings of their intended beneficiaries. From this study, the following are recommended to designers of CIPE initiatives in resource-limited settings;

• The CIPE initiatives should be underpinned by transformational learning philosophies linked with practical interprofessional exchanges among health professionals in the workplace;
• Engage distributive leadership approaches that reflect professional accountability, shared decision making, value clarification, and professional autonomy;
• The CIPE initiatives should be sensitive to human resource shortages and engage in trans-professional models of care driven by patient care needs;
• There should be a common language of communication among health professionals through the use of the ICF framework;
• There should be involvement and further research around culturally sensitive patient involvement in health care; and
• A shared documentation process that is driven by a common language.

The authors acknowledge limitations inherent within this study and the design applied, where further triangulation of data could have strengthened the authors’ perceptions of the interaction patterns of the health professionals. However, the data generated from this study is crucial in providing insights into the interprofessional interaction patterns of health professionals in resource-limited settings which seems to confirm research conducted in high-income settings. It is recommended that further research in this field should engage various strategies to further promote true collaboration among health professionals in resource-limited settings.

Supporting information

Acknowledgments

The authors would like to acknowledge Prof. Ruth Albertyn for critical insights in the structuring of this article.