Beyond formal policy: Engaging action research to promote a culture of interprofessional learning and practice

Transcription

1 Beyond formal policy: Engaging action research to promote a culture of interprofessional learning and practice Corresponding author: Peter NUGUS 1 PhD Research Fellow Centre for Clinical Governance Research Australian Institute of Health Innovation Faculty of Medicine University of New South Wales Sydney NSW 2052 Australia Contact details of corresponding author: Telephone: ++ 6(0) Fax: ++ 6(0) p.nugus@unsw.edu.au Authorship: Peter NUGUS PhD David GREENFIELD PhD Joanne TRAVAGLIA PhD Jeffrey BRAITHWAITE PhD Word count Abstract: 290 Main body: 4,076 Figures: 3 Tables: 1 References: 36 Total words (body, figures, references): 4,980 1

2 Abstract Background: System-wide attempts to change the culture of health organisations or systems often result in a gap between intention and outcome. One strategy to bridge such deficits is to pair action research with a formal system-wide policy to enact culture change. Aim of study: We examined the degree to which a formally-supported action research project across a politically autonomous health jurisdiction was promoting culture change. Methodology: We conducted a multi-method, action research investigation across five divisions (Aged Care and Rehabilitation, Oncology, Community Health, Mental Health and Acute Services) of the health jurisdiction delivering frontline clinical services. The researchers investigated interprofessional learning (IPL) and interprofessional (IPP) practice using questionnaires, interviews, focus groups and ethnographic observation over a one-year period. Researchers then made verbal presentations and submitted written reports of the findings of the audit to managers and staff in the various division. These formative evaluation feedback loops (FEFLs) involved discussion amongst staff of the strengths, weaknesses and opportunities to enhance IPL and IPP in their services. Findings: The research process has achieved the engagement of staff where staff and researchers have negotiated areas needing improvement in IPL and IPP. From 100 initiatives, driven by clinicians, clinicians and administrative staff across the five divisions, more than 50 remain in progress. These initiatives are stimulus for practice and culture change. They have generated grass-roots support for an international early adopter of policy on interprofessional learning, and to advance collaboration as one of the four values of the health service. Conclusions and implications: Action research is an effective strategy to promote a culture of IPL and IPP. Such approaches can help generate culture change where the research is both formally supported and when staff across the service are engaged reflexively in their work environments. 2

3 Introduction Policy-makers and researchers have demonstrably focused attention on transforming the culture of health organisations particularly since the 1980s. One movement which became known as the New Public Management involved an emphasis in public organisations, including in health care, on systematically promoting the quality and cost efficiency of services delivered to clients or to the public. Such continual improvement is to be delivered through greater accountability which, in turn, is to be delivered through performance measurement (Borins, 2009; Noordegraaf & Abma, 2003). Performance management through measurement means that accountability has come to be associated with system-wide aggregation, and standardisation taking priority over variation in local practices (Dawson & Dargie, 2002). The implications for contemporary health care management are an emphasis on collecting uniform types of data that are processed centrally, and uniform policies that are intended to be spread and shared over a range of services. In order to influence practices system-wide, new public management practices invariably involve attempts to engage organisational culture, with culture being seen typically as a shared set of beliefs, values and practices (Braithwaite et al, 2005; Braithwaite et al, 2010; Schein, 2004). Culture is built up interactionally and through mutual influence and negotiation of social structures (Griffiths, 2003; Nugus, 2008). Such is the case with the growing influence of interprofessional learning (IPL) and interprofessional practice (IPP). ILP is a collaborative, interdisciplinary education and learning process designed to produce effective, multidisciplinary patient centred care (Braithwaite & Travaglia, 2005a). IPP is the enactment of competencies that realise IPL Braithwaite & Travaglia, 2005b). Norms, values and practices of interprofessionalism are built up and negotiated through interaction, including through the interaction and mutual influence of researchers. IPL and IPP are a case study of system-wide cultural change because they involve a combination of attitudes and practices of collaboration and mutual respect among health professionals to deliver patientcentred care. Yet, whether to advance IPL and IPP, or any system-wide attempts to change the culture of health organisations is an open question. To do so can often result in a gap between intention and outcome. Researchers have observed an increasing distance between front line service activity and the management and monitoring of the performance of those activities from a distance. This has been framed as a gap between the governing and the governed (Adams, 1995; Furedi, 2005; Gutmann & Thompson, 2004). For instance, where top-down performance management does not reflect the realistically attainable goals or local context, 3

4 local actors have been able to thwart managerial initiatives, rendering them ineffective (Charlton, 2001; Wiener, 2000). The distance between standardised accountability measures and local practices is a serious policy and service problem. For instance, local autonomy, or resistance to managerial imposition of accountability measures perceived to be irrelevant or inappropriate can generate unproductive distancing, or competition between management and workers for ever smarter modes of regaining control, in the case of managers, and greater autonomy in the case of workers (Foucault, 1983; Goffman, 1959). One strategy to address this gap is to pair a formal system-wide policy designed to enact culture change with action research. This enables researchers not only to examine the system, but also to influence the culture through interaction with the people they research. Researchers can exercise influences that build, transmit and change culture. Action research is distinguished for the practical impact it has on the experience of those being researched (Walsh & Fegan, 2007). The action research process involves an iterative cycle of planning, action and research (Whitehead, 2005). Action research is an appropriate methodology for reducing the gap between governance and frontline work, given its focus on direct engagement with front line work to match proposed outcomes with practical change. The appropriateness of action research for resolving clinical problems and improving practice is reflected in its increasingly common engagement as a methodology in health care (Meyer, 2000). But despite its promise action research has not been engaged sufficiently as a strategy to influence system-wide culture. We aim to examine the degree to which a formallysupported action research project across a politically autonomous health jurisdiction was promoting culture change. Methods We are conducting a multi-method, action research investigation across five divisions (Aged Care and Rehabilitation, Oncology, Community Health, Mental Health and Acute Services) of a health jurisdiction delivering frontline clinical services. Each division spans the entire jurisdiction, covering a geographical area of 2,300 square kilometers and a population of 330,000. Multiple units within each division service that population. A partnership was formed between the jurisdiction and the visiting research team, following extensive literature reviewing and negotiation for a period of a year. The intention of the partnership was to conduct a collaborative action research project, over the period , using IPL as the basis for improving IPP (Braithwaite et al, 2007). The significance of this study and its sample, therefore, is that is spans an entire health system, striving to 4

5 engender culture change across-the-board. Ultimately, the partnership is translating learning across sectors: tertiary education; health service delivery; and professional bodies. In this paper, we focus on the health services sector. The cycle of research (auditing), feedback, practice improvement and ongoing cultural assessment is captured in Figure 1. [Figure 1 about here] The researchers audited the jurisdiction by investigating IPL and IPP using document analysis, questionnaires, interviews, focus groups and ethnographic observation over a oneyear period. Researchers then made verbal presentations and submitted written reports of the findings of the audit to managers and staff in each division. Such reporting represents Formative Evaluation Feedback Loops (FEFLs) (Braithwaite et al, 2007). Feedback involved discussion amongst staff of the strengths, weaknesses and opportunities to enhance IPL and IPP in their services. The intention of the FEFLs is to stimulate IPL and IPP practice improvement projects. An Interprofessional Audit Praxis Framework has been designed for the audit task of the action research process (Greenfield et al, forthcoming). The framework consists of four components: a context review (through organisational documents); a cultural assessment (through interviews and focus groups); a conduct investigation (through ethnographic observations); and an attitudes appraisal (through questionnaires) (Greenfield et al, forthcoming). The questionnaire was purpose-designed, combining two pre-validated surveys: a version of the Readiness for Interprofessional Learning Survey (RIPLS) (Parsell & Bligh, 1999) modified for health services; and the Heinemann s Attitude Towards Health Care Teams Scale (Heinemann et al, 1999). The dimensions that formed the focus for conducting and analyzing the transcripts of the interviews, focus groups and ethnographic observations were derived from a literature review on IPL and IPP. The topics are: staff wellbeing; communication; teamwork; sharing of ideas and knowledge; decision-making; leadership; service management; case management; quality and safety; collaboration and interaction; and, client-centred care. Interviews and focus groups were conducted, and questionnaires were distributed in staff workplaces. The researchers analysed themes that arose from the data. The transcripts were analysed using comparison and contrast of cases. Themes were incorporated into interpretations that change in line with the direction of analysis through the analytical process 5

6 (Glaser, 1992). The findings section, below, draws on the results from the audit and analysis of researchers notes on the action research process. Findings The audit activities were an important part of the action research process because they stimulated the reflection and discussion which itself influences culture, and which helped stimulate practice improvement projects. The audit activities yielded 122 interviews and focus groups (comprising 474 participants), 373 questionnaire responses, 182 hours of ethnographic observation, and more than 200 hours of document analysis. The data collection upheld the validity of the categories we derived form the literature review as being important to enacting IPL and IPP. Participants believed, and were supported by observations, that all dimensions of IPL and IPP were both being enacted to a certain degree and required improvement. From participants perspectives, and according to observations, a number of dimensions of IPL and IPP were being enacted to a greater extent than others. These were: client-centred care; sharing of ideas and knowledge; quality and safety; quality of interprofessional care; positive professional identity; and having different but integrated roles and responsibilities. For instance, on a five-point scale, questionnaires revealed an average rating of 4.4 out of five for quality of interprofessional care. The general accomplishment of other dimensions of IPL and IPP are evident in the following exemplary data and their interpretations. In the following observational excerpt, the manager of a unit devoted to intervening to help at-risk children informed the meeting about a pilot program by which counsellors, psychologists and social workers would debrief medical and nursing staff involved with at-risk children: Meeting chair: [For those of you who don t know], since [the unit for at-risk children] was put under the same umbrella [as children s doctors and nurses], [doctors and nurses] know that we debrief. It s not part of nursing or medical training or work. Nurses put up their hand. So Maria [a psychologist] undertakes group supervision for nurses in Community Health s Caring for Kids program. [Nurses] do 24-hour medical care. It s complex and stressful. [Pediatricians] in the community deal with very complicated cases and they re getting caught up in social issues. Anna [a counsellor] offered to 6

7 provide them support and others are on board. So we go to the clinic once a week and do counselling with them and their clients. They used to do 1000 phone calls and basically be a psychologist. We said you do the medical and we ll come once per week. It s a pilot. (Observations, Case conference, Community Health) This demonstrates the distribution of shared ideas and knowledge across occupations. The exposure of doctors and nurses to the work of psycho-social allied health staff, in being de-briefed by them, helps them in learning about the skills, contribution and priorities of different roles. Through the research process, staff were increasingly observed to discuss quality and safety issues supportively as part of their day-to-day work, rather than as challenging quality and safety protocols as managerial directives removed from their work in frontline services. An incident was observed in an acute inpatient mental health unit, in which part of a needle became separated, raising concerns by the nurse involved that the patient received an inappropriate or inadequate dose of medication. The nurse relayed the story to a psychiatrist, went to great lengths to find out what might have happened by replaying the scenario with several clinicians and asking their opinions, and, finally, documented the incident in the electronic incident reporting system. This simple illustration shows the preparedness of staff to use the incident reporting management system as a formal mechanism to enhance the quality and safety of care. Staff in community-based services, in particular, tended to be more satisfied with the level of interprofessional teamwork in their unit than that occurring in acute services. The relative satisfaction of staff in community-based services is evident in the following focus group comment: Occupational Therapist I love [working in this division]. We discuss a lot of things and we work well together and value each other s role. It s about learning about each other s role. We provide direct client care and the physio [physiotherapist] and I talk and see where we can help each other out. Allied Health Assistant 1: The focus is getting the client better. All our opinions are listened to. Allied Health Assistant 2: As allied health assistants we re not 7

8 excluded or treated and differently. Physiotherapist The Allied Health Assistants are very valuable in the skills they bring. (Focus group, Aged Care & Rehabilitation) One nurse manager addressed nurses about rumours of bullying among nurses: I ve heard there s bullying going on among nurses This must not happen. We have a difficult job and we can only do it if we support each other If you re bullying others, you re not a nurse; you ve forgotten those values you signed up to. (Observations, Community Health) The nurse manager promoted mutual support the antithesis of bullying as a core to the professional identity of nursing. Professional role relationships are a central focus of IPL and IPP: Meeting chair: The radiation oncologists have developed those procedures really well And the nurses have helped. This is great and I think it s a great aspect of our team. Every role does their bit. (Observations, Cancer Services) In the above excerpt, the chair of a staff meeting publically acknowledged the different but integrated roles that comprise an interprofessional team. There was a high degree of variability about whether the following dimensions of IPL and IPP were being enacted: staff wellbeing; communication; decision-making; leadership; teamwork; and service and case management. These topics revealed a range of views and observed circumstances from highly satisfied or satisfactory to highly dissatisfied or unsatisfactory. For instance, during an interview, a physician remarked: 8

9 This isn t the organisation I joined There s now so much bureaucracy and centralisation. So much of it s inefficient. I used to be able to concentrate on caring for patients I wish there was a study on what the new organisational structure has brought to patient care. (Interview, Acute services) Accordingly, there was wide variability in the degree to which staff enjoyed their workplace and the degree of satisfaction among staff that their wellbeing was assured at work. The following comment by a Mental Health manager reflects dissatisfaction with leadership of doctors in relation to other roles: There has been no leadership from the medical staff, individually as a profession or within the division more generally I haven t seen, for 8-10 years, this level of de-skilling of staff The existing directors couldn t see the problems, they have grown and been a part of it for so long talk about it being system issues. Team leaders have exceeded the scope of their practice; they have become seduced by the power they have had without the involvement of the doctors. They have exceeded their legal authority, and the medical staff have been disengaged. They have been private practitioners, uninvolved The organisation has to take back the responsibility and engage all staff appropriately There is the energy and enthusiasm to improve. (Interview, Mental Health manager) Case conferences were central formal mechanisms of case management, and staff meetings, of service management. In case conferences across the health system there was a wide discrepancy in the degree to which various roles were allowed input into client case management. Some case conferences featured input from clinicians in different roles where they defined their own scope of practice in client care. Others featured domination by the chair who allocated which roles would be involved with particular cases and what their tasks would be. 9

10 These results were fed back in writing and in verbal presentations across clinical divisions in FEFLs which prompted debate and discussion and the quality of IPL and IPP in particular services, and the determinants and variables upon which interprofessional culture relied. Staff across divisions and in various occupations nurses, allied health clinicians, administrative staff, technical staff and doctors participated in these forums and discussions. Culture change was promoted through FEFLs because new topics were being raised and debated publicly. Culture change was shaped by four interrelated issues. These are evinced below from staff responses during those sessions. First, staff demonstrated ongoing questioning of health and professional knowledge: [We don t know it all Patients have to be involved]. To be around patient care [we need to have] multiple stakeholders. (Staff member at IPL forum) Second, staff expressed critical views towards existing culture: We use excuses to justify non-ipl behaviours Why can we be emotionally intelligent and engaging with clients and not with each other? (Staff member at IPL forum) Third, staff demonstrated an active attempt to address power relations, such as domination of health care teams by doctors: [There are] turf invasion fears. [Maybe we can use] IPL [to] reduce the anxieties, such as the AMA [Australian Medical Association] worrying about nurse practitioners and [physiotherapists ] extended [scope of] practice and podiatrists worrying about podiatry assistants. (Staff member at IPL forum) 10

11 Fourth, staff demonstrated recognition of the social and organisational context and patterns in which the care of individual patients is set. For example, staff spoke in a public forum about the importance of the physical environment to shaping how staff related to each other. Through one of the improvement initiatives staff discussed ways to maximise shared spaces that create corridor conversations. The relationship between the core findings of the audit and the culture of the organisation is represented in Figure 2. [Figure 2 about here] The context of care and organisational culture that is, the shared beliefs, values and behaviours were found to influence and be influenced by professional and organisational issues. Staff used their knowledge and power to negotiate their everyday work. These four dimensions context, knowledge, power and culture represent the combination of variables that determined interprofessional relations in the health system. How interprofessional relations played out was different from service to service because these four dimensions were different in each service. The combination of variables were different in each service at dissimilar times because they involved diverse actors. This presented innumerable combinations of interprofessional dynamics featuring these dimensions. For example, in some settings staff used their knowledge either to dominate others or to negotiate what they were doing. Managers sometimes used managerial authority and doctors sometimes used the cultural authority of being a doctor to dominate others. Some services featured a struggle between professionals who wanted authority and the organisation that wanted standardisation, and negotiation that flowed from that struggle. What settings had in common during the investigation was the influence of these four dimensions in characterising interprofessional relations. Through the action research process, the researchers influenced interprofessional dynamics in relation to these four dimensions. As indicated earlier, debate among staff centred on such formal and cultural exhibitions of power and ways to redistribute power, and to make services more interprofessional and patient-centred. This was a core feature of the improvement initiatives that were generated as part of the action research process. 11

12 The research process has achieved the engagement of staff where staff and researchers have negotiated areas needing improvement in IPL and IPP. From the FEFLs more than 100 individuals and teams, representing clinicians, technicians, administrative staff and managers, registered to undertake one or more initiatives to enhance IPL or IPP with the assistance of the research team. Approximately 55 of these initiatives remain in active progress or have been completed. A sample of these initiatives is provided (Table 1): [Table 1 about here] The interprofessional improvement initiatives relate to the formal educational sphere, health services and professional bodies. They range from improvement activities to development, identification, establishment, design, integration and evaluation activities. They span care settings as diverse as pediatric services, community services, mental health services, acute medical services, acute surgical services, oncology, pediatrics, aged care and rehabilitation. The activities involve occupations as diverse as allied health staff, nurses, administrative staff, technical staff and doctors. They also reflect various combinations of context, knowledge, power and culture to identify and seek to resolve particular problems. The researchers are, to some extent, mediating these processes of identification and attempted improvement. The research team has adopted a high profile by presenting findings back to divisions verbally and in writing, and by re-visiting teams in their workplaces. The researchers and project staff in the jurisdiction have maintained a website of activities and maintained a presence in internal media. In addition to the abovementioned debates, forums and initiatives, the project and research teams have generated grass-roots support for a jurisdiction-wide policy on interprofessional learning, and to cement collaboration as one of the four values of the total organisation. The project team and research teams also jointly designed the world s first interprofessional learning policy in a health jurisdiction. The policy has since been approved. Discussion and conclusion Clearly, not all staff will have been influenced or be aware of the action research project. However, these activities are demonstrably promoting culture change. The interprofessional improvement initiatives are stimuli for practice and culture change. 12

13 They challenge conventional ways of working and promote collaboration and patientcentred care that centres less on the needs of health services and professionals, and more on the patient, surrounded by the diversity of professional skills and services that a patient needs. The project has shown that action research can be an effective strategy to promote change in shared behaviour in the direction of IPL and IPP. Action researchers engage directly to promote outcomes at the frontline of service delivery or where clinicians negotiate care with each other. Through action research, researchers become enmeshed in the same interdependent web of influence that builds culture through interaction. This highlights the primary of influencing culture for translating policy to practice. Figure 3 shows the determinants of interprofessional culture, as evident in this research. [Figure 3] The abovementioned initiatives, and IPL and IPP more broadly, have been shaped by: structures, values; care settings; and behaviour. These determinants are interrelated. Prevailing organisational and social structures create constraints and opportunities for IPL and IPP. Differences in care settings, such as whether acute or community-based influence the degree to which IPL and IPP can be exercised. IPL and IPP depend, to some extent, on the values and commitment of staff, which both influences and is influenced by structures. Behaviour is the manifestation of structures, values and care settings which are the in situ reflection and creation of, or resistance to, structures in interaction. Behaviour is the interaction that involves either: the transfer of knowledge during the application of practice-based or formal knowledge to a particular clinical or organisational decision; or the creation of new knowledge during the transfer of known knowledge (Quinlan, 2010). The findings serve to redress the assumption, addressed in the Introduction, that policy will unproblematically be translated into practice. This assumption leads to a distancing between management and workers, creating an artificial and unproductive distinction and competition. The translation of policy relies on its congruence with local settings and staff priorities. Such priorities are not necessarily fixed and can be altered or negotiated. Staff priorities may, for instance, require being valued and to simply be given reasons for particular managerial actions occurring. Action research engages researchers directly in the world of practice, and creates an opportunity for 13

14 them to be involved in the translation of system-wide policies into practice. The findings show that the project fulfills the aims of action research. By implication, an action research approach can help generate culture change where the research is formally and informally supported by managers and when staff across the service are involved, encouraged, and engaged reflexively in their work environments. Action research can promote a culture of interprofessionalism beyond formal policy mandates that generally characterise attempts at improving the quality and safety of patient care. This, of course, does not mean that most, or even a majority of staff, or even those most powerful, have been persuaded to enhance their work practices in the direction of interprofessionalism. Promoting culture change does not necessarily constitute culture change. Nor does it mean that counter forces cannot slow, distract or disable the momentum towards interprofessionalism. This article documents improvement that is attributable to the action research process, laying out the value of action research in translating policy to practice across a whole health system. More research is needed to test the culture of such organisations systematically over a number of years. 14

15 References Adams, J. (1995) Risk. London: UCL Press. Borins, S. (2009) The new public management is here to stay. Canadian Public Administration. 38(1), Braithwaite, J., Greenfield, D. and Westbrook, MT. (2010) Converging and diverging concepts in culture and climate research: cultate or climure? In: Braithwaite, J., Hyde, P. and Pope, C. (eds) Culture and Climate in Health Care Organizations, London, Palgrave Macmillan, pp 7-18, ISBN [ Braithwaite, J., Iedema, R., Westbrook, J., Foxwell, A.R., Boyce, R., Devinney, T., Budge, M., Murphy, K., Ryall, M-A., Beutel, J., Vanderheide, R., Renton, E., Travaglia, J., Stone, J., Barnard, A., Greenfield, D., Corbett, A., Nugus, P. & Clay-Williams, R. (2007) An action research protocol to strengthen systemwide inter-professional learning and practice. BMC Health Services Research, 7(144). Braithwaite, J. & Travaglia, J. (2005a) The ACT Health Interprofessional Learning and Clinical Education Project: Discussion Paper #3 [Interprofessional Relations]. Canberra: ACT Health Department. Braithwaite, J. & Travaglia, J. (2005b) Interprofessional Learning and Clinical Education: An Overview of the Literature. Canberra: ACT Health Department. Braithwaite, J., Westbrook, M.T., Iedema, R., Mallock, N.A., Forsyth, R. and Zhang, K. (2005) A tale of two hospitals: assessing cultural landscapes and compositions, Social Science & Medicine, 60 (5), [doi: /j.socscimed ]. Charlton, B.G. (2001) Quality Assurance auditing as a managerial technology: Clinical governance and the managerial regulation of NHS medical practice. In A. Miles (Ed.) Clinical governance: Encouraging excellence or imposing control? London: Aesculapius Medical Press. Dawson, S. & Dargie, C. (2002) New public management: A discussion with special reference to UK health. In McLaughlin, K., Osbourne, S.P. & Ferlie, E. New Public Management: Current Trends & Future Prospects. London: Routledge, pp Furedi, F. (2005) Politics of fear: Beyond left and right. London: Continuum. Glaser, B. (1992) Basics of Grounded Theory Analysis: Emergency versus Forcing. Mill Valley, CA: Sociology Press. Goffman, E. (1959) The Presentation of Self in Everyday Life. New York: Anchor Books. Greenfield, D., Nugus, P., Travaglia, J. & Braithwaite, J. (forthcoming) Auditing an organisation s interprofessional learning and interprofessional practice: The interprofessional praxis audit framework. Journal of Interprofessional Care. Greenfield, D., Nugus, P., Travaglia, J. & Braithwaite, J. (2009) Professional development through an action research project stimulating an interprofessional culture to enhance quality and safety. Twenty-sixth International Safety and Quality Conference: Designing for Quality, October 11-14, 2009, Dublin, Ireland. Griffiths, L. (2003) Making connections: Studies of the social organisation of healthcare. Sociology of Health & Illness, 25(3), Gutmann, A. and Thompson, D. (2004) Why Deliberative Democracy? Princeton, NJ: Princeton University Press. 15

16 Heinemann, G.D., Schmitt, M.H., Farrell, M.P., Brallier, S.A. (1999) Development of an Attitudes toward Health Care Teams Scale. Evaluation & the Health Professions, 22(1), Meyer, J. (2000) Using qualitative methods in health care. British Medical Journal. 320, Noordegraaf, M. & Abma, T. (2003) Management by measurement? Public management practices amidst ambiguity. Public Administration, 81(4), Nugus, P. (2008) The interactionist self and grounded research: Reflexivity in a study of Emergency Department clinicians. Qualitative Sociology Review, 4(1), Parsell & Bligh. (1999) Validating the Readiness for Interprofessional Learning Scale (RIPLS) Medical Education, 40(5), Quinlan, E. (2010) The actualities of knowledge work: An institutional ethnography of multi-disciplinary primary health care teams. Sociology of Health & Illness, 31(5), Schein, E. (2004) Organizational culture and leadership (5th ed.) San Francisco, CA: Jossey-Bass. Walsh, S. & Fegan, C. (2007) Action learning: facilitating a real change for part-time occupational therapy students. Action Learning: Research and Practice 4(2), Whitehead, D. (2005) Project management and action research: Two sides of the one coin? Journal of Health Organization & Management, 19(6), Wiener, C.L The Elusive Quest: Accountability in Hospitals. Hawthorne, NY: Aldine de Gruyter. 16

17 Figure 1. The IPL-IPP action research cycle in health services (Source: Greenfield et al, 2009) Audit of baseline IPL-IPP Action research feedback sessions with staff Staff IPL- IPP Initiatives Staff IPL- IPP Initiatives Assessment of ongoing development of IPL-IPP culture Assessment of ongoing development of IPL-IPP culture 17

18 Figure 2. Promoting interprofessional culture change (Source: Greenfield et al, 2009) CONTEXT organisational KNOWLEDGE POWER professional CULTURE 18

19 Table 1. A Selection of Interprofessional Improvement Initiatives A selection of completed or active interprofessional improvement initiatives Developing interprofessional pediatrics induction pathway Building an interprofessional surgical team Enhancing interprofessional teamwork in Palliative Care Improving interprofessional recovery planning in Mental Health services Embedding interprofessional chronic disease management in general practice and primary health care Integrating IPL perspectives in the development of a new simulation centre Evaluating the impact of the IPL policy Evaluating culturally competent and interprofessional strategies to retain Aboriginal women as clients in maternity care Identifying the role of non-health professionals as members of IPL teams Evaluating information-sharing in acute aged care Improving the transition of complex rehabilitation clients from the hospital to the community Evaluating doctor-nurse collaboration in Corrections Health Integrating IPL into the health system s mandatory training program Identifying and analysing clinical incidents involving interprofessional issues Developing an IPL simulation training ward Assessing the impact of IPL and IPP in professional accreditation and registration bodies 19

20 Figure 3. Determinants of interprofessional culture 20