Unpacking the black box of interprofessional collaboration within healthcare networks: a scoping review

Abstract

Introduction

Health systems are facing increasingly complex healthcare challenges, including system fragmentation, silos culture, lack of accountability, budgetary constraints and epidemiological transitions. Many governments adopted healthcare networks as a new strategy to address the complex healthcare challenges (eg, multidisciplinary care) by fostering effective clinical and interprofessional collaboration (IPC) across clinical pathways. Yet, limited evidence exists on how IPC is fostered within healthcare networks (ie, happening inside the structure of the network—including processes, systems, communication and practices).

Objectives

This review aims to identify the underlying processes and drivers for effective IPC within healthcare networks, as well as facilitators and barriers.

Design

We followed the scoping review guidance developed by the Joanna Briggs Institute and Preferred Reporting Items for Systematic Review and Meta-Analysis for Scoping Reviews reporting guidelines.

Data sources

We searched five databases (PubMed (Medline), Scopus, Web of Science, Research4Life and BDSP).

Eligibility criteria

We included peer-reviewed articles published between 2010–2024 in French or English that addressed IPC within healthcare networks.

Data extractions and synthesis

Data charting included the general characteristics of included studies, IPC characteristics, barriers and facilitators and implications for policy and practice. Thematic analysis was guided by the levels of IPC at individual, professional, interactional and organisational levels.

Results

29 studies were included in this review. Most scholars from the included studies indicated that IPC is a complex, socially stratified process that includes four levels: individual, interactional, professional role and organisational characteristics. The main barriers were poor communication, lack of shared knowledge and decision-making, hierarchy and power imbalances. Key facilitators included clarifying roles, building formal structures for IPC, enhancing communication and promoting interprofessional education and training.

Conclusion

Promoting IPC necessitates systemic interventions that target multiple levels, including the individual, interactional, professional and organisational dimensions. Additional research is needed to understand how to foster effective IPC and develop strategies to ensure high-quality patient care.

STRENGTHS AND LIMITATIONS OF THIS STUDY.

• This review follows the methodological guidelines of scoping reviews by the Joanna Briggs Institute and Preferred Reporting Items for Systematic Review and Meta-Analysis for Scoping Reviews.

• The searches were carried out systematically in five databases between 2010 and 2024.

• Thematic analysis of interprofessional collaboration was guided by a multilayered theoretical framework

• This review does not include quality as it is not required in scoping reviews.

• The review might have disregarded articles published in languages other than English and French.

Background

In recent decades, increased attention has been paid to the creation of healthcare networks, an interorganisational structure to address the lack of care integration and the silo culture between healthcare organisations in both high-income¹,³ and low and middle-income countries.^{4 5}

Healthcare networks are heterogeneous forms of interorganisational collaboration, which can be defined by groups of three or more organisations connected in ways that facilitate achievement of a common goal.^{6 7} Healthcare networks can take several forms, such as hospital groups, hospital networks and accountable care organisations.^{2 8 9} Other healthcare networks can combine hospitals with community care and primary healthcare institutions.⁵

They are considered to be suitable interorganisational partners for mutualising resources, increasing organisational joint capacity, organising coordinated clinical pathways and reinforcing interprofessional collaboration (IPC) and timely response to emergent outbreaks (eg, COVID-19).¹⁰,¹³ IPC improves the management of patients through effective coordination and integration of care, leading to the delivery of comprehensive, global, high-quality care and improved population health outcomes.¹⁴

IPC is defined as ‘when multiple health workers from different backgrounds work together with patients, families, caregivers and communities to provide high-quality care’.¹⁵

IPC involves the sharing of knowledge, skills and expertise among healthcare professionals. It emphasises the importance of mutual respect, team structure and processes to promote effective interprofessional teamwork.^{16 17} Evidence suggests that IPC in healthcare improves patient safety, health outcomes, work satisfaction and enhanced delivery of person-centred care.¹⁸,²¹

IPC is essential for optimising patient and population-centred care. It involves working with other health professionals to maintain a respectful, diverse, ethical and trusting environment. This involves assessing and addressing healthcare needs, communicating effectively and participating in various team roles to ensure safe, timely, efficient, effective and equitable care.²²,²⁴

However, several challenges hamper effective IPC within healthcare networks, leading to insufficient coordination of medical activities across clinical teams.^{25 26} This is often attributed to a lack of joint capacities to support interorganisational collaboration, lack of political support, silo and top-down hierarchical cultures across clinical departments.¹¹²⁷,²⁹

Recently, increased attention of policymakers, funding agencies and clinicians has been drawn towards addressing these gaps by strengthening IPC across professions, sectors and organisations to enhance the quality of care and to ensure efficient integration of healthcare systems, cost containment and efficient healthcare delivery.³⁰,³²

Although researchers have explored IPC in various settings, less attention has been given to facilitators and barriers of IPC within healthcare networks.³³,³⁶ Recent reviews focused on interorganisational and collaborative governance frameworks,^{4 13 37 38} which provide a systemic understanding of collaborative dynamics focusing on macro levels of collaborative governance regimes.⁴ They are ill-suited to explore the agency of actors and the characteristics of professionals working in healthcare networks. To fill this gap, we aimed to map the different configurations and levels of IPC, the underlying processes, strategies, barriers and facilitators to effective IPC within healthcare networks. First, we aim to identify the underlying processes for effective IPC within healthcare networks. Second, we aim to map IPC reported intended and unintended outcomes. Third, we aim to identify potential reported facilitators and barriers.

Methods

This scoping review was conducted in line with scoping review methodological guidance by Arksey and O’Malley³⁹ and the Joanna Briggs Institute (JBI).^{40 41} We followed the Preferred Reporting Items for Systematic Review and Meta-Analysis reporting guidelines for Scoping Reviews.⁴²

IPC framework

As indicated in figure 1, we used an integrative conceptual model in interpreting the results of this scoping review.⁴³,⁴⁵ These frameworks are inspired by the social exchange theory, which suggests that understanding social structures through interpersonal transactions is essential for unravelling complex social behaviours between groups.⁴⁶ This includes understanding the intertwined relationship between individual professions’ characteristics, their professional roles, interactional characteristics with other professional groups and organisational characteristics.

Figure 1. Different levels underlying effective interprofessional collaboration.

Individual characteristics include age, sex, seniority on the team and individual beliefs in the benefits of interdisciplinary collaboration. The interactional characteristics include the following processes: (1) knowledge sharing and integration, (2) team characteristics (affective commitment toward the team, autonomy, participative decision making, mutual trust, team climate and team conflict).⁴⁴ Professional role characteristics referred to professional profiles and multifocal identification profession (represent values, experience and expertise that members bring to teams). Organisational characteristics refer to organisational support and team size.⁴⁴

Identifying relevant studies

To define our review question, we used population-concept-context,⁴¹ where population corresponds to healthcare professional, with IPC as the key concept under study and the context was limited to healthcare networks also expressed as ‘hospital networks’ or ‘hospital grouping’ or ‘accountable care organisations’.

We only included: (1) primary peer-reviewed book chapters and grey literature that addressed IPC within healthcare networks (accountable care organisations, hospital networks or hospital grouping); (2) mixed methods studies, quantitative and qualitative studies, and no limitation was set related to the study design; (3) studies published in French or in English between January 2010 and August 2024. We did not restrict our searches to any geographical area.

We excluded (1) studies that were not conducted in the context of healthcare networks (eg, health centres, isolated hospitals); (2) studies that did not focus primarily on IPC such as topic addressing IPC from the perspective of focused healthcare education, its roles in palliative care and in complementary medicine, telehealth and telerehabilitation; (3) digital IPC; (4) literature reviews, thesis, commentaries and editorials.

Search strategy and sources

We searched relevant studies in five electronic databases: PubMed (Medline), Scopus, Web of Science, Research4Life and BDSP (‘Base de Données en Santé Publique’, a database in French relevant for identifying grey literature about hospital territorial groups, a French experience, often published in French language) (see online supplemental file 1).

According to JBI’s guidance for the conduct of scoping reviews,⁴¹ we developed search strategies using a combination of text words and index terms and carried out references tracking. The search equation used was as follows: ((“interprofessional collaboration” OR “interprofessional coordination” OR “interprofessional cooperation” OR “collaborative care” OR “multidisciplinary teams” OR “team-based care” OR “service integration” OR “integrated healthcare” OR “care integration” OR “coordination services” OR “healthcare collaboration”) AND (“networks” OR “grouping” OR “mergers” OR “alliances” OR “groups”) AND (hospitals OR “accountable care organisations” OR “groupements hospitalier territoire” OR “hospital network reforms” OR “territorial hospital groups”)). The search strategies for databases are shown in online supplemental file 1.

Study selection

We used Zotero reference management software to manage references and duplicate removal. In a first step, title abstract screening was carried out by the first author, and 20% of articles were checked by the second author in line, with methodological guidance from the Cochrane collaboration handbook.⁴⁷ In the second step, two authors reviewed independently the full-text articles and included them based on the predefined inclusion criteria. Any disagreements were resolved by discussion.

Data charting

Our data charting forms are composed of four sections: (1) the general characteristics of included studies (author, date publication, country of origin, study objectives, study designs, type of healthcare networks and participants).; (2) key IPC characteristics (levels and processes); (3) main barriers, facilitators to IPC (4) key implications for policy and practice.

Reporting of findings and synthesis

We adopted an abductive (deductive and inductive) approach in thematic analysis. We used the data charting forms to guide the coding process, but that was not restricted to it. We were sensitive to emergent themes identified inductively and guided by our review questions.

Results

Search results

As indicated in figure 2, a total of 906 studies were retrieved. 35 additional studies were identified through reference tracking. After removing duplicates, the titles and abstracts of 822 articles were screened. A total of 626 studies were excluded. 196 full texts were analysed for eligibility, and 167 studies were excluded with reasons (see online supplemental file 2). Most of the articles that were excluded were not investigated in healthcare networks or not focusing on IPC. Also, the reference list of included studies was screened for additional relevant articles. Finally, a total of 29 articles were included.

Figure 2. Flow chart of the study selection process. IPC, interprofessional collaboration.

General characteristics of included studies

Our review showed that 24 studies out of 29 were conducted in high-income countries (see online supplemental file 3, table 1): USA (n=6),⁴⁸,⁵³ Netherlands (n=4),⁵⁴,⁵⁷ Switzerland (n=2),^{58 59} Norway (n=1),⁶⁰ Ireland (n=2),^{61 62} Canada (n=3),^{44 63 64} Germany (n=1),⁶⁵ France (n=2),^{66 67} Australia (n=1),⁶⁸ Italy (n=1) and⁶⁹ Japan (n=1).⁷⁰ Two studies were carried out in lower-middle income countries: Pakistan (n=1) and⁷¹ Philippines (n=1)⁷² and three studies in upper-middle income countries: Iran (n=2) and^{73 74} Indonesia (n=1).⁷⁵

We found that 12 studies out of 29 studies were qualitative studies using focus group discussions and individual interviews, and 11 studies were quantitative. Only four studies used mixed methods designs. Among these, two studies used social network analysis to explore the density of social interactions between healthcare networks members.^{61 62} Two studies were grey literature reports from the French territorial hospital groups.

Characteristics of healthcare networks

The organisational configurations of healthcare networks depend on the context where this reform is implemented, its objectives, strategies and outcomes (see online supplemental file 3, table 1). For instance, the accountable care organisation (ie, private healthcare networks in the USA) represents an innovative healthcare delivery model to which participant hospital members and physicians are enrolled on a voluntarily basis and thus have mutual engagement to provide good quality of care to a designated population of patients and to reduce overall costs.^{52 53}

In contrast, the ‘regional territorial hospital groups’, such as in France, are networks based on a mandatory partnership that obliged healthcare professionals to follow the shared medical projects, a regulatory process to promote coordination between hospitals and are intended to facilitate the organisation of medical technical activities, the convergence of information systems and the mobilisation of healthcare providers.⁶⁷

Other hospital networks prioritised decentralisation (ie, regionalization) to improve service delivery and coordination between hospitals and health providers. In these settings, healthcare networks are organised into local service networks to provide health and social services to catchment area populations.⁴⁴

IPC

IPC was defined as ‘the process by which different health and social care professional groups work together to positively impact care, which includes communication and decision-making, enabling a synergistic influence of grouped knowledge and skills’^{60 72} (see online supplemental file 3, table 2).

We found that the underlying processes to effective IPC rely on four different mechanisms: (1) individual characteristics of network members, (2) the professional role, (3) interactional characteristics and (4) organisational characteristics of networks of care (see table 1).

Table 1. Key characteristics according to different levels of IPC.

Individual characteristics	Professional role	Interactional characteristics	Organisational characteristics
Sociodemographic characteristics can have an impact on IPC. 44 64 65 68 69 71 73 75 Divergent personal values and beliefs can hinder IPC.57 64 69 72 73	Professional hierarchy and professional status can reduce IPC.55 59 63 65 68 70 72 73 Power imbalance can hinder IPC.57 59 73 74 Clarifying roles to avoid misunderstandings.4854 55 57,59 64 65 68 69 71	Developing interpersonal relationships between leaders, enhancing trust and shared reflection among team members. 48 54 56 57 61 64 74 Promoting a positive team climate, knowledge sharing and integration. 44 48 55 58 60 73 75 Promoting positive attitudes toward IPC, encouraging professional and team identification. (54 55 57 65 73 74 Remaining alert to tensions to keep positive interpersonal relationships as well as sustaining the team dynamic. 44 63 68 69 73 75 Some engagement strategies that managers employed in engaging physicians: (1) individualism; (2) relationship-building, which builds a positive relationship with another group by dialogue with physicians; (3) subgroup engagement, which prioritises subgroup identity; (4) intergroup partnership, which emphasised collaboration around shared values.53	Increasing interprofessional communication and providing communication tools. 4855 57,59 69 Formal structures or guidelines for IPC within healthcare settings. 57 68 72 75 Positive leadership. 58 59 63 68 70 72 75 Offering interprofessional education/training. 4854,58 63 Elaborating a common medical project, the establishment of territorial medical teams and the territorialisation of hospital directors’ responsibilities.66 67

IPC, interprofessional collaboration.

Scholars of included studies emphasised the prominent role of interactional factors in driving IPC processes. They also stressed the influence of professional role characteristics and the importance of organisational support to facilitate IPC processes between different levels (see online supplemental file 3, tables 3–6).

Individual characteristics

Our review findings suggest that IPC is influenced by sociodemographic variables: year of graduation, age group, position, work experience, gender and working in a hospital or in the community.^{44 64 69} Professionals with experience over 5 years, aged over 40 years, who had a management position reported better IPC.⁶⁹

Professionals felt more comfortable in communicating and interacting with coworkers who are similar in age or with similar levels of experience.^{68 73} Whereas senior doctors were less involved directly in interprofessional activities. They influence IPC by altering the work environment of team members.^{64 68 75} In contrast, other scholars found a marginal association between younger age and IPC.⁴⁴

Most healthcare professionals from included studies recognised the necessity of IPC in providing effective patient care and the benefits of interdisciplinary collaboration.^{48 58 64 73} Additionally, female professionals reported higher levels of collaboration and had a better understanding of each other’s responsibilities than their male counterparts.⁶⁹

For instance, Ndibu Muntu Keba Kebe⁶⁴ identified four typologies of health workers: highly collaborative female professionals (engaged in knowledge sharing and integration who reported fewer conflicts), highly collaborative male professionals (with fewer conflicts, higher participation in decision-making and who instils strong mutual trust), moderately collaborative female psychosocial professionals (less participation in decision-making) and slightly collaborative professionals with senior professionals (who reported many conflicts and less knowledge integration and mutual trust).⁶⁴ This typology suggests the heterogeneity of beliefs and shared norms among health workers. Our review suggests that divergent personal values and beliefs among professionals from various disciplines hindered IPC in healthcare.^{57 69 72 73} Others suggest the primacy of personality traits, communication skills such as open communication, good manners, non-violent communication in facilitating interpersonal communication and collaboration.^{68 72} In contrast, personality clashes, egos, pride and closed-mindedness affecting teamwork and communication were reported as key barriers to IPC.^{72 75}

Scholars, from included studies, found that reinforcement (when physicians repeatedly cared for patients with the same colleagues) and clustering (when physicians who worked together also had other colleagues in common) were associated with high levels of reported teamwork.⁴⁹ Others suggested that individual incentives focusing on raising personal interests and rewards oriented towards team collaboration improved individuals’ perception of the benefits of teamwork and team cohesion.^{56 58 72 73} Jabbar et al and Van Duin et al^{65 71} highlighted the importance of providing a safe environment for junior doctors where they can reflect on their IPC experiences and emotional reactions under the supervision of experienced facilitators to their professional development.

Professional role characteristics

Scholars of included studies found different professional characteristics that influenced IPC. These include professional role and responsibility, professional status, as well as professional hierarchy and professional identity among health professionals.

Professional role and responsibility

Our review suggests that clarifying roles and responsibilities among healthcare providers can reduce conflicts in collaborative situations and enhance IPC among different professionals.^{4854 55 57},59 64 65 68 69 71 Multiple healthcare professionals described that they were unaware of other roles; as a result, they were unsure of when to involve them in patient care.⁴⁸⁵⁶,58 60 63 65 68 71

Role ambiguity creates staff resistance to change and reluctance to engage in IPC^{58 59} (eg, general practitioners who feared losing their responsibilities while referring a patient to specialists). Many included studies reported that role ambiguity hinders the engagement of young physicians who often lack explicit feedback on their role within interprofessional teams, which makes it difficult for them to understand their own roles and the roles of other team members.^{63 65 68 71} This creates what scholars call ‘blurred boundaries’ between professions, which refers to ‘the overlapped areas of specialties and professional roles’ particularly in rural environments.^{63 68 70} This can lead to role ambiguity and conflicts.^{44 48 54 73}

To address this, scholars called for interprofessional role models as standards for roles and responsibilities, which reduces role conflicts, misunderstandings and helps identify knowledge and competencies needed to fill each specific professional role.⁵⁷,^{5968 71 72} Moreover, scholars emphasised that professional responsibility, a core component of collaborative practice along with shared understanding and commitment of interprofessional teams, is a key lever to achieve quality of care, patient-centred care and health outcomes.^{48 55 59 63 75}

Professional status, hierarchy and identity

Difference in professional status and responsibilities may affect the perceptions and beliefs about IPC.^{55 59 63 72} Scholars reported that specialists generally perceived a higher level of interprofessional conflicts associated with collaboration compared with general practitioners, which may explain why they are often reluctant to engage in IPC,^{44 59 71 73} while the historical power imbalance between different professions was identified as the main barrier to IPC, which can lead to conflicts and reduce the effectiveness of IPC at different levels.^{57 59 73 74} Other scholars reported that interprofessional boundaries, also called ‘professional curtains’, hindered learning from feedback, reduced the ability of some physicians to anticipate other professions’ needs and their willingness to discuss new practices and preference towards patient treatment by a single professional, leading to professional and cultural silos.^{65 69}

Professional hierarchy can lead to a decrease in the quality of care. This was often attributed to a lack of patient-centred perspective, lack of sharing of patient information and lack of global integrated care across patients pathways.^{59 63 72} Professional hierarchy also reduces the ability of health workers to collaborate with physicians outside their professional groups, called outsiders, and prefer to deal with patients cases without sufficient collaboration and coordination with other providers.^{69 72 73}

Our review highlighted differences across age groups in relation to strict adherence to professional hierarchy, mostly supported by senior physicians who often lacked frequent interaction with other professionals, who preferred working with junior doctors.^{64 68 75}

Additionally, Morris and Matthews and van Duin et al^{63 65} emphasised that junior physicians’ performance and leadership abilities are frequently overlooked during performance review, and their interprofessional learning often remains implicit in the form of tacit knowledge. This hinders the ability to transfer these learnings to other members of the clinical teams.

Our review also suggests that in rural settings, professional hierarchy is often exaggerated. This may be attributed to the value given by the community to the role of rural physicians, whose opinions are considerably more valued than those in urban settings, which may improve patient safety.^{63 70}

Professional identity can lead to improved collaboration if professionals value the role of other health workers.^{48 54 74} Van Duin et al⁶⁵ reported that junior doctors build their professional identity on the perceived values of each professional role within their own medical or nursing community of practice. To promote IPC, scholars from included studies suggest that it is important to address value congruence and build a shared collective interprofessional team rather than a profession-based identity.^{55 57} Indeed, the shared group identity stimulates the interaction between health workers beyond organisational and professional boundaries.

Interactional characteristics

Interactional factors are the processes underlying IPC, which include knowledge sharing, knowledge integration, team dynamics processes including affective commitment, autonomy, participative decision making, mutual trust, team climate, team conflict and effective communication.

Team characteristics

Affective commitment towards the team and willingness to collaborate with various types of healthcare professionals can contribute to facilitating informal communication.^{44 55 57 64 68 72} Evidence suggests that casual interactions and informal conversation facilitate better understanding of their roles and responsibilities.^{56 63 68 73}

Scholars suggest that the downside of implementing vertical health programmes focusing on a single health issue may prevent a deeper engagement of health professionals in IPC and may lead to demotivation, burnout and workload overload.^{71 73} Other scholars reported that healthcare settings financially autonomous, influenced by the number and type of care provided, may discourage multidisciplinary team collaboration and create situations of competition, which may affect global integrated patient care.^{54 56 69}

Positive attitude towards engaging in IPC is considered a facilitator to effective IPC. Scholars reported that in general, healthcare professionals had a positive attitude towards IPC due to the increasing complexity of patient care.^{48 59 60 71 75} However, cultural perceptions and organisational culture can influence the attitudes of health professionals and can affect how professionals perceive each other’s roles.^{55 58 65 68 70 72 73} Other scholars indicated a discrepancy in mutual perceptions of IPC between health professionals^{54 55 73} or disparities in health professionals’ perceptions of other groups, suggesting the need for improved recognition and appreciation among different professions.^{56 69 74}

In rural areas, scholars suggest that most healthcare professionals were uncertain about the relevance and benefits and had limited understanding of the concept of IPC and its usefulness because of their limited education and experience.^{63 68 70} Ohta et al⁷⁰ reported that there was poor communication in rural areas between care managers and physicians, which is due to the lack of medical knowledge of the role of care managers.

Scholars called for fostering positive interpersonal relationships, which can enhance IPC by facilitating communication and collaboration as well as sustaining positive team dynamics.^{63 68 69 73 75} Whereas lack of mutual respect, limited interpersonal cohesion,^{48 56 73} lack of mutual trust,^{48 56 57} limited knowledge sharing across different levels of care^{55 56 70} and lack of shared goals and vision^{57 71 75} were identified as principal threats to IPC between professional groups.

Most healthcare professionals perceived that effective IPC is underlined by mutual trust and mutual respect, key ingredients to a cohesive network of healthcare professionals.^{57 72 75} Thus, fostering a collaborative culture of mutual respect and trust, valuing collaboration within healthcare settings can lead to more coordinated and patient-centred care.⁴⁸⁵⁴,58 63 64 73 74

Also, scholars highlighted the importance of shared knowledge and organisational learning^{44 55 57 63 64 68 70} and the inclusion of health workers in decision-making processes in regards to efficient patient care.^{48 55 64 72 73}

Challenges for effective communication

Scholars found that open communication, referred to as higher levels of communication and accommodation, leads to improved flexibility and adaptability between professionals and may lead to better IPC and positive interactional dynamics between healthcare professionals,^{55 69} while hierarchical structures or unsupportive organisational structures in healthcare can create barriers to open communication and collaboration among healthcare professionals.^{59 64 65 68 70 74}

Organisational siloed structures, physical separation and organisational boundaries in different care settings often prevent effective joint deliberation and reduce effective communication,⁵⁶,^{5963 68 70} which in turn leads to limited interaction between healthcare professionals.^{55 56 72}

In such settings, often, health workers develop parallel channels for communication, known as ad hoc collaboration that occurs occasionally in single institutions, focusing on general administrative concerns rather than around patients’ needs.⁷² Communication and collaboration were limited to patient referrals, without involvement of various practitioners and different organisations involved in clinical pathways.^{55 70 72} Coordination issues arose during referrals between care levels, creating tension between maintaining a balance between optimising patient flow and responding to patients’ needs.^{63 74}

In this regard, scholars showed that reinforcement and clustering are key social mechanisms leading to improved reported quality of teamwork,⁴⁹ whereas the network density (when physicians worked with a higher proportion of other physicians) was not directly associated with higher teamwork.^{49 55 69}

Additionally, the organisation of healthcare services and the quality of workplace settings influenced the frequency and quality of IPC.^{44 60 69 74} Scholars identified good working relationships and a positive working culture as facilitators to effective IPC and communication.4448 55 58 60 68,^{70 73 75} They emphasised the need to improve IPC by increasing multidisciplinary meetings.^{48 54 56 57 68 70} These spaces for collaboration and connectivity can facilitate discussions and sharing experiences between different levels and an open atmosphere for communication and feedback on care quality and guideline development.^{48 55 57 58 69 70 74 75}

In this interface, Walmsley et al⁶⁸ identified the seminal role of case management workers to manage complex cases within complex multidisciplinary team cases by coordinating care across different disciplines for effective IPC.

Informal effective communication

Informal effective communication relies on relationship-building based on building positive relationships, participative decision making between physicians, creating a professional and/or organisational identity,^{48 55 63 69 72 73 75} building intergroup closeness between physicians and managers^{51 53 61 62} and intergroup partnership with emphasis on collaboration around shared values.^{48 54 57 74}

Scholars reported that informal clinical integration, which often occurs during interactions between primary and specialty care physicians, was considered an appropriate flexible strategy to remove professional and physical barriers.^{50 52}

This can be done through the reduction of status difference, encouraging communication and collaboration among physicians and knowledge sharing using health information technologies.4850 55 56 58 59 70,^{72 74}

Our review suggested the importance of informal clinical integration which reinforces within specialty ties, promotes continuity between patient and physician and reduces the impact of professional curtains emerging from the need for specialisation of care.⁵² Scholars highlighted that higher levels of informal clinical integration were associated with lower care delivery payments for cardiac surgery. ^{50 52}Yet, fragmentation of care, lack of coordination and poor communication can be considered as key barriers to informal clinical integration and increased cost for patients, leading to poor quality of care.⁵⁰

Organisational characteristics

Organisational support

Our scoping review identified several organisational barriers hindering IPC. This includes organisational resource constraints and logistical challenges,^{5865 70},^{72 74 75} hierarchical barriers and bureaucracy,^{56 57 65 71 72 74 75} lack of formal structures or guidelines for IPC,^{57 68 72 75} lack of leadership,^{55 57 59 68 70 71 74 75} lack of appropriate size of healthcare professional’s network (team too large or too small)^{58 71} and lack of training in IPC.⁴⁸⁵⁵,58 65 68 70 71

Leadership

Strong distributed leadership and participative decision-making support were considered essential in order to develop policies and guidelines that facilitate collaboration across professionals and institutions.^{59 72}

Required leadership capabilities to promote IPC need to involve frequent communication using team meetings and inspirational motivation towards shared goals and idealised influence fostering mutual respect and trust.^{63 68 75} Walmsley et al⁶⁸ recommended assertive followership models of leadership, which involves IPC by encouraging team members from all levels, regardless of their professional hierarchy, to actively engage them in decision-making. This refers to the notion of collective leadership, understood as the dynamic process where leadership tasks and responsibilities are shared among several team members, fosters interprofessional cooperation and improves team performance.^{61 62} Collective leadership contributes to developing shared understanding, common working practices and maximising the use of group knowledge and expertise and removes obstacles to interorganisational cooperation and system integration in healthcare.^{54 61 63 74}

In healthcare settings, collective leadership emphasised the leadership capacity of teams rather than individuals. It promotes a positive workplace culture that guarantees the continuous improvement of high quality and the creation of a holding environment.^{58 62 68 70 72}

Collective leadership also allows for the reinforcement of existing social networks⁵³ and improved boundary spanning by building trust among colleagues, fostering interpersonal relationships, providing time and space for indepth and shared reflection, which are important conditions for enabling collective leadership in hospital networks.^{61 63 75}

However, the lack of legislation underpinning the healthcare network, the delays in formalising the new health system structures, lack of autonomy of hospital groups and restricted ability to function as an independent entity were major barriers to collective leadership within healthcare networks.⁶¹

Barriers and facilitators to IPC

Barriers and facilitators according to IPC levels reported in included studies were summarised in online supplemental file 3, table 6. Scholars reported major barriers to IPC, particularly at professional role and interactional characteristics, with organisational challenges.

Main barriers to IPC at the professional role level included role ambiguity,^{4854 56},58 60 63 65 68 71 professional hierarchy,^{59 63 65 68 70 72 73} professional status^{44 55 59 63 72} and power imbalance.^{57 59 73 74}

Interactional barriers referred to a lack of shared goals and vision,^{57 71 75} poor respect and trust,^{48 56 57 73} lack of motivation and commitment in IPC,^{71 73} poor interprofessional attitudes towards IPC^{55 56 69 73} and lack of shared knowledge.^{55 56 70}

Scholars reported that facilitators of IPC at professional role and interaction between health professionals include clarifying roles and responsibilities, shared goals, mutual respect, effective communication, affective commitment toward the team, team autonomy, relationship building and common identity and culture.4854 55 57 58 64 65 68,^{70 72}

Effective strategies for IPC

Scholars reported that healthcare organisations should create an enabling environment that fosters IPC by providing adequate resources and support for team-based care and a favourable organisational setting that promotes IPC⁵⁸,^{6064 70}; building formal structures or guidelines for IPC within healthcare settings for an integrated healthcare system to improve service delivery^{57 68 72 75}; adapting organisational structures and procedures to support IPC^{58 68 75}; enabling structured information exchange: effective information exchange and organisational learning were identified as key organisational levers for IPC, particularly for the timely and proper exchange of information (eg, interprofessional communication platforms, improved communication systems and tools for structured communication).⁵⁵,^{5863 70}

Other scholars called it important to provide incentives that promote the performance of both individuals, the team and interorganisational collaboration in order to foster collaboration within the system.^{56 58 72 73} This includes interprofessional education and training programmes to foster IPC skills.⁴⁸⁵⁴,^{58 63} Communication was identified as the most important competency for IPC that enhances teamwork and enables cohesive team performance.^{48 55 63 69} Thus, supportive healthcare policy is required to ensure such as interprofessional communication platforms and digital communication tools that can overcome barriers to communication across different care settings to better clinical decision making.⁴⁸⁵⁵,^{58 63 69} Organisational managers can also reduce hierarchical boundaries and status differences by, for instance, nominating interprofessional role models and skilled case managers.^{5455 57},59 65 68 71

To promote IPC within healthcare networks, scholars referred to the importance of leadership training programmes, executive development, financial incentives and health information systems.^{55 56 58 59 66 67 71 72 75} Scholars reported that healthcare reforms that prioritised shared accountability and collective incentives for collaborative practice may motivate physicians to develop better social networks and stronger relationships.^{5156 58},^{60 72 73}

Specific strategies to break down professional silos and to promote a culture for IPC include building shared knowledge and skills, communicating around shared goals, creating enabling contexts for inclusive decision, shared decision-making processes and mutual respect and trust among different healthcare professionals to establish multidisciplinary teams.⁴⁸⁵⁴,58 63 64 68 70 72

Additionally, Hubert and Martineau⁶⁷ and Beyer⁶⁶ emphasised the importance of a coherent territorial division based on a common medical project, convergent information systems, territorial medical teams, the mobilisation of hospital professionals and the territorialisation of hospital directors’ responsibilities. The directors and coordinators of care form the ‘pivot’ of cooperation between different levels of ‘territorial hospital groups’.

In rural healthcare settings, scholars suggested adapting the infrastructure for interprofessional communication and providing sufficient resources and training, encouraging a culture of collaboration by constant information sharing between healthcare providers^{63 70} and clarifying roles and responsibilities in resource-poor rural environments.^{63 68}

Practical managerial strategies for institutionalising IPC

The normalisation of IPC relies on key managerial practical strategies, these include:

1. Clarifying roles and responsibilities.^{4854 55 57},59 64 65 68 69 71 Scholars suggested that informal introductions and orientation (eg, informal channels, implementing shadowing programmes across professions) can successfully help to define the roles and expectations of health professionals in patient care.^{60 63 68}

2. Developing interprofessional guidelines and protocols to formalise collaboration within healthcare settings and defining structures and processes to ensure effective collaboration.⁴⁸⁵⁴,59 68 69 71 72 74 75

3. Formalised interprofessional interactions to facilitate communication and collaboration across different professions^{57 68 72} by organising regular multidisciplinary team meetings to foster communication among members from different professions and disciplines and interdisciplinary reviews for interprofessional feedback to discuss patient care, exchange perspectives and work together on treatment strategies.^{48 54 56 57 68 70}

4. Positive leadership who facilitates the breakdown of professional silos by promoting communication and interactions across various disciplines and supporting accreditation for career advancement and development.^{58 59 63 68 70 72 75}

5. Implementing interprofessional education in healthcare training programmes, which should focus on collaborative skills and teamwork competencies such as communication, situational awareness, leadership, role clarity and coordination.^{54 55 64 72 73} Scholars suggested that interprofessional education, including interprofessional learning at university, can enhance students’ understanding of the roles of other healthcare professions early in their careers.^{68 71}

Providing joint training and educational programmes can foster mutual understanding, interprofessional skills^{57 58} and can help new practitioners to establish successful teamwork.^{56 63} Also, it is essential that learning IPC should be a collaborative effort, based on multisource feedback from interprofessional teams, using existing practice expertise.^{60 65} Additionally, Ansa et al and Walmsley et al^{48 68} highlighted the importance of interdisciplinary conferences to promote collaboration and skill improvement and interprofessional training sessions to improve cognitive participation in IPC.

Promoting collective leadership

Collective leadership can play a key role by promoting a positive team climate, knowledge sharing, knowledge integration and encouraging both professional and team identification (multifocal identification) among health professionals working. This can contribute to strengthening IPC in health services networks.^{44 55 58 68 70 72 75}

Collective leadership can facilitate IPC within hospital networks, involving the development of cooperative dynamics and strong commitment of hospital leaders. It relies on the willingness of health professionals, the support of other stakeholders and the integration of information systems.^{66 67}

However, hierarchical structures and health systems can reduce the likelihood of the emergence of collective leadership due to disruption in the network and uncertainty.^{59 61 71 72 75}

Discussion

In the context of healthcare networks, our scoping review identified different levels of IPC including individual, professional role, interactional and organisational characteristics.

Our findings emphasised the need to promote IPC among health providers. This starts by promoting professional commitment and a shared culture of effective communication, knowledge sharing and teamwork to enhance the quality of care, patient outcomes and cost-effectiveness of healthcare.

Our review highlighted, in line with previous reviews,⁷⁶,⁷⁸ that IPC is hindered by organisational (lack of participative leadership and organisational support and limited opportunities of interprofessional education), professional (power dynamics and role ambiguity) and interactional barriers (lack of mutual trust and respect, poor communication and knowledge sharing).

Our review findings hallmarked, similar to previous reviews,⁷⁹,⁸¹ that IPC can be facilitated by interpersonal factors (positive attitudes toward IPC and trust-based relationship), organisational factors (conducive work culture, opportunities for training, positive leadership, recognition of staff contributions and building formal structures for IPC) and professional factors (definition of role and responsibilities).

Our findings are in line with^{82 83} strategies such as clarifying roles and responsibilities, increasing communication and creating a climate of mutual respect, and shared goals and vision can address existing barriers to IPC and improve collaboration. While considering the organisational context and providing resources, co-locating professionals for more interprofessional interaction, the development of protocols, guidelines and the use of information technology are essential for sustained improvements.⁸⁴,⁸⁶

Providing interprofessional education tools such as eLearning modules, interactive training, technological tutorials and virtual simulations to improve healthcare professionals’ communication skills, which are crucial for effective collaboration.⁸⁷,⁹⁰ Some examples of interprofessional education: using simulation scenarios can improve attitudes towards teamwork and communication,^{91 92} training on interprofessional conflict resolution and recognition for team members can lead to a more cohesive working environment⁸⁶ and using TeamSTEPPS training models (an evidence-based training system to track improvement of patient safety) can enhance team communication skills and team performance.^{26 92}

Therefore, scholars reported various forms of information and communication technologies such as electronic health record-linked tool, telehealth and telecare platforms, online communities and learning resources, virtual case conferences, telemedicine platforms and mobile health applications.⁸⁸⁹³,⁹⁷ These tools improve communication and collaboration among interprofessional healthcare teams, especially in overcoming distance barriers by facilitating information exchange and documentation, leading to better clinical decision-making. However, their implementation involves social, political and organisational dimensions and requires that organisational structures promote and support innovation.^{93 96}

Our review highlighted the importance of leadership, which is crucial to effective IPC by enhancing teamwork, fostering a collaborative environment and achieving common goals for improved patient outcomes.⁸²⁹⁸,¹⁰⁰ We stress the importance of building collective leadership, in line with other findings,¹⁰¹,¹⁰⁵ that catalyses cross-boundary collaboration, shared decision-making and shared vision among team members. Collective leadership also enables the emergence of informal clinical integration that is considered key in overcoming communication gaps and that increased communication flows across networks of healthcare providers.^{106 107}

Yet, there are some challenges, in line with other scholars,^{413 96 108},¹¹¹ that can impact the effectiveness of IPC, such as different professional cultures, power dynamics, technological disruptions and structural challenges such as hierarchical structure, top-down implementation of reforms and inefficient regulation of local healthcare markets.

Implications for practice and policy

We suggest, in line with Ndibu Muntu Keba Kebe et al,⁴⁴ that healthcare managers should be careful in adapting behavioural change strategies and conflict resolutions to the nature and types of network members. They need to provide sufficient supportive interprofessional collaborative strategies such as the creation of an IPC commission, modes and case managers in order to overcome the barriers of IPC.^{58 59 71} This starts by providing interdisciplinary training education, restructuring the working environment, ensuring shared accountability and conducting team-based collaboration evaluations^{48 55 60 68 70 72} (see table 2).

Table 2. Key practical implications for effective IPC within healthcare networks.

Levels of IPC	Key practical implications
Individual characteristics	Interprofessional education can help new practitioners to establish a successful interprofessional practice early in their careers and address concerns by exploring innovative ways to attract health professionals to rural communities. The perceptions of IPC should be considered while organising future collaborative programmes.
Professional role	Cultural competency training in healthcare programmes can enhance IPC among healthcare professionals, promoting skills for collaborative practice. Promoting common group identity among members, reducing silos and promoting cross-specialty participation within care delivery are important to enable effective collaboration.
Interactional characteristics	Guide interventions to improve physician interactions and teamwork among health professionals. Improving relationship-building strategies to effective intergroup relationships like two-way communication and participatory decision making. Implementing strategies to improve interprofessional collaboration: creating clear roles, effective communication among healthcare providers, interpersonal interactions and mutual respect. Solutions to improved IPC and its normalisation included induction processes and informal introductions and formalised interprofessional interactions.
Organisational characteristics	To improve IPC within healthcare networks, more attention is needed to improving communication systems, providing institutional support, creating enabling collaboration spaces, structures, guidelines for IPC, through systemic leadership, interprofessional education and capacity building with a focus on collaboration and communication. Interprofessional education is recommended in medical and allied health programmes. Implementing training programmes focused on interprofessional collaboration and teamwork competencies, such as communication, situational awareness, leadership, role clarity and coordination, online distance learning and simulation-based interprofessional education.

IPC, interprofessional collaboration.

Scholars emphasised that examining contemporary interprofessional practice with a historical perspective (power imbalance and professional silos) on IPC is crucial for understanding issues with professional group collaboration and for addressing current challenges in IPC.^{57 59 65 69 73 74}

Moreover, understanding cultural differences among healthcare professionals can help to improve IPC by highlighting the need to increase awareness around IPC culture and key values,^{5569 71},⁷³ in addition to training health workers in cultural competency and IPC education programmes.^{60 74}

As called by Kurniasih et al and Romijn et al,^{55 75} frequent assessments of perceived IPC can be used to monitor changes, evaluate the quality of clinical services and inform the design of shared medical clinical pathways and collaborative programmes.⁵⁹ Walmsley et al⁶⁸ suggest reflexive monitoring to evaluate IPC practices by organising senior review and reflective meetings (eg, morbidity and mortality or formal evaluation tools).

In addition, as stated by Polin et al,¹¹² governance, human resource reforms, payment reforms and capacity building programmes of health workers, considered as the key pillars of health system reforms, need to be oriented towards fostering and incentivising IPC competencies and performance, to promote transdisciplinary values and to reinforce teams’ dynamics and interorganisational collaboration in healthcare networks. There is also a need to develop parallel development of formal and informal clinical integration.^{2 52 113}

More qualitative indepth evaluation and theory-driven evaluation, such as the Realist Evaluation as defined by Pawson and Tilley,¹¹⁴ are needed to refine the suggested theoretical proposition and the underlying mechanisms to effective IPC in real world settings. Researchers might use innovative approaches such as social network analysis and theory-driven evaluation to unpack the complex dynamic processes underlying IPC within healthcare networks.

Furthermore, more studies are needed to investigate the notion of perceived IPC,^{55 75} encouraging healthcare organisations to evaluate and enhance collaboration practices based on emerging evidence and best practices.⁷¹

Further research is needed to understand the implications of IPC within healthcare networks to achieve quality and cost containment goals, with follow-up assessments including quantitative evaluation in the context of patient care outcomes.⁶⁸

Understanding the IPC approach to improve patient care and health outcomes can help policymakers and practitioners in implementing successful IPC strategies and, thus, effective health system reform. Additionally, as seen by Schweizer et al,⁵⁹ we would advise using observational studies to directly observe healthcare professionals’ practices.

Limitations of the study

We noted that IPC is still a heterogeneous polysemic concept (see online supplemental file 3, table 1). More integrative evidence synthesis and further conceptualisation work are needed to allow the development of explanatory middle range theories underlying the IPC in healthcare. Second, the review’s findings included quantitative studies that often fail to grasp the role of context in shaping the effectiveness of IPC strategies. More theory-driven evaluation research and qualitative studies are needed to delve into the inner workings of IPC in healthcare networks. We also had to make some trade-off decisions between comprehensiveness, feasibility and depth of analysis, as is often the case in scoping reviews.³⁹ Yet, some relevant articles might have been missed.

Conclusion

Our scoping review identified that interactional relationships, professional role characteristics and collective leadership are key to fostering IPC in the context of hospital networks. Interprofessional teams and consequent sustained care relationships are crucial to enhance coordination and patient outcomes within healthcare networks. Also, fostering a collaborative culture, developing efficient communication channels, supporting interprofessional education and training and motivating professionals to provide coordinated care are all examples of critical initiatives to promote teamwork, information exchange and patient-centred care. In fine, these collaborative dynamics might contribute to improve quality of care and population health outcomes.

Data availability statement

All data relevant to the study are included in the article or uploaded as supplementary information.