Factors influencing mutual trust in interprofessional partnerships within primary care settings: a systematic review

Abstract

Background

Trust between healthcare providers is important in facilitating collaborative practices, especially in primary care, where disciplines collaborate across communities to deliver patient-centred care.

Objective

To identify the facilitators and barriers that influence trust in interprofessional partnerships within primary care settings.

Methods

We searched PubMed, PsycInfo, Embase, and CINAHL using key words to identify articles published up to 16 August 2023. Facilitators and barriers to trust were mapped onto the Consolidated Framework for Implementation Research (CFIR). Quality assessment utilized the Mixed Methods Appraisal Tool (MMAT).

Results

From 5750 screened articles, 11 studies were included. Sixteen facilitators and seven barriers were identified. Facilitators included co-location, familiarity, competence, professional identities, and effective communication. Barriers included perceived conflicts of interest, lack of familiarity, and transgressions of professional boundaries. Trust was often unbalanced, with a perception among non-medical healthcare professionals that they need to earn trust from medical healthcare professionals.

Conclusions

Formation and nurturing of interprofessional trust is the foundation for building strong partnerships between healthcare professionals that promote collaborative practice in primary care. Future research should include non-English and grey literature and focus on the unequal trust dynamics.

Key Messages.

• Trust between primary care health professionals is essential

• Co-location, familiarity, competence, role differentiation, and effective communication facilitate trust formation. Perceived conflict of interests, lack of familiarity, and lack of professional role boundaries hindered trust formation.

• There is a perception among medical health professionals that trust needs to be earnt by non-medical colleagues.

Introduction

Trust is fundamental to relationships. From a scholarly perspective, trust can be defined as ‘the belief others will not, at worst, knowingly or willingly do you harm and will, at best, act in your interests’ [1]. From a sociological perspective, trust is defined as a confident expectation of others’ intentions and behaviours when interacting under conditions of risk and uncertainty [2]. Mayer et al. [3] defines trust from an interpersonal perspective stating, ‘To trust someone means to show willingness to be vulnerable to another's actions based on expectations that the benefits of trust will outweigh the potential harm of not trusting’. Mutual trust between healthcare providers is important in facilitating interprofessional partnerships and collaborative practices, especially in primary care, where different healthcare disciplines from different organizations collaborate across communities to deliver comprehensive patient-centred care [4–9]. Trust may be conferred explicitly, when the trustor believes the trustee's action to be beneficial; for example, as a result of satisfactory performance on agreed tasks or communication in an effective and timely manner [6, 8]. Alternatively, trust may be conferred implicitly, when the trustor believes the trustee as trustworthy more broadly; for example, as a result of academic qualifications or leadership position [7]. In the absence of mutual trust, interprofessional partnerships are not possible [5].

For patients, primary care is the first point of contact when accessing the healthcare system [9]. Over the past three decades, a range of strategies have been implemented to enhance interprofessional partnerships. For example, in Australia, the national health insurance scheme provides rebates for medical and allied health consultations as part of chronic care planning in partnership with the patient's usual general practitioner (GP) [10]. These are complemented locally by referral pathways such as HealthPathways, established in 2008 to guide referrals for common clinical conditions, and SmartReferrals, established in 2019 to improve communication between primary, secondary, and tertiary care service providers [11, 12]. However, few strategies have focused on the relational dynamics, such as mutual trust, its facilitators and barriers, and how it influences interprofessional partnerships [4–8]. This systematic review aimed to examine the facilitators and barriers that influence mutual trust in interprofessional partnerships within primary care. We focused on registered healthcare professionals who work in primary care settings, such as GPs, practice nurses, nurse practitioners, psychologists, dieticians, physiotherapists, exercise physiologists, and community pharmacists.

Methods

This systematic review was registered with the International Prospective Register of Systematic Reviews (PROSPERO) in 2023 (CRD42023486726). We report in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines [13].

Search strategy and study selection

This review focused on facilitators and barriers that influence mutual trust in interprofessional partnerships in primary care. We searched PubMed, PsycInfo, Embase, and CINAHL electronic databases from July 17 until 16 August 2023. Our search focused on the following key words: trust, mutual trust, interprofessional relationship, interprofessional collaboration, and primary care (see Supplementary Appendix A for the search strategy).

The title and abstracts were uploaded to EndNote 21 and Covidence software for duplication removal, screening, and selection. Two independent reviewers (H.W. and M.G.) conducted the title, abstract, and full-text screening; any discrepancies were resolved through team discussion and consensus (A.M., H.W., M.G., and K.V.), with focus on reasons for inclusion and exclusion based on the research questions and pre-specified criteria. We included peer-reviewed research publications, irrespective of study designs, on registered primary healthcare professionals, such as GPs, practice nurses, nurse practitioners, psychologists, dieticians, physiotherapists, exercise physiologists, and community pharmacists, in Australia and other countries with comparable healthcare systems and burden of disease. We excluded research on trust between patients and health professionals, students and healthcare professionals, and healthcare professionals in institutional settings, such as schools, prisons, or residential aged care facilities. We also excluded studies published in languages other than English, grey literature, conference abstracts, protocols, systematic reviews, meta-analyses, and dissertations.

Data extraction and quality assessment

Two independent reviewers conducted the data extraction and quality assessment (H.W., M.G., and A.M.). Any discrepancies in the rating were resolved through team discussion and consensus. The quality of included studies was assessed using the Mixed Methods Appraisal Tool (MMAT) [14]. This validated tool supports the quality appraisal of qualitative, quantitative, and mixed-methods studies. It appraises the methodological quality according to appropriateness to the research question, data sources and analytical approaches (qualitative studies), appropriateness of the measurements, its completeness and analytical approaches (quantitative studies) and appropriateness and integration of the qualitative and quantitative components (mixed-methods studies) using 5-point quality criteria. For each included study, a score 1 or 0 was given to each quality criterion to indicate whether the criterion was met or not, with 100% indicating all quality criteria were met.

The facilitators and barriers to mutual trust were reflexively analysed and mapped to the Consolidated Framework for Implementation Research (CFIR) domains [15]. Firstly, themes were inductively analysed based on steps as recommended by Braun and Clark, namely: (1) data familiarization, (2) creating codes, (3) constructing initial themes, (4) reviewing initial themes, (5) defining and finalizing themes, and (6) producing the report. Secondly, we deductively mapped the emergent themes to the CFIR domains. CFIR is well suited for examining complex interventions [16, 17]. CFIR comprises five domains: Innovation, Outer Setting, Inner Setting, Individuals, and Implementation Process. The Innovation domain refers to the ‘thing’ that is being implemented; for example, training and recommendations. The Outer Setting domain refers to the wider environment; for example, a system or community; guidelines and regulations, physical closeness and shared understandings. The Inner Setting domain refers to the actual location; for example, a clinic or hospital, where the implementation takes place. The Individuals domain refers to the persons involved in the implementation. The Implementation Process domain refers to the activities and strategies used to implement the innovation.

Results

A total of 5750 titles and abstracts were identified; 5638 were excluded at title and abstract screening, and 101 were excluded at full-text screening, leaving 11 studies for inclusion (Supplementary Appendix B). The studies were conducted in six countries: Canada (n = 4), USA (n = 3), England (n = 1), Australia (n = 1), the Netherlands (n = 1), and New Zealand (n = 1). Six focused on GPs and pharmacists, two on GPs and nurses, the remainder on three or more disciplines. The facilitators and barriers to mutual trust have been mapped to the CFIR framework (Fig. 1). Most studies fulfilled the MMAT quality criteria according to its study design (Table 1).

Figure 1.

Overview of barriers and enablers that influence mutual trust in interprofessional partnerships within primary care setting according to the CFIR domains [15]. Key: + = Enabler, − = Barrier, ± = Both barrier and enabler.

Table 1.

Study characteristics and quality assessment.

Title	Author, year published, and country	Study design	Aims	Participants	Main outcomes		MMAT score
					Facilitator	Barrier
Family physicians’ perceptions of pharmacists prescribing in Alberta	Faruquee et al. [6] (2020), Canada	Qualitative	To explore family physicians’ perceptions around pharmacists’ prescribing practice	Pharmacists n = 2 GPs n = 12	Policies & laws Local conditions Communications Individual capability	External pressure Relational connection Individual capability	5/5
Communication between pharmacists and primary care physicians in the midst of a U.S. opioid crisis	Curran et al. [35] (2019), USA	Qualitative	To explore key emergent themes around the communication between primary care physicians and pharmacists on opioids	Pharmacists n = 60 GPs n = 48	Local conditions (e.g. co-location or geographical proximity)	Nil	5/5
The challenge of integrating community pharmacists into the primary health care team: A case study of local pharmaceutical services (LPS) pilots and interprofessional collaboration	Bradley et al. [18] (2009), England	Mixed Methods	To examine the local pharmaceutical services pharmacists perceived level of integration into the primary health care team, and investigate their relationships with local GPs	Quantitative component: Pharmacists n = 20 Qualitative component: Pharmacists n = 20, GPs n = 13, Primary care trust representatives n = 6	Local attitudes (e.g. lack of trust in multiple chain pharmacies) Local conditions (e.g. co-location or geographical proximity) Work infrastructure Individual capability	Nil	5/5
Trust in interprofessional collaboration: Perspectives of pharmacists and physicians	Gregory and Austin [7] (2016), Canada	Qualitative	To characterize the cognitive model of ‘trust’ in interprofessional collaboration in primary care, from the perspective of community pharmacists and family physicians	Pharmacist n = 11 GPs n = 8	Organizational leadership (e.g. more trust is conferred with positional authority or high-level position in health care hierarchy) Individual capability	Nil	5/5
How improving practice relationships among clinicians and non-clinicians can improve quality in primary care	Lanham et al. [23] (2009), USA	Qualitative	To understand the characteristics of relationships within primary care practices	Pooled data from four other studies (n = 4612)	Nil	External pressure (e.g. risk of litigation erodes trust)	5/5
The influence of power dynamics and trust on multidisciplinary collaboration: a qualitative case study of type 2 diabetes mellitus	McDonald et al. [24] (2012), Australia	Qualitative	To explore the influence of power dynamics and trust on collaboration between health professionals involved in the management of diabetes and their impact on patient experiences	Various primary care health professionals n = 35	Communications Relational connections Implementation team members Individual capability	Communication	5/5
‘My pharmacist’: Creating and maintaining relationship between physicians and pharmacists in primary care settings	Mercer et al. [20] (2020), Canada	Qualitative	To explore (a) how and when physicians and pharmacists communicate, (b) how and if pharmacists and physicians discuss personal relationships, (c) what are the barriers to communication between them, and (d) how and if co-location changes their relationship	Pharmacists n = 25 GPs n = 9	Work infrastructure Relational connections Individual capability	Relational connections	4/5
Identification of influencing factors and strategies to improve communication between GPs and community nurses (CNs): a qualitative focus group study	Nieuwboer et al. [8] (2018), The Netherlands	Qualitative	To investigate how GPs and CNs experience their inter-professional communication and to identify hindering and facilitating factors, as well as identifying strategies to enhance their communication	GPs n = 13 CNs n = 18	Individual capability Team building	Implementation team members	5/5
Competence, respect and trust: Key features of successful interprofessional nurse-doctor relationships	Pullon [26] (2008), New Zealand	Qualitative	To explore attitudes and perceptions about the roles of, and relationships between primary care nurses and doctors	GPs n = 9 CNs n = 9	Implementation team members Individual capability	Implementation team members Individual capability	5/5
Exploring successful community pharmacist-physician collaborative working relationships using mixed methods	Snyder et al. [21] (2010), USA	Mixed Methods	To describe the professional exchanges that occurred between community pharmacists and physicians engaged in successful collaborative working relationships	Pharmacists n = 5 Physicians n = 5	Relational connections Communication Individual capability	Nil	3/5
Effects of a longitudinal interprofessional educational outreach program on collaboration	Yu et al. [19] (2016), Canada	Mixed Methods	To identify whether and how a real-world longitudinal diabetes-focused outreach program targeting interprofessional health care teams affects self-efficacy and team function	Quantitative component: various health professionals n = 96 Qualitative component: various health professionals n = 18	Innovation source Innovation evidence base Innovation relative advantage Innovation adaptability Innovation trialability Individual capability	Structural characteristics Communication	4/5

Innovation domain

We identified two intervention studies [18, 19] aimed at improving interprofessional partnerships. In Canada, Yu et al. [19] investigated the impact of an interprofessional education workshop to improve team efficacy and function. Trusting relationships were fostered by face-to-face attendance in locally accessible settings as it showcased competencies and knowledge. In the UK, Bradley et al. [18] investigated the integration of privately owned community pharmacies with primary healthcare teams, including GPs, practice nurses, and others. Mutual trust was facilitated by geographical proximity, staff continuity and familiarity, and individual capabilities. However, there was distrust among GPs regarding sharing patient information and referrals to community pharmacies.

Outer Setting domain

In a study by Faruquee et al. [6], GP participants reported concerns about pharmacist prescribing in the community; they believed pharmacists should obtain further training and that legislative measures should be implemented to regulate the process. The authors concluded that having established policies or professional bodies in place to guide health professionals’ clinical practices, or both, was foundational to trust formation. Studies by Yu et al. [19], Bradley et al. [18], and Farauqee et al. [6] reported that co-location or geographical proximity to other professionals also facilitated trust formation. In primary care, where disciplines are predominantly located away from each other, health professionals appeared to appreciate the opportunity for in-person interactions and collaborations, afforded by geographical proximately. Enhanced patient satisfaction and other health-related outcomes were also reported [6, 20, 21], reinforcing primary care providers’ understanding of each other's roles in delivering comprehensive longitudinal care to their shared patient cohorts.

Barriers to trust include perceived financial interests and fear of litigation [6, 18]. Studies by Bradley et al. [18], Yu et al. [19], and Farauqee et al. [6] discussed how medically trained participants hesitated to trust community pharmacists. They speculate that the commercial nature of pharmacy practice may encourage overprescribing. These concerns were weighted towards chain pharmacies, with greater trust shown towards independent pharmacies [18]. In the USA, where litigation in health settings is more common [22], the study by Lanham et al. [23] reported fear of litigation as a barrier to trust.

Inner Setting domain

Communication was frequently discussed and presented as both a facilitator and a barrier to trust [6, 8, 19, 21, 24]. Participants highlighted their preference for timely, clear, and respectful communication [6, 21]. Telephone communication was reported to provide greater opportunities for trusting relationships compared with written communication [24]. For example, some participants viewed written communication, such as facsimile, as impersonal and challenging for trust building [6]. Perceived untimely or inappropriate communication, or both, may corrode trust; for example, sending a facsimile instead of a telephone communication for an urgent case [21]. Familiarity, nurtured through previous professional partnerships, mutual colleagues, or shared patient cohorts [6, 20], promotes continuity of care and mutual trust [18]. Personal relationships, however, may be both a facilitator and barrier to trust [24]. For example, while personal relationships developed over time may enhance confidence in each other’s competence, they may also mask unresolved conflicts such as power imbalance.

Individuals domain

Perceived clinical capability, which is earned only after professional expectations are met [25], was important for facilitating trust [6, 8, 18–21, 24, 26]. It should be noted that this is unequally shared among primary care professionals. The study by Gregory and Austin [7] found that the trust placed on GPs by pharmacists was implicit, with perceived power imbalance within the interprofessional teams: ‘The simple fact that a family physician was an MD was (in and of itself) reason enough for most pharmacists to determine that trust should be conferred’. Professional roles also impacted on trust [8, 24, 26], with perceived threats to roles and a lack of agreement on scopes of practice identified as challenges to the establishment of mutual trust [8, 24].

Implementation Process domain

Predictable work routines and established programs enhanced team building and facilitated trust formation [19]. However, these programs, including co-located consultations, shared patient visits, and team meetings, required commitment to interprofessional collaboration as schedule alignment may be difficult [8].

Discussion

Studies included in this review [6,7,8, 18,19,20, 23, 24, ] revealed that mutual trust among primary care professionals is underpinned by multiple factors. Studies that were not included in the review due to not meeting the selection criteria [27–34] also offered insights as discussed below.

Mutual trust is facilitated by co-location, familiarity, competence, professional identity, and effective communication. The main barriers included perceived conflict of interests, lack of familiarity, and transgression of professional boundaries. Co-location and familiarity are important facilitators to mutual trust, and where geographical proximity was not present, informal relationships bridged the gap between practices [6, 18, 20, 24, 35]. Similarly, Gucciardi et al. [30] explored interaction between diabetes educators and primary care doctors and observed that co-location and familiarity are closely inter-connected for fostering mutual trust. The geographical proximity allowed for frequent interactions between the primary care and specialized diabetes team members, leading to a high degree of familiarity. Consequently, the primary care team members were more willing to trust and refer their patients for diabetic care. In their review of barriers and facilitators to interprofessional collaboration, Rawlinson et al. [4] found that when health professionals are co-located, a more favourable attitude towards interprofessional collaboration was present as proximity enabled familiarity, in-person communication, and recognition of complementary skillsets. These findings indicate that the foundations of trust formation are grounded in opportunities to interact face to face, observe one another's professional conduct and clinical reasoning, and see how they respond to patient and other health professionals’ needs. These encounters, when repeated and with positive experiences, appear to increase health professionals’ confidence in each other, and ultimately, a greater willingness to share patient care. However, primary care practices are commonly distributed across different geographic areas, especially those located in remote and rural regions. When co-location is not possible, Bacci et al. [36] found that informal relationships or peer-to-peer introductions were key facilitators to the development of trust.

Competence, skill and perceived confidence were other facilitators to the development of mutual trust, while a lack of competence and skill was identified as a barrier [7, 8, 18–21, 24, 26]. Pullon [26] reported that an acknowledgement of one another's knowledge and competencies contributed to improved collaborative behaviour. Sisk and Baker [37], who explored clinician–family relationships in paediatric settings, found that interprofessional relationships relied heavily on the acknowledgement of complementary skillsets and abilities as well as confidence in one's own skills and abilities. Perceived competence appears to enhance willingness to collaborate, thereby forming a sense of interdependence and moving away from operating in professional isolation.

Lack of clarity about roles, scopes of practice, and perceived dilution of professional responsibilities lead to corrosion of trust and even withdrawals from collaborative partnerships [8, 32]. The significance that health practitioners placed on professional identity and responsibilities during their collaboration with others is recognized in the general literature [28, 32]. The mutual recognition for interprofessional collaboration within multidisciplinary teams as part of optimal chronic care management enabled primary care clinicians to overcome barriers of competing professional identities and responsibilities [28]. Hudson [31] suggested that seeking commonality among team members, such as the shared commitment towards patient care, was a vehicle for progressing mutual recognition. Rawlinson et al. [4] recommended flexible and shared leadership within the multidisciplinary team as a way for reconciling disagreements about professional boundaries. In mental health, Stasiulis et al. [34] reported that having an organization-wide protocol assisted with improving clinicians’ role clarity, referral processes, and collaboration that facilitated the formation and maintenance of trust. Shared commitment to patient-centred outcomes and institutional recognition of interprofessional collaboration support clinicians to transcend professional silos and recalibrate identity boundaries. Shared leadership models in mitigating boundary disputes demonstrated that organization-wide protocols that clarify referral pathways and responsibilities reduced uncertainty and supported sustained trust.

Consistent, timely and responsive communication, regardless of the method, was a facilitator to mutual trust [6, 19–21, 24]. Timely, respectful, and responsive communication reinforced trust by demonstrating accountability and commitment to shared care. On the other hand, a lack of communication, disrespectful communication, or delayed communication were shown to be barriers to trust. Al Sayah et al. [38] found frequent and closed loop communication between health professionals contributed to teamwork and trust formation. Sutherland et al.’s [39] study on communication between different levels of the healthcare system found that shared electronic health records or other electronic communication tools could enhance effective communication and in turn, support trust building, especially in rural and remote regions.

In Australia, initiatives such as GP chronic condition management plans and mental health care plans serve as platforms where multidisciplinary providers can collaborate, communicate, and contribute their expertise and build trusting interprofessional partnerships [27]. However, it has been found to be generally under-utilized by GPs and other primary care professionals [29]. This highlights a need for system re-designs to facilitate stronger interprofessional partnerships in primary care settings.

Our comprehensive review of the facilitator and barriers contributing to mutual trust between primary care professionals highlight opportunities for future research, including the need to incorporate multidisciplinary perspectives, the potential use of quantitative research designs, and the use of technologies to enhance mutual trust among primary care professionals. Most of the included studies examined perspectives from non-physician primary care clinicians, such as the pharmacist and community nurse, on ways to gaining trust from GPs and not vice versa [6–8, 18, 20]. This finding requires exploration to ascertain the underlying reasons. It could be hypothesized that in the primary care context, GPs have ultimate decision-making authority; however, they also carry the greatest risk of litigation when things go wrong. We did not identify any quantitative research studies in our review. This evidence gap may be due to the difficulties in measuring trust quantitatively, especially the trust between health professionals [40]. The use of technology has been shown to support communication processes, collaboration, and trust in relationships between health professionals working in secondary and tertiary healthcare settings [33, 39]. However, we did not identify any studies on the use of technology, exclusively in primary care. We recommend the following to improve interprofessional trusts:

• Co-location of interdisciplinary teams in primary care settings to foster familiarity, in-person communication, and mutual recognition of complementary skillsets.

• Training systems that expose primary healthcare students, post-graduate trainees, and providers to interdisciplinary teams.

• Embedding structures to support interprofessional collaboration and communication within interdisciplinary teams. Importantly, role clarity should be framed as enabling interprofessional practice and collaboration rather than reinforcement of professional silos and a transfer of service.

Strengths and limitations

To our knowledge, this is the first review to focus on identification of facilitators and barriers to mutual trust in interprofessional partnerships within primary care settings. Our multidisciplinary research team, from pharmacy, nursing, and general practice, ensured that the analytical approaches were examined from different lenses. Nonetheless, there are limitations. We included studies from different countries. While these countries share similar chronic disease distributions, the healthcare systems are different, and there are differences in professional roles, scopes of practice, and responsibilities. We did not include non-English and grey literature; this may have reduced the comprehensiveness of our findings. We focused on factors that are applicable within the Australian primary care setting. While we have been able to shed light on interpersonal and organizational modulators of trust, we have not been able to provide information that would help with understanding how gender, colonial legacies, or healthcare hierarchies interplay in the development and nurturing of interprofessional trust. Despite growing evidence from secondary and tertiary care settings, the role of digital technologies as deliberate trust-building tools in primary care remains underexplored. Future research should investigate how shared electronic health records, secure messaging platforms, and other digital communication tools influence trust, particularly in geographically dispersed or resource-limited environments. While our findings will likely assist with the development of mutual trust and interprofessional interventions elsewhere, local systems need to be considered.

Conclusion

This systematic review revealed that the formation and maintenance of trust are shaped by systems, organizations, and individuals. The main facilitators to formation and maintenance of mutual trust included co-location, familiarity, competence, professional identity, and effective communication. The main barriers included perceived conflicts of interest, lack of familiarity, and transgression of professional boundaries. By mapping the facilitators and barriers to the CFIR, strategies can be identified for implementation to promote mutual trust. This study also highlighted the need for further research to explore GPs perspectives and the use of technologies within the primary healthcare setting, as well as the need for quantitative research methodologies.

Supplementary material

Supplementary material is available at Family Practice online.

Funding

This research received no external funding.

Data availability

The data that support this study cannot be publicly shared due to ethical or privacy reasons.