Can relational coordination theory be used to understand and improve interprofessional care coordination in schools? A pilot study

Abstract

Attending to the health needs of students with chronic conditions requires a fluid exchange of information and coordination between parents, educators, administrators and school healthcare professionals. Previous research often omits school nurses in this exchange, although their role is key to successful outcomes. Relational Coordination (RC) theory posits that cohesive relationships help support communication, enabling stakeholders to coordinate their work. This paper preliminarily explores whether RC domains might be relevant in school health settings, utilizing existing qualitative data. Responses from focus group sessions were analyzed using a deductive and inductive analytic approach. Data was coded using the 7 RC domains as a priori codes. Frequent, timely, and accurate communication emerged as major themes in the communication domain. Shared knowledge was a major theme within the relationship domain. Problem-solving communication, shared goals, and mutual respect were minor themes. The results suggest that improving interprofessional collaboration (IPC) and health outcomes in children with chronic conditions using RC theory-informed interventions will be important to deepen the understanding of how these different domains interact and influence student health outcomes.

Introduction

Efficient school health services are critical to improve student academic performance and well-being, especially for the growing population of students with chronic conditions. The health needs of these students require fluid exchanges of information and coordinating actions between parents, educators, administrators and school healthcare professionals. Unfortunately, care coordination in schools is frequently viewed narrowly, resulting in fragmented care (McClanahan & Weismuller, 2015).

When examined in school settings, team-based approaches, particularly interprofessional collaboration (IPC) focus primarily on the collaboration between school teachers, counselors and administrators (Mellin et al., 2010; Wolk et al., 2019). Though IPC has been noted to be a key function of school nursing practice (Fleming & Willgerodt, 2017), little research has been devoted to the role of school nurses when studying IPC in school settings. Relational Coordination (RC) theory posits that functional relationships help to support and enable stakeholders to effectively coordinate their work (Bolton et al., 2021)—all salient principles in effective care coordination in schools. The purpose of this study was to preliminarily explore whether RC domains might be relevant in this space, utilizing existing qualitative data.

Background

In schools, care coordination — the organization of care and sharing of information for safe and effective care (Agency for Healthcare Research and Quality, 2018)— is critical for children with chronic conditions to support illness management. Approximately 40% of families needing care coordination for their child report not receiving it (Toomey et al., 2013). Barriers to effective care coordination include communication issues, tendencies to work in silos, workload, and lack of experience/ in caring for chronic conditions (Cordeiro et al., 2018). The extant literature lacks actionable strategies, across the health care, education and community sectors (New York Academy of Medicine, 2013).

RC theory offers a relevant framework to understand IPC in schools (Bolton et al, 2021; Parsons, 2012). When used to guide change initiatives, RC strengthens, siloed thinking shrinks, and team members become more holistically oriented (Bolton et al., 2021). Recently, we led an IPC intervention in inpatient settings and demonstrated sustained improvements in RC over time (Blakeney et al., 2020; M. A. Willgerodt et al., 2020). Considering our previous RC theory experience and the growing evidence that children with chronic conditions experience fragmented coordination from key caretakers in their academic life, we postulate that RC may be a useful and salient theory to guide care coordination research in schools, focused on team approaches to care.

Parent Study

Data drawn for this study stems from a parent study aimed to understand the operationalization of care coordination in schools among children diagnosed with Type 1 diabetes (T1D). In that study, 20 focus groups took place with school nurses, parents of children with a diagnosis of T1D, and providers across Washington State. At the beginning of the focus group sessions, participants listed their responses to 3 questions on notecards; responses served as the basis for this study. The parent study methods and findings are reported elsewhere (M. Willgerodt et al., 2020).

Methods

Our study was guided by principles of rapid qualitative analytic techniques, indicated for more targeted and specific explanatory approaches to inquiry (Taylor et al., 2018). Responses to three questions—1) Where along the continuum of care does coordination work well and what happens at those points in time; 2) Think about when things go smoothly with your student/child/client while they are in school and what makes it go smoothly, and; 3) Think about a time or times when things didn’t go smoothly and why do you think it didn’t go smoothly—were transcribed and examined using a deductive and inductive analytic approach (Elliott, 2018). The two authors independently coded the data using the 7 RC domains (frequent, timely, accurate, problem-solving communication and shared goals, shared knowledge and mutual respect) as a priori codes. Additional unique codes were created as they emerged; by reviewing codes together to determine final RC domain indexing, emergent themes were completed.

Ethical Considerations

The study was reviewed by the University of Washington Institutional Review Board (#00004757) and deemed exempt from human subjects review.

Results

Fifty school nurses, 38 family members, and 8 clinic/providers (N=96) participated in the parent study (see Table 1); 396 statements were recorded across the three questions. Overall, each RC domain was noted from the perspectives of parents, school nurses and providers. Within the communication domains, frequent, timely, and accurate communication emerged as major themes. Shared knowledge was a major theme within the relationship domain. Problem-solving communication, shared goals, and mutual respect were noted as minor themes. Across all domains, statements did not vary considerably in the specifics of content within the RC domains.

Table 1.

Sample Characteristics

Variable	School Nurse (N=50)	Parent (N=38)	Provider (N=8)
Ethnicity
Caucasian	45	35	7
Hispanic/Latino	1	2
Asian	2		1
Multiracial	2	1
Age
Less than 31	2	3
31–40	12	15	5
41–50	15	16	1
51–60	16	3	2
Over 60	5	1
Sex
Female	49	35	7
Male	1	3	1
Education
High School		12
Associate/Vocational	3	7
4 year college	27	11	4
Graduate School	20	8	5
Over 10 years			2

Table 2 presents illustrative statements from participants by RC domain. Minor themes did not figure as prominently in the data but were nevertheless present. Six themes identified did not fit within the RC theoretical domains: staffing, training/experience, infrastructure, engagement and social influences of health. Parents and school nurses consistently noted staffing issues as impacting their experiences of IPC, as well as training, experience or knowledge about T1D. Infrastructure-related components (i.e. reliable wireless internet, diabetes supplies) provided stability that supported IPC. Last, family engagement and social influences of health played a role in the success of IPC.

Table 2.

Categorization of Responses by RC Domain

RC Domain	Definition	Comment
		Positive	Negative
Communication
Frequent	How frequently do people in each of these groups communicate with you about the work that you do together?	“Good communication with parents with email, calls, log books” (school nurse, FG#1)	“lack of communication between teacher, nurse and myself” (parent—FG #5)
Timely	How timely is their communication with you about the work that you do together?	“School nurse faxes report 1–2 days before appointment” (provider, FG #1)	“field trip information not getting conveyed until the morning of” (school nurse, FG #7)
Accurate	How accurate is their communication with you about the work that you do together	“changes are communicated right away” (parent, FG #4)	“dose and bolus was wrong!” (parent, FG #5)
Problem-solving	When there is a problem in the work that we do together, do people in these groups blame others or try to solve the problem?	“able to call parent when issues arise” (school nurse, FG #3)	“student being sent back to class because he can’t stay in the health room” (school nurse, FG #7) School unwilling to communicate/work to create a plan that didn’t involve sending child to another school (FG #3)
Relationship
Shared goals	Do people in these groups share your goals for the work that you do together?	“shared mental model with child’s best interest in mind” (provider, FG #3)	“school nurse, parent and clinic disagree on what to do” (school nurse, FG #1)
Shared knowledge	Do people in these groups know about the work you do in the work that you do together?	“meet with all the relevant parties to establish a plan” (school nurse, FG #8)	“lack of understanding of roles” (school nurse, FG #7)
Mutual respect	Do people in these groups respect the work you do in the work that you do together?	“teachers are invested and willing to communicate with home” (parent, FG #6)	“parent not responsive to needs” (school nurse, FG #10)

Discussion

This study extends the findings from the parent study by illuminating the utility of RC theory in exploring and understanding IPC in caring for school-aged children with T1D. Donabedian’s Quality Model (Donabedian, 2005), which uses a structure-process-outcomes approach, is among the most commonly employed when guiding research and practice in school health services. While useful for many aspects of quality improvement and research, these types of models do not adequately consider the role of individuals nor the interdependent relationships that influence these variables, and impact the success of interventions. Current RC theory offers a more dynamic view of these interdependencies which can be used to guide intervention development to comprehensively attend to the relational, structural and process factors, offering a more holistic approach to improving IPC.

One key strength of using RC theory is precise identification of the IPC-related areas representing opportunities for change of further development. School nurses play a key role in the care of students with chronic disorders; students have much to gain when care is well coordinated and much to lose when it is fragmented.

Other findings of interest include a lack of shared view of who comprises the school health team for students with chronic conditions. Multiple roles were described as the health team: the school nurse, students, parents, teachers (both permanent and substitute), clinicians, counselors, and administrators. Participants also reported a fear of, and lack of knowledge about, T1D among team members as problematic, suggesting that further exploration of who should know what is needed. Last, several participants made very general statements about communication and teamwork, such as “we work well together,” or things don’t go well when “there is no communication.” A better understanding of these statements is essential to identify effective strategies to improve IPC and care coordination in school settings.

Limitations

This study utilized existing data focused on exploring how care coordination is operationalized in schools; therefore, interpretation of findings from this secondary analysis are situated within this context. Data may not capture all dimensions of care coordination because participants were asked to write short statements on notecards in response to the questions and were not required to complete them before the focus groups took place. Further, the number of parents and school nurses participating far outnumbered the number of clinicians in this study. Analysis illuminated the overlap in coding the RC domains, potentially impacting what emerged as a major vs minor theme. The aim of this pilot study was to explore where RC theory is relevant for school-based IP care coordination and despite these limitations, findings suggest that it is a useful framework by which to guide intervention development.

Conclusion

The combination of RC theory domains and additional emergent themes suggest that improving IPC and health outcomes in children with T1D necessitates a comprehensive approach that considers the structural, relational and work processes and their interactions outlined in the Relational Model of Organizational Change. Research using RC theory-informed interventions to improve IPC and care coordination in schools will be important to deepen the understanding of how these different domains interact and influence student health outcomes.