Review
Interprofessional collaboration in
palliative nursing: what is
the patient-family role?
Christine McDonald, Antoinette McCallin
Abstract
Interprofessional collaboration occurs when health professionals from
different disciplines work together to identify needs, solve problems,
make joint decisions on how best to proceed, and evaluate outcomes
collectively. Interprofessional collaboration supports patient-centred
care and takes place through teamwork. Team interactions, wider
organizational issues, and environmental structures, such as safety,
quality, efficiency and effectiveness issues influence this model of care.
These broader contextual influences affect practice where there are
tensions between the ideals of interprofessional collaboration and the
realities of practice. This is evident when the patient and family
position in interprofessional collaboration is considered. This article
will discuss factors that affect interprofessional collaboration in
relation to patients and families in palliative care. First, a definition of
interprofessional collaboration is given, followed by an outline of the
need for interprofessional collaboration. A brief discussion of key
issues that influence collaboration follows, and a review of the
implications for practice is presented.
Key words: Interprofessional collaboration ● Patient-centred care
● Collaborative practice ● Palliative care
P
alliative care requires health professionals
from different disciplines to work together
for the patient and family using a collabo-
rative model of care, which has become very pop-
Christine McDonald is ular in all areas of service delivery. Herbert
Palliative Nurse
Specialist, Hospice
(2005) provides a helpful definition of interpro-
Waikato, Hamilton fessional collaboration that assists palliative care
3240, New Zealand,
and Antoinette
nurses, as the patient and family are at the centre
McCallin is Co-Director of care (Box 1). Interprofessional collaboration
Research and
Interprofessional
involves paying attention to sharing, partnership,
Advisor, National joint working, and power issues (D’Amour et al,
Centre for
Interprofessional
2005). The World Health Organization (WHO)
Education and (20010: 13) believes that collaboration occurs
Collaborative Practice,
Faculty of Health and
when ‘multiple health workers from different
Environmental Sciences professional backgrounds work together with
AUT University,
Auckland, New Zealand
patients, families, carers and communities to
deliver the highest quality of care’.
Correspondence to:
Christine McDonald
Interprofessional collaboration is about working
cmcdonald@xtra.co.nz together and usually occurs in teams (Baldwin,
285
2007; Kemp, 2007). While working together for
patients and families drives nursing practice in
palliative care, appreciating that interprofessional
collaboration seldom occurs in isolation is
important. Factors that are more complex in the
wider health-care context drive interprofessional
collaboration.
Why is interprofessional
collaboration necessary?
Mounting health-care costs, the increasing short-
age of health-care workers (Baldwin, 2007), and
the rising demand for care have influenced health
services delivery. As the population ages, people
are living longer with chronic conditions.
Consumer health literacy has improved so that
patients and families expect services that are
more comprehensive. This means that health-care
organizations need a model of care that will
improve efficiency and effectiveness and reduce
service delivery costs (Cashman et al, 2004). In
this context, interprofessional collaboration has
become an ‘innovative strategy to develop policy
and programmes and to bolster the health work-
force’ (WHO, 2009: 7). Supporting patient-cen-
tred care and quality service delivery is also
important. While patients are central to collabo-
rative care, health professionals can benefit too,
as interprofessional collaboration looks promis-
ing to improving continuity of care (Robins et al,
2008: 325), potentially increasing job satisfac-
tion, possibly reducing staff turnover. This model
of care seems to be ideal at the end of life, where
a team approach is assumed essential for the pro-
vision of good palliative care (Hermsen and
Have, 2005). As such, palliative care practitioners
may be considered leaders in interprofessional
collaboration and able to show how this model
works in practice. However, collaborating with
colleagues from different professional groups is
not quite as straightforward as it seems.
What are the key issues?
The key issues of interprofessional collaboration
are presented in Table 1.
International Journal of Palliative Nursing 2010, Vol 16, No 6

Uncertainty
As interprofessional collaboration is a multi-fac-
eted concept, professionals may be unsure about
what exactly is involved. Some authors, for
example, describe interprofessional collaboration
in terms of organizational and interpersonal rela-
tionships (McWilliam et al, 2003; Belanger and
Rodriguez, 2008; Pullon, 2008). Others describe
interprofessional collaboration in terms of inter-
actional, organizational and systemic determi-
nants (Martin-Rodriguez et al, 2005). Theoretical
discussions focus on interprofessional collabora-
tion in relation to social accountability in health
care (Ho, 2008), management of the interprofes-
sional environment (Rogers, 2004), and contin-
gency theory (Willumsen, 2008). In reality, these
inter-relationships are complicated, especially
when service delivery crosses organizational,
agency and professional boundaries (Johnson et
al, 2003).
Multi-provider service delivery
The second issue of interprofessional collabora-
tion concerns the challenges associated with
multi-provider service delivery. Not surprisingly,
interprofessional collaboration is essential if mul-
tiple agencies work together (Mitchell, Harvey
and Rolls, 1998; Infante, 2006) or when commu-
nity stakeholders are involved (Ansari and
Phillips, 2001). As a single provider rarely pro-
vides palliative care (Hermsen and Have, 2005;
Dawson, 2007) this issue is very relevant.
Interprofessional collaboration facilitates care
although the quality of care, standards, and
safety issues become even more critical in an
inter-agency situation. Indeed, ‘the link between
poor communication and patient safety is well
recognized in the health-care community’ (Boaro
et al, 2010: 1).
Communication and role
understanding
The third and most common issue in interpro-
fessional collaboration involves communication
Table 1. Key issues of interprofessional
collaboration
1. Health professionals are unsure about what exactly
is involved
2. Challenges when multi-provider service delivery is
required
3. Communication and role understanding are
problematic
4. The role of the patient and family is unclear and
variable
International Journal of Palliative Nursing 2010, Vol 16, No 6
Review
Box 1. Definition of interprofessional collaboration
‘[Interprofessional collaboration is] a practice orientation, a way of health-
care professionals working together with their patients. It involves the con-
tinuous interaction of two or more professionals … organized into a
common effort, to solve or explore common issues with the best possible
participation of the patient. Collaborative patient-centred practice is
designed to promote the active participation of each discipline in patient
care. It enhances patient- and family-centred goals and values, provides
mechanisms for continuous communication among care givers, optimizes
staff participation in clinical decision making within and across disciplines
and fosters respect for disciplinary contributions of all professionals.’
Source: (Herbert, 2005: 2)
that overlaps with role understanding.
Interprofessional collaboration encourages and
facilitates communication (Shaw et al, 2005)
through interaction and the sharing of knowl-
edge. However, if role confusion is present, or
there is poor understanding of roles, collabora-
tion is compromised (Shaw et al, 2005). Lack of
understanding of other professional roles and
responsibilities influences team communication
in what can be a confusing or negative manner
(Conner et al, 2008; Demiris et al, 2008).
Therefore, knowledge of roles, responsibilities,
and good communication skills are crucial for
effective interprofessional collaboration (Robinson
and Cottrell, 2005). Communication skills recog-
nized as important include networking, interper-
sonal skills, conflict resolution, managing change,
and negotiation (Norris et al, 2005).
Unclear roles
The final and most important issue in interpro-
fessional collaboration relates to the role the
patient and family have in this model of care.
Advocates for greater patient and family involve-
ment argue that including the patient as a team
member makes care safer (Howe and Sherman,
2006). There is little mention of how and when
this might happen. Whether or not the patient
and family want to be included is another matter.
Inclusion may improve communication, yet it is
not routine (Oliver et al, 2005; Thompson, 2007;
Demiris et al, 2008). While inclusive processes
are poorly documented, those that are docu-
mented are not necessarily good examples of
interprofessional collaboration (Hall et al, 2007).
Power sharing seems to be an issue that chal-
lenges everyone involved.
Overall, the patient-family position in interpro-
fessional collaboration is unclear. Although the
WHO (2009) certainly sees the patient-family as
central to collaborative practice this is not neces-
sarily the norm within practice. One exception is
the Canadian Nurses Society position statement
286
Review
❛ The patient on interprofessional collaboration, which states
and family (Canadian Nurses Association, 2005: 2):
cannot be the ‘Health professionals work together to opti-
centre of care mize the health and wellness of each individual
if they are not and involve the individual in decision-making
included in the about his or her health.’
collaborative Once again, there are no guidelines to indicate
process at how this working together might happen. So far,
every level ❜ there is little research on the patient and family
role in receiving interprofessional care in pallia-
tive care. Not understanding the roles of the
patient and family make it very difficult to prac-
tice using a collaborative model of care. These
problems do not stand in isolation and have
implications for practice.
Implications for practice
The notion of interprofessional collaboration is
interesting when examined more closely. On the
face of it, this model of service delivery has
much to offer. A closer inspection suggests there
are other contextual and cultural issues at stake
that have implications for practice (Table 2).
For example, palliative care providers assume
that the dying patient has multiple complex
problems that a single discipline cannot solve.
Because problems are considered complex, the
patient and family needs access to the knowl-
edge and skills of various experts. Providing this
care under the collaborative umbrella should
ensure that the patient has a ‘good death’.
However, if problems are not complex or the
only ‘problem’ is impending death, the risk is
the identification of unnecessary problems, sim-
ply because a collaborative team is available.
This may occur in part because the definition of
hospice and palliative care states that care must
involve collaboration and teamwork. If the
patient and family are included in the collabora-
tive process, risks decrease.
The second practical problem requiring some
scrutiny is that the patient and family is the cen-
tre of care. However, the patient and family can-
not be the centre of care if they are not included
in the collaborative process at every level. On
the one hand, the patient and family may want
an active role at the end of life. Alternatively,
Table 2. Implications for practice
Contextual, cultural and diversity issues
Patient and family is the centre of care
No comparison to other models of care
Further research is required
287
they may find that participation takes time and
energy that they would rather spend elsewhere
at this sensitive time. Whatever the choice, the
various levels of participation must be
respected. What is important for palliative care
nurses is to find out if the patient and family see
themselves as the centre of care. If they do, how
might they choose to engage in the sharing of
responsibilities, partnership working, and power
sharing? If their preference is not to take on this
role, whom do they want to make decisions on
their behalf? These are beginning questions and
the diversity of patients and families is such,
many more are likely.
Overall, what is known is that in health care
generally, interprofessional collaboration as a
practice norm is rare (Gardner, 2009). It is most
unlikely that palliative care functions differently
although those who work in this area may disa-
gree. This means that the collaborative model of
care should be viewed cautiously in what is a
highly specialized area of practice. In some situa-
tions, it will work very well and in others, an
alternative model of care might be a more practi-
cal option. Context, culture and the diversity of
all involved will influence choice. Certainly, few
have argued against interprofessional collabora-
tion as the best model of care but there is no
research examining or comparing different team
models in palliative care (Higginson et al, 2003).
In the final analysis, it is important to remember
that interprofessional collaboration is not
required for all decisions and collaboration is not
a panacea, nor is collaboration needed in every
situation (Gardner, 2009).
Conclusion
In this paper, factors affecting interprofessional
collaboration in palliative care have been exam-
ined. This model of practice is not quite as
straightforward as it seems. There are several
issues to consider, including understanding
exactly what is involved in interprofessional col-
laboration and how interprofessional collabora-
tion happens when multiple-provider service
delivery is required. Of particular note are the
issues of communication and role understanding,
both of which raise questions about the patient
and family and where they sit in this model of
care. While there is no doubt that interprofes-
sional collaboration involves patient-centred care,
teamwork and partnership working, the role of
the patient and family is not at all clear. Caution
is required before embracing this way of working
wholeheartedly, as one model of care does not
suit every family, and alternatives may be required
to ensure care focuses on patient needs. Research
International Journal of Palliative Nursing 2010, Vol 16, No 6

in the palliative setting to investigate further how
the interprofessional collaborative model of care
works in practice is required. I●
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