The Difference Between Integration and Collaboration in Patient Care: Results From Key Informant Interviews Working in Multiprofessional Health Care Teams

Article Outline

• Abstract
• Methods
• Results
• Discussion
  • Limitations
• Conclusion
• Funding Sources and Potential Conflicts of Interest
• References
• Copyright

Abstract 

Objectives

Despite the growing interest in integrative health care, collaborative care, and interdisciplinary health care teams, there appears to be little consistency in terminology and clarity regarding the goal for these teams, other than “working together” for the good of the patients. The purpose of this study was to explore what the terms integration and collaboration mean for practitioners and other key informants working in multiprofessional health care teams, with a specific look at chiropractic and family physician teams in primary care settings.

Methods

Semistructured interviews were conducted with 16 key informants until saturation was obtained in the key emerging themes. All interviews were audiorecorded, and the transcripts were coded using qualitative content analysis.

Results

Most participants differentiated collaboration from integration. They generally described a model of professions working closely together (ie, collaborating) in the delivery of care but not subsumed into a single organizational framework (ie, integration). Our results suggest that integration requires collaboration as a precondition but collaboration does not require integration.

Conclusions

Collaboration and integration should not be used interchangeably. A critical starting point for any new interdisciplinary team is to articulate the goals of the model of care.

Key Indexing Terms: Chiropractic, Medicine, Integrative Medicine, Delivery of Health Care, Integrated, Qualitative Research

The evolution from the traditional mechanistic view of the human body to one encompassing a biopsychosocial approach has come about as a result of a greater understanding of the interrelationship between health, illness, and disease.¹, ², ³ This view has moved the focus from the health care provider to the patient in an effort to appreciate the complexity of the multiple dimensions underlying the interplay between patient's illness and disease, thus capturing the indivisible whole of the healing relationship.⁴ This inherent complexity of human health requires the involvement of individuals with disparate expertise collaborating in multidisciplinary teams to provide the best patient care. For example, the Ontario government is establishing primary health care teams across the province to provide comprehensive and coordinated care to meet the needs of patients.⁵ The integration of different health services has been highlighted as a common strategy to address the delivery of effective and cost-effective comprehensive care.⁶, ⁷, ⁸, ⁹, ¹⁰ However, the increasing number of different heath-related disciplines bringing unique insight to the care of patients challenges integration, with the absence of training in collaborative team methodologies.¹¹

Despite the growing interest and amount of literature on the topics of integrative care, collaborative care, and interdisciplinary health care teams, there appears to be little consistency in terminology and clarity regarding the goal for these teams, other than “working together” for the good of the patients. To contribute to a definition, this article explores what the terms integration and collaboration mean for practitioners and other key informants working in multiprofessional health care teams, with a specific look at chiropractic and family physician teams in primary care settings. Our study permits conclusions about goals for the relationships among teams comprising disparate health care professions.

Collaborative care (ie, the collaboration of different health care providers in the delivery of patient care) has been proposed as the answer to many complex health care issues including growing resource constraints, increasing rates of chronic illnesses, and a growing and aging population.¹², ¹³, ¹⁴ However, there are almost as many definitions of collaborative care as there are authors that have discussed purported benefits. For example, Sullivan¹⁵ (1998) applied concept analysis to definitional terms found in the literature to identify collaboration as “a dynamic, transforming process of creating a power sharing partnership for pervasive application in health care practice, education, research, and organizational settings for the purposeful attention to needs and problems in order to achieve likely successful outcomes” (p. 6). Way et al¹⁶ described collaborative care as “… an interprofessional process for communication and decision making that enables the separate and shared knowledge and skills of care providers to synergistically influence the client/patient care provided.” Similarly, interdisciplinary collaboration has been described as the “process by which individuals from different professions structure a collective action in order to coordinate the services they render to individual clients or groups” (p. 992)¹⁷ and as conveying “the idea of sharing and implies collective action oriented toward a common goal, in a spirit of harmony and trust, particularly in the context of health professionals” (p. 116).¹⁰

It has been argued that different types or levels of collaboration may occur among the same team members in different situations. Another approach is a focus on how different levels of collaboration may differentiate types of teams and their interactions. For example, Hudson¹⁸ considered the level of communication and the organizational structure to differentiate between progressively more involved levels of collaboration, such as simple communication, coordination, colocation, and commissioning. In contrast, Kinnaman and Bleich¹³ (2004) applied complex systems theory to identify different types of collaboration based upon the level of need for interprofessional agreement/involvement and certitude of clinical outcome. Their model defined 4 levels of progressively greater interprofessional involvement, namely, toleration, coordination, cooperation, and collaboration. These models describe a continuum where the highest level of collaboration may be attained when inequities in power, decision-making, professional boundaries, and hierarchy are transcended.

In another approach, Boon et al¹⁹ propose a continuum of ways in which team members interact. They identified 7 different levels, where each one is differentiated by increased levels of interprofessional interaction, involvement in the delivery of care, and the nature of the organizational structure and processes. These different levels range from parallel practice to collaboration to integration, with collaboration falling in the middle of the continuum. The continuum of Boon et al identifies “integration” rather than “collaboration” as the ultimate goal of teams working together to solve complex patient care problems. One problem in distinguishing collaboration from integration is that many authors like Boon et al appear to assume the terms essentially describe the same phenomenon, that is, describe the ways in which team members interact without taking into account the context of those activities. Often, the term collaboration is used as part of the definition of integration and vice versa.

Integration is another term with numerous definitions in the literature and is not limited to multiple health care professionals trained in conventional, biomedical care of patients.²⁰ Boon et al identified more than 50 articles that attempted to describe how complementary and alternative health care was being combined with conventional biomedical care. These authors identified that most definitions of integration comprised combinations of 4 components: (1) philosophy or values, (2) structure, (3) process, and (4) outcomes. Their qualitative content analysis of definitions in the literature resulted in what is defined as a working definition of integration as a goal or ideal type (as opposed to a description of a concrete model of how care is currently being delivered). According to Boon et al, integration:

A more succinct definition of integration from the Program in Integrative Medicine at the University of Arizona is “Integrative medicine [is] healing oriented medicine that takes account of the whole person (body, mind and spirit), including all aspects of lifestyle. It emphasizes the therapeutic relationship and makes use of all appropriate therapies, both conventional and alternative.”²¹ A similar definition is that it “seeks to combine the best insights of both conventional and alternative medicine, while providing a unifying perspective to guide physicians in intelligently combining these heterogeneous systems of thought” (p. 1085).²² These 2 definitions raise one of the current debates within the literature: the role of the physician in integrative care or what is often called integrative medicine or integrated care/medicine. The debate concerns whether or not integrative care delivery requires a multidisciplinary team or simply reflects a single health care practitioner incorporating different therapies in patient care.

Although the terms care and medicine are often used interchangeably, the use of care instead of medicine in the label may reflect an author's views on the centrality of physicians in health care delivery systems. Another aspect of the definitional confusion is whether the terms integrative and integrated are interchangeable or have unique meanings. In this article, we choose to use integrative care to signify that we are interested in a team process that includes multiple players from different disciplines.

Hsiao et al²³ identified that health care practitioners do have a range of conceptions of integrative care, many not fully consistent with the “official” definition of the study coordinators. Some practitioners thought the goal of integration was to “harmonize the biomedical and CAM paradigms into a single unified paradigm” (p. 2981).²³ In contrast, others felt that it was vital to maintain distinct paradigms while the different practitioners are working together, as one participant of the study explains: “A certain amount of integrative medicine is healthy and to a certain degree when it's too integrated, then you lose the essence and beauty of each [paradigm]” (p. 2981).²³

A practical problem raised by this debate over terminology is as follows: What is the goal of working together? When teams of caregivers want to work together, what are they trying to achieve: collaboration or integration? And what, practically, should that look like? Establishing the parameters concerning goal setting was a key challenge facing our research team when we set out to develop a model of care in which chiropractors and physicians work together in a primary care setting.

It has been estimated that 12% of Canadians²⁴ and 35% of Canadians with musculoskeletal disorders,²⁵ as well as 7.5% of Americans,²⁶ visit chiropractors each year. Evidence-based guidelines and reviews have acknowledged the effectiveness of manual therapy, the main treatment intervention provided by chiropractors, in the management of back and neck pain.²⁷, ²⁸, ²⁹, ³⁰, ³¹ The implementation of these types of guidelines may result in improved outcomes in the management of back pain and potentially save considerable direct and indirect costs. However, one barrier to including chiropractic services in patient care plans is that chiropractors, like other allied health professions, tend to set up offices independent of other health care providers, which may limit their ability to work with them.²⁶

A growing number of projects exploring the inclusion of chiropractic services in multidisciplinary settings, particularly in the United States, have met with varied success.³², ³³, ³⁴, ³⁵, ³⁶, ³⁷, ³⁸ Barriers to the inclusion of chiropractic services include provider competition and bias, philosophical differences, physicians' lack of knowledge of the intervention, lack of or limited evidence in support of clinical efficacy, cultural bias and prejudice, and lack of funding for services.³⁹, ⁴⁰, ⁴¹, ⁴², ⁴³, ⁴⁴ These barriers result in limited referrals and utilization of chiropractic care, or patients seeking care without the knowledge of their general physician.⁴⁵

This article reports on the first phase of a multiphase study in which a model of care with physicians and chiropractors working together was developed, implemented, and assessed. The purpose of this part of the study was to propose a model for how chiropractors and physicians might work together in a primary health care setting. However, a critical barrier to model development was the lack of clarity over whether our goal was to develop a model of collaboration or a model of integration. This article describes our investigation of key stakeholders' perceptions of these 2 terms and their recommendations with respect to our goal.

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Methods 

A qualitative approach, based on grounded theory, was used to guide this study because it was identified as the best way to conduct an in-depth examination of opinions, attitudes, and perspectives on the development of relationships between chiropractors and physicians in primary care settings.⁴⁶ Between September and December 2001, semistructured interviews were conducted with key informants who were selected for their expertise in primary health care practice and research involving health care teams and/or chiropractic care. Each key informant was selected based on his/her ability to provide richness and variety of information with respect to models of physicians working with other health care practitioners, with an emphasis on chiropractic. Key informants from disciplines such as midwifery, nursing, and physiotherapy were interviewed to provide information about how physicians work with other members of the conventional health care team to allow exploration of whether these models of care may be transferable to chiropractic/physician teams. This kind of sampling is known as theoretical or purposive sampling.⁴⁶, ⁴⁷ A list of possible participants was created based on an extensive literature review and research team members' knowledge. In addition, at the end of each interview, participants were asked if they could recommend additional key informants that we should consider interviewing (ie, snowball sampling).⁴⁸ Key informants were identified until the research team concluded that a point of saturation (the point at which additional data do not appear to yield new insights) was achieved in the key emerging themes.⁴⁶

The semistructured interview guide developed by the team was designed to explore the key informants' experiences in collaborative/integrative practice settings and identify benefits, facilitators, challenges, and success factors of these types of practices. Questions about preferred terminology (ie, integration vs collaboration) and detailed probing about the meaning of different language used to describe relationships between practitioners in interdisciplinary teams were important parts of the interview. The interview guide was modified and refined based on the emerging findings in an iterative process throughout the data collection period to enable the team to develop insights and to elicit explicit and detailed data about key issues in subsequent interviews.

In total, 16 interviews were completed: 5 chiropractors, 4 physicians, 1 midwife, 2 nurse practitioners, 1 physiotherapist, and 3 others with more administrative or academic roles. Three of the key informants were from the United States, and 13 were from Canada (one residing outside of Ontario). Only one individual refused our request for an interview (because of lack of time), and interviews were conducted until saturation of key themes was achieved.

All the interviews were audiotaped and transcribed verbatim. Each transcript was checked for accuracy before being sent to the research team for analysis.⁴⁹ Audiotapes were erased at the completion of the study. The study protocol received ethical approval from the Office of Research Ethics at the University of Toronto and the Research Ethics Board of the Canadian Memorial Chiropractic College.

A minimum of 3 members of the research team individually participated in the initial open coding of each transcript. The constant comparison method was used to assess the open coding categories that evolved from team meetings, held after every 3 to 5 interviews, to compare open coding, develop a detailed coding scheme, and refine the scheme over time. Differences in individual coding were resolved through discussion until consensus was achieved. NVIVO Version 1.1 qualitative software (QSR International [Americas] Inc, Cambridge, Mass) was used to facilitate data management.

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Results 

Interviews with the key informants identified various models of how health care practitioners can work together in teams. Experiences commonly revolved around the collaboration of nurse practitioners with physicians in medical offices; however, examples of relationships between midwives, physiotherapists, and chiropractors with physicians and various other health care providers were also described. One of the most important themes that emerged from the data was that most participants clearly differentiated between 2 key concepts: integration and collaboration. One of the study team's biggest challenges was the lack of clear and widely accepted definitions for the terms integration and collaboration. Thus, interviewers continually probed to ensure each respondent's use of these terms was defined explicitly and explored deeply.

In general, key informants described integration as an interaction between professionals of different disciplines that extended beyond working together in the fundamental delivery of care to include organizational or structural components. Organizational aspects included processes such as defined referral mechanisms, practice guidelines, treatment planning, decision-making, and reimbursement strategies. The key informants described integration as subsuming health care professionals under a common policy, organization, and structure.

When I think of the word integration, it brings to mind a team approach that is so inter-related that they are working together on a regular basis as part of a single entity. It is a kind of integration in terms of organizations that have come together under the same … governance structure. [It is] health care under a single structure. (Physician)

Integration is that formal recognition of who you are and what you are and the role that you play in the healthcare system. (Other health care professional)

In contrast, study participants described collaboration as a model of team care that enabled health care practitioners to maintain their autonomy while working together in the absence of formal structures and processes to deliver optimal patient care. Collaboration emphasizes the cooperative sharing of information and accessing the unique treatments provided by different providers:

Collaborative in my mind is where you cooperate, you talk to each other, but there is some distance between you. (Chiropractor)

Essentially I collaborate with [physicians] in that I may have a particular issue with the patient and I will refer a patient to a physician. The physician will give their input and deal with what is occurring, but I don't necessarily lose the person as my client. It's just sort of a moving back and forth or a sharing. (Other health care provider)

Collaboration is independent. You have more of an independence as opposed to integration which I think is more like a team. There is certainly less autonomy in integration versus collaboration. (Physician)

Although most of the participants clearly distinguished between these 2 concepts, several acknowledged that the 2 words, integrative and collaborative, were often used interchangeably:

… they [integration and collaboration] actually look much alike. (Physician)

Some saw collaboration as a distinct approach that may be required to achieve the much broader concept of integration. It was seen as a precondition for integration to be possible because integration involved a more complex organizational structure requiring greater provider interdependency:

I would say that collaboration is one of the methods used to create integration. (Administrator)

I think a very strong collaboration is probably a stepping stone towards an integrative system. (Physician)

The whole notion of integration is a very complex one and there are different versions of what integration means. One version is collaboration. (Physician)

The idea of practitioners being subsumed or consumed by an overarching team structure featured prominently in discussions about integration models of care that may result in challenging the uniqueness of each participating discipline. One physician commented:

If chiropractors were integrated in medical practices, they would run the risk of losing their identity and being swallowed up. Collaborating would be more respectful of each others' professional identities, business arrangements and the like. (Physician)

Many practitioners talked about the necessity for respect for differences in expertise as being a core value in any model of interdisciplinary care:

There has to be a mutual and strong respect between both providers to offer differences of direction in a team on behalf of the patient. (Physician)

I think you have to have a clear understanding of what each other does. I think there has to be mutual respect. (Other health care professional)

I think collaborating would be more respectful of each others' professional identities and current business arrangements and all the rest. (Physician)

This was related to the idea that an optimal model of care must preserve the identity of the practitioners who were working together:

We interact and interface with other people, but we don't lose our identity…. We are still responsible for what we do and the care we give. We are still primary care givers … we are not supervised by anyone. There is an appropriate recognition of what our role is and where we hand over to someone else that has a different role. (Other health care professional)

For many key informants, collaboration, rather than integration, appeared to be the goal of multidisciplinary patient care. It is unclear if this distinction is made because they want to maintain their autonomy and distinct paradigms while working together or because they believe that it is unlikely to attain full system integration in a way in which their paradigm is respected:

Integrative would be the best world, but I don't think the best world, at least initially, is going to happen. I think collaborative care is going to be more reflective of what actually is going to happen out there. (Chiropractor)

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Discussion 

Our findings reveal differences in stakeholder perceptions of the terms collaboration and integration, suggesting that these terms must be defined to avoid confusion in discussions of interdisciplinary patient care (Table 1). Participants in this study generally supported the creation of a model of care that enhanced working relationships between chiropractors and physicians in a primary care setting. However, any model that resulted in perceived loss of autonomy by any participant was generally considered less desirable.

Table 1. Summary of participant views of components of the models of interdisciplinary integration and collaboration

The perceptions of integrative care described by practitioners in this study may be influenced by the “integrative medicine” movement in the United States that appears to be physician-dominated as exemplified by the Consortium of Academic Health Centers for Integrative Medicine.⁵⁰ For example, the consortium describes integrative medicine as:

Integrative medicine is a new approach to medicine that embraces the concerns of the public and medical profession for more effective, compassionate, patient-centered medicine. Integrative medicine has been defined as healing-oriented medicine that takes account of the whole person (body, mind, and spirit), including all aspects of lifestyle. It emphasizes the therapeutic relationship and makes use of all appropriate therapies, both conventional and alternative (p. 10).⁵¹ [emphasis added]

One of the tensions throughout the integrative medicine literature is whether integrative medicine is by definition an interdisciplinary endeavor or whether a single practitioner (such as a physician) can practice integrative medicine alone. Can integrative medicine be a medical specialty similar to internal medicine or pediatrics?

A similar concern with maintaining professional autonomy was identified in an examination of complementary and alternative medicine (CAM) practitioners and physicians working together in biomedical settings (hospitals) in Israel.⁵² The authors of this study describe how the medical profession identified and secured boundaries around the work of the CAM practitioners as a mechanism for the inherent preservation of mainstream professional identity (eg, autonomy and power) while at the same time enabling medical professionals to avoid overt confrontations with CAM practitioners. All the physicians in the study expressed explicit support and respect for the CAM practitioners working with them at the hospital. However, the study describes a multidimensional process they term boundary at-work by which the physicians excluded CAM practitioners from formal structures within the workplace setting or discourses about knowledge (ie, what constitutes truth). This situation allows the 2 groups of practitioners to work together in the same physical space, but prevents any need to engage in discussions of “alternative” forms of knowledge or what the authors call epistemological integration.⁵² Sicotte et al¹⁷ (2002) describe a tension between “disciplinary logic” and “interdisciplinary logic” in Quebec community health care centers. Although professionals do value interdisciplinary collaboration and the associated benefits, they tend to retreat to traditional professional models when their territory is threatened. The preference for collaboration over integration identified in our study may be an example of an unwillingness to threaten professional boundaries by either the chiropractors or the physicians.

Shuval and Mizrachi⁵³(2004) suggest that organizational boundaries (ie, physically working together) are much easier to redefine than cognitive boundaries. Cognitive boundaries appear to be more difficult to change, and it is these boundaries that are used by the dominant group to maintain jurisdictional control when groups attempt to work cooperatively. In our study, the practitioners often talked about the drawbacks of integration in structural terms (ie, integration is health care under a single structure); but in essence, they appear to be most concerned about changing cognitive boundaries to achieve the epistemological integration that was identified as unachievable in the Israeli study. Boon et al¹⁹ also identified that a hallmark of integrative care is an interdependence in both structure and process, and a confluence of providers' philosophies and values. In contrast, collaboration involves structures and processes that are more cooperative and that preserve the uniqueness of philosophy and values of the players. In our study, hesitancy to move toward epistemological integration was identified from both the chiropractors and the physicians.

Limitations 

The major limitation of this study is that our findings are derived from a relatively small sample of North American practitioners, academics, and researchers with a focus on chiropractic/physician primary care teams and thus may not be generalizable to other jurisdictions or practitioner groups. Because our research question was very focused, we were able to reach saturation in the key qualitative themes emerging from the data with relatively few participants. However, the literature suggests that issues similar to those raised by our participants exist across North America when practitioners from different disciplines try to work together. This hypothesis should be tested in a larger, comparative study, including other health care professions.

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Conclusion 

In conclusion, participants generally described a model of professions working closely together in the delivery of care (ie, collaboration) but not being subsumed into a single organizational framework (ie, integration). Our participants suggest that, whereas integration requires collaboration as a precondition, collaboration does not require integration. Collaborative practice has been proposed as a means by which interdisciplinary health care teams can work together and has been defined as “… an inter-professional process for communication and decision-making that enables the separate and shared knowledge and skills of health care providers to synergistically influence the client/patient care provided” (p. 3).¹⁶ This definition is consistent with preferences expressed by the practitioners in this study. It is also characteristic of other similar models such as that in mental health and primary care⁵⁴ and in nursing.¹⁶ A critical starting point for any new interdisciplinary team is to clearly articulate the goals of the model of care.

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Funding Sources and Potential Conflicts of Interest 

The authors are grateful for the financial and material support provided by a grant from the Ontario Ministry of Health and Long Term Care in cooperation with the Ontario Chiropractic Association, and the Canadian Memorial Chiropractic College. H Boon received salary support as a CIHR New Investigator during this study. The views expressed in this article and any errors or omissions are the responsibility of the authors. No conflicts of interest were reported for this study.

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