Table 5 Consolidated list of barriers and enablers to implementation of teams using the CFIR

I: Intervention Characteristics

Buy-in from medical professional organizations

Good data and research to understand impact of changes in system

Neutral funding models that link funding to activities of whole team on a per patient basis

Independent income generation, not dependent on their activities or those of colleagues

Resourcing and funding for interprofessional practice and related initiatives

Unstable, inadequate, or lack of long-term funding or reimbursement models

Space & equipment covered by income of a specific provider

II: Outer Setting

Client-centered approaches (i.e., assessing patient/community characteristics and needs)

Involving patient and family in care planning and delivery

Patients willing to receive care from teams.

Multi-component models that involve patient education, systematic follow-up, medication adherence

GP networking in community to establish contacts with community partners (e.g., social services, hospitals)

Managers supporting integrating care (e.g., care coordination, connecting to social services, nursing homes, prevention resources)

Inter-organizational collaboration, including service integration and coordinating care for patients with complex needs

GPs in alternate payment plans (APPs) may be more incentivized to participate in collaborative activities than fee for service plans.

Health professional regulatory bodies incorporating interprofessional competencies into licensing requirements

Incorporating interprofessional education into academic curricula for healthcare professional programs, pre- and post- licensure

Graduate level education for advanced practice nurses

System-level collaboration and policies (i.e., legislative and regulatory reforms) which may set targets for interprofessional care or introduce non-physician professionals into teams

Lower compensation and benefits for teams compared to hospitals and private sector results in poor recruitment and retention

Different remuneration systems for different professionals (e.g., referrals from GPs vs. NPs)

When funding or compensation does not facilitate participation in team (e.g., meetings discussing patients)

Salaries that originate from different funding sources

Fee for service payment models, which reward interprofessional isolation.

Top-down policies that require physician authority or decision-making

Team members lack competency in interprofessional collaboration due to lack of/inadequate interprofessional training

Difficulty in engaging with wider community in rural/remote areas when practitioners are new

III: Inner Setting

Move away from physician-driven care; include nurse practitioners on team

Adopting a “whole system” approach by involving non-clinical staff and clerical staff on team

Ensure there is an established team leader/manager responsible for managing and facilitating collaboration and day-to-day activities

Single-handed governance structures, in place of a partnerships, are positively associated with team climate

Clinics operating under a board of directors

Integrating both bottom-up and top-down governance associated with heightened efficiency and coordination

Developing new organizational infrastructure crucial for care delivery

Tech supports (e.g., EMRs, computerized message & booking, telehealth) facilitate collaborative decision making and information sharing

Standardize documentation and tools (e.g., integrated care pathways, common patient charts, interprofessional care plans)

Encourage information sharing, task delegation, and supportive communication through: weekly scheduled interprofessional team meetings, frequent and reciprocated ad-hoc communications (e.g., clinic huddles)

Meetings include procedures for negotiation, decision making and conflict management and resolution

Clearly defining roles and understanding roles and respective scopes of practice

Set interprofessional guidelines (e.g., referral mechanisms between members)

Interprofessional case conferences allows opportunity to collaborate

Non-hierarchical organizational structure that encourages equality, mutual respect, low levels of conflict, willingness to cooperate and collaborate

Balance between group culture, hierarchy and focus on efficiency and achievement

Balanced power relationships through shared leadership, decision making, authority and responsibility

Identify and adjust power imbalances to build mutually supportive workplaces

Financial incentives based upon unique collaborative care demands (e.g., after-hours services, compilation of care plans)

Feeling supported and formally recognized for performance

Opportunities for all staff to receive bonuses based upon target achievement

A clear vision and well-defined goals that have been collectively identified contribute to a shared sense of purpose

Processes for group decision making and problem solving promote shared purpose amongst the team

Colocation leads to greater mutual understanding, increased role clarity and superior care delivery

Educating staff in interprofessional care on the job (e.g., social and organizational training to mitigate power dynamics and training on co-workers’ roles)

Offering learning opportunities and leadership training courses to support collaboration

Clearly explained team processes, policies, and procedures as well as accessible and intuitive documentation

Lack of clear/inadequate leadership, and system-level leadership

Ambiguous roles, lack of understanding of the knowledge and skills of different professionals, and concerns about professional scope and liability

Lack of training or experience required to evolve into facilitators of collaboration

Physical separation creates a symbolic barrier and reinforces perceived divisions

Insufficient workspace or profession-specific spaces negatively impact communication, workflow, and team cohesion

Lack of training or educational opportunities

Insufficient time in the day to engage in and share reflections and learnings, instill a trusting environment

Insufficient human resources impact the implementation of initiatives to improve collaborative care

IV: Characteristics of Individuals

Belief in, or positive attitude towards, the concept of collaboration

The ability to be flexible in one’s professional role within the team

GPs accommodate the new skill mixes on a team and acknowledge the potential benefit of non-physician/patient interactions

Collaborative skills possessed by individuals within the team

Opposition or disagreement among team members on the potential value of interprofessional initiatives and education, and the impact on patients

Opposing interests, values, and beliefs and interprofessional conflict

Concern or territoriality around one’s role within the team, with a shift in attitude needed to allow all appropriate team members to have meaningful patient interactions

V: Process

Plan human health resources in a manner that encourages collaboration and coordination

Establish human resource plans that allow time for staff to participate in interprofessional activities

Reduced team turnover to optimize growth

To foster future collaboration, allow opportunities for students from different professions/programs to engage with one another

Promote greater interprofessional networking

Management structures and system level foundations that are explicitly collaborative and support local leadership and team development & processes

Engage and develop interprofessional leaders among the point-of-care health professional

Developing and having team champion(s) and facilitators within the team to integrate team actions, facilitate team building

External accountability like focusing on quality through audits or other processes and motivate a collaborative approach to problem solving

Monitoring and evaluation are a method to overcome system level barriers to interprofessional communication

Team members reflecting on their practice and sharing informal feedback with colleagues about their interprofessional work

Limited human resource planning

Physician reluctance to collaboration

Reluctance of patients to see multiple providers

Difficulty reporting relevant outcomes measures of interprofessional education and practice