An Overview of Reviews

on Interprofessional
Collaboration in Primary
Care: Barriers and
Facilitators RESEARCH AND THEORY

CLOE RAWLINSON
TANIA CARRON
CHRISTINE COHIDON
CHANTAL ARDITI
QUAN NHA HONG
PIERRE PLUYE
ISABELLE PEYTREMANN-BRIDEVAUX
INGRID GILLES
*Author affiliations can be found in the back matter of this article

ABSTRACT CORRESPONDING AUTHOR:

Ingrid Gilles
Introduction: Interprofessional collaboration (IPC) is becoming more widespread Center for Primary Care and
in primary care due to the increasing complex needs of patients. However, its Public Health (Unisanté),
implementation can be challenging. We aimed to identify barriers and facilitators of Department of Epidemiology
IPC in primary care settings. and Health Systems, Route
de la Corniche 10, 1010
Methods: An overview of reviews was carried out. Nine databases were searched, and Lausanne, Switzerland
two independent reviewers took part in review selection, data extraction and quality ingrid.gilles@unisante.ch
assessment. A thematic synthesis was carried out to highlight the main barriers
and facilitators, according to the type of IPC and their level of intervention (system,
organizational, inter-individual and individual).
KEYWORDS:
Results: Twenty-nine reviews were included, classified according to six types of interprofessional; collaboration;
primary care; barriers;
IPC: IPC in primary care (large scope) (n = 11), primary care physician (PCP)-nurse
facilitators; overview; review
in primary care (n = 2), PCP-specialty care provider (n = 3), PCP-pharmacist (n = 2),
PCP-mental health care provider (n = 6), and intersectoral collaboration (n = 5). Most
TO CITE THIS ARTICLE:
barriers and facilitators were reported at the organizational and inter-individual levels.
Rawlinson C, Carron T, Cohidon
Main barriers referred to lack of time and training, lack of clear roles, fears relating to
C, Arditi C, Hong QN, Pluye P,
professional identity and poor communication. Principal facilitators included tools to Peytremann-Bridevaux I, Gilles
improve communication, co-location and recognition of other professionals’ skills and I. An Overview of Reviews on
contribution. Interprofessional Collaboration
in Primary Care: Barriers and
Conclusions: The range of barriers and facilitators highlighted in this overview goes Facilitators. International Journal
beyond specific local contexts and can prove useful for the development of tools or of Integrated Care, 2021; 21(2):
guidelines for successful implementation of IPC in primary care. 32, 1–15. DOI: https://doi.
org/10.5334/ijic.5589
Rawlinson et al. International Journal of Integrated Care DOI: 10.5334/ijic.5589 2

INTRODUCTION identification and selection, as well as methods of data

extraction and synthesis were pre-defined in a protocol
The ageing population and growing burden of chronic registered on PROSPERO (CRD42017069922).
diseases have brought new challenges for healthcare
systems, and particularly primary care, with higher risks ELIGIBILITY CRITERIA
of care fragmentation, poorer quality of care, and higher Eligibility criteria covered three domains. First, reviews
health costs. This has led to the development of new had to be centered on IPC, defined as an ongoing
models of care, such as those based on interprofessional partnership and/or interaction between at least two
collaboration (IPC) to improve health care processes, healthcare professionals from different backgrounds
patient outcomes and reduce health costs in primary care working together to improve patients’ care. More
[1–4]. IPC in primary care can be defined as an integrative specifically, two forms of collaboration were considered:
cooperation of different healthcare professionals, 1) collaboration within primary care practices/institutions
blending complementary competences and skills, making and 2) collaboration between primary care provider(s)
possible the best use of resources [3]. Several studies have (primary care physician(s) (PCP) or primary care nurse(s),
shown positive effects of working as a team, including such as for example family physicians/practitioners,
better care continuity and coordination, beneficial general physicians/practitioners, nurse practitioners,
changes in patient behavior, improvement of patient practice nurses) and healthcare professional(s) working
symptoms and satisfaction through better response to outside the primary care setting. We excluded reviews
their needs [5–10]. However, studies also suggest that its focusing on interprofessional education, on a specific
implementation can be challenging [11, 12]. In practice, aspect of IPC, on instruments measuring IPC or reviews
IPC can be compromised when professionals are not primarily targeting structural collaboration and not
convinced of its benefits for patients, or when primary involving interactions between healthcare providers.
care providers perceive it as a loss of continuous and Second, the setting of the review had to be primary care,
holistic patient care, a loss of professional identity [13] as defined by Starfield [22], the Institute of Medicine [23]
or of their jobs’ attributes [14]. The lack of knowledge or the World Health Organization [24]. The IPC intervention
of other professionals’ skills, reluctance to change [11, had to include at least one primary care provider if the
15], and the absence of interprofessional education setting was not clearly mentioned. Third, we only included
in curriculums [12, 16, 17] have also been reported reviews that had been conducted in a systematic manner
as hindering practice of IPC. Currently, the growing [25], i.e. with a rigorous and explicit methodology for the
interest in IPC in primary care, reflected in the amount of search strategy, study selection, quality appraisal, and
published literature, including several systematic reviews, synthesis of results. Reviews including only qualitative,
suggests that it is crucial to obtain a comprehensive view only quantitative (with or without meta-analysis), or
about what hinders and facilitates the practice of IPC. a combination of qualitative, quantitative or mixed
We thus conducted an overview of reviews (i.e. review methods studies, as well as conceptual and theoretical
of systematic reviews) of IPC in the primary care setting, work were eligible for inclusion.
to analyze and synthesize results from existing reviews,
in terms of effectiveness, barriers and facilitators, and SEARCH STRATEGY
theoretical models or conceptual frameworks. The current The search strategy, elaborated with a librarian, included
article presents the results related to the identification of MeSH terms and words relating to the concepts of IPC,
the main barriers and facilitators of IPC (also referred to primary care and review (S1 Table). The search was
as factors) in primary care. carried out on May 10th, 2017 in nine databases: MEDLINE,
EMBASE, CINAHL, PsycINFO, the Cochrane Database of
Systematic Reviews, the Database of Abstract Reviews of
METHODS Effects (DARE), JBI Database of Systematic Reviews and
Implementation Reports, PROSPERO, and Epistemonikos.
Overview of reviews, also known as umbrella review, The search was updated on January 31st, 2019. We checked
meta-review or review of reviews, aims to integrate reference lists of included reviews for additional reviews.
information from multiple systematic reviews, by using a
rigorous methodological process, to offer a comprehensive STUDY SELECTION AND DATA EXTRACTION
synthesis regarding a specific subject by adopting a broader Screening of titles and abstracts (stage 1), and of full-
scope than is proposed in each systematic review [18–20]. text papers (stage 2) were carried out in the Covidence
We performed the overview of reviews in alignment with platform. A standardized predefined data extraction
the Preferred Reporting Items for Systematic Reviews and form (S2 Table) was used to extract data from eligible
Meta-Analysis (PRISMA) statement [21] and in accordance reviews. We contacted corresponding authors for missing
with the recommendations outlined by the Joanna Briggs or incomplete data. Results reported in the reviews
Institute [18]. Review eligibility criteria, methods of review were extracted separately according to whether they
Rawlinson et al. International Journal of Integrated Care DOI: 10.5334/ijic.5589 3

were presented as barriers or facilitators of IPC. Three was disagreement on 24 (10.4%). Thirteen of these
authors took part in these processes (T.C., C.R. and C.A.). disagreements were solved in discussion between the
Among them, two independent reviewers selected all three authors involved in the screening (T.C., C.R. and
articles (using title/abstract then full-text) and extracted C.A.). For the 11 remaining, disagreements were solved by
data. Disagreements were resolved during discussions consulting a fourth author (I.P.B.). Fifty-eight reviews met
between authors. When necessary, a fourth author was the selection criteria and were included in this overview,
consulted for final decision (I.P.B.). of which 29 reported factors hindering or facilitating IPC
(Figure 1). This corresponded to 1,091 primary studies
QUALITY ASSESSMENT (9 to 251 primary studies per review). The CCA value was
The methodological quality of each included review was of 0.6%, indicating a slight degree of overlap.
assessed by two independent reviewers (among T.C.,
C.R., or C.A.) using the ROBIS tool [26]. We attributed a CHARACTERISTICS OF INCLUDED REVIEWS
Low, High or Unclear risk of bias to each domain (study Of the 29 reviews, 20 were mixed methods reviews, six
eligibility criteria, identification and selection of studies, were qualitative, and three were quantitative. The most
data collection and study appraisal, and synthesis and frequently used method of synthesis was thematic
findings), and to the review as a whole. These results synthesis (n = 16), followed by narrative synthesis
served as an indicative purpose to inform on the quality (n = 8), framework synthesis (n = 2), taxonomic analysis
of the included reviews. No reviews were eliminated (n = 1), realist approach (n = 1) and pragmatic meta-
according to their risk of bias. aggregative approach (n = 1). We identified six types of
IPC, based on the authors’ way of defining the setting
DEGREE OF OVERLAP and the type of health professionals involved in IPC
To avoid interpretation biases and address the inclusion (Figure 2): (1) IPC in primary care (large scope) included
of primary studies in more than one review [27], we reviews focusing on healthcare professionals working
calculated the degree of overlap by using the “Corrected in interprofessional primary care teams, without
Covered Area” (CCA) measure [28]; a CCA value ≤5% targeting specific professions (n = 11); (2) PCP-nurse
being considered as a slight overlap, and values ≥15% as collaboration corresponded to reviews focusing on
a very high overlap [28]. collaboration between physicians and nurses in primary
care, for example in general practices or reporting nurse
SYNTHESIS OF RESULTS practitioners’ views and experiences (n = 2); (3) PCP-
The textual content relating to barriers and facilitators specialty care provider collaboration included reviews
identified in the reviews were coded separately using targeting collaboration between a PCP and a specialist
thematic synthesis according to the Braun & Clarke (e.g., palliative care providers, oncologists, psychiatrists,
method [29] and using the Maxqda® (v.11) software. cardiologists) (n = 3); (4) PCP-pharmacist collaboration
Themes were progressively generated by following an corresponded to reviews specifically addressing colla­
inductive approach, to provide broad types of barriers and boration between PCP and community pharmacists
facilitators. The latter were then classified into four levels: (n = 2); (5) PCP-mental health care provider collaboration
system (determinants from the environment outside contained reviews reporting interventions implemented
the organization), organizational (conditions within the in primary mental health settings, such as “Collaborative
organization), inter-individual (relating to the interpersonal care” models (multi-professional approaches to patient
relationship between professionals and/or within the care typically involving a PCP, a mental health specialist,
team), and individual (specific to the individual). Moreover, and a case manager) (n = 6). The final type of IPC, (6)
since the included reviews targeted specific types of intersectoral collaboration, included reviews on the
collaboration, in terms of setting and professionals involved, collaboration between primary care and other sectors
we classified them in broader types of IPC. Then, we (nursing homes, sport sector, oral health or public health)
tagged the coded segments according to this classification (n = 5). The risk of bias was low for 11 reviews, high for
in order to identify barriers and facilitators that were both 15 and unclear for 3. Characteristics of the reviews are
the most reported and the most specific for each type of presented in S3 Table.
IPC. We chose to present barriers and facilitators by type of The synthesis identified 22 types of barriers and 20
collaboration in the form of tables and narratively. types of facilitators impacting IPC across all types of
collaboration (Figures 3 and 4). Among the reported
barriers, four were common to all types of IPC, 16 were
RESULTS reported in three or more types of collaboration and
SEARCH RESULTS two were specific to one or two types only. Regarding
From 9998 records identified, 230 full text articles were facilitators, eight were common to all types of IPC, 12
screened. Of the 230 screened full text articles, there were reported in three or more types of collaboration
Rawlinson et al. International Journal of Integrated Care DOI: 10.5334/ijic.5589 4

Figure 1 Flow chart.

Figure 2 Six types of interprofessional collaboration identified.

 Rawlinson et al. International Journal of Integrated Care DOI: 10.5334/ijic.5589

Figure 3 Barriers to interprofessional collaboration with the number of reviews reporting them, by type of collaboration.
5
 Rawlinson et al. International Journal of Integrated Care DOI: 10.5334/ijic.5589

Figure 4 Facilitators of interprofessional collaboration with the number of reviews reporting them, by type of collaboration.
6
Rawlinson et al. International Journal of Integrated Care DOI: 10.5334/ijic.5589 7

and none were specific to one or two types of IPC. In the a common vision, and creation of team cohesion through
next sections, for each of the six types of IPC, we present team building were also identified [11, 15, 32–38].
first the findings regarding barriers and then regarding
facilitators (S4 Table for detailed results). PCP-nurse collaboration
At the system level, inadequate reimbursement policies and
BARRIERS AND FACILITATORS OF problems with payment mechanisms for nurses’ services
INTERPROFESSIONAL COLLABORATION (poor reimbursement or insufficient financial support) were
IPC in primary care (large scope) the most frequently reported barriers [45, 46]. Besides these
At the system level, the barriers that were most legal and financial issues, barriers were mostly reported
often reported concerned financial barriers (e.g., lack at the inter-individual level where traditional hierarchies
of long-term funding, inadequate reimbursement between both disciplines and ideological differences
policies) [11, 30], followed by the lack of leadership at in practice and cultural perception of care (biomedical
national/political level and the lack of support in legal versus experiential) led to power struggles and difficulties
constraints for the expansion of roles [11, 30, 31]. At the regarding professional identity. In fact, whereas nurses
organizational level, limitations in human resources (e.g., feared disadvantages due to their extended roles in the
lack of time and skilled professionals) led to an increased absence of clear definitions of roles boundaries, physicians
workload [11, 15, 31–33]. The lack of professionals’ misunderstood these extended roles.
training in IPC implementation and of organizational Facilitators at the organizational level included tools
support in this process were also mentioned [11, 15, 31, for team communication (e.g., regular meetings, open
32, 34, 35]. At the inter-individual level, the imbalance channels of communication, use of technologies) and
of power between professionals, due to hierarchies close physical proximity between professionals [45,
between disciplines (especially physicians versus other 46]. At the inter-individual level, definition of roles and
professionals) at a structural level [11, 15, 32–35] was responsibilities, the acceptation of other professionals’
mentioned. The lack of clarity regarding functions views, competences and practices, and shared leadership
and scopes of other professionals and fear of loss of were reported [45, 46]. At the individual level, a positive
territory/professional identity in newly defined roles [11, attitude and interest in IPC was identified [45, 46].
15, 31–35] was associated with the depreciation of other
professionals’ contributions and skills as well as the lack PCP-specialty care provider collaboration
of common vision and goals [11, 15, 31, 32, 35]. Poor or Barriers at the organizational level concerned lack of
deficient communication between actors was also an time, work overload [47, 48] and the lack of adequate
important barrier [11, 15, 31–33, 35]. At the individual electronic data sharing solutions [47, 49]. The lack
level, professionals were concerned about the benefits of of PCP experience and uncertainty in knowledge also
collaboration for their patients [15, 34, 35]. limited patients’ follow-up [49]. At the inter-individual
Facilitators at the organizational and inter-individual level, discrepancies in role definitions between primary
levels were particularly frequently cited in this type of care physicians and specialty care providers, and lack of
collaboration. At the organizational level, reinforcement clarity in role boundaries led some specialists to assume
of human resources, with an equitable involvement a PCP role [47–49]. Lack of and poor communication also
of professionals and available time [11, 15, 32–37], weakened IPC [47, 49]. At the individual level, doubts
re-organization of practice and, more specifically, from specialty care providers regarding IPC benefits
team composition with formalized partnerships and limited patients’ referrals to primary care physicians
coordination rules were often identified [11, 15, 30, 32– during acute phases of disease [48, 49].
34, 36–38]. The use of tools to improve care processes Facilitators were mainly at the organizational level.
(e.g., care planning, referral, guidelines) was also These included providing tools for care processes,
mentioned [11, 15, 30, 32–34, 36–38]. Organizing regular especially shared care guidelines or pathways, favoring
meetings and feedback, using clear communication patient data transmission (electronic medical records,
routines or information channels were also facilitators survivorship care plans), and improving PCP knowledge
of IPC [15, 30–38]. Supportive institutions and having a and experience in specialty care [47–49]. Reorganizing
team leader or champion to organize interprofessional practice [47, 49], favoring proximity and access between
collaboration was also mentioned [11, 30–38]. At the professionals [48, 49], increasing resources in trained staff
inter-individual level, effective, openly shared knowledge and personnel, and providing tools for communication
and information regarding patients and moments of [48, 49] were also mentioned. At the inter-individual level,
informal face-to-face discussions [15, 30–38] were effective communication and information exchange
important. Valorization of other professionals’ work and (timely, relevant detail) [47–49], and agreement on
understanding of their roles, trust and respect between role definition and sharing of decision-making [47, 48]
professionals [11, 15, 32–38], shared interests, goals and facilitated IPC.
Rawlinson et al. International Journal of Integrated Care DOI: 10.5334/ijic.5589 8

PCP-pharmacist collaboration as well as regular meetings, and systematic feedback to

Barriers at the organizational level included lack of improve communication [41–43] were also mentioned.
available time and specific training on IPC, difficulty Effective leadership by a physician champion, and visibility
for pharmacists to access PCPs and not working in of the benefits of IPC through audits and evaluations were
geographically close areas [50, 51]. At the inter-individual also mentioned [41–43]. At an individual level, a strong
level, lack of clear role boundaries and responsibilities, engagement of professionals was reported as facilitating
especially the lack of knowledge about the other IPC [41–43].
profession were reported. These were associated with
the fear of a weakened professional identity, and a Intersectoral collaboration
lack of or deficient communication [50, 51]. Moreover, Barriers were characterized at the system level by financial
depreciation of pharmacists by PCPs was also an constraints, including uncertain or unstable funding
important barrier, especially regarding confidence in and costly IPC implementation, lack of political support
pharmacists’ skills and experience in patient care and due to low prioritization, and insurance specificities (i.e.
perception of pharmacists as retailers, which led to lack separation of medical and dental treatment in insurance
of respect and trust [50, 51]. systems) [52]. At the organizational level, available
At the organizational level, facilitators concerned access time and professionals’ retention in programs [52–55],
to professionals through the use of integrated settings insufficient training and lack of skills [52–55] were
or co-located spaces, increasing proximity between mentioned. Lack of PCP engagement in leadership due
PCPs and pharmacists, and joint training [50, 51]. At the to poor incentives or absent administrative infrastructure
inter-individual level, facilitators focused on establishing to facilitate cross-domain operability were also reported
a respectful environment in which professionals’ skills [54, 55]. At the inter-individual level, depreciation of
would be valued, with mutual recognition, respect and others’ contribution and lack of time to install a trusting
trust, in addition to clearly defining responsibilities [50, environment between professionals [53, 55] hindered
51]. At the individual level, prior experience of IPC or IPC. Finally, doubts about IPC benefits [52, 54] were
informal collaboration during formative years reinforced identified at the individual level.
willingness to engage in IPC initiatives [50, 51]. Facilitators at the system level concerned funding,
including its stabilization through strong government,
PCP-mental healthcare provider collaboration stakeholders or non-profit organizations’ support,
Barriers at the system level concerned financial introduction of incentives for team involvement and
constraints in general (absence of long-term funding compensation of time used for IPC activities [52, 54–56].
solutions) [39–42], inadequate reimbursement policies Developing a common vision between different partners
and problems with payment mechanisms such as such as authorities and communities, and political
compensations and reimbursements [39–41]. At the willingness to support IPC [52, 53, 56] were also reported.
organizational level, barriers concerned the limited At the organizational level, reorganizing practices by
number of skilled professionals involved, of time motivating professionals to work in a multi-disciplinary
available, and work overload [39–43]. In addition, the approach, adopting a flexible community driven definition
lack of specific training on IPC led to professionals’ of care, formalizing coordination and dedicating time
unfamiliarity with the IPC model and difficulty for non- to IPC [52–56] were important facilitators. Improving
mental healthcare providers in managing patients with professionals’ training and involving the whole staff
mental health issues [39–42]. At the inter-individual by using a “bottom-up” approach were also described
level, lack of communication between professionals as crucial [52–56]. A strong engagement of the team
and the threat to professional identity (mainly for supported by organizational structures or management
PCP) [41–43] were reported. Barriers at the individual systems [55, 56], and a strong leadership [52, 54–56]
level included professional’s resistance to change and facilitated IPC. At the inter-individual level, facilitators
the perception of IPC as burdensome and resource- included reinforcing or creating a strong team cohesion
consuming to implement [39, 40, 42]. Professionals were by improving communication between professionals,
also concerned about patient confidentiality through the clarifying roles and responsibilities, and creating a
use of shared medical records [39, 41]. trusting environment to value each professional’s skills
Facilitators concerned mainly the organizational [52–56].
level and included the importance of proximity between
professionals to facilitate access to each other (through
co-location, full-time presence) [40–44], reorganizing DISCUSSION
practice, and including a case manager to the
collaboration [41–44]. The implementation of tools such The results of this overview show that, even if some
as standardized care pathways, scheduled follow-ups and specificities exist, the reported barriers were similar
structured management plans to improve care processes, across the different types of collaborations, with the
Rawlinson et al. International Journal of Integrated Care DOI: 10.5334/ijic.5589 9

most frequent ones being: 1) lack of long-term funding be invested in continuing professional education and
and inadequate reimbursement policies, and payment training.
mechanisms at the system level; 2) lack of time, insufficient When system-level actions are essential to increase
training, and lack of leadership at the organizational level; the recognition of the roles of healthcare professionals
3) lack of clear role boundaries and responsibilities, poor and legitimize IPC [46], they must be complemented
communication, professional identity, and power issues by organizational and inter-individual level changes to
at the inter-individual level; and 4) doubts regarding the favor professionals’ acceptance and embracement. For
benefits of IPC and resistance to change at the individual example, a policy analysis conducted in Ontario (Canada)
level. In contrast, facilitators varied depending on the [63] reported that a legislative support favoring IPC did
type of IPC, suggesting that reported facilitators were not suppress important barriers. Moreover, since the
more context-specific than barriers. The most reported implementation of IPC through a top-down approach
facilitators related to: 1) available funding, supportive increased professionals’ impression of an injunction to
policies, incentives and compensations for professionals collaborate, several reviews underlined the importance
at the system level; 2) reorganizing practices and team of using bottom-up strategies to tailor IPC to its context
structure, co-location, tools for care processes, and and favor its acceptance by professionals [11, 31, 37, 55].
providing training and sufficient human resources at the At the organizational level, human resource limitations,
organizational level; 3) the quality of communication, particularly lack of time, were a major concern in all
the respect and cohesion between professionals and types of collaboration. Implementing organizational
a shared power at the inter-individual level; and 4) a changes, such as team reorganization and coordination,
positive attitude toward IPC at the individual level. or provision of efficient tools, requires not only energy
We observed that barriers and facilitators at organi­ and time but also skills that professionals may not
zational and inter-individual levels were particularly have. Coaching strategies have thus recently emerged
prominent in included reviews and across all types of IPC, in primary care to guide interprofessional teams on
in contrast to the system-level. These latter aspects were organizational aspects [64]. A strong facilitator of IPC
potentially less sought-after in interventional studies that was mentioned in the majority of included reviews
that aimed to improve process or health outcomes and and across all types of collaboration is co-location. This is
had received funding for this purpose. It is thus likely not a surprise, as it has often been cited as a key enabler
that they focused on what worked or not at the level of of collaborative work in the literature [65–67], by not
their intervention rather than at the system-level. Yet only facilitating communication but also reducing power
system-level factors, and in particular the possibility of imbalances between professionals [68].
the health system to sustainably fund IPC, are critical for Regarding inter-individual factors, results show that
some types of collaboration such as primary care teams, perceived threats to professional identity, role definition
collaborative care models, and PCP-nurse collaboration. and poor communication represent central challenges
Integrating nurses into the PCPs’ practices can be a major for IPC in primary care. In fact, these barriers are crucial
challenge in terms of funding, particularly in countries in primary care where IPC requires strong and effective
where PCPs are generally independent small-business teamwork [69], even though professionals are less used to
owners, and function on a Fee-For-Service (FFS) model. adopting a team-based functioning [70]. If role definition
In such contexts, it is in fact more convenient for PCPs to and poor communication seemed to be of concern in all
develop a collaboration outside the practice but with the types of IPC, fear of losing one’s professional identity was
risk of losing quality in collaboration [57]. not reported in all types of IPC. This was particularly true
The lack of multidisciplinarity in healthcare professio­ regarding PCP-nurse and PCP-pharmacist collaboration,
nals’ education and training was another system-level where PCPs have to accept to delegate or even transfer
factor under-reported in the included reviews, most likely activities to other professionals. Moreover, PCPs feel
because it may represent a distal cause not immediately that the involvement of other healthcare professionals
perceptible to the actors. However, scholars agree that in their patients’ management may jeopardize, or even
it is an indispensable prerequisite for the adoption of hinder, relational continuity, a fundamental tenet of
IPC by healthcare professionals in the future [58]. More primary care [13, 24, 71]. In addition, IPC may be difficult
specifically, the creation of a common culture around to implement in a context where traditional hierarchies
IPC, a main goal of interprofessional education [59] and between disciplines persist. Actually, compliance with
a key aspect to maintain collaborations [60], should be the medical hierarchy could result in power imbalances
encouraged and promoted at the system level. Currently, in collaborative teams [72], and lead to non-inclusive
efforts are made to enhance interprofessional education decision-making processes, poor communication and
during under- and graduate studies [61, 62]. Even though coordination issues [73]. Unfortunately, issues related to
the latter is essential to change future professionals’ professional identity are difficult to address because they
perception and practice of IPC, similar efforts should also are often rooted in power struggles [68]. In fact, some
Rawlinson et al. International Journal of Integrated Care DOI: 10.5334/ijic.5589 10

authors have attempted to develop and conceptualize an can be used when assessing the quality assessment of
interprofessional identity that could replace the existing different types of reviews, it was not specifically designed
identities of each professional group involved in IPC [74, for qualitative and mixed methods reviews. Therefore,
75]. However, even if there is a rising interest towards the quality assessment of the included reviews should be
developing such an identity, its conceptualization interpreted with caution.
and the way it could be promoted among healthcare
professionals remains unclear [76]. Other authors have
suggested to focus on team functioning by promoting CONCLUSION
shared roles and leadership, or by adopting open
communication. For example, role boundaries defined by Despite some specificities according to the types
separate lines of management and lacking flexibility are of collaboration, the most often cited barriers and
known to decrease teamwork effectiveness in primary facilitators were reported across different contexts
care [70, 77]. Thus, efforts could target flexibility and and intervened mostly at the organizational and inter-
shared leadership between professionals [78]. In the long individual levels. It can be expected that the barriers
term, however, the most promising option seems to rely identified at the system and individual levels will be
on education, and more particularly on mentoring [68]. gradually overcome with the broader implementation
The main strength of our review is that we com­ of interprofessional education and the setting up
prehensively examined and summarized barriers and of collaborative projects and practices at the local
facilitators of IPC in the primary care setting, using state- level. In fact, governance, professional practices and
of-the-art methodology. Nevertheless, results need to be attitudes are closely linked, and will evolve together as
interpreted according to the following limitations. First, IPC becomes more and more familiar in primary care.
our two main concepts (primary care and IPC) are not We believe that this overview of reviews, by identifying
consensually defined in the literature. The operational the most prominent barriers and facilitators to IPC in
definition used for the literature search and identification primary care, can prove useful for the development of
of reviews could have led us to miss some reviews. Also, tools to guide decision-makers in the implementation of
the search strategy and eligibility criteria were not defined interprofessional collaboration.
specifically to find barriers and facilitators, but according
to the larger objective of the overview to include a wide
range of articles on IPC in primary care, which means that ADDITIONAL FILE
we have also incorporated data from reviews that were
not primarily intended to study barriers and facilitators The additional file for this article can be found as follows:
of IPC. Second, it was not possible to distinguish barriers
and facilitators to implementing IPC from barriers and • Supplementary material. Table S1–S4. DOI: https://
facilitators to practicing IPC since they were most of the doi.org/10.5334/ijic.5589.s1
time not differentiated in the included reviews. These
were considered jointly despite the fact that some
barriers or facilitators may be more specific to one or ACKNOWLEDGEMENTS
the other phenomenon. Third, even though thematic
synthesis of our data allowed the identification of clearly The authors thank Thomas Brauchli (from the Unit for
prominent themes in an organized and structured way, it Documentation and Data Management, Center for Primary
offers little possibility to develop thematic categories of Care and Public Health (Unisanté), University of Lausanne,
higher order beyond those identified in the literature [79]. Switzerland) for his help in the elaboration of the search
Fourth, we were confronted to the common challenge strategy and conduction of the search, and Jolanda
of study overlap when conducting overviews [27]. Even Elmers (from the Medical Library, Lausanne University
though the Corrected Covered Area (CCA) suggested Hospital and University of Lausanne, Switzerland) for her
only a slight overlap between the 29 reviews, some support and assistance in the CCA calculations.
primary studies were included in more than one review.
Therefore, we cannot exclude that some study results,
overrepresented, may have biased the overall depiction REVIEWERS
of barriers and facilitators. Overlap between the six
types of IPC is also possible. In fact, the latter were not Sanneke Schepman, HU University of Applied Sciences
mutually exclusive, which is due to an overlap between Utrecht, Heidelberglaan 7, 3584 CS Utrecht, The Netherlands
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a high risk of bias. Despite the fact that the ROBIS tool One anonymous reviewer.
Rawlinson et al. International Journal of Integrated Care DOI: 10.5334/ijic.5589 11

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TO CITE THIS ARTICLE:

Rawlinson C, Carron T, Cohidon C, Arditi C, Hong QN, Pluye P, Peytremann-Bridevaux I, Gilles I. An Overview of Reviews on Interprofessional
Collaboration in Primary Care: Barriers and Facilitators. International Journal of Integrated Care, 2021; 21(2): 32, 1–15. DOI: https://doi.
org/​10.5334/ijic.5589

Submitted: 19 July 2020 Accepted: 03 June 2021 Published: 22 June 2021

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