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      The influence of power dynamics and trust on multidisciplinary collaboration: a qualitative case study of type 2 diabetes mellitus

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      BMC Health Services Research
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          Abstract

          Background

          Ongoing care for chronic conditions such as diabetes is best provided by a range of health professionals working together. There are challenges in achieving this where collaboration crosses organisational and sector boundaries. The aim of this article is to explore the influence of power dynamics and trust on collaboration between health professionals involved in the management of diabetes and their impact on patient experiences.

          Methods

          A qualitative case study conducted in a rural city in Australia. Forty five health service providers from nineteen organisations (including fee-for-service practices and block funded public sector services) and eight patients from two services were purposively recruited. Data was collected through semi-structured interviews that were audio-taped and transcribed. A thematic analysis approach was used using a two-level coding scheme and cross-case comparisons.

          Results

          Three themes emerged in relation to power dynamics between health professionals: their use of power to protect their autonomy, power dynamics between private and public sector providers, and reducing their dependency on other health professionals to maintain their power. Despite the intention of government policies to support more shared decision-making, there is little evidence that this is happening. The major trust themes related to role perceptions, demonstrated competence, and the importance of good communication for the development of trust over time. The interaction between trust and role perceptions went beyond understanding each other's roles and professional identity. The level of trust related to the acceptance of each other's roles. The delivery of primary and community-based health services that crosses organisational boundaries adds a layer of complexity to interprofessional relationships. The roles of and role boundaries between and within professional groups and services are changing. The uncertainty and vulnerability associated with these changes has affected the level of trust and mistrust.

          Conclusions

          Collaboration across organisational boundaries remains challenging. Power dynamics and trust affect the strategic choices made by each health professional about whether to collaborate, with whom, and to what level. These decisions directly influenced patient experiences. Unlike the difficulties in shifting the balance of power in interprofessional relationships, trust and respect can be fostered through a mix of interventions aimed at building personal relationships and establishing agreed rules that govern collaborative care and that are perceived as fair.

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          Most cited references14

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          Strategies of Engagement: Lessons from the Critical Examination of Collaboration and Conflict in an Interorganizational Domain

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            Trust in health care theoretical perspectives and research needs

            Purpose This paper presents some key theoretical issues about trust, and seeks to demonstrate their relevance to understanding of, and research on, health systems. Although drawing particularly on empirical evidence from low and middleincome countries LMICs, the paper aims to stimulate thinking across country settings. Designmethodologyapproach Drawing both on conceptual literature and relevant empirical research from LMICs, the paper presents an argument about the role of trust within key health system relationships and identifies future research needs. Findings Theoretical perspectives on four questions are first discussed what is trust and can it be constructed Why does it matter to health systems On what is it based What are the dangers of trust The relevance of these theoretical perspectives is then considered in relation to understanding the nature of health systems issues of equity and justice in health care and policy and managerial priorities. The identified research needs are investigation of the role of trusting workplace relationships as a source of nonfinancial incentives the influence of trust over the operation of different forms of citizenhealth system engagement approaches to training trustworthy public managers and the institutional developments required to sustain trustworthy behaviour within health systems. Practical implications The policy and management actions needed to strengthen health systems within LMICs, and elsewhere, include recruitment of health workers that have the attitudes and capacity for moral understanding and motivation training curriculae that develop such motivation and developing the institutions e.g. communication and decisionmaking practices, payment mechanisms that can sustain trusting relationships across a health system. It is also important to recognise that distrust in some relationships may act to guard against the abuse of power. Originalityvalue Although the notion of trust has become of increasing importance in health policy debates in highincome countries, it has received less attention in the context of LMICs. The papers adds to the very limited literature on trust in LMIC health systems and also opens new lines of thinking for those working in high income countries particularly around the role of health systems in generating wider social value.
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              The value of health care – a matter of discussion in Germany

              Background Interest in assessing the value of health-care services in Germany has considerably increased since the foundation of the Institut für Qualität und Wirtschaftlichkeit im Gesundheitswesen, IQWiG (Institute for Quality and Efficiency in Health Care). The practical application of value assessment illustrates how problematic the process can be. In all decisions made for the provision of health care, data concerning the measurable dimensions (quantity and quality of efficacy and effectiveness, validity of the results and costs) flow into a complex and not yet standardized decision-making process concerning public financing. Some of these decisions are based on data of uncertain validity, unknown reproducibility and unclear appropriateness. Discussion In this paper we describe the theoretical aspects of value from psychological and economic viewpoints and discuss national and international approaches. Methodic details and difficulties in assessing the value of health-care services are analysed. A definition of the intangible value of health-care services will be proposed which contains only three factors: the absolute risk reduction (usually a measure of efficacy), the validity of the scientific papers examined and the type of the expected effectiveness (prevention of death and disability, restitution of well-being). The intangible value describes the additional benefit when comparing two possible actions, like treatment or observation only. Conclusion The description of intangible value from the viewpoint of different stakeholders is a useful measure for subsequent steps (not discussed here) – the evaluation of costs and of patient benefit. A standardised, transparent, fair and democratic evaluation is essential for the definition of a basic benefit package.
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                Author and article information

                Journal
                BMC Health Serv Res
                BMC Health Serv Res
                BMC Health Services Research
                BioMed Central
                1472-6963
                2012
                13 March 2012
                : 12
                : 63
                Affiliations
                [1 ]Centre for Primary Health Care and Equity, University of New South Wales, Sydney, Australia
                [2 ]School of Public Health and Community Medicine, University of New South Wales, Sydney, Australia
                Article
                1472-6963-12-63
                10.1186/1472-6963-12-63
                3376040
                22413897
                f70e01f1-d9e5-4e21-b841-3997b7d2e2c4
                Copyright ©2012 McDonald et al; licensee BioMed Central Ltd.

                This is an Open Access article distributed under the terms of the Creative Commons Attribution License ( http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

                History
                : 22 November 2011
                : 13 March 2012
                Categories
                Research Article

                Health & Social care
                Health & Social care

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