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Journal of Interprofessional Education & Practice 17 (2019) 100279

Contents lists available at ScienceDirect

Journal of Interprofessional Education & Practice

journal homepage: www.elsevier.com/locate/jiep

Interprofessional collaborative practice in primary healthcare settings in T

Indonesia: A mixed-methods study
Ardi Findyartinia,b,∗, Daniel Richard Kambeyc, Rezki Yeti Yusrab, Amandha Boy Timorc,d,
Candrika Dini Khairania,b,c, Daniar Setyorinib, Diantha Soemantria,b
a
Department of Medical Education, Faculty of Medicine, Universitas Indonesia, Indonesia
b
Medical Education Centre, Indonesia Medical Education and Research Institute (MedEC IMERI), Faculty of Medicine, Universitas Indonesia, Indonesia
c
Indonesia Young Health Professionals' Society (IYHPS), Indonesia
d
Faculty of Medicine, Universitas Sebelas Maret Solo, Indonesia

A R T I C LE I N FO A B S T R A C T

Keywords: Background: Interprofessional collaborative practice (IPCP) in high-quality healthcare is contextual and dy-
Interprofessional collaborative practice namic. Objectives: The study aimed to identify the perceptions of the current workforce towards IPCP and to
Primary care settings explore the challenges and barriers associated with socio-cultural values and other factors that could potentially
Indonesia affect the implementation of IPCP.
Collaborative practice assessment tools
Design: This study adopted a mixed-methods -explanatory sequential design. Participants: Participants were
Mixed-methods design
health professionals in primary health care setting who voluntarily participate in the study and recruited using
systematic random sampling.
Methods: A 53-item validated Collaborative Practice Assessment Tool (CPAT) with 8 subscales was administered
in the quantitative stage and focus group discussions were completed in the subsequent stage.
Results: A total of 303 health professionals participated (61.8% response rate), from which 290 completed
questionnaires were eligible for further analysis. Based on the collaborative practice assessment tool, the mean
score = 204.05 with highest possible = 265. Nine focus group discussions involving 73 health professionals
were held. Comparative analyses based on group demographics on quantitative data and thematic analyses for
qualitative data, were conducted. Between the physicians and other groups, there were score differences in the
leadership and vision–mission–aims subscales, as well as the decision-making (based on length of work ex-
perience) and patient-involvement subscales (based on age). The semantic thematic analysis resulted five
themes: structures, supporting factors, inhibiting factors, perceived benefits and challenges of IPCP.
Conclusion: The respondents’ perceptions towards interprofessional collaborative practice were positive. There
are differences which could be attributed to professional background, the length of work experience and age.
Factors at the organisational, group and individual levels contributed in IPCP at the primary care setting. They
include socio-cultural factors such as uncertainty avoidance tendency, power differentials, and collectivist cul-
ture.

1. Introduction mismatch between the competencies of health professionals and the

The current landscape of health services around the world, in-
cluding in developing countries, is determined by the emergence of
infectious diseases; epidemiological transitions from communicable
diseases to non-communicable diseases; and climate, environmental,
behavioural and demographic changes. Health professionals are ex-
pected to work together effectively to overcome these health risks.
There are challenges which need to be considered, however, such as the
needs of the population, as well as poor teamwork skills, weak lea-
dership skills and other issues among health professionals.1,2
The ability to work as a team has become an important pillar of
health-service improvement. Relevant competencies in interprofes-
sional communication, conflict management, leadership, patient-
centred care and ethical practice3 are developed through interprofes-
sional education (IPE) and interprofessional collaborative practice
(IPCP).4 The benefit of interprofessional collaborative health service is

∗
Corresponding author. Department of Medical Education & Medical Education Centre, Indonesia Medical Education and Research Institute, Faculty of Medicine,
Universitas Indonesia, Salemba 6, Central Jakarta, 10430, Indonesia.
E-mail address: ardi.findyartini@ui.ac.id (A. Findyartini).

https://doi.org/10.1016/j.xjep.2019.100279
Received 6 January 2019; Received in revised form 9 July 2019; Accepted 22 July 2019
2405-4526/ © 2019 Elsevier Inc. All rights reserved.
 Author's Personal Copy
A. Findyartini, et al.
evident; it improves, for example, access to and coordination of health
services, services for patients with chronic diseases, the efficiency of
patient-referral and patient-care systems, and the quality of community
health services. In addition, interprofessional collaboration also reduces
the complications experienced by patients, such as length of hospital
care, staff turnover in health services, undesirable events in healthcare,
and mortality5–7; Reeves, Perrier, Goldman, Freeth & Zwarenstein,
2013).49 An updated systematic review by Reeves et al.8 also underlines
that interprofessional activities such as collaborative planning, reflec-
tion activities, interprofessional rounds, interprofessional meetings, and
interprofessional activities may slightly improve patient health out-
comes, patient care efficiency outcomes, and collaborative behaviour
outcomes. Despite this, the studies which fulfilled the review criteria
show low certainty; therefore, this calls for further rigorous mixed-
method and longitudinal studies.8
A study by van Schaik, O'Brien, Almeida and Adler9 suggests that
the characteristics of a strong interprofessional team includes effective
teamwork, good leadership and clear common goals. The ways in which
group members work and interact with each other greatly affects the
quality of their teamwork. For example, a team's hierarchy often de-
termines which member will be the team leader, while the hierarchy
itself is influenced by several factors, such as seniority, experience and
culture. Van Schaik et al.‘s9 study further emphasises the need for each
group member to identify prejudices, negative stereotypes and hier-
archies within the healthcare system.
Understanding the role and authority of each health profession is a
crucial factor for effective teamwork. MacNaughton, Chreim and
Bourgeault10 proposed a useful model for role construction and inter-
professional boundaries in primary healthcare teams. Their study
highlighted that flexible role boundaries between health professions
can be implemented by considering two important aspects: inter-
professional interactions (i.e. whether the role can be done autono-
mously or collaboratively) and distribution of tasks (i.e. whether the
roles are differentiated or interchangeable). Several factors can influ-
ence the dynamics of interprofessional collaboration, such as workplace
characteristics, interpersonal factors (including the dynamics between
team members and leadership) and personal attributes.10
Xyrichis and Lowton11 conducted a systematic review to identify the
factors that drive or inhibit IPCP. They found that teams with a greater
variety of health professionals tend to perform better, but uncertainty
about team goals and leadership can lead to poor-quality work.12 For
interprofessional cooperation to work effectively, trust, team con-
fidence, team orientation, psychological comfort, mutual respect and
team development are required.9 A focus group study performed in the
primary health centres of Indonesia underlined several factors that
contribute to collaborative practices at the organisational level, the
health-system level and the personnel level.13
IPCP in healthcare cannot simply be formed, however; it requires an
educational process that enables students to develop interprofessional
cooperation, communication skills, recognise the roles and responsi-
bilities of their chosen professions as well as other health professions,
and provide patient-centred health services, which are encompassed in
IPE.14 Differences in the implementation of IPE and IPCP between
hospitals or educational institutions is influenced by various factors,
including socio-cultural characteristics within an institution or within
each group of health professions. To the authors’ best knowledge, the
implementation of IPE in Indonesia and other Asian countries varies
significantly. Some countries have implemented IPE to a broader degree
than others within the region, as evidenced by Watanabe and Koizumi
(2010)51, who explored the experiences and practices of various IPE
programs in Japan. In Indonesia, while Soemantri et al.15 have for-
mulated national guidelines for IPE implementation, including a cur-
riculum framework, IPE is still in a very early stage and tends to be
sporadic depending on the abilities and commitment of each educa-
tional institution and health professional. The differences between
Japan and Indonesia are just a few examples of the state of IPE
2
Journal of Interprofessional Education & Practice 17 (2019) 100279
implementation in Asia. Readiness among educational faculty and
students has also been cited as a significant factor in the development
and implementation of IPE16.
Prior to the present study, no research has explored the similarities
and differences in value and culture that affect the development and
implementation of IPCP and IPE in various Asian countries, including
Indonesia. Regarding IPCP in particular, no previous study has thor-
oughly evaluated the ways in which IPCP has been implemented in
various healthcare settings, both in hospitals and primary health cen-
tres or other primary care settings, and the current workforce in
Indonesia has virtually never received interprofessional courses or
training. As such, this study aims to identify the gap between the re-
quirement to implement IPCP in Indonesia and the perceptions of the
current workforce towards IPCP, thereby highlighting the importance
of bridging this gap. To achieve this, the authors measured the IPCP of
primary care centres in Depok City, Indonesia, using a validated col-
laborative practice assessment tool (CPAT).17 The authors also explored
the challenges and barriers associated with socio-cultural values and
other factors that could potentially affect the implementation of IPCP.
This exploration is in line with the spirit of the globalisation of health
education and practice, which not only imposes homogenisation and
the adoption of favourable IPCP and IPE practices from Western
countries but also encourages adaptation (hybridisation).18
2. Methods
2.1. Context
The Indonesian health system is evolving from a fee-for-service
model towards universal health coverage, thus requiring many altera-
tions to daily practices in primary, secondary and tertiary care settings.
One major issue rising from these changes is an increasing demand for
team-based practice. The government recently announced a team-based
placement model for health professionals, which will be deployed to the
most rural areas of Indonesia. The programme is called ‘Nusantara
Sehat’ which comprised of various background of health profesionals.
An accreditation system was also introduced in the nation's primary
care centres, with an emphasis on implementing collaborative prac-
tices.
Primary care centres in Depok City were chosen as the study setting,
as the first author's institution is within this area. Depok City covers an
area of 200.29 km2 divided into 11 regencies, with a registered popu-
lation of 1,430,190. There are 35 primary care centres in this area, all of
which were included in the study.
2.2. Research design
The study adopted a mixed-methods i.e explanatory sequential de-
sign, using both quantitative and qualitative approaches. The first stage
involved circulating the validated CPAT (Indonesian version17; to all
primary care centres in Depok City, whereas the second stage was
comprised of focus group discussions (FGDs) to explore the enabling
factors and obstacles of collaborative practice, as perceived by health
professionals, which were then attributed to the socio-cultural factors
present their daily practices. The inclusion criterion was health pro-
fessionals who self-identified as having experience in IPCP. The defi-
nition of IPCP was provided in the questionnaire and introduced in the
FGD following the leading question on understanding on the inter-
professional collaborative practice (question number 1) to assure that
the health professionals can self-identify correctly.
2.3. Data collection
For the first stage, a systematic random sampling technique was
implemented, which considered the proportion of each health profes-
sion in the primary care centres. The minimum sample size was
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A. Findyartini, et al. Journal of Interprofessional Education & Practice 17 (2019) 100279

Table 1 Table 2
Focus Group Discussion guiding questions. Demographic characteristics of respondents in Primary Health Centres at Depok
City (n = 290).
Opening questions
1. Please describe how you have been working in the current primary health care Survey stage (n = 290) Focus Group Discussion
setting Variable stage (n = 73)
2. What do you think about interprofessional collaborative care? What do you think
about the practice in your current setting? Total (n) Percentage (%) Total Percentage (%)
3. How would you describe an ideal interprofessional collaborative care? (n)
Main questions
1. What do you think of benefit of interprofessional collaborative care? Would you Sex
please give examples from your daily work/practice? Male 25 8.6 5 6.8
2. What factors do you think would enable interprofessional collaborative care? Why Female 265 91.4 68 93.2
do you think so? Age group
3. What factors do you think would hinder interprofessional collaborative care? Why 20–30 year old 46 15.9 15 20.5
do you think so? 31–40 year old 129 44.5 22 30.1
Closing 41–50 year old 87 30.0 25 34.2
• If you have an opportunity to initiate system change or becoming the policy
maker, what would you do in regards to interprofessional collaborative care in
> 50 year old
Health professions
28 9.7 11 15.1

your practice/setting? Nurse 70 24.1 16 21.9

Physician 63 21.7 18 24.7
Midwife 55 19.0 15 20.5
Dentist 27 9.3 9 12.3
calculated at 216 (with Zα power was determined at 1.96 with sensi-
Nutritionist 20 6.9 4 5.5
tivity of 5%, confidence level of 95%, and an anticipated dropout rate Analyst 10 3.4 1 1.4
of 10%). The sample size for each health-profession group was adjusted Pharmacyst 9 3.1 2 2.7
according to the total population of 490 and the proportion of health Public health 5 1.7 5 6.8
professionals available in the primary care centres. A total of 420 Radiographer 1 0.3 0 0
Other 30 10.3 3 4.1
questionnaires, with informed consent forms attached, were distributed
Length of work in the health profession
to the eligible health professionals. The total number of distributed 1–5 year 27 9.3 7 9.6
questionnaires considered the aim of involving different health pro- 5–10 year 82 28.3 25 34.2
fessionals in 35 district primary care centres in Depok and in facilitating > 10 year 181 62.4 41 56.2
the questionnaire administration (a total of 12 questionnaire was di- Forms of collaboration team
Primary care 244 84.1
rectly distributed in each centre). Emergency 11 3.8
For the second stage, the authors invited 73 of the respondents from Geriatric care 5 1.7
the first stage to participate in FGDs. The authors arranged the parti- Family practice 5 1.7
cipants into small groups of 8–10, based on the professions. There were Surgery 1 0.3
Transplantation 1 0.3
nine groups in total, which consisted of two groups each of midwives,
Tropical disease 1 0.3
physicians, nurses and other professions, and one group of dentists. The management team
total number of groups of each profession considered the proportion of Others 22 7.6
the profession in the primary health centres (see Table 2). Uniprofes-
sional groups were chosen to give participants convenience to share
specific perspectives from each profession in regards to the inter- test, p < 0.05), further analysis used a non-parametric approach to
professional collaborative practice. To determine the total number of compare median for more than two groups of data (Kruskal–Wallis
FGDs, data saturation was considered. The duration of each FGD ranged test). Afterwards, Mann-Whitney test was used as a non-parametric
from 60 to 90 min, in which one researcher acted as the moderator. post-hoc test to assess difference between each two groups in the re-
Another researcher assisted with recording each session, after obtaining spective dataset.20
the participants’ consent. Verbatim transcriptions were developed from After the FGD transcriptions were completed, they were analysed to
the recordings. identify key themes. Independent theoretical thematic analyses were
conducted by four of the authors (AF, DS, DRK, ABT). Each two authors
analysed two similar transcriptions hence a total of four transcriptions
2.4. Instruments
were analysed first. The researchers identified semantic themes con-
sisting explicit meanings of what the participants had said and docu-
A validated Indonesian version of CPAT questionnaire was used in
mented in the transcription.21 The researchers discussed the emerged
the first stage of this study. The CPAT was originally developed in
themes and subthemes until agreement was reached. The subsequent
Canada to assess levels of collaboration based on the health profes-
thematic analysis process of the five transcripts was completed using
sionals' perceptions in practice setting.19 The 56-item instrument un-
the agreed-upon themes.
derwent a robust adaption process: translation and back translation,
expert panel review and exploratory factor analysis, and resulted in 53
questionnaire items with 8 subscales (Cronbach's α value of 0.916).17
2.6. Ethical considerations
This present study used the 53-item CPAT Indonesian version.
The FGD was moderated by researchers and utilised several guiding
This study has been approved by the Research Ethics Committee of
questions (Table 1).
the Faculty of Medicine, Universitas Indonesia. All quantitative and
qualitative data has been kept secure and can only be accessed by the
2.5. Data analysis authors. The questionnaires were completed anonymously, and pseu-
donyms were used in the FGD transcriptions as well as any reports or
Quantitative analyses were completed using SPSS 22.0. Descriptive publications that resulted from the study.
analysis was conducted to describe the respondents’ characteristics.
Internal consistency analysis of the CPAT instrument using Cronbach
alpha was completed. Given the abnormal distribution of data based on
health profession, length of work and age group (Kolmogorov–Smirnov

3
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A. Findyartini, et al. Journal of Interprofessional Education & Practice 17 (2019) 100279

3. Results

p (Kruskal-Wallis)
3.1. Survey of IPCP using the CPAT

0.019*
0.029*
0.139
0.091
0.570
0.133
0.226

0.342
0.080
Out of 490 total, 303 health professionals in Depok City primary
care centres participated voluntarily in the study, resulting in a 61.8%
response rate, which exceeds the minimum sample size required. A total

204.5 (157,255)
Other (n = 75)
of 13 respondents self-identified themselves as having no experience in
healthcare interprofessional collaboration despite the provided defini-

37 (27,45)

56 (48,70)

36 (31,45)
18 (1,25)
16 (4,20)

20 (6,25)

20 (4,25)
tion in the questionnaire. Therefore, the 13 responses were excluded

4 (2,8)
from the dataset and resulted in the final 290 responses to be analysed
further. The 53-item CPAT used in this study has high internal con-
sistency (0.901). The reliability coefficients of the subscales range be-

Midwife (n = 55)
tween 0.539 and 0.890.

206 (187,238)
Table 2 describes the demographics of the respondents in the survey

36 (30,45)
18 (12,21)
16 (12,20)
56 (51,69)

20 (12,25)
36 (30,45)
20 (10,25)
and FGD stages. Almost all the respondents were female (91.4%), with a

4 (2,8)
larger proportion between the ages of 31–50 years old. Physicians,
nurses and midwives were the three largest health-profession groups,
and most of the respondents (62.4%) had been working in their re-

Nurse (n = 70)
spective professions for more than 10 years.

205 (170,239)
The mean CPAT score was 205.8, which is 77% of the highest

37 (33,45)
18 (11,22)
16 (12,19)
56 (44,67)

20 (11,25)
36 (27,45)
20 (16,20)

Kruskal-Wallis test was completed in this study to compare median of more than 2 groups of respondents which data is abnormally distributed.20
possible score of 265 (scores ranged between 157 and 255). Based on

4 (2,9)
health profession, there are no differences in scores across the CPAT
subscales, except for leadership (Subscale 6) and missions, goals and
objectives (Subscale 7) (see Table 3 for the comparison of the 5 groups

Dentist (n = 27)
using Kruskal-Wallis test). A post-hoc analysis using the Mann–Whitney

206 (175,232)
test showed that the differences are as follows:

37 (35,45)
18 (16,22)

56 (46,65)

20 (16,23)
36 (29,45)
20 (14,25)
16 (7,19)

4 (2,8)
• Subscale 6: Leadership: There were significant differences between
Median score (min, max)

the physician and nurse group and between the physician and
midwife group (p = 0.017 and 0.035, respectively), physician and

CPAT: Collaborative Practice Assessment Tools (53 items; adapted with permission from Schroder, C et al. (2011)).
Physician (n = 63)

other-health-profession group (p = 0.007), and the dentist and

202 (174,253)
other-health-profession group (p = 0.042).
•
36 (28,45)
18 (10,24)

56 (41,70)

35 (27,45)
20 (14,25)
Subscale 7: Missions, goals and objectives: There were significant
16 (2,20)

19 (3,25)
4 (2,8)
differences between physician and nurse group (p = 0.030), physi-
cian and midwife group (p = 0.004), and physician and other-
health-professional group (p = 0.006).
Max subscale score

Based on length of work experience, there was a significant differ-

ence (Kruskal–Wallis test, p < 0.05) in scores for Subscale 5 (Decision
making and conflict management). This subscale was only comprised of
two items, which reflects its instability. A post-hoc test revealed a sig-
265
45
25
20
70
10
25
45
25

nificant score difference between groups with 1–5 years and more than
CPAT questionnaire results based on group of health professions (n = 290).

10 years of work experience (Mann–Whitney test, p = 0.006).

Finally, based on age group, there was a significant difference in
Patient involvement, responsibility, autonomy (5 items, α = 0.590)

scores for Subscale 8 (Patient involvement, responsibility and au-

Decision making and conflict management (2 items, α = 0.732)

tonomy). A post-hoc test showed that there were significant score dif-
Team coordination and organisation (14 items, α = 0.553)
Relationships among team members (9 items, α = 0.890)

Team relationships with community (4 items, α = 0.726)

ferences between the age groups of 20–30 years and 31–40 years
(p = 0.048), 20–30 years and > 50 years (p = 0.005), and 41–50 years
Barriers in team collaboration (5 items, α = 0.539)

Missions, goals and objectives (9 items, α = 0.822)

and > 50 years (p = 0.006).

3.2. FGDs on factors influencing IPCP

Table 2 describes the composition of the FGD participants based on

Leadership (5 items, α = 0.732)

gender, health profession, age group and length of work in the pro-
fession. The proportion reflects the composition of the respondents
based on the demographic characteristics in the survey stage quite
Total score (53 items)

adequately.
*p significant at < 0.05.

Thematic analyses revealed the themes and subthemes of the par-

ticipants' responses (see Table 4). The number of quotes reflecting each
Subscales

theme and subtheme were totalled, and descriptions for each theme and
subtheme, along with a selection of quotes, is provided in the following
subsections. The quotes were tagged using a detailed set of information,
including the FGD number (‘FGD#‘), the participant's number/code
Table 3

within the respective FGD (e.g. ‘I’, ‘R’, ‘N#‘, etc.), the participant's
1–8
1
2
3
4
5
6
7
8

profession and the page the quote can be found on within the

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A. Findyartini, et al. Journal of Interprofessional Education & Practice 17 (2019) 100279

Table 4
Thematic analysis results of FGDs in primary health centres at Depok City.
No Theme Sub-themes Number of quotes

1 Structure of interprofessional collaborative practice in Interprofessional collaboration with limited human resources 38
primary healthcare setting Interprofessional collaboration in referral system 15
Interprofessional collaboration for patient based and community based healthcare 10
Interprofessional collaboration with adequate human resources 9
Interprofessional meetings 5
Ad-hoc interprofessional collaboration 3
2 Supporting factors of interprofessional collaborative practice Communication and togetherness of team members 23
in primary healthcare setting Standard Operational Procedure for interprofessional collaboration 15
Supportive leadership and role model 11
Role distribution of health professions 9
Good medical record and referral documentation 8
Understanding of ideal interprofessional collaboration 7
Adequate infrastructure 5
Arrangement of workload 4
Adequate number of human resources 4
Reflective attitude of health professionals 2
Clear reward and punishment 2
Monitoring of collaborative practice 2
Involvement of health professionals 1
3 Inhibiting factors of interprofessional collaborative practice Unbalanced workload and leadership problems 35
in primary healthcare setting Limited number of human resources 24
Interpersonal factors and communication 22
Unreliable individuals 9
Seniority/hierarchy 9
Unmatched competence 7
Limited infrastructure 4
4 Perceived benefit of interprofessional collaborative practice Safe and effective healthcare 9
in primary healthcare setting Complementary functions in the healthcare 2
Pride of interprofessional collaboration 1
Pride of professional roles in the collaboration 1
Knowledge gain 1
5 Challenges of interprofessional collaborative practice in National health insurance implementation 4
primary healthcare setting Patient and public expectation 3
Public appreciation of health professions 1
Regulation 1

transcription documents. (FGD8_Nurse_S_4–5)

3.3. Structure of IPCP in primary healthcare settings
According to the FGD participants, IPCP could easily be im-
plemented in the primary care setting, since the scale of healthcare is
smaller compared to the hospital setting. In addition, given that there is
much work to do in individual/patient-based and community-based
healthcare, collaboration is inevitable; health professionals must work
collaboratively by recognising each health profession's role for patient
care because all their healthcare and administrative obligations would
not be completed otherwise.
Most of the participants underlined that the structure of inter-
professional collaboration is impacted by limited human resources. This
study shows that, given the heavy burden of work in the primary
healthcare setting, the roles of health professionals are blurred, espe-
cially when they are not profession-specific and as long as blurring
them does not harm the patients and communities being served. A se-
lection of quotes on this topic is as follows:
“Since we do not have any dental nurses in our primary healthcare
[centre], I do rely on my paramedic friends who were not trained as
dental nurse[s] to help me [provide dental care].”
(FGD3_Dentist_N_5)
This study also identified the danger of blurring the boundaries
between health professionals’ roles, which occurred when there were
problems in delegating patient care and when the health professionals
did not work according to their competencies. One of the nurses noted:
“If the doctor needs to attend important meetings, some-
times—reluctantly—we need to cover everything, from registration
[and] patient examination to prescribing drugs.”
There are two categories of primary healthcare settings in Depok
City: Technical Implementation Units (Unit Pelaksana Teknis [UPT]) and
Functional Implementation Units (Unit Pelaksana Fungsional [UPF]).
The first category had more health professionals from diverse back-
grounds. Consequently, interprofessional collaboration in these settings
was more feasible and ideal. Interprofessional collaboration was also
observed in the referral system between health professionals, as evi-
denced in the following quote:
“The nurse will take the history of the dental patient first, and [then
measure] their blood pressure. I will then treat the patient. Then,
when I prescribe [a] certain drug and [it] turns out that our phar-
macy does not have it, the pharmacist assistant will contact [us] and
say, ‘The drug you prescribed is not available. Can we change it with
another drug? Will there be any allergic reaction?’ And then I will
ask the patient whether he/she [is allergic] to certain drugs or not. If
the problem is, for example, high blood pressure, I will refer [the
patient] to the physician first; [this is the] internal referral system.
The physician will prescribe…antihypertensive drugs. I am grateful
that the patient can be treated holistically [in this way].”
(FGD3_Dentist_I_4)
Finally, the participants also suggested that meetings among health
professionals in the primary healthcare setting is one of the most im-
portant elements of interprofessional collaboration.
3.4. Supporting factors for IPCP in primary healthcare settings
Several supporting factors for IPCP were identified. The five most
common factors across the focus groups were communication and ‘to-
getherness’ of the team member, standard operational procedures

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A. Findyartini, et al.
(SOPs) for interprofessional collaboration, supportive leadership and
role model, role distribution of health professions and good medical
records and referral documentation. The participants from diverse
health-professional backgrounds highlighted ‘communication and to-
getherness' as the backbone of IPCP. A selection of quotes on this topic
is as follows:
“Given [the] small scale of our primary healthcare centre, we have
this benefit of frequently meeting…each other. In the morning, we
usually [meet to coordinate] what we will do today, where to go and
so on. Such communication is very important.”
(FGD4_Physician_N5_14)
“When we do it together and we have good communication, it
means [our] differences can be overcome.” (FGD6_Other health
profession_1_8)
SOPs were also found to be a supporting factor for interprofessional
collaboration. In this setting, SOPs are those which explain the health
professionals’ roles and responsibilities in collaborative healthcare
practices, as described in the following quote:
“The work and organisational structure has to be developed well.
Physicians, dentists and other health professionals have their own
roles and responsibilities. I will add [further details,] such as who
[is] responsible for patient-based healthcare and who [is] re-
sponsible for community-based healthcare. Therefore, the roles and
responsibilities are clear [and] in accordance with the competencies,
…both individual/patient-based and community-based healthcare
can be conducted.” (FGD3_Dentist_R_24)
Furthermore, supportive leadership and role models are considered
fundamental for IPCP. The participants suggested that supportive lea-
ders should nurture collaboration, balance health professionals’ work-
loads and provide good role-modelling for collaborative practice.
Leadership was also expected to distribute the roles of the health pro-
fessionals in each primary healthcare setting in a clear and balanced
manner. One example of this can be seen in the following quote:
“In our centre, there are groups of health professionals. [The head of
the centre] is very smart in encouraging and allowing all of us from
different groups [to work together]. No one has hard feelings, and
whenever there is conflict [among us], [the head of the centre] will
not accuse certain groups.” (FGD2_Midwife_12)
The understanding of role distribution for patient care according to
each profession's competence was also recognised as one of the sup-
porting factors of IPCP, as described in the following quote:
“….when I have an incoming prescription, I would prepare it ac-
cordingly. [When I give the medicine to the patient], I usually ask
the chief complaint of the patient before I give the medicine. [This
way], I can check whether there are mismatches of the patient's
chief complaints and the prescription. [Should I find something
suspicious], I would reconfirm it to the doctor.” (FGD 7_Other health
profession_ 2_5)
As mentioned earlier, participating in an internal referral system,
especially between different health professions, is considered an im-
portant form of collaboration. Accurate medical records and referral
documentation were identified as supporting factors for IPCP. A selec-
tion of quotes on this topic are as follows:
“We have a referral form [for patients transferring] between out-
patient clinics. [We realise] that [referrals] cannot [only] be done…
verbally, since there will be no evidence.” (FGD3_Dentist_N_11)
3.5. Inhibiting factors for IPCP in primary healthcare settings
This study also uncovered several inhibiting factors for IPCP,
6
Journal of Interprofessional Education & Practice 17 (2019) 100279
including unbalanced workloads, inadequate human resources and in-
terpersonal barriers, such as issues with communication. Unbalanced
workloads among health professionals could be caused by ineffective
leadership. Since IPCP in primary healthcare settings are often con-
ducted with limited human resources, unbalanced workloads may
hinder collaboration. The following two quotes describe this finding:
“I wonder why [the] physicians tend to ask [for] help from the
nurses while different attitudes are directed towards [the] mid-
wives. I feel like my midwife colleagues are very relaxed. For ex-
ample, when a physician want[s the] midwives to measure [a] pa-
tient's blood pressure, they can say no, while we cannot.”
(FGD8_Nurse_T_17)
Limited human resources was identified as the main deterrent
keeping primary healthcare centres from achieving ideal collaborative
practices. One participant shared a strong opinion about this, as fol-
lows:
“I think all primary healthcare centres would face the same problem.
[The health professionals] will have a lot of roles and responsi-
bilities. For example, a physician will be assigned to lead four to five
programmes. When we, for example, have to deal with trauma pa-
tients in the emergency [department], we have to leave the out-
patient clinic. When there is only one physician in the centre, …
patient care in the outpatient clinic will stop. [In another case],
when a physician need[s] to fulfil [their] duty [in the] integrated
health services unit [in the community], the outpatient clinic in the
centre will have no physician and needs to be run by other health
professionals.” (FGD4_Physician_N6_13)
In addition, both interpersonal and interprofessional communica-
tion barriers were identified as inhibiting factors for collaborative
practice. The participants considered these barriers to be related to the
socio-cultural backgrounds of the individuals and the health profes-
sions. Seniority and hierarchy within the health system was also sug-
gested as an inhibiting factor. A selection of quotes on this topic are as
follows:
“When I was assigned [to] the primary health centre [in Depok]
before moving to current primary health center, the nurses were all
more senior than me. I think I was the youngest health personnel
[at] that time. Because there was a high patient load, and there were
only two physicians—myself and the head of the centre—we often
asked for the nurses' help to manage patients who did not need
antibiotics. One of the nurses refused to help me even though she
[was] not do[ing] anything [at] that time. I was upset and com-
plained about this attitude.” (FGD4_Physician_N2_ 23)
3.6. Perceived benefits of IPCP in primary healthcare settings
Most of the health professionals in the primary healthcare settings
noted that the main benefit of IPCP is safer, more effective patient care.
For example:
“For us, it means that we can work more safely. When I had an
elderly patient with teeth problem, I suspected that he might have
diabetes mellitus. He looked sick. When we referred [him] to the
lab, [it] turned out that [his] glucose level was 500. If I did not
collaborate with the analyst in the lab, it could [have been] dan-
gerous for the patient [to undergo] a dental procedure.”
(FGD3_Dentist_I_15)
Other perceived benefits include pride among health professionals
when they collaborated well and help each other while conducting
health services. Feelings of pride also came from having the role of each
health profession in interprofessional collaboration.
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A. Findyartini, et al.
3.7. Challenges of IPCP in primary healthcare settings
The final theme resulting from the thematic analyses is the chal-
lenges of implementing IPCP in primary healthcare centres. Two main
challenges were identified: implementation of the national health in-
surance system and patient/public expectations regarding the roles of
health professionals in healthcare provision. One example of this ap-
pears in the following quote:
“...In our society, the paradigm being [maintained] is not disease
prevention. Whenever [patients] are ill and they feel that they have
already paid for…health insurance, they want to get treated and get
medicine. Therefore, we are not yet able to arrange time for out-
patient [care] and other programmes…” (FGD4_Physician_N1_7)
4. Discussion
This mixed-methods study assesses IPCP in primary healthcare set-
tings within Depok City, Indonesia, using a CPAT (Indonesian version),
thereby revealing the perceptions of health professionals towards IPCP,
as well as the influencing factors. The demographic data captured by
the CPAT shows that the participants are varied in their health pro-
fession backgrounds (i.e. physicians, dentists, nurses, pharmacists,
health analysts, radiographers, public health practitioners and nutri-
tionists), which allows for the contribution of each field to the health-
care and interprofessional collaboration in each primary healthcare
centre. The more diverse the health professionals’ background are, the
better the team performance.11 However, each health professional may
want to demonstrate the roles specific to their profession; this can lead
to team conflict if it is not well anticipated.22
In the primary healthcare setting, the internal consistency of the
CPAT (0.901) and its subscales (0.539–0.890) are high. For Subscales 2
(barriers in team collaboration), 5 (decision making and conflict man-
agement) and 8 (patient involvement, responsibility and autonomy),
the internal consistency tended to be lower than for other subscales.
Internal consistency for each subscale was determined by the response
patterns, the total number of items within the subscale and the item
relevance, among other factors.23,24 The relatively low internal con-
sistency of Subscale 5 (0.553) can be explained by its very limited
number of items (only 2). In the hospital setting, however, the CPAT
administered had better internal consistency in this subscale (0.768).25
For all subscales, tendencies towards low internal consistency may be
explained by inconsistent response patterns by the health professionals,
which can be attributed to socio-cultural factors influencing inter-
personal and interprofessional interactions.
The low internal consistency in barriers in team collaboration
(Subscale 2) can be explained by the high amount of uncertainty
avoidance among Asians.26,27 This cultural phenomenon reflects the
anxiety or discomfort of a group of people when they are exposed to
uncertain or unknown situations.26 Barriers in team collaboration en-
courage members to assess the conflicts that may happen at the in-
dividual, interpersonal and interprofessional levels. Individual re-
sponses to these barriers require flexibility, as both the problem-solving
process and its solution can be uncertain. High uncertainty avoidance
encourages individuals to favour the presence of rules and clear
guidelines for overcoming barriers. In a study by Soemantri et al.25; the
internal consistency of this subscale is better (0.663) than in the present
study, but it was still relatively low compared to the other subscales.
The possible influence of uncertainty avoidance was also evident in
other studies, as seen in the low internal consistency of the ‘flexibility in
thinking’ subscale in a diagnostic thinking inventory.28,29
Furthermore, low internal consistency in decision making and
conflict management (Subscale 5), and patient involvement, responsi-
bility and autonomy (Subscale 8) may reflect a hierarchical culture,
which is also common in Asian countries. Reeves30 stated that power
differentials can influence IPCP in healthcare. Hierarchical culture
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Journal of Interprofessional Education & Practice 17 (2019) 100279
corresponds to large gaps in power, in which authority, including de-
cision making, is not equally distributed throughout society.26,27
Overall, the CPAT scores were good, indicating that the health
professionals in the primary healthcare centres of Depok City have a
positive perception of interprofessional collaboration. Further analyses
of the CPAT showed differences between several subscales, based on
health profession, age group and length of work experience. When
analysing the scores based on health profession, the authors found a
significant difference in the leadership subscale (6), in which the phy-
sician group had a slightly lower score compared to other groups
(nurses, midwives and other health professions). Leadership is funda-
mental to IPCP in healthcare,31 including the primary healthcare set-
ting. Moreover, leadership in IPCP is quite a complex concept, due to
several reasons, one of which is the need to be dynamic and flexible
according to healthcare needs.32
According to Turner (1995), from a sociological perspective on
health profession development, physicians may see leadership in IPCP
as one of three processes: subordination, limitation and exclusion.32 In
the subordination process, physicians delegate professional healthcare
activities to nurses or midwives; hence, the autonomy or self-regulation
of other professions is limited.30,32 In the present study, the results may
indicate that this process operates within the primary healthcare cen-
tres of Depok City. As mentioned earlier, the physicians’ leadership
approaches may also explain the difference in perspectives regarding
the missions, goals and objectives of IPCP in healthcare (Subscale 7)
between the physician group and the nurse and other-health-profes-
sional groups.
The FGD results underline the importance of leadership in primary
healthcare settings, which nurtures and encourages a balanced dis-
tribution of roles and responsibilities within the interprofessional team.
The concepts of transformative leadership,33 which include becoming a
good role model for the surrounding people, nurturing the spirits of
others and inspiring others when around them and providing moral
encouragement from the rear are highly relevant to interprofessional
collaboration. Transformative clinical leadership, which highlights both
leadership and active followership, is considered to be a key determi-
nant in the success of IPCP implementation in any clinical setting.34
The present study also demonstrated that most health professionals
in primary healthcare centres within Depok City have worked in their
respective fields for a long time. For Subscale 5 (decision making and
conflict management), there was a significant score difference between
the groups with more than 10 years of experience and the groups with
1–5 years of experience. Having diverse lengths of work experience
within the interprofessional team allows members to interact with other
health professionals whose backgrounds differ from theirs, thereby
helping them adapt to a variety of collaborative processes,35 and
gaining more work experience enhances the health professional's un-
derstanding of the roles of other health professions involved in the
collaborative practice36; Sayed, 201150). This may further support the
group dynamics within a health interprofessional team towards per-
forming stage.37 In addition, self-confidence in decision making and
conflict management may also be facilitated by maturity, seniority and
knowledge of the health system, and self-confidence influences the ef-
fectiveness of the collaborating team.38 This finding was also supported
by the FGDs, which underscored that seniority may have a positive
impact when senior health professionals use their positions to be good
role models for junior health professionals, thus helping them adapt to
the IPCP environment.
Subscale 8 of the CPAT explored the perceptions of health profes-
sionals towards patient and family involvement in decision making and
the role of each health profession in the process. The quantitative
analysis revealed that these perceptions can be influenced by age group;
health professionals > 50 years old achieved a lower score in this
subscale compared to the other age groups. This finding can be ex-
plained by the generational gap between older and younger health
professionals, which led to different perspectives on patient
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A. Findyartini, et al.
involvement in the decision-making process. The older generation did
not seem to regard patient involvement as a critical aspect of healthcare
provision in primary health centres. This may reflect the hierarchical
nature of the relationships between health professionals, their patients
and the patients' family members.26,27 The FGD results also showed that
the health professionals (i.e. physicians) attempted to satisfy their pa-
tients’ requests that all information related to nutrition and disease
management be directly provided by the physician. This may introduce
challenges to the IPCP, since the attempt may limit delegation process
of healthcare management to other health professionals.
Results from the qualitative analysis of the nine FGDs, some of
which were mentioned earlier in relation to the quantitative results,
provided further insights into the structures of collaborative practice
and its influencing factors in the primary healthcare setting. The find-
ings indicate that IPCP should be encouraged in primary healthcare. All
the health professionals, regardless of background, were unable to take
on the heavy burden of providing comprehensive health services for
individuals, families and communities in Depok City without colla-
borating with colleagues from other health professions. This is in ac-
cordance with the definition of IPCP, which is described as integrated
co-operation among health professionals with different professional
backgrounds, accompanied by a possible blending of competencies and
skills that allows the effective utilisation of human resources for patient
care.39 This blending is an attempt to overcome the burden of patient
care, both in the primary healthcare centres and in the community,
despite limited human resources, thereby enabling the interprofessional
team greater flexibility and responsiveness to patient needs.40 However,
this method must be used in tandem with a deep understanding of the
competencies and roles of different health professions, thus ensuring
that the interprofessional team does not exceed patient needs while still
complying with patient- and community-safety protocols. In addition,
the blending of professional roles in healthcare may erode professional
identity.40,41 In the present study, example of confusion over profes-
sional roles happened among dental nurses who were assigned to per-
form a tooth extraction while the dentist completed other healthcare
tasks.
Professional role formation requires both the creation and nego-
tiation of tasks, which refer to individual multi-functions to fulfil the
team's responsibilities37; A role reflects the uniqueness of a professio-
nal's competency, knowledge and skills.42 The present study revealed
that, in the primary healthcare setting, health professionals tend to
engage in collaborative interactions and differentiated role distribution
when dealing with individual patient care, whereas, in community-
based healthcare, they tend to engage in collaborative interactions and
interchangeable role distribution.10 Limited human resources seemed to
be the main determinant of the form of IPCP the health professionals
engaged in. Leadership, as an interpersonal element, as well as the at-
titudes and competencies of the health professionals in this setting also
affected the form of IPCP.10 Health professionals should consider their
role boundaries to be in constant flux, due to cultural and social in-
teractions.43 The present authors believe that this concept is highly
relevant to leadership in the primary healthcare setting, especially
concerning the distribution of roles and responsibilities among health
professionals according to individual or community-based healthcare
needs. The dynamics of the professional role formation also highlight
that patient-centred care in various settings also requires interprofes-
sional attributes such as communication, care, respect, excellence, al-
truism and caring from all health professions.44
Interpersonal and interprofessional communication in the primary
healthcare setting play important roles in team dynamics as well.
Communication is the backbone of effective team collaboration45 and a
key competency in interprofessional collaboration.46 If it is not man-
aged well, however, communication barriers can be very challenging to
overcome. The FGD participants in the present study highlighted the
importance of interpersonal communication and togetherness in facil-
itating IPCP. These factors are thought to be closely related with
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Journal of Interprofessional Education & Practice 17 (2019) 100279
patterns of interaction between health professionals and the organisa-
tional culture of the healthcare setting.47 This finding might also reflect
a more collective, rather than individualistic culture.26,27
The FGD results also highlighted the need for clear standards in
operational procedures for IPCP. The participants suggested that SOPs
would facilitate collaboration, especially at the individual, inter-
personal and organisational levels, as they would provide clear doc-
umentation of health professionals' roles and responsibilities. This re-
sult further supports the presence of high uncertainty avoidance,26,27 as
discussed earlier. Despite the benefit of SOPs, the present authors
suggest that interprofessional teams must also be flexible by adjusting
the process and outcomes of their collaborative practices according to
the patient's or community's healthcare needs. In other words, SOPs
should be evaluated and revised accordingly on a regular basis.
The authors recognise three potential limitations in the present
study. First, this study adopted a mixed-methods design involving a
quantitative survey using the CPAT, followed by a qualitative ex-
ploration in FGDs, which were conducted in primary healthcare centres
in one setting (Depok City, Indonesia). The authors realise that the
participants of the present study came from different primary health-
care centres; yet, some professions were underrepresented and no
comparison between practice settings could be completed because of
this. Therefore, the results may not be generalisable to other settings.
However, since the sample size was adequate, and the health profes-
sionals working in Depok City came from a variety of professional
backgrounds, the results can still be applicable to other primary
healthcare settings with similar parameters. Second, the results of this
study were based on the self-assessment and self-perception of the re-
spondents in the current setting. Future studies using this approach can
be completed by assessment on the collaborative competence through
observation in practice (e.g Interprofessional Collaborative Competency
Attainment Survey, [ICCAS]48). Third, the socio-cultural impacts pro-
posed in this study may sound stereotypical, although this was not the
authors’ intentions. The authors would like to clarify that under-
standing the socio-cultural values of the setting will help health pro-
fessionals identify which values will facilitate or hinder IPCP.
5. Conclusion
IPCP is a vital component in improving the quality of health ser-
vices. The socio-cultural complexity of the setting, including the socio-
cultural aspects of each health profession, must be understood as a
common challenge in IPCP implementation. For students of the health
professions, collaborative health practices are an integral part of IPE; in
certain stages of their education, students need to engage directly with
and be shown examples of such practices in the daily operation of
health services. This study demonstrated that the Indonesian version of
the CPAT can be used in the primary healthcare setting. Several char-
acteristics, including professional background, age group and length of
work experience, may influence the perceptions of health professionals
towards IPCP, especially in terms of leadership; decision making and
conflict management; and patient involvement, responsibilities and
autonomy. Socio-cultural factors such as uncertainty avoidance ten-
dency, power differentials between professions, and collectivist culture,
the healthcare setting and organisational factors also affect the effec-
tiveness of IPCP. In the primary healthcare setting, IPCP involves the
blending of roles and responsibilities among health professionals,
especially in community-based healthcare. Future explorations of IPCP
require an understanding of the specific characteristics of the health-
care setting and an awareness of the socio-cultural factors that exist at
the organisational, group and individual levels.
Funding
This study was funded by the teaching hospital of Universitas
Indonesia (Rumah Sakit Universitas Indonesia, RSUI).
 Author's Personal Copy
A. Findyartini, et al.
Declaration of interest
The authors report no conflicts of interest. The authors alone are
responsible for the content and writing of this article.
Appendix A. Supplementary data
Supplementary data to this article can be found online at https://
doi.org/10.1016/j.xjep.2019.100279.
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