Law matters: How the legal context in Canada influences interprofessional collaboration

Introduction

Many factors affect whether and how practitioners from different professions work together to deliver healthcare services. In a recent review, Mulvale, Embrett, and Razavi (2016) identified 18 factors associated with interprofessional collaboration in primary care. Most of the research exploring these factors focuses on the micro level of care teams. Little attention has been given to characterising and analysing legal and governance factors and studying how these macro-level factors impact—positively or negatively—on organisational cultures, decision-making and communication processes, levels of conflict, and practitioners’ attitudes and beliefs.

In this editorial I encourage researchers in the interprofessional field to start to fill these knowledge gaps. I start by sharing some key findings from my recent analysis of legal factors that influence interprofessional collaboration in Canadian health systems (Ries, 2016). I conclude that innovation and adaptations are happening in the law to support new ways of working that involve interprofessional teams. I hope that insights from Canada can prompt comparative work on law and governance in other jurisdictions.

Law sets the context

The law sets the context in which health professionals work and it can enable or hinder interprofessional team models of care. Through statutes, regulations, and other legal instruments, the law establishes which occupational groups are legally recognised as health professions and sets the expectations and boundaries of their standards and scopes of practice (Elwood, 2013; Nancarrow, 2015). Negligence (or malpractice) law describes the duties that care providers owe to their patients and identifies the conduct that falls below expected standards. Legal decision-makers, including courts and professional bodies, can impose penalties for conduct that breaches these rules.

Care providers’ perceptions and attitudes about the law and the legal risks entailed in new ways of working together are also important determinants of the success or failure of interprofessional collaboration (Supper, Catala, Lustman, Bourgueil, & Letrilliart, 2015; Flottorp et al., 2013). Health professionals who are uncertain about their legal roles and responsibilities, and who fear lawsuits and professional complaints, will understandably hesitate to work in new ways.

Legal innovation to support healthcare innovation?

In healthcare, there is a constant call for innovative ideas, practices, and systems to achieve desired goals, including higher quality and safer care, better patient experiences and outcomes, more effective use of professional expertise, and higher job satisfaction for care providers. While there is an ongoing need for rigorous outcome evaluations, a growing body of evidence indicates that interprofessional collaboration and teamwork can help to achieve these important goals (Körner et al., 2015; Tsakitzidis et al., 2016; World Health Organization, 2010).

It is worth asking, then, whether the law provides a strong foundation for innovative healthcare practices or whether it entrenches traditional hierarchies and structural barriers. This is the question I explored in my study of Canadian law (Ries, 2016), which focused on legislation that regulates health professions and negligence decisions from courts across the country.

Legislative reforms

Each Canadian province and territory has its own legislation to regulate health professions and there is no uniform law across the country. However, all governments are engaged in law reform projects to recognise a broader range of health occupational groups as professions and to remove outdated scope of practice restrictions.

These legal changes mark a major shift away from the traditional siloes into which health professions have been organized (Davis, 1971; Chadi, 2011). For example, nurses, pharmacists, and other health professionals are being legally empowered to perform acts that were previously reserved to medical doctors. Scopes of practice are defined in non-exclusive ways, meaning lower risk patient care activities can be shared.

Health profession regulatory bodies in some Canadian jurisdictions have statutory duties to implement interprofessional education and practice initiatives. They may also work together to develop joint standards and guidelines for professionals who work together in shared-care settings. The aim is to create a legal framework that supports professions working to broader scopes in collaborative team models (Nelson et al., 2014).

Legal liability fears

Yet, the introduction of new professional roles in health workforces, and new ways of working in expanded and overlapping practice scopes, can cause legal anxiety. Professionals worry about the allocation of legal responsibility for patient care and outcomes. Medical doctors, in particular, may believe they have the ultimate responsibility for the acts and omissions of other health professionals with whom they work (Schadewaldt, McInnes, Hiller, & Gardner, 2013).

It is important to find out whether these fears are grounded in reality. How do courts and professional bodies deal with lawsuits and complaints where patients claim they suffered harm when their care was delivered in a collaborative team context? How do courts articulate the standard of care expected of the various professionals involved?

My analysis of negligence decisions from Canadian courts reveals that judges interpret and adapt legal liability principles in ways that support team-based, collaborative models of care delivery. Judges are able to do this because lawyers perform an educative function in dispute resolution processes. They provide evidence and arguments about innovations taking place in health systems and how the law should apply in contemporary contexts (Lahey & Currie, 2005).

Canadian courts do not adopt a traditional view of a healthcare hierarchy where legal liability automatically flows up to a doctor at the top of a pyramid. Nor does the law expect health professionals to be infallible. Rather, they must meet a reasonable standard of competence consistent with the practices of their own professional peers. To achieve the goals of interprofessional collaboration, it is necessary and appropriate for a care provider to be able to rely on other colleagues to meet their duties to patients. Teams would not function if the law expected every professional to second guess what others have done in their interactions with a patient.

Furthermore, courts recognise the importance of meso-level influences, such as organisational policies and procedures, on interprofessional collaboration. Some negligence cases bring to light organisational failings that undermined the ability of professionals to work in a coordinated and effective manner. Where this occurs, organisations can also bear legal culpability. Communication and information-sharing processes are of vital importance to ensure that professionals understand one another’s roles and responsibilities, talk to each other, and maintain appropriate records. An observation from a Canadian court is a sage reminder: “one of the advantages of a shared-care approach for the patient is that two heads examining a problem is better than one. Such is true if the two heads communicate.” (Allen v. University Hospitals Board, 2000 ABQB 509, para 101).

Concluding comments

Building on the analysis presented here, I suggest four areas where further work is needed to support interprofessional teams to work effectively within their legal contexts.

The need for collaborative research to help bridge the gaps

My goal here has been to highlight how the law sets a framework for healthcare practice and to share examples from Canadian legislation and court decisions. But just as there are many evidence-to-practice gaps in healthcare (Lau et al., 2016), there are principle-to-practice gaps in the law. This is especially true for complex interventions in complex systems. Government health ministers might endorse the principles of interprofessional collaboration and change laws and policies to establish an enabling regulatory framework. The practical implementation of new roles in healthcare teams can, however, be a “tortuous journey” (Andregård & Jangland, 2015).

Consider model legislation

Law- and policy-makers across Canada and other countries are trying out new regulatory models to promote interprofessional collaboration. It is an empirical question as to which models work best and under what conditions. Through further research, including qualitative study of the experiences of care providers, patients, and other stakeholders, model legislative instruments could be developed with evidence-informed recommendations for implementation in different systems.

Investigating legal disputes and outcomes

Courts and disciplinary bodies get involved when patients claim that care has gone wrong. The adjudication of these disputes helps to develop legal principles on a case-by-case basis. Systematic analyses of legal disputes and outcomes in a variety of jurisdictions would help advance knowledge of how legal rules are interpreted and applied in practice. The challenge then is to learn from such investigations to identify factors that support interprofessional collaboration and minimise the risks of legal liability for care providers and the organisations in which they work.

Collaborative international comparative research

Further studies into law and interprofessional collaboration in healthcare will, ideally, involve collaborative research teams with expertise in legal, health, and social sciences. International comparative work will also be valuable to study the commonalities and differences in macro-level legal and regulatory frameworks and to learn the lessons from law reforms across different healthcare, legal, and government settings.

Declaration of interest

The author reports no conflicts of interest. The author alone is responsible for the content and writing of this article.