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The rise of the collaborative ideal
Implications for pharmacy practice and research?
My Background
Born & Raised
2002-6Hon B.A.
2006-11Stanford Ph.D.
2011-2Currie PDF
Wilson Centre
2012-3UCSF
Jan 2014Wilson Centre
Sociologist.
Sociology is the scientific study of social behaviour, including its origins, development,
organizations and institutions.
Sociologists investigate a wide range of social phenomena. Their expertise is defined by either or
both theoretical and methodological anchors.
We are adaptable and flexible, as I have shown by studying areas as diverse as…
We are adaptable and flexible, as I have shown by studying areas as diverse as…
We are adaptable and flexible, as I have shown by studying areas as diverse as…
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0.6We are adaptable and flexible, as I have shown by studying areas as diverse as…
We are adaptable and flexible, as I have shown by studying areas as diverse as…
We are adaptable and flexible, as I have shown by studying areas as diverse as…
My Research Programme
My Research ProgrammePart 1: Anchors
How does change happen in organizations?
Different theories of organizational change
Neo-institutional theory.
Meyer. 1977. Institutionalized Organizations: Formal Structure as Myth and Ceremony. American Journal of Sociology.
DiMaggio & Powell. 1983. The iron cage revisited. American Sociological Review.Meyer et al. 1997. World society and the nation-state. Am J of Sociology.
Policy
Policy Outcomes
Paradis & Whitehead. 2015. Louder than Words. Medical Education.
IPE
Paradis & Whitehead. 2015. Louder than Words. Medical Education.
IPEBetter
Team-based Care
Paradis & Whitehead. 2015. Louder than Words. Medical Education.
Something missing.
Policy Outcomes
Policy Practices Outcomes
IPE
Better Team-based Care
IPE
Better Team-based Care
IPEChanging Practices
Neo-institutional theory recognizes that reality is often messier
Decoupling
Decoupling
Meyer & Rowan. 1977. Institutionalized Organizations: Formal Structure as Myth and Ceremony. American Journal of Sociology.
Bromley and Powell. 2012. Decoupling in the Contemporary World. The Academy of Management Annals.
misalignment of policies, practices and outcomes.
Policy OutcomesPractices
Policy Practices
Policies are implemented at all, or
may not change practices.
Outcomes
Policy Practices
Practices may not yield the desired
outcomes.
Outcomes
Institutional Context
Policy
Institutional Context
Three mechanisms for organizational change.
DiMaggio & Powell. 1983. The iron cage revisited. American Sociological Review.
Coercive. Organizations are told what to do and do it (for money, survival and legal reasons).
e.g. Research ethics board are implemented in universities worldwide.
Coercive. Organizations are told what to do and do it (for money, survival and legal reasons).
Mimetic. Organizations look at what others do and copy it (because it’s easy, legitimizing).
e.g. Countries worldwide implemented the same structures to support science and innovation (Finnemore. 1993; Drori et al. 2003).
Mimetic. Organizations look at what others do and copy it (because it’s easy, legitimizing).
Normative. Organizations do what they feel is right
(given the institutional climate, values).
Normative. Organizations do what they feel is right
(given the institutional climate, values).
e.g. Human rights are taught in schools worldwide (Meyer et al. 2010).
So when I ask “How does change happen in organizations?” I
want to know two things.
So when I ask “How does change happen in organizations?” I
want to know two things.
1.
Institutional Context
Policy
1.
Institutional Context
Policy
1.
Coercion?
Institutional Context
Policy
Imitation?
1.
Institutional Context
Policy
Norms?
1.
Institutional Context
Policy
Norms?
Coercion?Imitation?
1.
Institutional Context
Policy
2.
Policy Practices
2.
Policy Practices
?
2.
OutcomesPractices
?
If there is decoupling,use newly-gained insights to improve
policy, practices and outcomes.
Collaboration in Healthcare
Collaboration in Healthcare
Two areas.
Interprofessional Collaboration
Interdisciplinary Research
Interprofessional Collaboration
Definitions.
Professions = Healthcare Delivery
Professions = Healthcare Delivery
Anesthesia
Surgery
Intraprofessional
Anesthesia
Surgery
PharmacyMedicine
Intraprofessional
Interprofessional
Profession = Healthcare Delivery
Disciplines = Research
Interdisciplinary
Sociology
Public Health
Disciplines = Research
Anesthesia
Surgery
PharmacyMedicine
Intraprofessional
Interprofessional
Interdisciplinary
Sociology
Immunology
Collaboration in Healthcare
Anesthesia
Surgery
PharmacyMedicine
Intraprofessional
Interprofessional
Interdisciplinary
Sociology
Immunology
Collaborative Ideal
My ResearchPart 2: Some Findings
Interprofessional Collaboration
1 Award
Interprofessional Collaboration
(+ 1 Nomination)
8 PR publications
1 Award
(+ 4 under review)
Interprofessional Collaboration
(+ 1 Nomination)
8 PR publications
1 Award
(+ 4 under review)
1 Successful CIHR Grant as
CollaboratorPI: C.R. Whitehead
Interprofessional Collaboration
(+ 1 Nomination)
8 PR publications
1 CIHR Grant Application as PIw co-Is H. Boon; S. Nelson; S. Spadafora; C.R. Whitehead
1 Award
(+ 4 under review)
1 Successful CIHR Grant as
CollaboratorPI: C.R. Whitehead
Interprofessional Collaboration
(+ 1 Nomination)
28 presentations(4 invited)
8 PR publications
1 CIHR Grant Application as PIw co-Is H. Boon; S. Nelson; S. Spadafora; C.R. Whitehead
1 Award
(+ 4 under review)
1 podcast with Medical Education
1 KT Video with PGME
1 Successful CIHR Grant as
CollaboratorPI: C.R. Whitehead
Interprofessional Collaboration
(+ 1 Nomination)
Interprofessional Rhetoric and Operational Realities: Rounds in Four Intensive Care Units
This research was funded by the Gordon and Betty Moore Foundation.
CONTEXT
Interprofessional collaboration – defined as the provision of team-based care to improve quality and outcomes – has been championed for several decades now.
Kohn et al. 1999. To Err is Human; Health Council of Canada. 2009; World Health Organization. 1988, 2010.
Interprofessional rounds are one of three strategies to improve collaboration in care delivery.
Zwarenstein et al. 2009. Interprofessional collaboration: effects of practice-based interventions. Cochrane Library.
Early in our study, rounds stood out as a key place and moment of interprofessional interaction, negotiation and contention.
Early in our study, rounds stood out as a key place and moment of interprofessional interaction, negotiation and contention.
Overt conflict was rare, but dissatisfaction was palpable and often verbalized, despite strong commitment by both medical and nursing leadership on all units.
Therein lay a puzzle.
Therein lay a puzzle.
Why were rounds so contentious?
Why were clinicians so unhappy with a process that was
successful in the literature?
[ ]Why didn’t the new policy yield the desired outcomes?
[ ]Why did there seem to be decoupling?
Part of an ethnographic study of the factors that impact interprofessional collaboration on 4 American ICUs.
Paradis et al. 2014. Journal of Interprofessional Care 28(1).
Ethnography evolves as the study progresses, involves direct, sustained and extensive contact with participants, and uses participant observation and interviews to tell rich and credible stories that respect the complexity of the social world under observation.
O’Reilly. 2012. Ethnographic Methods; Leslie, Paradis et al. 2014. BMJ Q&S.
We collected detailed ethnographic fieldnotes for 576 hours of observation across our ICUs, conducted 56 interviews, and 47 shadowing sessions.
Ethics approval was obtained at all 4 sites.
Rounds-related events extracted and coded using the constant comparative method.
Boeije. 2002. Quality & Quantity; Glaser & Strauss. 1967.
What did we find?
While purportedly interprofessional, rounds typically looked like this: an inner circle of MDs,
surrounded by a peripheral circle of non-MDs.
While purportedly interprofessional, rounds typically looked like this: an inner circle of MDs,
surrounded by a peripheral circle of non-MDs.
While purportedly interprofessional, rounds typically looked like this: an inner circle of MDs,
surrounded by a peripheral circle of non-MDs.
They filled most of the
available space, most of the
time.
They were described as a cluster, a barricade, a forest. They counted
between 10 and 15 people, mostly MDs, and up to 5 WoWs.
They were “always in the way”
-- RN interview.
Bodies as Barrier
Dave, RN
The barrier is semi-permeable.
It is polysemic.
It is managed.
Boundary Work
“Boundary work” has typically been used in the context of knowledge production and demarcation (e.g. science vs.
pseudoscience, Gieryn. 1983. Am Soc Rev).
Boundary work in medicine has been used to discuss the different strategies used by physicians to maintain their systemic dominance and cultural authority (e.g. Fournier, 2000; Kuper & Whitehead, 2012, J Interprof Care 26(5)).
“Boundary work” has typically been used in the context of knowledge production and demarcation (e.g. science vs.
pseudoscience, Gieryn, 1983, Am Soc Rev).
Boundary work in medicine has been used to discuss the different strategies used by physicians to maintain their systemic dominance and cultural authority (e.g. Fournier. 2000; Kuper & Whitehead. 2012. J Interprof Care 26(5)).
Physicians’ boundary work is not necessarily a conscious attempt at domination. It can merely be a manifestation of traditional hierarchies, as suggested in other studies.
e.g. Long et al. 2006. The (im)possibilities of clinical democracy. Health Sociology Review 15(5).
Nurses & BW
Two types of responses: the “easy” way and the fight.
Observations, 19 March 2013
Roger (RN) sat behind the rounding team as they presented his patient today. Later I asked him how he decides where to stand during rounds. Nervously, he answered: “I just stand where I want to stand.” I pushed further.
E: So you don’t really make a decision.
Roger: Sometimes you just elbow in, to be involved, other times I just stand at the computer, because they want to ask about vitals trends… Whatever you can do easily. It’s just a giant, you know, cluster of people and you just have to huddle up as best as you can, and… get in where you can.
E: And do you think that most of the time you can get in when you want to get in?
Roger: Yeah. Part of the time. … It works out.
Interview with Zoe (RN)
E: So one of the things that I have noticed is when [physicians] do their rounds, they make a circle.
Zoe: Right, try and get around them, it’s close to impossible.
E: ... Anything else you notice about their circle formation?
Zoe: Well, you have to fight to get in it. As a nurse, as a person at the bedside, I will walk through the
whole thing. I’ll say, “Excuse me,” and I’ll kind of go in there, and I want to hear.
Pharmacists & BW
They have knowledge that is highly valued by physicians, and their presence has been demonstrated to cut costs and reduce adverse events in inpatient settings (e.g. Kopp et al. 2007).
Pharmacists are in a somewhat privileged situation.
Yet some research suggests that they are reluctant to intervene if they perceive that it may taint their relationship with physicians (Lambert. 1995, 1996; Basak et al. 2015).
There are also important cultural differences between pharmacy and medicine, some of which are anchored in status and power differentials (Austin, Gregory and Martin. 2007).
Amelia, PharmD
Bradley, MD
Interview with Amelia, Pharmacist
[T]here are times where I’ll want to be part of [rounds], and then there’s just not enough physical space ... Sometimes I do get kind of – I wouldn’t say pushed out of the way, but there are other people that are part of the discussion that … can stand a little bit of in front of me, … so that is kind of frustrating.
Interview with Amelia, Pharmacist
And that is something that even in pharmacy school, we just know that we have to make ourselves visible and we have to be part of that circle. And most teams are not going to say, “Oh, hey, come on in.”
Interview with Amelia, Pharmacist
And that is something that even in pharmacy school, we just know that we have to make ourselves visible and we have to be part of that circle. And most teams are not going to say, “Oh, hey, come on in.”
DISCUSSION
The vignettes discussed here show us that different healthcare providers see, navigate and experience the space occupied by physicians’ bodies differently.
In a context where a history of medical dominance, of structural imbalances, of
incompatible incentives, of pay differences, etc. taint interprofessional relationships…
It is not hard to see why the interprofessional rounds we observed
failed to deliver on their goals.
The rhetoric of interprofessionalism clashed with operational realities defined
by limited time, limited space and the conflicting goals of IPC and med ed.
Σ
IPR
IPRColl.
practices
IPRColl.
practices
Team-based, pt-centred
care
Decoupling
=
Depressing?
No!
Recognition of these failures led to the revision of policies and practices on two study units.They have also inspired a new study of
bullet rounds in a TAHSN hospital.
Interdisciplinary Research
Interdisciplinary Research
Mathieu Albert & Ayelet Kuper
Funded by SSHRC Grant
1 PR publication
Interdisciplinary Research
1 PR publication
2 book chapters
Interdisciplinary Research
1 PR publication
2 book chapters
6 presentations
Interdisciplinary Research
1 PR publication
2 book chapters
6 presentations
SSHRC Grant Application as Co-IPI: M Albert; Co-I: A Kuper
Interdisciplinary Research
CONTEXT
In 2000, CIHR was created to promote
interdisciplinary health research; in 2009, SSHRC
decided to stop funding health-related research.
How has the health research field changed as a result, esp. in medicine?
How has it adapted to the presence of SSH scholars?
We asked:
We analyzed key policy documents and interviewed 29 SSH scholars about their experiences working in 11 faculties of medicine in Canada.
Interviews were recorded, transcribed and analysed using content analysis. Categories were generated reflecting the various experiences expressed by participants.
Interviews were then re-analyzed based on these categories (vertical analysis) and compared across participants (transversal analysis).
What did we find?
1A telling absence of SSH scholars on key decisional committees at CIHR, such that their views are unrepresented.
2Many SSH scholars adapted their knowledge production to match the expectations of faculties of medicine, but the field has not adapted to them.
2SSH scholars responded in 5 different ways to their work environment and its academic standards:
2SSH scholars responded in 5 different ways to their work environment and its academic standards: conversion,
2SSH scholars responded in 5 different ways to their work environment and its academic standards: conversion, reaffirmation,
2SSH scholars responded in 5 different ways to their work environment and its academic standards: conversion, reaffirmation, partial adaptation,
2SSH scholars responded in 5 different ways to their work environment and its academic standards: conversion, reaffirmation, partial adaptation, resistance
2SSH scholars responded in 5 different ways to their work environment and its academic standards: conversion, reaffirmation, partial adaptation, resistance and self-exclusion.
Type of Response N
Conversion 3
Reaffirmation 3
Partial adaptation 18
Resistance 2
Self-exclusion 3
Total 29
Type of Response N
Conversion 3
Reaffirmation 3
Partial adaptation 18
Resistance 2
Self-exclusion 3
Total 29
Type of Response N
Conversion 3
Reaffirmation 3
Partial adaptation 18
Resistance 2
Self-exclusion 3
Total 29
Partial Adaptation
I have a publishing strategy where I divide my efforts between more theoretically-oriented work and more applied empirical work. I want to have some measure of respect within the social science world, but I also do more empirical papers that are oriented to traditional audiences. (SSH07)
I feel almost alienated from myself doing that kind of work [publishing in clinical journals]. I feel like the work I’m doing is irrelevant. What am I contributing, what am I helping to develop around social theory? Nothing. So I feel irrelevant. And it hurts, right? It’s painful. (SSH10)
Partial Adaptation
Staying a sociologist was the biggest challenge of my career. I personally was never interested in betraying my discipline. So I tried to achieve promotion by other means so that I didn’t have to compromise my integrity, because that would have been a horror to have to turn out junk. (SSH05)
Resistance
I’m not on an upward swing, because in a way I’ve kind of just given up. I find myself in a game that I can’t stand. I can’t stand the basic struggle for legitimation. I’m really repulsed by these criteria. I can hardly wait to retire. (SSH15)
Self-Exclusion
Σ
Policy Practices
Policies to promote interdisciplinarity have not changed practices:
SSH scholars do not feel welcome in their new
environment.
Decoupling
=
Depressing?
No!
We have been sharing our findings with SSH faculty across Canada and have been receiving
emails from around the world.There has also been growing interest in non-
experimental research in faculties of medicine.
Interprofessional Collaboration
Interdisciplinary Research
Interprofessional Collaboration
What is going on?
Why are initiatives designed to foster collaboration not delivering
on their goals?
Institutional Context
Collaborative Ideal
A new belief which suggests that better-quality outcomes will emerge from work that combines multiple perspectives, ideas, skills, personalities, etc.
Collaborative Ideal
Is the gradual and increasing institutionalization and formalization of collaboration in healthcare delivery and research, to the point that questioning its value is somewhat heretical.
Collaborative Ideal
I am not saying that collaboration has no place in healthcare, or that is new.
What I am saying is that:
What I am saying is that:
1. there has been a growing interest in collaboration, its demonstration and its effects over the past decades;
2. is now almost universally seen as the best way to do things.
What I am saying is that:
1. there has been a growing interest in collaboration, its demonstration and its effects over the past decades;
2. collaboration is now almost universally seen as the best way to do things.
Broad claims.
?How do I know that a new collaborative ideal has emerged in healthcare?
Massive rise of research on collaboration.
19601962
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19761978
19801982
19841986
19881990
19921994
19961998
20002002
20042006
20082010
20120
5,000
10,000
15,000
20,000
Figure 1: Number of articles using collaboration-related terms in the PubMed database, 1960-2013
Communication Collaboration IP MeSH Teamwork
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Figure 2: Percentage of all articles in the PubMed database using col-laboration-related terms, 1960-2013
Communication Collaboration IP MeSH Teamwork
Massive growth of the literature on educating for collaboration (IPE).
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Figure 3: Annual count of articles on IPE in the PubMed Database, 1954-2013 (n = 1,411)
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0.01
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0.025
Figure 4: Percentage of all articles on IPE in the PubMed database, 1954-2013 (n = 1,411)
Multiplication of reports and white papers by influential healthcare
organizations.
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Figure 5: Number of Archived Reports on IPE and IPC Pub-lished Each Year in Canada, 1964-2014
105
?But what about pharmacy?
?Has it seen the rise of the collaborative ideal?
19601962
19641966
19681970
19721974
19761978
19801982
19841986
19881990
19921994
19961998
20002002
20042006
20082010
20120
50
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250
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Figure 6: Number of articles in the pharmacy literature using col-laboration-related terms, PubMed database, 1960-2013
Communication Collaboration IP MeSH Teamwork
19601962
19641966
19681970
19721974
19761978
19801982
19841986
19881990
19921994
19961998
20002002
20042006
20082010
20120
0.01
0.02
0.03
0.04
0.05
0.06
Figure 7: Percentage of all articles on pharmacy in the PubMed database using collaboration-related terms, 1960-2013
Communication Collaboration IP MeSHTeamwork Combined
Strategic Plan Tomorrow. Today.
1Delivery.
1“A health care team-approach to patient care is emerging. Political pressure is influencing pharmacy practice and all health care providers to move to an
interprofessional model.”
p. 5
Delivery.
1“A health care team-approach to patient care is emerging. Political pressure is influencing pharmacy practice and all health care providers to move to an
interprofessional model.”
p. 5
Delivery.
1“A health care team-approach to patient care is emerging. Political pressure is influencing pharmacy practice and all health care providers to move to an
interprofessional model.”
Coercion!!
p. 5
Delivery.
2Research.
2“The focus of our research has to change from isolated individual research … to one of
collaborative endeavours if we are going to maintain our status of a first class research
Faculty … Collaborative initiatives will undoubtedly enhance success rates in research funding during times of austerity. Our research
must continue to have an impact on healthcare.”p. 12
Research.
2“The focus of our research has to change from isolated individual research … to one of
collaborative endeavours if we are going to maintain our status of a first class research
Faculty … Collaborative initiatives will undoubtedly enhance success rates in research funding during times of austerity. Our research
must continue to have an impact on healthcare.”p. 12
Research.
2“The focus of our research has to change from isolated individual research … to one of
collaborative endeavours if we are going to maintain our status of a first class research
Faculty … Collaborative initiatives will undoubtedly enhance success rates in research funding during times of austerity. Our research
must continue to have an impact on healthcare.”
Mimetic pressures!
p. 12
Research.
2“The focus of our research has to change from isolated individual research … to one of
collaborative endeavours if we are going to maintain our status of a first class research
Faculty … Collaborative initiatives will undoubtedly enhance success rates in research funding during times of austerity. Our research must continue to have an impact on healthcare.”
Coercion!
p. 12
Research.
2“The focus of our research has to change from isolated individual research … to one of
collaborative endeavours if we are going to maintain our status of a first class research
Faculty … Collaborative initiatives will undoubtedly enhance success rates in research funding during times of austerity. Our research
must continue to have an impact on healthcare.”p. 12
Normative pressures!
Research.
3“nurturing a collaborative culture” (p. 15) & “tapping the major synergistic potential” (p. 16).
Collaborative ideal
Partly explains why the initiatives I studied failed to foster
collaboration.
They did not arise out of a local need to collaborate but rather by a translation of the
collaborative ideal into policies.
Policies
Normative
CoerciveMimetic
Collaborative ideal
By making the collaborative ideal visible, I believe that we can study
its influence, but also…
Policies
Policies Practices
Policies Practices Outcomes
My Future
Vision?
Sociology of
Pharmacy Practice & Education
Sociology of
Pharmacy Practice & Education
Students
Sociology of
Pharmacy Practice & Education
Students
Policy
To bring sociological theory and methods to the design and conduct of
high-quality empirical research
with a specific emphasis on
collaboration.
How has pharmacy been influenced by the rise of the collaborative ideal? How can policies in support of collaborative care and research be
designed to yield their desired outcomes?
What do I bring?
Theory
Theory
NIT
Theory
NIT
Pierre Bourdieu
Theory
NIT
Pierre Bourdieu
S of Education
Theory
NIT
Pierre Bourdieu
S of Education
S of Professions
Theory
NIT
Pierre Bourdieu
S of Knowledge
S of Education
S of Professions
Methods
Methods
Ethnography
Methods
Ethnography
Bibliometry
Interviews
Methods
Ethnography
Bibliometry
Interviews
Methods
Ethnography
Bibliometry
Surveys
Reviews
Interviews
Methods
Ethnography
Bibliometry
Surveys
?What would my future research in pharmacy look like?
1
CIHR Grantco-Is H. Boon; S. Nelson; S. Spadafora; C.R. Whitehead
CIHR GrantStudies the rise and impact of the collaborative ideal at UT/TAHSN.
Phase 1: Interviews and document analysis.
CIHR Grant
Phase 1: Who were the individual and organizational actors who built the current collaborative ideal at UT/TAHSN and what were their objectives?
CIHR Grant
Policies
Institutional Context
Norms?
Coercion?Imitation?
CIHR GrantPhase 2: Ethnography (observations, interviews and document analysis).
CIHR GrantPhase 2: How are intra- and inter-professional boundaries and identities redrawn, renegotiated and transformed in an era where collaboration is the ideal? How do healthcare providers perceive the rise of the collaborative ideal? How do they enact collaboration during patient care activities?
Policies
Policies Practices
Policies Practices
?
CIHR Grant2 sites: Comparative study that follows anesthesia and family medicine residents.
CIHR Grant2 sites: Comparative study that follows anesthesia and family medicine residents.
Data collection could focus specifically on relationships with pharmacists.
2
Legitimate knowledge and the profession of pharmacist
Legitimate knowledge and the profession of pharmacist
Interviews and questionnaires.
Legitimate knowledge and the profession of pharmacist
What types of knowledge do pharmacy students see as valuable and critical to their role as pharmacist? Does this understanding change over the course of their studies at the LDFP?
Legitimate knowledge and the profession of pharmacist
Are pharmacy students engaging in boundary work when they discuss various types of knowledge and their relevance?
Legitimate knowledge and the profession of pharmacist
This research could tell us about the impact of multidisciplinary environments such as the LDFP on students’ appreciation for different forms of knowledge.
Legitimate knowledge and the profession of pharmacist
Ultimately: Are we training pharmacists that are ready to provide high-quality, team-based and patient-centred care by tapping into the knowledge that is best suited to these goals?
Legitimate knowledge and the profession of pharmacist
Ultimately: Are we training pharmacists that are ready to provide high-quality, team-based and patient-centred care by tapping into the knowledge that is best suited to these goals?
If not, how do we get there?
The rise of the collaborative ideal
Implications for pharmacy practice and research?