The World Health Organization (WHO) provides a framework for interprofessional collaboration in education and practice as a means of strengthening the capabilities of healthcare professions in addressing the multifaceted global health workforce crisis.1 One strategic action is through interprofessional education (IPE), which can enhance collaboration, collegiality, and teamwork. IPE introduces students from two or more professions to learn about, from, and with each other to be fully immersed in collaboration and improve health outcomes.1 Furthermore, students are prepared for a collaborative, practice-ready workforce to emulsify the skills of their members, share case management, and provide better health services to patients and the community.1 Hence, IPE is an educational strategy and activity to enhance attitudes, knowledge, skills, and behaviors of the students to develop collaborative practice.2

Several frameworks and models have been developed to build a sound basis for the health profession education. For instance, in the USA, a public-private partnership was formed to develop the National Center for Interprofessional Practice and Education. This partnership supports the national leadership, scholarship, evidence, and coordination. It also contributed to the advancement of IPE and practice.3 The academic-service partnership (ASP) between the Academic Health Center at the University of Minnesota, and the Office of Health Information Technology at the Minnesota Department of Health, initiated team-based health care grounded in care coordination, patient engagement, and the utilization of health information technology (IT).4 In the UK, the inception of the Center for the Advancement of Interprofessional Education (CAIPE) in 1987, aimed to promote health and wellbeing, and improve the health and social care of the public by advancing IPE.5 The Japan Association for Interprofessional Education initiated a three-year, government-funded project to formulate its interprofessional competency framework with various professional organizations in healthcare and social sciences.6 Qatar initiated the IPE-based model using the College of Pharmacy proposed by the University of British Columbia. The initiative was run for 14 programs, at four healthcare institutions, including Qatar University, Weill Cornell Medical College in Qatar, the University of Calgary in Qatar, and the College of North Atlantic in Qatar.7 The results of this initiative provided better understanding, planning, facilitation, and integration of IPE towards competency development within the practice and education.7 The evidence from different countries revealed that IPE is a strategic preparation to provide optimal patient care, engaged clinicians, and collaborative interprofessional practice.8–10 The integration of IPE in higher education institutions before graduation supports learning assimilation.11,12

In Oman, the education of health professionals appeared to be at an early stage of development and was described as discipline-specific, and thus offered little opportunity for learning interprofessional skills.11 In recent years, health professions such as nursing, medicine, and other allied health professions are working in a uni-professional paradigm. In the meantime, there is a paucity of evidence about ASPs to support health professions and prepare future graduates as managers.4,13 ASPs can bridge the gap between theory and practice, strengthen team cohesion, nurture collegiality, and prevent hierarchical professionalization and compartmentalization of each discipline. The healthcare system in Oman is looking forward to improving its quality of care as a collaborative practice.

There are other issues that Oman is currently facing. The Ministry of Health (MoH) surmised that there is a radical demographic and epidemiologic transition, aging, and a predominance of non-communicable diseases and injuries, as well as other concerns related to political, economic, social, technological, environmental, and legal aspects.14 Thus, the MoH’s Health Vision 2050 was developed to serve as a schematic blueprint, which focuses on the critical role of education in developing effective and efficient human resources for health.14,15 This roadmap also hopes to empower the academic and service industries in preparing future leaders and managers in meeting the increasing demands of its growing population.

Many countries have already witnessed IPE as an enabling factor in achieving both short- and long-term goals, and how a collaborative practice sustains quality care.1,5,6,9,11,16,17 The MoH aims to develop a responsive workforce as the demands for globalization become palpable. Hence, there is an urgent call to develop fit-for-purpose competencies for health service managers who will stand at the forefront. The development of interprofessional competencies for health service managers will be a direct basis towards an active interprofessional learning and interprofessional working environment. Oman needs succinct IPE preparation and interprofessional collaborative practice to achieve safe, efficient, effective, patient-centered, and equitable quality health outcomes and to sustain the human resources for health in the coming years. Lastly, the Health Vision 2050 can be realized through such concerted efforts to prepare future health service managers vis-a-vis curricular reforms, educative-innovative mechanisms, abrogated academic-service silos, and adaptive mindsets for better graduate outcomes.14

Methods

This study utilized a multiple methods research design comprising of qualitative content analysis and a three-round e-Delphi technique.18 The use of qualitative content analysis guided the researchers to understand the multifaceted dimensions of participants’ views through systematic coding and categorizing emerging statements.19 The e-Delphi study design was used to obtain expert panel opinions to facilitate the development of interprofessional competencies for health service managers. This technique utilized a series of sequential rounds that sought to gain a reliable consensus from a group of experts.20–27 Despite the integration of many strategies, the format always followed a series of rounds of data collection and analysis. An e-Delphi technique is an environmentally friendly approach to research that leads to rapid feedback and responses from an expert panel.26 Donohoe et al,27 surmised that using e-Delphi, participants could have access to the virtual laboratory or online platform that saves time, effort, and cost.

The Institutional Review Board reviewed the proposal, and the study was approved by the MoH independent ethics committee. Following approval, a consultative meeting was initiated to identify the selected panel of experts from different healthcare institutions. Twenty experts were nominated based on their position, educational requirement, and work experience. Experts had to be knowledgeable, with at least five years experience in administration, leadership, and management to participate in the study. There were three rounds and a web-based designed survey used for data collection. Ten experts who met the inclusion criteria were included in a pilot study and underwent three rounds and a similar platform to determine the usability and clarity of the questions and instructions included.

In round one, the eligible experts were provided with a one-day seminar workshop to provide a background of the research study, its purpose, objectives, outcomes, expectations, and process. Each participant was given a study kit manual and the dates of the next round. The SurveyMonkey® URL website and password were included. Informed consent was obtained; confidentiality and anonymity were given emphasis. Two weeks were given as a waiting period for an expert to respond and they were reminded every week via email. In round two, a blind email was sent to the experts with the identified competencies generated from round one. The researchers analyzed the results and the extracted responses were combined to those with similar context to formulate specific themes using NVivo® (QSR International Pty Ltd. Version 11.4.0). Experts were contacted for clarity and refinement of ambiguous terminologies. The completed responses based on the constructed themes were sent via email for further suggestions and recommendations. In round three, experts were contacted by email with the final list of the competencies to evaluate the level of importance of each identified domain and indicator.

In round one, an open-ended question was introduced to the experts. The question for round one was: “What are the required interprofessional competencies for health service managers in Oman?” Members of the panel were asked to list down all the required interprofessional competencies for health service managers. The researchers met for several weeks for coding, categorizing, and thematization until the statements were saturated.18,19 The themes and statements were sent to the experts for their review and clarification. In round two, the completed responses based on the constructed themes were sent via email for further suggestions and recommendations. In round three, experts were instructed to rate the level of importance using a 5-point Likert Scale from very unimportant (1) to very important (5). Responses were analyzed using SPSS Statistics (IBM Corp. Released 2015. IBM SPSS Statistics for Windows, Version 23.0. Armonk, NY: IBM Corp.) to determine the mean values, interquartile range (IQR), and frequency. The accepted competencies were established with means ≥ 4.4, an interquartile distribution (IQD) ≤ 1.25, and when the consensus reached 80.0%.

Results

Table 1 presents the profile characteristics of the participants. Based on the findings, 20 experts were informed and consented to participate in the study from various health professions including nursing (n = 6, 30.0%), medicine (n = 3, 15.0%), laboratory science (n = 3, 15.0%), pharmacy (n = 4, 20.0%), medical imaging science (n = 2, 10.0%), and physiotherapy (n = 2, 10.0%). Sixty-five percent (n = 13) of participants were from clinical practice, and the majority had 5–14 years experience (n = 16, 80.0%). The majority of participants were 30–39 years old (n = 16, 80.0%) and female (n = 14, 70.0%). Seventy-five percent of the participants had a master’s degree (n = 15), 10.0% had a doctorate (n = 2), and 15.0% were medical doctors (n = 3).

Twenty experts were informed, consented, and validated the final lists of the competencies. From the lists, nine domains and 41 emerging statements reached the consensus of agreement among the experts’ criteria. The statements with means (M) ≥ 4.4 and IQD ≤ 1.25 and where the consensus reached 80.0% were considered to have a higher level of importance. Table 2 presents the overall themes based on qualitative content analysis. There was 90.0% to 95.0% level of agreement among the experts on the nine interprofessional competency domains, which included: resilience (M = 4.7, IQD = 0.40), research leverage (M = 4.7, IQD = 0.60), interprofessional ethics (M = 4.7, IQD = 0.80), quality improvement (M = 4.7, IQD = 0.80), IT (M = 4.6, IQD = 0.80), leadership (M = 4.5, IQD = 1.00), management skills (M = 4.5, IQD = 0.80); communication (M = 4.5, IQD = 1.00), and team dynamics (M = 4.5, IQD = 1.00).

Table 3 represents the interprofessional competencies along with the indicators and level of importance as evaluated by the panel of experts. Each domain comprised of three to five indicators.

Figure 1 presents the IPE competency domains for health service managers in Oman. This framework is comprised of nine domains including resilience, research leverage, interprofessional ethics, quality improvement, IT, leadership and management skills, effective communication, and teamwork. The integration of these domains will serve as the basis for academic and service organizations to further enhance the level of competencies among the graduates as future practitioners. Grounded and supported by the Health Vision 2050 and WHO Framework for Action on Health System,1,14,15 the interprofessional competency domains aim to bridge the gap between theory and practice as IPE becomes an inherent strategy. Thus, this builds the ASP to integrate both interprofessional and service learning, where students and practitioners are engendered with strategic visions to enhance and promote the health of Omani society, disease prevention strategies, patient-centered approaches to care, equity, transparency, and collaboration, among others. According to the MoH, as the country progresses, future health service managers will need to immerse themselves in the understanding of the six building blocks of the health system in Oman, (i.e., governance, finance, health services, human resources for health, medical equipment and products, and IT) that are aligned with the proposed interprofessional competency.14

Discussion

In 2008, Oman was ranked 84th out of 184 countries in the Human Development Index, an increase from previous years. The country is considered as showing high human development by the United Nations Development Program.14 The MoH has been an instrument in the development of a sustainable workforce and needs to continue strengthening the resources for human health. Oman needs a workforce recognized as stewards and key players in policy analysis and development, strategic planning, standard setting and regulation, organization of service provision, ensuring intersectoral coordination, and the monitoring and evaluation of health plans implementation.14 Hence, this study was conducted as a moral commitment and social responsibility of the researchers to be part of leveraging the required competencies for future health service managers. The Interprofessional Competency Framework hopes to motivate and empower current and future leaders to advance practice, inform policy, and transform the health system. The proposed framework is grounded on the MoH’s Health Vision 2050 and the WHO Framework for Action on Health System to ensure a strategic alignment based on country-specific needs1,14 and fit-for-purpose competencies, which will be required in the coming years.

Furthermore, based on expert opinions, resilience was ranked the number one quality that embodies adaptability to the changes, challenges, and any other forms of stressful situation inherent within and outside the organization. With the advent of technology, the demands are also increasing, including changes in patient demographics, as patients are becoming more informed and are no longer passive recipients but collaborators in their care.14 Developing one’s resilience means developing one’s tenacity, patience, resourcefulness, optimism, and persistence. Resilience is a prelude to critical thinking and shared decision-making concerning the organization, patients, families, communities, and profession. Resilience is the ability to perform well, adapt to changing circumstances, and maintain a sense of professional and personal fulfillment.28 Optimism was identified as a critical attribute of resilience along with flexibility, adaptability, ability to bounce back against adversity, tolerance, excellent organizational skills, communication, and teamwork.29 The future of a sustainable workforce relies on the managers’ responsiveness to the emerging changes and trends in the health system in the country and international communities.14

The service delivery, to a large extent, requires evidence-based approaches in planning, directing, controlling, and organizing. Research leverage widens the opportunities to utilize the dynamic processes and approaches for strategic actions, project initiatives, or quality improvement. The health system requires shared decision-making and problem-solving skills that are not based on trial and error, subjectivity, biases, or antiquated practices. Having a sound background in research, managers will be able to integrate facts to inform the health profession and practice. Managers who exemplify research competence can motivate teams to develop service initiatives or improvements for the organization and the country at large. Those initiatives can further meet the demands, expectations, and needs of patients, families, and communities. Managers need to be encouraged to be increasingly committed to translating scientific outputs relevant to patient care, patient service initiatives, resources cost-efficiency, and overall organizational success. With this, the organization leverages its competitive advantage through evidence-based management to sustain quality care and effective outcomes.30–32 The MoH also envisions to “develop mechanisms to measure peoples’ needs, satisfaction and utilization of health services and ensure that the health system is responsive to these needs,”14 which can be achieved through health system research. The Research Council has been established to develop a National Research Strategy as an instrument to ingrain research backgrounds among future health service managers and is not only intended for academicians or clinicians.33 Managers can strengthen their organizations “building a research environment and research capacities to achieve scientific excellence and through assisting research dissemination and utilization”.14

Interprofessional ethics is also an enabling competency for health service managers. This domain codifies the foundation toward work values, value integration, and value-based management. Interprofessional ethics will guide the implementation of effective management processes. Engel and Prentice34 mentioned that collaboration is a relational process that operates within a framework of moral action and moral integrity. Healthcare organization is a diverse system and is exposed to many sentinel events that may affect operation, interaction with others, and even the organization’s overall performance. Thus, interprofessional ethics can alleviate the conundrum of conflicts, fragmented health care, and compartmentalization of various health professions because the collaborative practice needed focuses on patient-centricity and a humanistic component of care segregating the health profession differences. Further, through embodied interprofessional ethics, the code of professionalism and code of conduct can be developed to guide practice, which is grounded in mutual understanding and respect while in a diverse and inclusive environment.35 Managers need to integrate quality practice to improve the organization, patient services, and interprofessional work environment through quality improvement initiatives. Managers should engage in continuous professional and interprofessional development to enhance team performance and efficient uses of resources (both internal and external).17,36 Quality improvement is the consolidated effort of the service providers, patients, and their families, payers, policymakers, educators, and stakeholders. In an era of healthcare driven by biological and technical advances, sustained quality improvement and quality service produce better patient outcomes, better system performance, and better professional development.37–39 Quality improvement purports that at all levels of the organization, each member needs to be empowered to deliver individualized, holistic, and patient-centered care.

The MoH described Oman as being in the transitional stage of development between efficiency-driven and innovation-driven economy.14 The use of IT can provide a more critical understanding of big data and data science, their effective utilization, and the positive impact on the overall performance of the organization. Hence, managers need to understand the principles upon which the organization and professional health information system used by service providers and patients are based. It has been posited that informatics in healthcare could provide effective and efficient utilization of services in the organization.3 For instance, the American Medical Informatics Association biomedical informatics leads to more scientific and practical use of data, information, and knowledge for scientific inquiry, problem-solving, and decision-making to improve human health.3 In the modern age, IT is not only utilized for clinical services or patient care management, but also for human resources management (HRM). Efficient and effective HRM contributes to the success of any national healthcare system.40 The integration of IT within the context of health services organizations yields accurate statistical data and information on the healthcare workforce. Human resource executives from 92 private hospitals identified critical factors in the adoption of the information systems, which need to be addressed. These key factors include IT infrastructure, top management support, IT capabilities of staff, perceived cost, competitive pressure, perceived compatibility, centralization, perceived complexity, formalization, innovativeness of senior executives, technology vendor support, relative advantage, and government regulations and supports.40

The MoH mentioned that “an effective health system requires increasing numbers of other human resources in categories such as health economists, clinical statisticians, health planners, and health system researchers”.14 In a similar vein, the MoH needs an initial boost to increase numbers of human resources to face shortages. These human resources for health, which are needed and required, should understand and cultivate leadership best practices to achieve the organization’s vision and mission aligned with the Health Vision 2050. According to Kim et al,41 a hospital requires effective leadership to influence others in providing safe, effective, efficient, equitable, patient-centered, and quality health services. The interprofessional leadership along with the teamwork, coordination, communication, and collaboration can further improve patient-centered and family-centered practices. However, territorial behavior has been observed among professional groups and agencies, which was considered a deterrent to interprofessional collaboration.42 Managers who have the mindset to defend their territories in a bureaucratic organization may result in these behaviors. Thus, to alleviate these barriers, altruistic leadership has been found to be substantially grounded in concern for others, the organization, and society.

Managers need to integrate practical management skills and the core principles of management processes.1 The comprehensive approach to leading and managing the workforce relies on the capability of the managers to enhance other employees, utilize their utmost capacity, level of productivity, and quality outcomes. Managers should sustain a culture of excellence where human behaviors and human relations are embedded.38 With this, managers need to develop capabilities to revitalize the health system during turbulent times and become more sensitive to the needs of both organizations and stakeholders.43 Managers are expected to address challenges such as patients’ needs and demands, an adequate workforce, accessibility to quality care, health equality, medical costs, and the adoption of technology, among other issues.43 Thus, through effective management processes, the managers can further introduce service co-production and value co-creation to heighten organizational capabilities.44,45 On the other hand, management processes also require “reliable, relevant, up-to-date and timely health and health-related information” for sound health policy formulation, and for the development of health plans and strategies.14

Interprofessional communication reflects the ability to communicate respectfully and responsively with others including patients, families, communities, and colleagues in a diverse working environment, regardless of race, religion, place of origin, language, socioeconomic status, and background. Communication, though a fundamental component of active management, is highly integral to the strengthening teamwork and collaboration. Matziou et al,46 mentioned that through open communication, there would be mutual understanding and collaborative relationships. Despite physicians and nurses varying in views about their practice, open communication will strengthen their relations because there is trust, respect, and shared accountability.38 Undeniably, the health system is in rapid transformation, and managers need to continue as both beacon and steward to build a collaborative practice and milieu that will require understanding how teams work together.47,48 The interprofessional teamwork should be efficient, open, and equitable tactical, with shared responsibility and influence.49 Shoham et al,47 recommended evaluating the communication process regarding types, quality, and dynamic nature of interprofessional interaction so that managers can determine the areas for improvement.

Within interprofessional team dynamics, managers develop a holistic team for safe, effective defect-free care.50 Team dynamics enhance interprofessional relationships and yield high-quality, comprehensive, coordinated care, and affect providers’ outcomes.48,51,52 However, interprofessional teams need a manager who acts as the mediator and facilitates the interaction.53 According to Mitchell et al,54 more than 70% of medical errors are attributable to dysfunctional team dynamics, and through interprofessional teams these errors can be prevented. To develop interprofessional teams, it requires transformational leadership, shared values, and shared group identity.54 The MoH heightens the intersectoral partnership and collaboration in Oman as joint actions among the health sector and one or more other sectors to improve health.14 In this regard, health service managers of the future need to understand that true collaboration among sectors is expected to be effective if it takes place at more than one level (i.e, national, governmental, and community), especially if the activities are integrated through policy or legislation.14

This study offers a novel contribution to the emerging era of Internet research. We used a multi-method approach using qualitative content analysis and e-Delphi technique to ensure the accuracy of the findings where country-specific expert opinions were illuminated. The use of e-Delphi is cost-effective and provides access to an expert opinion without geographical limitations or the time restrictions placed on face-to-face data collection,22 and the anonymity prevents undue influence and other expert dominance. Further, the use of a web-based design survey (i.e., SurveyMonkey®) provides a virtual platform without geographical limitations, minimizes the issues in handwriting, and eases the data entry. Owing to the limitation of this study, although 20 experts were consulted, the response rate yielded more than 80.0%.

Conclusion

The development of interprofessional competency domains for managers in various healthcare organizations is imperative. The academic and service industries have the responsibility to prevent compartmentalization of the health professions through the integration of IPE where the collaborative practice is envisioned. The growing demand for interprofessional managers who have the resilience, research background, ethics, quality improvement, IT, leadership and management, communication, and team dynamics are needed. Those managers who have the fit-for-purpose competencies can further address the challenges faced. Thus, the MoH needs to empower both academic and service industries to develop graduates into holistic leaders and managers through IPE integration to fully become an instrument in the realization of the Health Vision 2050. The interprofessional competency domains will also prepare future health service managers to become more adaptive, responsive, with the integral component of progressive reforms toward safe, quality, and sustained health outcomes at the macro-level grounded in collaboration, collegiality, and mutual trust between the academic and service sectors.

Disclosure

The authors declared no conflicts of interest. No funding was received for this study.

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