Interprofessionalism and Healthcare: Introductory Notes

Interprofessionalism and Healthcare: Introductory Notes

(SSM Rheumatology; SSM Heart Care and interprofessionalism)

Dr. Vicky Gunn

Learning and Teaching Centre

“A growing body of evidence suggests interprofessionalism offers greater benefits for patient care and safety than multi-professionalism…”

(Bleakley, et al., 2006, p. 467)

From a practice perspective this seems especially (though not exclusively) true of healthcare provision which is designed to respond to chronic medical conditions. Areas such as chronic pain, rheumatology, palliative care, geriatric care and cardiac care are all dependent on effective inter-professional working.

1. Why is inter-professionalism a healthcare issue?

(a) Increasing specialization;

(b) Greater recognition of the need for collaborative practice;

(c) Changing roles, levels of responsibility, and authority of practitioners within

healthcare organizations;

(d) Group dynamics research in healthcare settings.

(e) When conflict arises amongst inter-professional teams this is painful and

demoralizing for all staff involved. Resolving it seems to be a reasonably critical

work force support issue for the NHS.

Put simply, at the same time as specialization grows in all the healthcare professions so too does the need for the simultaneous development of practice that encourages working together. Also, healthcare organizational roles and responsibilities are not stable but ones which change in response to a variety of factors (economic constraints, political ideologies, education and knowledge base changes etc.) Consequently, being able to manage inter-group interaction as well as intra-group activities is seen as increasingly important both in terms of aptitudes and skills within the portfolio of a healthcare professional. We need, basically, to be responsive and adaptive to a complex and changing set of circumstances. These circumstances impact on both the knowledge about medical conditions and also how the various professions are to interact to achieve the best healthcare outcomes. Currently practice and research both suggest that inter-professionalism when effective does improve healthcare outcomes (cf Meads, Ashcroft,et al, 2005).

BUT:

“Interprofessional relationships continue to be characterized by conflict rather than co-operation...”

(Irvine, et al, 2002, p.199)

2. So, where do the tensions in inter-professional settings seem to come from?

“Rather than promoting more egalitarian and collaborative social formations, healthcare teams tend to reflect, reproduce and perpetuate the traditional divisions of labour, status systems and systems of authority.”

(Irvine, et al., 2002, p. 204)

Irvine et al’s Useful Framework (2002)

Professional divisions / Cultural Barriers
Authority and the division of labour / ‘Intellectual baggage’
Subverting medical dominance / Language
Professional organization (including uni-professional audit) / Intra-professional variation
Different value systems (cf Irvine, et al., 2004) / Identity
Legal effects (especially governance) / Training / socialization

But, let’s try this assumption:

“When we list apparent obstacles to interprofessionalism, we are just embodying inter-group emotionality and psychodynamics within a reason-based framework. The actual behaviours and attitudes expressed are far less about reason and far more about emotional responses to situations.”

In short, how do we all get on with one another in the workplace?

What assumptions do we make about what other people ‘should’ be doing?

What do we expect of other professionals? For example, do we expect the same as we expect of ourselves? Or do we expect alternatives roles for different folk in different professional settings?

How did we come to learn about / make these assumptions and expectations?

When these assumptions and expectations are not met how do we understand the situation?

How do we come to judge one another?

How do we moderate our anxiety in these situations?

3. How can we begin to mediate the negative aspects of inter-professionalism?

By recognizing the difference between common, complementary and collaborative aspects of the inter-professional situations in which we find ourselves. This involves reviewing and, at times, reforming our uni-professional approaches to situations. It requires placing them in a collaborative framework which allows for mutual recognition of both the commonalities and the distinguishing features of our different roles, responsibilities and attitudes (Barr, 1998; Bokhour, 2006).

Common / Complementary / Collaborative
Roles, responsibilities and values held in common between all professions. / Roles, responsibilities and values which distinguish professional groups but at the same time complement other professional groups. / Attitudes, approaches and interpersonal approaches and values that every profession needs to collaborate within its own ranks, with other professions, with non-professionals etc. (Often simplified as communication practices.)
eg.
‘Provide the best patient care possible.’
‘Manage patient pain effectively.’ / eg.
A psychologist giving advice to an anaesthetist with respect to psychological intervention rather than pharmacological support of a patient in pain.
The psychologist values an approach that emphasizes enabling the patient to manage pain from a perspective of not depending on drugs to take the pain away, but instead developing psychological techniques to make quality of life better and pain management owned by the patient. The anaesthetist in this case sees their first priority as ‘to take the pain away’ and initially focuses on pharmacological and technological intervention. / eg.
Making effective collaborative decisions about patient care.
Collaborative decision in such a case likely to include much wider range of professionals than this (eg social workers, physiotherapists, nurses, nurse specialists AND the patient.)

By recognizing how we respond to situations of pressure. These are the circumstances where we are most likely to make negative, potentially conflict-inducing, judgements that then impact on how we work with our colleagues within our own professional group and with other individuals in different professional groups to ours.

Personal reflection on inter-professional situations:

1. Are there any values, beliefs, roles that I feel are absolutely imperative for good patient care?
2. Why do I believe this?
3. What evidence have I seen and what experiences have I had that challenge my position on these values, beliefs and roles?
4. How do I respond in tense, under-pressure, situations?

4. How to observe inter-professional working:

1. How are decisions made?
2. How is care coordinated amongst the professionals?
3. How are case histories taken?
4. How are treatment plans drawn up?
5. How do different professionals report to their colleagues about patients?(For example, is there a basic process of stating problems, goals and interventions?)
6. Is there collaborative discussion about issues (ie is there open discussion with input from multiple team members to come up with a solution to a patient-centred problem?)

Also Meads’ taxonomy of collaboration (Meads, Ashcroft et al, 2005, 16):

Aspects of collaboration / Examples of their expression
Goal
Level
Process
Structure
Power and influence
Proximity
Duration
Complexity / Functional or transformational or both?
Strategic, executive, operational, technical?
Cooperation, coordination, exchange, sharing?
Networks, teams, pathways, partnerships, area-based initiatives, merged organizations?
Participation, empowerment, co-option, control, infiltration, subversion?
In time/space
Temporary task focused or longer term strategy or both running parallel?
Uni-dimensional, bi-dimensional, multi-dimensional?

References and Further Reading:

Inter-professional working

Bleakley, A. (2006) A Common Body of Care: The Ethics and Politics of Teamwork in the Operating Theater are Inseperable. Jnl of Medicine and Philosophy, 31, 305-322.

Bleakley, A.., Boyden, J., Hobbs, A., Walsh, L. & Allard, J. (2006) Improving Teamwork climate in operating theatres: The shift from multiprofessionalism to interprofessionalism. Jnl of Interprofessional Care, 20:5, 461-470.

Bokhour, B. (2006) Communication in Interdisciplinary team meetings: What are we talking about?, Journal of Interprofessional Care, 20(4), 349-363.

Farrell, M. P., Schmidt, M. H. & Heinemann, G.D. (2001). Informal roles and the stages of interdisciplinary team development. Journal of Interprofessional Care. 15: 281-295.

Farrell, M. P., Heinemann, G.D., & Schmidt, M. H. (1988) Organizational environments of interdisciplinary health care teams: impact on team development and implications for consultation. International Journal of Small Group Research. 4: 31-54.

Irvine, R., Kerridge, I., McPhee, J. & Freeman, S. (2002) Interprofessionalism and ethics: consensus or clash of cultures? Jnl of Interprofessional Care, 16:3, 199-210.

Irvine, R., Kerridge, I., McPhee, J. (2004) Towards a dialogical ethics of interprofesionalism. Jnl of Postgraduate Medicine, 50:4, 278-280.

MacKenzie, S. (1995) Surveying the organizational culture in an NHS trust, Journal of Management in Nursing, 9:6, pp.69-77.

Meads, G., Ashcroft, J. et al (2005) The Case for Interprofessional Collaboration in Health and Social Care, CAIPE: Blackwell

Reason, P. (1991) Power and conflict in multidisciplinary collaboration:

Sarra, N. (2005) Working with organisational issues in the NHS, Psychotherapy, 4:5, pp.18-20.

Perspectives of Socialization and IPE in the Undergraduate Curriculum

Barr, H. (1998) Competent to collaborate: towards a competency-based model for interprofessional educations, Journal of Interprofessional Care, 12(2), 181-

Fraser, S. & Greenhalgh, T. (2001) Complexity Science: Coping with complexity: educating for capability. BMJ, 323, 799-803.

McNair, R. (2005) The case for educating health care students in professionalism as the core content of interprofessional education. Medical Education, 39, 456-464.

Theoretical Perspectives Applied to groups within healthcare organizations

Gould, L., Stapley, L. & Stein, M. eds. (2001) The Systems Psychodynamics of Organizations: Integrating the Group Relations Approach, Psychoanalytic, and Open Systems Perspectives. Karnac, London.

Obholzer, A. & Roberts, V. Z. ed (1994). The Unconscious at Work: Individual and Organizational Stress in the Human Services. Routledge, London.

Tuckman, B.W. (1965) Developmental sequence in small groups. Psychology Bulletin. 63: 384-399.

Tuckman, B. W. (1977). Stages of small group development revisited. Group and Organization Studies. 2: 419-427.