An extract from an assignment for Module: Interprofessional Practice and Team Management (BA Hons Degree in Social Work).
The context of this assignment is based on a hypothetical interdisciplinary team operating in a primary care setting. The team comprises GPs, community nurses, occupational therapists, home-care supervisors and social workers/ care managers.
The principles of collaboration between health and social services authorities were set out by the Conservative Government in 1989. This ideology assumed joint financial responsibility for the provision of community care (Department of Health (DoH) 1989) and by 1993 care management was seen as the new way of delivering an effective service to those in greatest need (Sharkey 2007). Across the UK and in Scotland the National Health Service (NHS) and Community Care Act, 1990, were a platform for significant legislative and policy change across organisational boundaries, introducing new concepts, including purchaser/ provider contracts and user rights (NHS Executive 1996, DoH 1994, DoH 1996, Scottish Executive 2000).
To comprehensively examine interdisciplinary processes, it is important to give consideration to interagency processes (Lishman 2007) and the range of factors which predispose agencies to collaborate (Hudson 2002). The structures and logistics of the systems through which professionals organise their collaborative efforts are informed by government policy and direction, but also, crucially, they are influenced by the history, culture and context of each profession (Barrett, Sellman and Thomas 2005).
The legal framework for the NHS in Scotland is the National Health Service (Scotland) Act 1978. It is population focused and works on the principle of greatest need (Robson 2007). Reorganisation has produced a single tier of governance and accountability and the introduction of Community Health Partnerships represents a further shift towards healthcare in the community. The Social Work (Scotland) Act 1968 laid down the theoretical and structural foundations of modern social work in Scotland (Hothersall 2006). It focused on the welfare of those who were affected by major inequalities, such as poverty, and concentrated on personal and social problems. Current legislation formalises joint working recommendations (Scottish Executive 2002) and the introduction of the Health (Care and Treatment) (Scotland) Act 2003 (Scottish Executive 2003a) relies upon integrated practice in order to maintain people in the community. UK law is also bound by supra-state legislation (the Human Rights Act 1998, European Convention on Human Rights 1998).
Using these frameworks in conjunction with different ethical perspectives can inform our analysis of the processes that affect the performance of the hypothetical interdisciplinary team. Callahan and Jennings (2002) purport different types of ethical analysis specific to different professions. Medical practitioners within the team are likely to operate within a context of protecting the trust and legitimacy of their profession whereas social care professionals within the team may use applied ethics, focusing on professional conduct (Scottish Executive 2003b). By working together, an advocacy-ethics base with a strong orientation towards social justice and equality may be promoted, formulating a direct link to the public health model. Rogers (2006) advocates a feminist approach to address health inequalities and embrace the political dimensions of public health.
The Research Governance Framework for Health and Social Care (Scottish Executive 2006a) sets out the standards and requirements in health and social care research, acknowledging important differences between the two, such as the range of disciplines. In practice, each profession is governed by its own ethical codes of practice (British Medical Association (BMA) 2004, Scottish Social Services Council 2005). Kass (2001) proposes a framework of ethical analysis to advance public health goals whilst maximising individual liberties and furthering social justice. Within these professional codes of conduct, professionals make decisions that require application and interpretation of these codes. They establish guidelines that are relevant for the circumstances of particular cases or situations (BMA 2004). Lishman (2007) points to the importance of interdisciplinary teams working as a collective, with an emphasis on collaboration particularly in areas such as decision making (Payne 2000) to benefit the service user/ patient (McLean in Lishman 2007).
Each member comes from very different ethical and professional traditions (Watson and West 2006) and his/her identity is derived from within each profession. Each has its own culture which encompasses a particular set of beliefs, values and norms. Bion (1961) noted that these basic assumptions mobilise different emotions, values and ideas in relation to the central task. Community nurses and General Practitioners (GPs) work from a medical model of health and wellbeing. The assessments they make are likely to be restricted to aspects of functionality related to their own discipline, e.g. can the service user wash and dress unaided. The underlying assumption is that of the ‘expert’ worker with the skills to diagnose the problem and affect a solution with minimal involvement of the service user (Glasby and Littlechild 2004).
Social workers and occupational therapists are more likely to evaluate the situation using a social model of health that attempts to assess people within their social situations using a holistic approach to assessment. From this perspective, service users are viewed as being the experts in their own lives and therefore are more likely to be involved in the process of developing appropriate solutions (Mactavish and Mackie 2003). For service users, these differing emphases can be problematic and can lead to contradictory approaches.
Differing beliefs about the nature of presenting problems, possible solutions and the relationship between professionals and service users can result in tensions and conflict (Woodhouse and Pengelly 1991). However, if different beliefs and perspectives are shared through open and honest communication, professionals in the team may be able to view problems from new standpoints which will benefit both themselves and the service user (Irvine, Kerridge, McPhee and Freeman 2002).
Loxley (1997) identifies the two key themes of power and culture central to the concept of professionalism in which professionals seek permanence and autonomy. Struggles for power are rooted in professional tradition and social difference. Payne (2000, pg. 141) identifies power as ‘people’s capacity to get what they want’ exerted through control or legitimised through the authority of the profession or organisation. Within a traditional health care setting, power tends to be located with the medical profession.
If power is to be shared or distributed on the basis of the knowledge and expertise of all the professionals within the team, medical practitioners will need to relinquish traditionally held dominance which they may find difficult to do. They may feel that their autonomy is being threatened (Cook, Gerrrish and Clarke 2001). Autonomy may be seen as a defining characteristic of a profession and the concept of clinical freedom has been used to enable some to hold onto power (Loxley 1997). Perceptions exist that some occupational groups in health and social care are semi-professional, such as home care supervisors, on the basis that there is a lack of a unique, scientific knowledge base (Bassett 1995). Professionals have sought to strengthen their power through restricted entry; this is sanctioned through controls associated with qualification and education. Unequal power distribution can be oppressive (Payne 2000) and can limit participation for some team members.
Professional judgement, therefore, becomes associated with individual power and there may be intergroup conflict between doctors and nurses as well as between disciplines (Forte 1997). In relation to the notional team traditional role, boundaries particularly between doctors and nurses, are likely to be in the process of breaking down under the influence of’ ‘work pressures, differences between clinical areas and the changing knowledge context of nursing’ (Snelgrove and Hughes 2000 pg. 661). To some extent this erosion is a consequence of some deliberate changes in policy; community nurses have increased responsibility for day to day work with little additional authority (Gavin 1997).
Another concern is that, being located out of their professional context, nurses may also be isolated from professional support from others of a similar background (Berger 1991). As honest and open communication and the sharing of professional perspectives are key attributes of interprofessional working, power differentials must be acknowledged, recognised and resolved within the team (Loxley 1997). Central to effective interprofessional working is a shared power that is based on hierarchical relationships. However there is evidence that the more people who are involved in a joint enterprise, the more difficult it becomes to maintain equality in terms of power relations and consequently hierarchies develop (Boulding 1990). There may be assumptions within the team about who will be responsible for following through agreed decisions. There is the potential for oversight which would be to the disadvantage of the service user. Such problems can be avoided if the collaborative team utilises interprofessional action plans, documents specific areas of responsibility and reviews dates and procedures.
To maintain power, professionals develop and sustain an occupational culture that allows them to identify themselves as different and distinct from other professional groups. The establishment of a professional identity is elemental in the development of an occupational culture. This begins during training; it demonstrates proficiency and informs confidence and role clarity. Millerson (1964) determined a model of professional identity which distinguished key characteristics including assessing the professional competence of potential members before they would be able to practice.
Jones and Joss (in Yelloly and Henkel 1995) identify three approaches to understanding how professionals manifest their professionalism. The ‘occupational control’ approach advocated views professionals as competing to secure their interests; for example, the GPs within the team will negotiate contracts separately from other colleagues in the NHS.
Barrett and Keeping (2005) identified several factors that they believed could either help or hinder interprofessional work. Knowledge and understanding of professional roles, responsibilities and boundaries are crucial to promoting collaborative working. There is some debate that interdisciplinary work creates role blurring and this can be beneficial to service users; it also fits well with the devolved community-based initiatives, particularly within mental health (Martin et al, 1999). Others argue that this more flexible, less defined approach can contribute to role strain and confusion for practitioners (Moller and Harber 1996). Antai-Otong (1997) insists that confusion about individual roles is an important feature of individuals not functioning well as team members.
Payne (1982) suggests that professional identity is an essential part of belonging to a multi-disciplinary team. In fact, it can provide a platform for greater work satisfaction, reduce feelings of detachment from service users and encourage professionals to challenge the traditional authority of other professions (Mistral and Velleman 1997). It can be further argued that boundaries between professionals are actively encouraged by the experience of interdisciplinary modes of working and that managers and policy makers need to take account of this. We can concur that both health and social care models have their strengths and, if acknowledged and valued within a multi-disciplinary context, there is considerable potential to enhance the creativity and effectiveness of the team as a whole.
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