The interprofessional topic drawn from the IPLU (Interprofessional Learning Unit) report is the impact of cultures, both professional and organisational, on inter-professional working within the IPLU programme in relation to confidentiality and better communication with the patients. The Group 35 IPLU report was an exercise in assessing whether we, as a multi-disciplinary team of 10 health and social care students, had gained something worthwhile both for ourselves in terms of knowledge and for the end service users in terms of skill mix and cost. It pertained mainly to the issues of confidentiality, better communication and co-operation between staff.
This CSRT (Community Stroke Rehabilitation Team) consisted of 2 Medics, 4 nurses, 2 social workers, an occupational therapist (OT) and a radiographer, which essentially meant that this was a team of multi- disciplinary professionals. The project mainly assessed the viability of a 7-day service as well as the possibility of a change in working hours in terms of staff satisfaction and overall costs in line with the changing governmental policy. This had to be done keeping in mind that some members of the team (like OT’s) are often unavailable during the weekend.
The aim of the CSRT is to become a means to an end for achieving the effective application of the parameters of post stroke recovery care dispensed through a multidisciplinary care team. Effective Interprofessional communication and interactions need to be followed in stroke rehabilitation to assess how the nursing care needs of patients with a post stroke recovery condition may be addressed effectively.
Due to the multi-agency, multi-practice nature of this team it is possible to state at the outset that there is a need to have effective communication in order to provide a comprehensive service to end users. However, the overall usefulness of the multi-disciplinary team has had a mixed response from academia itself. It has been suggested by academics (Bleakley et al, 2006:467) that interprofessionalism/multiprofessionalism within medical practice inevitably offers “greater benefits for patient care and safety”. This is indeed true for the purpose of medical practice pertaining to stroke management, recovery and rehabilitation.
The IPLU report acknowledges the need for the promotion of better arrangements to look into the cultural aspects of current service provision to better achieve the needs of service-users. One of the major recommendations with in the report asks for a seven-day working time and the benefits and detriments of the same are weighed through staff and patient opinions in the IPLU report. Therefore, in line with my choice of issues arising from the IPLU report, it has also been recognised that the outcome of the project has more communication based cultural repercussions for the staff related operation of the IPLU rather than the service users alone for which this effort has been undertaken.
Issues arising from the Group 35 collaboration
Interprofessionalism/multiprofessionalism has become a significant part of the modern health care culture in Britain due to the increasing trend of specialisation within the medical profession and the increasing stress on professionalism and ethical aspects (Reason, 1991). One of the perceived threats to the success of our Group 35 practice was the danger of disagreement within inter-professional teams and whether this could cause major difficulties in the achievement of the objectives of such interprofessional initiatives. The development of a healthy interprofessional culture is conducive to a better organisational set up with in the NHS.Failure to communicate and disagreements are a challenge to the effective management of inter-group interaction as well as intra-group activities. At times it often became an issue of unity for our Group 35 in terms of the team’s varied skills and professional dynamics.
In reflection, the problems faced by Group 35 were largely due to the cultural challenges being faced by NHS organisations in the face of increasing multi-disciplinary co-operations. These problems have been well highlighted in contemporary literature and arise due to a lack of communication and co-operation. Such problems often out-weigh the benefits of the interprofessional collaboration and as Nyatanga.B (2002) suggests, if such problems are not tackled immediately as an organisational concern then there is a danger that the perceived benefits of multi-disciplinary teams become a ‘myth’ rather than having any truth attached to it. Nyatanga.B (2002:1) admits that while “the benefits of interprofessional learning are often witnessed in the closer and better interprofessional working in clinical areas (with) obviously patients (being) the biggest winners…” the whole concept is beset with contradictions and politics, or as he chooses to call it “a professional myth supported by rhetorical statements”(Nyatanga, 2002:1). Nyatanga views are supported by quite a few observations of the interprofessional collaboration of the Group 35 as many problems became obvious. Firstly, the reconciliation of different work and professional cultures coming together. This means that there was a sense of power plays between the doctor’s, nurses and OT’s as there was a general complaint that if the OT’s, Radiographers and Speech Therapists could not show up at weekends then it would be an exercise in futility and, basically, unfair to expect the doctors and nurses to work a 7 day week.
The cultural issues are in fact aggravated by the irritating extent of the lack of financial resources available to make such collaborations a success (Carpenter et al (1996 cited by Nyatanga (2002:1)). Finances were indeed a concern in the Group 35 report which meant that in line with the concerns pertaining to professional standards, quality management, internal politics and accountability the costs and benefits of the “7 Day” multidisciplinary collaboration would need to be considered as well. Robson (1998) is of the view that there is a pronounced trend of interprofessional working within the UK health sector where a distinction can be drawn within the ‘managerialist’ and the ‘professional’ paradigms. The study of the relevant literature shows an increased tendency for power struggles with the management and regulation within such interprofessional initiatives (Carpenter et al, 1996).
The impact of culture and the changing meanings of professionalism on IPLU practice
Cultural issues with regards teamwork were apparent from the warnings in the Appendix of the IPLU report and the efforts to maintain a tension-free collaboration. The heightened stress on the financial and cost perspective of the IPLU report has more to do with this culture of what Banks (1998:213) has called the wave of “’new consumerism” laying emphasis upon the technical skills of the private sector labour force (instead of professional ethics) and consumer rights (as opposed to professional obligations). In the face of this, medical professionals are no longer expected to be ‘fairy tale good Samaritans’. Rather, this is a quality which they have to retain as an inherent aspect while at the same time competing with each other in the wake of ‘new radicalism’ which emphasises the professional worker’s own personal or political commitments rather than stressing individual moral responsibility (Freidson, 2001).
Coming back to the main problem, as Nyatanga (2002) has suggested, based on the observations of the evolving audit and consumer culture, (as pointed out and witnessed in the IPLU experience), for many professionals there was the subtle feeling that such a ‘melting pot’ was actually threatening the professional identities of all members, whether they were nurses, medics or doctors. Could this individual hesitation then be attributed to a lack of motivation with the programme? A similar view has been taken by Sarra, N (2005) and this is what Nyatanga (2002) has labelled as professional “ethnocentrism” which he has defined as a serious cultural issue as it is the “belief that one’s own professional group is superior and better than all the others” (Nyatanga (2002:1). Such attitudes are detrimental to success and can only cause disharmony within the IPL initiatives to the extent that academics have begun questioning whether interprofessional learning is in fact the solution to the achievement of better and closer interprofessional working. There was also a lapse in communication and a clear failure to communicate.
The way ahead to promoting a healthier work culture within the IPL would be that there should be a practical approach to the promotion of an organisational culture of “clear boundaries” whereas the ‘melting pot’ acknowledges and appreciates rather than snubs these professional cultures (Sarra, N (2005). Such an approach will better support the aims of IPL through promoting professional development. If these issues are not dealt with now then one cannot help agreeing with the views of Nyatanga (2002:1) that “interprofessional learning may not produce a workforce with a fitness for practice, but a fitness for rhetoric”. In addition to this, Irvine et al, 2002:199) have noted interprofessional relationships will “continue to be characterized by conflict rather than co-operation…” until such issues are better managed. This is quite evident from some of the tensions faced during the research and formulation of the Group 35 Report.
Irvine et al (2002:204) have noted that IPLU collaborations often “reflect, reproduce and perpetuate the traditional divisions of labour, status systems and systems of authority.” Irvin et al (2002:204) also identify this cultural baggage manifesting itself in the form of professional divisions, intra-professional variation and varying value systems. From a perspective of the IPLU practice report there is evidence of an effort (See Appendix A Page 22) to enforce a culture of collaboration where there would be efforts to “respect all other members of the group at all times…. be non-judgemental at all times, support and encourage each other when working on any given tasks ….be open and honest at all times, treat others how you wished to be treated yourself – i.e. equally, share workloads as evenly as possible” and so on. While this looks like a very noble attempt to promote a better culture of collaboration ‘on paper’, enforcing these small gestures is perhaps a bigger challenge for us rather than patient satisfaction itself. It should also be noted that these requirements are reinforced through the HPC code and the NMC code (2008) particularly where the HPC (The Health Professionals Council code) (HPC, 2004) requires the health professionals in to “ be able to practice in a non-discriminatory manner’ (HPC 2004:7) and to recognize that “relationships with patients, clients and users should be based on mutual respect and trust, (and the GP should) be able to maintain high standards of care even in situations of personal incompatibility’ (HPC, 2004:8). The NMC Code of Conduct (2004, para 5.1) expressly requires all nurses and student nurses to “treat information about patients and clients as confidential, and use it only for the purposes for which it was given” (NMC, para 5.1). Furthermore, the code goes on to warn the practitioner or trainee nurse, “you must guard against breaches of confidentiality by protecting information from improper disclosure at all times” (NMC, Para, 5.1). Rare exceptions to such prohibitions within the NMC Code against disclosures include informed consent and public interest (para 5.3 and 5.4, NMC Code, 2004).
The power struggle
Finally, in attempting to explain and analyse interprofessional conflicts within the IPLU, one can use Robson’s model which has drawn upon the “four ‘actors’ model” by Burrage et al (1990) where she states that the four actors are the professionals (the team), the state, the end-users and the institutions (p.2). It is true in the context of IPLU practice that all these four actors will have their own interests and limitations at heart: for example, professionals will be concerned mainly to preserve their group interests and autonomy (Carpenter and Hewstone 1996:239-257). These interests might often conflict with the state, which will struggle to establish its dominance and authority though implementing financial or tight budgetary goals through the tools of “policy, regulation and legislation” (Robson, p.2). This will often amount to irritation within the interprofessional groups already struggling with the “getting on” aspect of such collaboration. This explains one reason why the survey and interview stage of the project was beset with problems as to task allocation and the amount of work being put in by each member of the team.
It is possible to see that the impact of culture may just all be about “getting on” with each other in a team and mainly an issue of “emotionality and psychodynamics” (Irvin et al (2002): 206) rather than rational reactions. This may be because of different expectations from each other in a healthcare team, and reluctance to see how these professionals ‘stood in their own shoes’ before passing judgements on other teams, so perhaps professionals need to be aware of, and develop, greater empathy for their colleagues.
As a personal reflection on my inter-professional learning I was able to reflect, as a result of the Group 35 IPLU collaboration, on the values and beliefs I held, compared to other members’ perceptions pertaining to the same. This also prompted me to scrutinise with an open mind how group decisions were being made as well the methodologies for patient interaction, as well as inter-staff and inter-patient co-ordination and, perhaps more importantly, whether team members took the trouble of sharing patient problems, goals and interventions to each other and how they did so. In a group environment maintaining confidentiality and effective communication is a significant ingredient of success and should be given its due significance.
In conclusion, based on the above I would now like to conclude that the way ahead for interprofessional practice cultures would be to alter uni-professional approaches to situations, and view them via the lens of mutual recognition of the differences within group behavioural dynamics and professional capabilities, and thereby exploit fully the benefits these can bring for patient health. Moreover, based on the observations made from the Group 35 report, effective communication is not only necessary between a health professional and a patient, but also between the members of health care teams so the interests of the patients (in this case stroke patients) can be better addressed
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