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. This IPLU report was based on a collaboration of ten health and social care students from the Universities of Portsmouth and Southampton with the stated aim of examining “the impact of inter-professional working in the context of service improvement…from personal, professional and organisational perspectives”(Page.6 of the IPLU report)
Some preliminary reflections on the IPLU report
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, this overall usefulness of the IPL has had a mixed response from academia itself. It has been suggested by academics (Bleakley et al, 2006:467) that interprofessionalism within medical practice inevitably offers “greater benefits for patient care and safety”. This is indeed true for the purpose of medical practice, particularly regards the cure for and/or treatment of serious chronic health complications, and especially those pertaining to coronary, geriatric and cardio logical complications in patients. In this vein the report has duly taken into account these cultural aspects of clinical governance for a better patient-led health service for the provision of “responsive, consistent, high-quality and safe service-user rehabilitation”(Page 19 of IPLU report).
This 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. The CSRT needs the interprofessional input from the local ward staff to “ensure service-users” are able to avail a higher quality of service “in order for them to continue community rehabilitation”(page 19 of the IPLU report). Therefore it has also been recognised that the outcome of the project has more cultural repercussions for the staff related operation of the IPLU rather than the service users alone for which this effort has been undertaken.
Interprofessionalism within medical care
Interprofessionalism has become a significant tool for the health care sector due to the increasing trend of specialisation within the medical profession and the increasing stress on professionalism and ethical aspects(Reason.P.1991). Such collaboration becomes indispensable also because of its significance to ‘clinical governance’, which has been defined by Scally and Donaldson (1998:61-65) to point to a framework for accountability and quality of service within the health sector. In fact the reflective dimension of the IPLU report here (hereafter referred to as IPLU report) pertained to the author’s perception as a result of the learning process that the aim of “ improving the quality of … services and safeguarding high standards of care by creating an environment in which excellence in clinical care will flourish.”(Scally and Donaldson, 1998:64) is based significantly on the impact of cultures on the IPL practice. This is what forms the centre of discussion in this report.
Threats to successful IPL practice
The biggest threat to the IPL practice is the danger of disagreement within inter-professional teams and this can cause major difficulties in the achievement of the objectives of such interprofessional initiatives. The development of a healthy interprofessional culture is conducive to the simultaneous development of practice and the goal of better knowledge management through collaboration. The report has then duly taken into account the economic and political considerations within NHS organisational culture. However, the aspect of managing inter-group interaction as well as intra-group activities becomes an issue of unity in terms of their varied skills and professional dynamics.
The report has also subtly shown the cultural challenges being faced by NHS organisations. These problems have been well highlighted in contemporary literature. Nyatanga.B (2002) has spoken of the benefits of such IPL as 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 and obviously patients are 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.B (2002:1).
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)). The concept of a conducive work culture in the current IPLU context has given rise to a number of issues in terms of professional standards, quality management, internal politics and accountability. As stated in Fertig (2003), Robson (1998) and Harper (2000) share 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.
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. These ‘cracks’ in the overall atmosphere of collaboration could be a result of the tensions of not only various professional identities coming together but also the emergence of a new audit culture within the NHS which has been defined by Strathern (2000) (cited by Fertig (2003)] as “…the shift from professionalism to audit [being] yet another instance of the swing of the liberal pendulum from a romantic primacy of the ethical to a utilitarian primacy of the economic”. This dichotomy has been further classified by Stronach et al [(2002:109) as cited by Fertig (2003)] as one between an “economy of performance’ and ‘ecologies of practice’. Thus what we have at hand now is the dilemma of the new ‘market driven’ approach in the health sector where the tax-paying patient is a “service-user” or “end user” of the public good called “health”. Swailes [(2003:134) as cited by Fertig (2003)] has indicated “The effect of market changes was to make professionals far more accountable to their client/customer markets in addition to greater scrutiny from an increasingly assertive management”. NHS is one such example and Banks (1998:213) has endorsed these notions of the emerging audit culture, leading to notions of value for money.
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 the 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.
It is indeed true that the sociological experience of the 1950s and 1960s of Health Care sector management was based upon the functionalist theory (Robson) and professionalism was defined as embodying ‘traits’ [Macdonald (1995) as cited by Robson, p.1] that were identified as including ‘altruism’, ‘specialist intellectual knowledge’ and ‘a self-governing body’ [Lieberman (1956) and Goode (1957) as cited by Robson, p.1]. Later, what we saw emerging was the ‘power approach’ [Macdonald (1995) as cited by Robson, p.1]. This trend of internal struggle in interprofessional practice dominance or interactions has also been pointed out by Freidson (1970) and Larson (1977) as cited by Robson and is apparent from the subtle instances of tension within the IPLU report.
Common issues perceived as threats to IPLU success
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? 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.
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. 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 IPL relationships will “continue to be characterized by conflict rather than co-operation…” until such issues are better managed.
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.
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, the 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 can, accordingly, show the position of the NHS here in an IPLU context.
Conclusions and the way ahead
In conclusion, 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 individual standings before passing judgements on other teams.
As a personal reflection on my inter-professional learning I was able to reflect, as a result of IPL 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.
Based on the above I would now like to conclude that the way ahead for IPL 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.
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