Professional differences in interprofessional working.
ABSTRACT UK government policy is encouraging healthcare staff to blur traditional roles, in the drive to increase joint working between practitioners. However, there is currently a lack of clarity regarding the impact that changes to traditional working practice might have on staff delivering the services, or on patient care. In this article, we report findings from three qualitative case studies examining interprofessional practice in stroke care, in which the influence of professional differences emerged as a significant theme. We draw on findings from individual semi-structured interviews, as well as fieldwork observations, to describe the influence of professional knowledge and skills, role and identity, and power and status considerations in interprofessional working. The insights that were gained contribute to the understanding of how professional differences impact on healthcare staff joint working, and suggest that the elements identified need to be fully considered in drives towards changed working practice.
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ABSTRACT: To explore the experiences of governance and incentives during organizational change for managers and clinical staff. Three primary care settings in England in 2006-2008. Data collection involved three group interviews with 32 service users, individual interviews with 32 managers, and 56 frontline professionals in three sites. The Realistic Evaluation framework was used in analysis to examine the effects of new policies and their implementation. Integrating new interprofessional teams to work effectively is a slow process, especially if structures in place do not acknowledge the painful feelings involved in change and do not support staff during periods of uncertainty. Eliciting multiple perspectives, often dependent on individual occupational positioning or place in new team configurations, illuminates the need to incorporate the emotional as well as technocratic and system factors when implementing change. Some suggestions are made for facilitating change in health care systems. These are discussed in the context of similar health care reform initiatives in the United States.Health Services Research 07/2013; · 2.29 Impact Factor
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Baxter, S.K. and Brumfitt, S.M. (2008) Professional differences in
interprofessional working. Journal of Interprofessional Care, 22 (3). pp. 239-251.
Professional differences in interprofessional working
Susan K. Baxter PhD, MSc, M.Ed, BSc, MRCSLT, Reg HPC
Shelagh M. Brumfitt PhD, MPhil, Reg HPC, CertMRCSLT (Hons)
Academic Unit of Child Health
University of Sheffield
PGME Stephenson Unit
Telephone: 01226 765183
Department of Human Communication Sciences
University of Sheffield
31 Claremont Crescent
UK government policy is encouraging healthcare staff to blur traditional roles, in the
drive to increase joint working between practitioners. However there is currently a
lack of clarity regarding the impact that changes to traditional working practice might
have on staff delivering the services, or on patient care. In this article, we report
findings from three qualitative case studies examining joint working practice in stroke
care, in which the influence of professional differences was a subsidiary theme. We
draw on findings from individual semi-structured interviews, as well as fieldwork
observations, to describe the influence of professional knowledge and skills, role and
identity, and power and status considerations in interprofessional working. The
insights that were gained contribute to the understanding of how professional
differences impact on healthcare staff joint working, and suggest that the elements
identified need to be fully considered in drives towards changed working practice.
Keywords: interprofessional working; professional; case study; stroke
Word Count: 4958
In the UK the call for change to healthcare service delivery has become a resounding
one over the last few years, with attention being paid to the way that healthcare staff
are trained, employed, developed by further training, and work together. These
changes have been driven by an explosion of policy documents (Department of
Health, 2000a, DOH, 2000b, DOH, 2000c, DOH, 2004) as part of a ten-year process
of reform of the National Health Service. Leathard (2003, p.30) describes these
policy documents as leading to an “avalanche of change” in healthcare staff working
Throughout the history of the National Health Service, the professions and elements
of professionalism have played a central role in service delivery. It has been noted
that a major distinction between joint working practice in healthcare and in other
contexts such as business and industry, is that workers in healthcare have professional
groupings and different allegiances (Firth-Cozens, 2001). Professional organisations
were developed to support practitioners in enhancing standards of care and in policing
standards of their colleagues, a process that Saks (2000) describes as “social closure”,
where legally underwritten self-regulation of the professions excluded the unqualified,
and gave power and status to the qualified.
Traditionally, definitions of professional practice have emphasised the key aspects as
being: a high degree of expertise; the freedom to control the management of the task;
a system of ethics; professional standards; and autonomy and dominance over other
groups (Southon and Braithwaite, 2000). Hugman (1991) emphasised the “social
power” that professionals possess, with claims to a particular knowledge base
marking each one apart. As the primary means of distinguishing one profession from
another, professional knowledge is a key concept in healthcare working practice. Hall
(2005) for example highlights differences in the way that individual professions
construe and use professional knowledge. He describes clinicians “looking at the
same thing and not seeing the same thing”, as a result of possessing profession-
specific “cognitive maps” which determine the framework for their clinical decision-
Medicine is the most established, and still dominant of the healthcare professions
(Page and Meerabeau, 2004, Hafferty and Light, 1995). In the context of this medical
dominance, other professions such as nursing and the therapy professions
(Physiotherapy, Speech and Language Therapy, Occupational Therapy) have faced
challenges in establishing position and status (Saks, 2000). Historically there has been
“an acute power gradient” between doctors and nurses, with a well-documented
professional hierarchy (Page and Meerabeau, 2004).
Interprofessional working clearly presents considerable challenges to practices
dominated by power and status considerations. Professional differences have been
described as “tribalism” (Beattie, 1995), developed as a result of professions evolving
separately, with deeply rooted boundaries between them. These differences may also
be a result of different training and philosophical approaches underpinning the
professions (Fitzsimmons and White, 1997). Practitioners traditionally have been
trained to function both independently and autonomously within professional
groupings, and also have adopted the values, norms and stereotypes held by members
of their particular profession as part of a process of professional socialisation (Mann
et al., 2005, Howkins and Ewan, 1999, Fitzpatrick et al., 1996).
With the advent of changing healthcare delivery, authors have emphasised the need
for new understandings of professional practice. Higgs and Jones (2000 p.4) for
example propose a new model called the “interactional professional”, redefining
professional autonomy as “independence in function……..combined with
responsibility and accountability for one’s actions”. Similarly, Hafferty and Light
(1995) discuss the possibility of “reprofessionalisation” as individuals shift their
identity and commitments from their profession to the organisation that they work in.
In a discussion of professional perspectives on working together, Hubbard and
Themessl-Huber (2005) highlight that that joint working is not just about transferring
information, but about creating new thinking. They argue that there is a need to focus
attention on “how knowledge is created rather than upon how knowledge is
exchanged”. Authors such as Jeffery et al. (2005) have adopted the term “shared
mental models” to refer to this creation of shared knowledge amongst different
professionals working together, which has the potential to lead to changed practice.
As highlighted above, the policy changes are encouraging role blurring and role re-
design amongst staff. The need for substantial change is raised by Humphris and
Masterton (2000) who argue that health need and workforce requirements necessitate
a “whole system approach” to role development, with the opportunity to let go of past
constraints. They contend that the professions need to evolve, and “may become
almost unrecognisable in the nature of their role and function”. Other authors
emphasise that a balance has to be found which respects individual profession
expertise and responsibility, but which equally recognises interests and qualities
shared with others (Biggs, 2000). It has been proposed that in changes to role and
identity, there is a need for “domain mapping” to help workers understand their own
domain and that of others (Hornby and Atkins, 2000). It has also been highlighted that
in a state of rapid change there is a danger of role confusion (Lahey and Currie, 2005),
and also, there is the potential for “a sense of loss and insecurity” (Williams and
Sibbald, 1999) in the healthcare professions.
Our purpose in this article is to report findings from a qualitative multiple-case study,
which explored the role of professional differences as a subsidiary theme in a study of
joint working practice amongst staff providing care to stroke patients. We aim here to
present the findings which describe aspects of interprofessional working relating to
staff knowledge and skills, professional role and identity, and perceptions of power
and status linked to professional groupings.
The findings reported are from in-depth case studies of joint working practice at three
sites providing care to stroke patients. We used purposive sampling to select examples
of practice across a typical stroke care pathway of hospital ward, specialist stroke unit,
and community stroke team. The studies were located within a single region of the
UK. Ethical approval was obtained via the NHS ethics procedure as a multi-site study,
and research governance procedures for each organisation were adhered to.
Data were collected via several sources. In particular for the findings reported here,
we used semi-structured interviews with staff of approximately thirty minutes
duration, together with periods of fieldwork observation. The interviews were carried
out by the first author, tape-recorded and later transcribed. The topics for the
interview were drawn from the literature on joint working, and were developed
following three pilot study interviews. Although a topic guide (Berg, 1998) was
prepared, the semi-structured nature of the interview also allowed the opportunity to
explore and gain further insights into the data generated from the parallel fieldwork
observations. The interview topics included: organisational conditions; goal setting;
conflict and problem-solving; group process and team roles; professional roles and
identity; beliefs about teamworking; patient involvement in care; and communication
systems. A total of 37 interviews with staff were carried out, with representation from
the range of professions providing care for stroke patients, encompassing: nursing;
medicine; physiotherapy; occupational therapy; speech and language therapy;
dietetics; clinical psychology; and assistants.
In order to gain insight into the context at first hand, we used an observation method
in conjunction with the individual interviews. Observational methods may be of
several types, with a continuum of participation at one end to observation at the other
(Bechofer and Patterson, 2000), depending on the role of the researcher. For this
study a non-participant observer role was adopted, with the first author carrying out
the observations in parallel to the interviews. During the field work, data were
collected via field notes, which documented observations, conversations, feelings and
interpretations (Roper and Shapiro, 2000). Periods for observation were selected to
give representation across a working week when more than one profession was
present totalling 110 hours of observation, with study periods at the three sites of 30
days, 19 days and 26 days duration. Data gathering was concluded at a study site
when we believed that saturation was reached and that new material was only adding
bulk to the data (Glaser and Strauss, 1967). In total we analysed 68 documents,
consisting of 30 field note transcripts, 37 interviews transcripts, and a research diary.
Data management and analysis
The QSR NVIVO software was used to facilitate storage and retrieval of the data.
The transcripts were stored as individual documents, and each document was read on
a line-by-line basis and coded. A start framework (Miles and Huberman, 1994) of
codes derived from the literature on joint working and the pilot interviews had been
prepared, however this start framework was continually revised and expanded in an
iterative process, as the coding proceeded. Coding was carried out in parallel to data
gathering, with revisiting of all coding at the conclusion of each case study before
commencing the next, and at the conclusion of the data gathering. Emerging findings
were discussed with and reviewed by the second author, and also in a process similar
to respondent validation, emerging concepts were discussed with participants during
the fieldwork, and interviews.
Following analysis of the data we uncovered three aspects of professional differences
which are significant in joint working: (1) knowledge and skills, (2) professional role
and identity, and (3) power and status.
Knowledge and skills
The “knowledge and skills” code was the fourth most frequently occurring code in the
entire data set, occurring in 134 passages across 39 different documents. The data
highlights the significance of depth of knowledge, with the perception of staff being
that the difference between professions was linked to the level or depth of specialist
knowledge and skills, for example:
“You need the background knowledge to be doing what you’re doing
effectively....I think...I think it probably does come down to effectiveness...I
mean anybody can go and sit...with a patient and do some language
stimulation but not everybody knows why they’re doing it in which case...they
might not be quite on the right track.” (Document 'individual interview’).
“I think you can do up to a certain level and I think that assistants are a good
example, that yeah it works at a level, but you cannot dilute that depth of
knowledge.” (Document 'individual interview’).
The linking of individual professions with having greater depth of knowledge and
skills raises the question of how junior staff functioned within the teams. Elements of
the data relating to this area were gathered under a code called “how long qualified”,
with 49 paragraphs coded across 21 documents. Within this code an element that was
highlighted by staff was the importance of seeking guidance from senior colleagues,
“I think when you are newly qualified you um you link to someone more
experienced, and sort of follow them really.” (Document 'individual
Staff also described how their joint working practice had changed as they had gained
experience, for example:
“I think the development of it comes alongside so many other things as well.
You’ve got to be grounded in your actual discipline first I suppose in order to
be able to contribute in a team.” (Document 'individual interview’).
“So...when you first qualify that’s what’s on your mind...what’s my plan what
am I doing with this patient....you tend to think of yourself more...but
then...the more experienced you get..you’re more comfortable with what
you’re doing physio wise and you think a bit wider...oh I need to speak to so
and so about this...I need to refer on about that..” (Document 'individual
Professional role and identity
Professional knowledge was presented above in relation to professions being
distinguished by different depth of knowledge. There was also some data that
represents an alternative view, that it is the type of knowledge and skills that
determine the role and identity of each profession rather than the depth.
For example, data describing nursing practice identified the nurse role as having
primacy in two knowledge and skill areas. Firstly, the role of the nurse as provider of
personal and basic needs care, and secondly the nurse role as relating to medicines
and medical needs. Data coded to “nurse role” is the most frequently occurring of the
data describing professional roles, being present in 110 passages across 37 documents,
“I think it’s that they think you’re a nurse so you’re things medical and
pressure area care and things like that as opposed to rehab the actual rehab.”
(Document 'individual interview’).
“Nurses would talk more about medication and continence and things.”
(Document 'individual interview’).
Staff referred to nursing as being in a unique co-ordinating role, which was different
to that of other professions:
“I almost feel that nursing are the main bit in the middle as they have the
fewest links out...they don’t have a main department.....they tend to be the
ones right in the middle of everything...that are there all the time..” (Document
'individual interview ’).
“We pull everything together we’re the ones in the middle.” (Document
The physiotherapists were seen as a key staff group at the locations studied, having a
clearly defined area of professional role and responsibility:
“It’s usually the physios who do an assessment....you know as to the moving
and handling.” (Document 'individual interview’).
“The main people I thought were the physios....” (Document 'individual
There are 80 passages coded across 31 documents for “doctor role” in the data, second
only in number to “nursing role”. This is surprising considering that at two of the
sites patients were required to be medically stable to be transferred there, and that one
of these sites had no doctor as part of the team. The doctor role seemed to be clearly
defined amongst the staff, particularly in terms of decision-making, for example:
“Yes we sometimes will look at the consultant as having to do the doctor bit..”
(Document 'individual interview').
“Nurses emphasising need for medical confirmation of discharge for patients
indicated, and other team members also using medic as discharge tool, and
using medic as authority figure to give emphasis to information or decisions
made e.g. talking to a difficult relative.” (Document 'field notes’).
Other professions at the sites included speech and language therapy, dietetics and
clinical psychology. These professions seemed to have defined roles by nature of area
of expertise, for example:
“Team leader asked what SLT recommending that other team members who
were going to work with him should do in regard to his talking, and asked for
specific things - SLT responded by giving specific advice”. (Document 'field
However, by virtue of them not having a full time presence at the location, elements
of their role could be taken on by other staff, for example:
“No SLT present, medic asked nurse for each patient whether they were
swallowing all right and nurse gave information.” (Document 'field notes').
“When I go and see them think oh... are they on thickened fluids, or oh... how
are they swallowing so I can feed back to the SLT cos they’re not going to be
there all the time.” (Document 'individual interview ').
The occupational therapy role seemed the least well defined role, and could vary
“It’s well who co-ordinates the whole package who’s really there to sort it all
out to make sure they go home with everything that they need..and that to me
feels a bit hit and miss...kind of ..often the OT picks that up.” (Document
'individual interview ').
“The OT is going to know most about perception and cognition...although now
we’ve got more psychology input that’s going to be an interesting more of a
merger that will develop.” (Document 'individual interview ').
The data indicated evidence of a blurring of boundaries in particular between the
occupational therapy and physiotherapy professions, particularly amongst more senior
staff, and some evidence of nursing taking on a role that encompassed elements of all
the therapy professions, for example:
“Here it has at times gone the other way...in that actually boundaries are
getting slightly blurred.....um...because the home visit for example is an area
which is predominantly the OT...area and it’s for us to set it up for us to decide
who goes...and it gets very much on here like it’s a joint thing with the OT and
physio.” (Document 'individual interview ').
“Discussed the nurse role in acute settings as the co-ordinator of services
around the patient, she agreed that that was often the role in acute settings and
that she had a similar co-ordinating role in community.” (Document 'field
As mentioned above, some staff linked any blurring of roles to availability of
colleagues, with staff either based full time at a location and or others having a part-
time presence or limited time availability, for example:
“I mean that’s very much blurring of roles..cos we’re not here at night.”
(Document 'individual interview ').
“A little bit, I would say there is role blurring on here.. I think when it’s
necessary there is.. if people are around.. then you don’t necessarily need to
have to although.. you do try and engage other people in trying to help you
make that decision even though it’s not necessarily their role... I think if
you’re the one that’s there, if you are the one doing something with them, and
it naturally imposes upon you to do aspects” (Document 'individual
In contrast to this perceived reduction in defined roles associated with availability of
staff, the data also provided evidence of role clarity amongst staff and clear
boundaries between professional groups, often linked to the depth of professional
knowledge, described above. In the data 143 passages (the third most frequently
occurring code) are coded to “role and identity – know boundaries”, with staff
reporting that professional role boundaries remained clear, for example:
“I know what my job is...and I know what other peoples job is...I think... I
don’t overstep the boundaries and I don’t think they do either.” (Document
“What marks each profession apart is actually...everybody has got this
genericy surface bit but that once you get....into this real depth of
competence...that’s almost where you have got the boundaries....” (Document
“Well obviously it’s profession led...cos physio and OT are not always the
same.....yeah...cos they’re two different professions you see...but they all look
for the same thing....and you know...they all talk…but you know physios
obviously….see physio side...OT...OT side and so on....”(Document
During the interviews professional identity was explored by asking participants where
they felt their loyalties lay, to the team or to their profession. Staff frequently referred
to themselves and their colleagues as being “the team” in discussions, however, in
contrast to this espoused team membership, it is interesting to note that there was
variation amongst staff as to whether they saw their identity as a team member or as a
member of their profession. Some staff linked their perceived identity as a team
member to feelings of closeness achieved by regular contact and smaller staff
numbers, for example:
“I do see myself as part of the physio department....but um..I probably feel my
loyalty is more to the stroke unit than the physio department as a whole because it
is too big....” Document 'individual interview'.
“I would say probably slightly a larger percentage to the team...than to the OT
service cos I am based here and these are the people that I work with every
day....but um...yeah I am still sort of....” Document 'individual interview').
However, professional identities remained strong, in particular relating to notions of
duty of care, and everyday patient treatment:
“Primarily I am a physiotherapist and my responsibilities are to the patient.”
(Document 'individual interview').
“I refer back to the OT team a lot..my colleagues...for support and where am I
going with this patient...and..clinical knowledge”. (Document 'individual
Power and status
The data that was coded to power and status was often also classified within two other
codes, with links being made to the medical role, and also to decision making. The
influence of power and status in the study sites seemed therefore to relate to the role
of the doctor and especially related to decision-making. References to power and
status in relation to the profession of medicine include, for example:
“Written in notes by consultant. Decisions re discharge seem to be taken solely
by the consultant, one occasion when he seemed to have put back discharge
date, only staff nurse knew about it, no-one else.” (Document 'field notes').
“There has to be a discharge form which the medics have to sign.” (Document
“The doctor will be saying, are we getting anywhere do we need to go, you
know we should be getting them moved on.” (Document 'individual
However, in contrast to this, there was evidence of some staff perceiving there to be
an erosion of these traditional assumptions:
“I don’t see a consultant being at the top of the tree... because I see that 99%
of the time we can manage without one.” (Document 'individual interview').
“It should be a circle with everybody in it..I don’t think it should be ...a
hierarchy ...a sort of pyramid with the consultant at the top....the rest of us at
the bottom...I think that’s wrong...cos...I think that yes the consultant is the
highly paid highly qualified um..professional..but they have quite a limited
role..” (Document 'individual interview').
Also, it was reported that the particular context of stroke care impacted on traditional
power and status assumptions. Staff linked this to a transition from a more “medical
model” view of care in acute medicine, to the more “rehabilitative model” needed in