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Interprofessional Communication and its Challenges
Susanne Lindqvist
Introduction
In the UK, it has become increasingly evident over the years that when things go
wrong or nearly go wrong in the care setting, breakdown in communication between
professionals is high on the list of things associated with the failure to provide a safe
and high quality service (Kennedy et al., 2001; Laming, 2003; Haringey, 2009;
Francis, 2013). Statements made by the Department of Health
(DoH 2001 2008 &
2011) and professional bodies (NMC, 2008; GMC, 2009)
highlight the need for
effective communication and collaboration between professionals and agencies
involved in care delivery. However, there are no clear guidelines across the
professions as to what education and training should be provided to ensure
development of the key skills underpinning effective collaboration, namely
interprofessional communication.
Most health and social care students will receive some opportunities to learn and
practice communication skills within their respective courses. According to
Silverman and colleagues (2005), a doctor needs to adopt a person-centred,
engaged and empathic approach whilst building rapport during a consultation. In
parallel, they also need to follow a structured process to ensure all relevant
information is collected and understood correctly by both parties. In order to prepare
future doctors, many medical schools have adopted the Calgary-Cambridge model
(Kurtz, Silverman & Draper, 1998; Silverman, Kurtz & Draper, 1998) as a framework
for their communication skills teaching. However, a recent publication by Bachman
and colleagues (2013) states that non-medical courses often have less structured
teaching sessions. Also, the focus of this type of teaching session is on the students
learning to communicate with the person seeking advice, or care
rather than with the
colleagues they need to work with.
In the practice setting, different professionals are expected to work together
effectively, and in order to do this they need to use interprofessional communication
skills. Rarely, if at all, will they receive training in how to work and communicate
effectively with their colleagues once qualified. In response to the call for
professionals to be equipped with the necessary skills required for interprofessional
communication and working, not only in the UK (Francis, 2013), but also globally
(Frenk et al., 2010; WHO, 2012), many universities now offer opportunities for
students to learn and work together with peers from different health and social care
courses. The Centre for the Advancement of Interprofessional Education (CAIPE)
recently published a guide to support those who wish to introduce interprofessional
learning (IPL) into their curricula (Barr & Low, 2013), and a number of interventions
are also available in the literature (Hammick et al., 2007; Reeves et al., 2010).
Despite growing evidence related to the effectiveness of IPL, there is still room for
more research, evaluation and discussion amongst stakeholders to tease out what
the challenges are for professionals as they communicate with each other and how
educators can support the future workforce by providing high quality education and
training.
This chapter aims to look at some of the known challenges, present examples of
how they are currently addressed, and suggestions of how future educators can best
support the development of the skills that underpin effective interprofessional
communication.
Challenges associated with interprofessional communication
As with any relationship, a key ingredient in the recipe for success is effective
communication. In the health and social care arena, such communication can be
particularly difficult to carry out and possibly even harder to maintain. Known
challenges associated with communication between professionals are often linked
with a lack of:
- self-awareness of own role in communication;
- understanding of, and ability to deal with, rank dynamics between professions;
- understanding of different professions’ roles and responsibilities;
- courage and being proactive;
- skills to deal with conflict and emotional stress;
- common language and consistency in the interpretation of confidentiality;
- respect and trust towards the abilities of other professions;
- time.
Self-awareness of own role in communication
The emphasis of self-awareness within the team and the importance of effective
communication is much more developed within other service providers, such as the
aviation
(Gordon et al., 2012) and retail industries (Fill, 2001). Within these two
types of organisations the main drivers for making sure professionals are sufficiently
educated and trained in communication skills are related to safety and customer
satisfaction. For pilots and sales managers there is no doubt that it is not enough to
have the skills related to flying a plane, or marketing a product. Rather, these
professionals need to possess the skills that enable them to interact and
communicate effectively with their customers and their team members in order to
successfully fulfil their professional role. To ensure professionals in such fields are
reaching and maintaining the expected standards, they receive the necessary
education and training to develop the required skills, which are monitored thereafter
on an ongoing basis. For each health and social care professional group there are a
set of standards
(NMC, 2008; GMC 2009) that individuals need to meet in order to
continue their current practice. However, the importance of being skilled in
interprofessional communication simply does not appear as high on the agenda, if
explicitly mentioned at all.
All too often do we hear, or read, about breakdown in communication between
members of different professions, but less often we see evidence of individuals and
teams actually being offered appropriate learning opportunities to develop these vital
skills. The starting point must be with the “self” to ensure all learners are given the
opportunity to develop an awareness of personality style (Champangne & Hogan,
1979)
and preferred team role (Belbin, 2013)
to identify personal strengths and
weaknesses, and how they are perceived by others. This will help enhance each
team member’s emotional intelligence (Goleman, 1995)
so they can optimise their
ability to interact effectively with others, regardless of rank.
Understanding of, and ability to deal with, rank dynamics between professions
Knowledge and understanding of self, together with a clarity about how one’s own
professional role complements others in the delivery of high quality care will help
individuals understand how their actions impact on their interactions
(Gordon et al.,
2012). As described by Collins and Lindqvist
(2013) in their chapter about rank
dynamics, issues around power between and within professions are frequent causes
of communication breakdown.
Rank dynamics are complex
(Collins & Lindqvist, 2013) and well rooted in our
society, also historically between health
(Paley, 2002) and social
(McLaughlin, 2012)
care professions, creating a barrier to communication. The literature offers a wealth
of insight into power struggles between care professions
(McLaughlin, 2012), many
of which can be linked to the skills and behaviour of the team leader
(Collins &
Lindqvist,
2013; Reeves, MacMillan & Soeren, 2010). It is essential for team leaders
to appreciate the power of rank dynamics and the emotional labour
(Ronald et al.,
2008)
associated with dysfunctional teams where members do not feel free, or able,
to challenge decisions, actions and interactions – yet asked to deliver
compassionate care (Reeves, MacMillan & Soeren, 2010). Team leaders must
therefore have the ability to create an environment that allows for this to happen.
They also need to make sure that all team members understand their responsibility
in the process and receive appropriate support to communicate across ranks
(Gordon et al., 2012; Goleman, 1995).
Despite health and social care professionals being absolutely clear that their
common goal is to deliver person-centred care, they do not always agree how this
should be accomplished, or have the ability to overcome the challenges linked to
interacting with members of professions with perceived higher, or lower, rank.
Differences in power and status within the health and social work professions often
derive from a lack of understanding of the roles and responsibilities of those
contributing different aspects of care and how they depend on each other in order to
provide a holistic service to someone
McLaughlin, 2012; Mizrahi & Abrahamson,
2000).
Understanding of different professions’ roles and responsibilities
Knowledge of different professional roles and responsibilities will enable the team to
provide a person with the care they need by referring them to the appropriate
professional(s) with the most appropriate skills at the right time. This is the core of
interprofessional education when two or more professions learn with, from and about
each other to improve collaboration and the quality of care
(CAIPE, 2002). During
IPL students from different courses come together to share and develop their
understanding of their respective roles and responsibilities. Although the evidence is
not conclusive as to when IPL should be introduced in order to gain most benefit,
there is increasing support for early introduction (Hammick et al., 2007; Reeves et
al., 2010)
in order to foster the necessary attitudes (Hawkes, Nunney & Lindqvist,
2013) and behaviours that allow for fruitful exchange of skills and knowledge across
the professions. Gordon and colleagues (2009)
recognise that the adult learner
needs to take incremental steps to become a capable interprofessional worker.
Educators within the higher education setting have a responsibility to create
opportunities for students to meet, learn and work together so that they are not left to
be educated in silos.
As roles and responsibilities evolve with people’s changing needs, tensions will arise
unless everyone is aware of who does what, when, why and how. This is discussed
in an article by Hawkes et al. (2013)
who also highlight the challenge in managing
such change without diluting professional identities. The blurring of boundaries will
threaten the safety and quality of care thus it is imperative for professionals to
understand their roles and responsibilities. However, there will be valuable overlaps
where two different professions are capable of performing a task. Effective
interprofessional communication will enable the team to decide who will be the most
suited to provide a particular aspect of care where such overlaps exist and to avoid
gaps in care occurring.
Incidents from the past (Kennedy et al., 2001; Laming, 2003; Haringey, 2009;
Francis, 2013) remind us that some matters are the responsibility of each and
everyone involved in care delivery and that every contact matters.
Courage and being proactive
To have the courage and skills to ask someone about suspected abuse can be very
challenging even for experienced staff. Students and professionals need support in
this area so that they know who to contact with their concerns and make sure they
are followed up. Opportunities for IPL where students and professionals from
different organisations and agencies come together to learn and work together with
people with lived experiences
(CIPP, 2014) is a way to generate ideas of effective
interprofessional communication and working. Its effectiveness lies in all
stakeholders being present to share experiences, discuss and compare
expectations, explain barriers and explore solutions.
Having the courage and confidence to approach someone who may have underlying
problems or surrounding issues in their life that may threaten their wellbeing -
alongside the issues they are presenting with - is indeed a challenge for both health
and social care staff to deal with
(Munro, 2011). However, it is likely to be even more
difficult to have the courage to address concerns related to a colleague, especially if
this colleague is of a higher rank
(Collins & Lindqvist, 2013). All students and staff
have an obligation to report real or suspected concerns about unsafe practice.
Whistleblowing has been discussed at length in the literature following past incidents
(Kennedy et al., 2001)
and has recently been encouraged for the safety of care
delivery
(Francis, 2013). Having the bravery to do this, whilst keeping the team spirit
high and avoiding a blame culture
(Berwick, 2013), is not an easy task and our future
workforce needs support in this
(Gordon et al., 2012).
The sad and unexpected death of Emily Bromiley in 2005 highlighted the issue
around human factors and how people behave in stressful situations. Taking
lessons from the aviation industry, guides and checklists are now available to ensure
care is delivered as safely as possible
(WHO, 2009). For this to happen, the team
needs to be self-aware and each member needs to possess the courage and skills to
challenge the decisions and actions of any colleague regardless of rank
(Gordon,
2012). All members of such a team will play a proactive role in checking that all
measures are in place to avoid harm, and to make explicit that the human factor in
the care process is of a positive nature. The surgery checklist
(WHO, 2009) was
created to facilitate the process and help prevent mistakes by following some simple
steps. There are other checklists available e.g. for discharge
(Thornton, 2004), but
some consider that they prevent care from being holistic in that professionals may
not see what is in front of them, because they are too busy checking that all the
boxes are ticked.
Students and professionals need to be aware of the different tools available to assist
with different processes of care, and for assessing risk or analysing root causes
when an error has occurred, but they also must learn about how their own emotional
wellbeing can affect others
(Goleman, 1995; Gordon, 2012).
Skills to deal with conflict and emotional stress
Dealing with any kind of conflict is challenging and it is a true skill to learn to manage
and deal with various situations and responses when emotions are running high
(Goleman, 1995; Patient Safety First, 2009; Institute for Innovation and
Improvement, 2010). Currently, students may be able to practice communication
with angry or “difficult” patients, but there are less frequent examples in the literature
of how to deal with challenging colleagues. Effective communication and awareness
of body language is very important when trying to resolve a conflict. Although all
professionals need education and training in such skills, it is central to the leadership
and manager role to create a working environment that allows for different
communication channels to be open and to arrange opportunities for learning how to
deal with conflict. Where conflict is not dealt with appropriately, emotional stress is
likely to build up, which can impact on staff health and performance. This, in turn,
can affect care delivery and safety (Maben, 2012).
The care setting, whether it be in hospital or the community, is a stressful working
environment with ongoing changes and high expectations of professionals constantly
in the media headlight. Professionals need safe environments where they can
communicate their feelings and concerns to each other. One initiative that followed
in the wake of the Francis report was the rolling out of the Schwartz Center Rounds
for staff as a way to share difficult emotions that can occur for professionals during
their working life. This can help professionals manage their own emotional wellbeing
so that they can provide compassionate care for others.
The NHS also offers a range of activities that can be employed by both students and
staff to practice ways of communicating around emotive topics
(NHS, 2010). Some
of these are very simple to use and can also act as a trigger for discussions related
to interprofessional communication, such as the use of language and the issue of
confidentiality.
Common language and consistency in the interpretation of confidentiality
A person who needs support and care from the police, social services and health
may assume that all these different professionals understand each other, speak the
same language and freely share relevant information. However, each of these
groups of professionals use a different: language; models of care; and interpretations
of how they manage confidentiality across agencies (Police, 2004; BASW, 2008;
GMC, 2009; Munro, 2011). Confidentiality is a means to protect the individual, but it
can also hinder care delivery
(BASW, 2008) and at worst cause harm
(Munro, 2011).
Open lines of communication between professionals and agencies in cases where
confidentiality may need to be breached is vital so that decisions can be made
around the best way forward for the person in question. As alluded to earlier, IPL
opportunities can be offered to students during their studies so that they take active
part in discussions with members of different professions and agencies together with
people who have ‘lived experiences’ as this will equip them to take a multi-agency
approach in their future practice
(CIPP, 2014)
Multi-agency safeguarding hubs (MASH, HM Gov., 2013) have been initiated across
the UK to address concerns around the safety of children and vulnerable people in
order to initiate early interventions. Professionals with concerns can contact the
MASH team who will then share and analyse information and act accordingly. These
meetings have proven successful, but participants in the MASH need to be mindful
of the differences associated with each profession and how they may each see the
needs of the same person from a different perspective according to their own
knowledge and experiences. Together they need to communicate without jargon in
order to make shared decisions and coordinated interventions
(HM Gov, 2013)
.
Acronyms and jargon are commonly used within each profession and such language
is developed early on during students’ education. Educators can play an important
role in making sure students are aware of the necessity of using a common language
that can be understood by all. Learning to communicate in small interprofessional
groups from the outset with the support of a facilitator gives students the chance to
explore how they come across when communicating with students from other
courses in a safe environment. As they progress in their courses, such opportunities
can also help students learn to articulate their current understanding of their future
roles and responsibilities as they develop their professional and interprofessional
identities (Murdoch-Eaton &Roberts, 2009) thus enabling them to build respect for
what each profession brings to the care delivery process.
Respect and trust towards the abilities of other professions
As our students embark on their professional socialisation they need to interact with
students from different professions. If they are kept in silos during their education it
is likely that they will lack understanding of the abilities of others due to varying
philosophical approaches to education (Fitzsimmons & White, 1997) and ideological
worldviews
(Apker, 2012). Such lack of understanding and appreciation of how and
what each profession contributes to care delivery can breed negative attitudes,
stereotypical views, fear towards professional integrity and jealousy (McFayden et
al., 2010; Hawkes, Nunney & Lindqvist, 2013). As students arrive at their higher
education institutes with views of their own and other professions
(Lindqvist et al.,
2005), we as educators have an obligation to try to prevent negative feelings from
developing
(Carpenter & Dickinson, 2011) and instead build a foundation for positive
attitudes to form that will allow for the culture change that is sorely needed in the
health and social care workforce.
As students learn and work together as part of their course they will be able to gain
respect for their knowledge and skills mix that will later enable trust to form between
individuals working as part of the interprofessional team. A recent publication by the
Centre for Workforce Intelligence
(CfWI, 2013)stated that team building promotes
respect and trust between its members and in turn empowers professionals to
engage with each other
(CfWI, 2013). Building trust across professions takes time,
and experience of learning and working together will equip individuals with the
confidence in their abilities to communicate freely, also through challenging times.
Time
Educators struggle to find slots in the busy curricula for students from different
professions to come together, but it can be done if the will and commitment is there.
Opportunities for IPL in the very early stages of students’ education in the classroom
setting may be the way forward, especially if the numbers of professions and
students are high
17
.
If time is sparse for students, it is even more so for professionals. It is increasingly
challenging, not only to find the time for the individual worker, but to find a time
mutually convenient for all who need or wish to meet to discuss and learn from each
other. In the primary and secondary care setting, meetings are commonly held on a
regular basis to optimise the resources available for each person in need of care.
Making time for these meetings is the first step, however, ensuring all professionals
are there - empowered and equipped to represent their role in care - is another
matter. Many professionals feel that their meetings are ineffective. Clearly face to
face encounters are not enough. There are other ingredients necessary for
successful interaction and dialogue such as participants having equal opportunities
to contribute views; working towards a common goal or vision; institutional support;
opportunities to discuss similarities and differences; positive expectations; and
perception of members of other professions as representatives for that group
(Carpenter & Dickinson, 2011). With these parameters in place, effective
interprofessional communication that allows for initiating, managing and sustaining
change can take place.
Concluding remarks
The type of care people want and need is rapidly changing and professionals need
to adjust the provision of services accordingly. Following a number of incidents
where care has been less than optimal, and in some cases disastrous, the pressure
is now on how to improve quality of care by optimising available resources. The UK
government has announced its intention to integrate services and is calling for a
culture change
(Francis, 2013; CfWI, 2013). Educators play an important part in
supporting students and professionals in this process however, as adult learners, it is
the individual’s responsibility as well.
The challenges listed in this chapter are not exhaustive, but highlight important
aspects of interprofessional communication that educators need to be aware of as
they facilitate students and professionals during their education and training. Timely
and constructive feedback will help learners reflect on their development and how
they manage these challenges. Together with stakeholders, innovative and
meaningful opportunities for IPL can be developed that are available from the outset
of students’ education and throughout professionals’ careers. For culture change to
happen there needs to be a full commitment to the vision of what educators are
trying to achieve so that within the students’ courses this ethos is emphasised
wherever possible.
Educators also need to make sure they are self-aware and continuously remind
themselves of their part in this process. No one is perfect at communicating and as
humans we will make errors and say the wrong thing at times, but there are ways to
amend mistakes, and some ways of communicating that are more effective than
others. For educators involved with one professional group it is essential to support
their students with their professional development with the understanding that they
will work as part of a team where everyone plays an important role. Equally
important is that the IPL facilitator remains professionally neutral when supporting
collaboration and interprofessional communication when working with students in
mixed professional groups.
All educators, in higher education as well as mentors and supervisors in practice
play a key role in driving the much needed change in culture. With a clearly
communicated vision and achievable goals in sight for each individual,
transformation can take place. It is a journey, which educators need to embrace
wholeheartedly, preferably with a smile on their face, and to guide the way step by
step - making sure all are able to progress in the same direction.
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