Boundaries, teamwork dynamics and power

Conceptualising central aspects of interprofessionalism in health and social care

Abstract

Over the last three decades, increasing attention has been paid to how different professionals can work together to improve the quality and efficiency of health and social care services. As a result, achieving interprofessional collaboration, in its various guises, has become an almost universal ambition of health and social work practitioners, organisations, and policymakers. Set in the field of mental health and substance use care, this dissertation explores how health and social workers function as a team and how we can conceptualise the central aspects of interprofessional teamwork. In general, successful interprofessional teamwork occurs when each member has a role and performs it with great skill, while also understanding others’ roles and contributions. However, this type of collaboration can be challenging and demands a high degree of knowledge, flexibility, and creativity from those professionals involved. Especially, within the field of mental health and substance use care, patients often have complex conditions rooted in somatic health problems, mental illness, drug use, poor finances, and a lack of housing, among others. Hence, providing sufficient treatment and care for this group depends on health and social work professionals with different qualities and knowledge working together. Given this complexity, several studies analyse the elements, factors, and issues that affect interprofessional collaboration. Inspired by this literature, this dissertation is based on an ethnographic study of how professionals work together as a team. The data consist of 14 observation sessions and 18 in-depth interviews of health care and social work professionals working in three interprofessional teams in Norway. This material reveals that interprofessional teamwork centres on three aspects: professional boundaries and roles, inner teamwork dynamics, and power structures. As we will see, previous studies mostly concentrate on one of these aspects; in fact, the focus is generally on a single sub-aspect of each. In comparison, this dissertation attempts to look into all three aspects. This dissertation consists of three related research articles, each of which presents a theoretical model created from a synthesisation of concepts and perspectives found in the literature, and then examines the models’ empirical adequacy. By exploring the social relations and dynamics found in interprofessional teamwork, this dissertation provides a more comprehensive view of interprofessional complexity than previous studies. The first article discusses professional boundaries and roles as a central aspect of interprofessional teamwork. Much research points to three logics to understand such dynamics, namely: 1) assimilation, that is, how professionals tend to adapt the work and competence of others, 2) segregation, where professional roles are separated and boundaries defended, and 3) integration, which refers to working in a complementary fashion. However, no previous studies have analysed all three logics jointly. The term ‘logic’ refers to how a particular social world works. By compiling all three and investigating how, when, and why each one comes into play, this study emphasises the importance of including all three logics to leverage each one’s purpose and shows that they appear simultaneously in many situations of interprofessional teamwork. The second article examines inner teamwork dynamics and how the professionals in a team relate to each other which goes beyond boundary issues. In previous studies of interprofessional interaction, three modes have been found to be central: professional diversity, friction, and harmonisation. Again, no empirical studies discuss them jointly. By synthesising all three concepts into an ‘ideal-type model’, the article clarifies the functions and risks of each mode, as well as the dynamic between them. Furthermore, it argues for analysing all three modes jointly to better understand the process of productivity in interprofessional teamwork. For example, the article discusses how friction between diverse professional perspectives is needed to promote innovation, encourage new insights, and intensify discussions. However, elements of group harmonisation such as trust and mutual respect are also important as they help balance professional distinctions and tie professionals together. The last article explores the power structures inherent in interprofessional health and social care. Specifically, it explores the tension between the ideas of egalitarianism and hierarchy. Inspired by the potential difference between ‘what people say’ and ‘what people do’, the article builds a simple model of four positions: 1) egalitarianism articulated and realised, 2) egalitarianism articulated, hierarchy realised, 3) hierarchy articulated, egalitarianism realised, and 4) hierarchy articulated and realised. Based on these four positions, it analytically discusses how we can conceptualise power in interprofessional teamwork. Though the empirical findings do not support any of these positions separately, the results indicate that the professionals operate ‘across’ them. In other words, that interprofessional teamwork may operate within a context of both hierarchy and egalitarianism and that the professionals are aware of this tension.