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According to Cullen et al (2003), ‘in order to meet the demands of a modern National Health Service (NHS) professionals are encouraged to work collaboratively and form partnerships to ensure seamless delivery of care. Interprofessional Education (IPE) is advocated as a means to enable professionals to understand one another and break down boundaries between them.’ (p.427). The nature of nursing care is predicated on an idea of working within a team, and a premium is almost always placed on communication, not just as a means of caring for patients and ultimately saving lives, but also to alleviate the stresses and strains associated with frontline care. Whilst the idea of communication being important is not new, the formation of IP teams, particularly within the realm of nursing, is. Cullen et al set out in order to try and better understand what positive lessons could be learnt from such a process. This essay will seek to try and understand the thinking that went into this study, based on the real life experiences of the author.
Cullen et al conclude their study with the point that ‘The development of IPE aided communication and collaboration between the academics and health professionals and helped to break down professional boundaries. Testing out new methods through action research has enhanced our understanding of the implications for students and teachers.’ (p.432). Whilst I ultimately found this to be the case, I would like to go into a bit of detail as to why exactly I came to these conclusions. Having met the group for the first time, we were all introduced and began to mingle. Given how short we had all known each other, it was difficult to establish any common points of reference. One imagines that within the workplace, where relationships are formed and cultivated over a longer period of time, always within a professional context, such relationships would be less artificial or constructed. Nonetheless, our different perspectives were in no way artificial, and it was useful to try and understand everyone’s reasons for choosing to study what they do, even if few of us had had the chance to put those studies to consistent, long-term effect under the professional’s rigours of frontline care. As such, many of the early discussions were very much more theoretical, idealistic even, than they might possibly be after a few years of experience within frontline care. There was however, a certain amount of agreement too. All of the students were aware of the positive benefits of IPE and felt that by virtue of being medical students, they were in some way isolated from the larger university student body as a whole. This had both positive and negative effects. Whilst some argued that it brought the students closer together, others admitted that they felt isolated at times. Either way, it is clear that stereotyping is not a positive factor in IPE. As Fraser et al (2005) acknowledge, ‘Professional stereotyping is considered to cause barriers to effective working relationships and team approaches to care. Learning together at undergraduate level can promote different professional groups’ understanding and respect for one another and an appreciation of the importance of team working in the health sector.’ (p.271)
This collaborative way of thinking helped us formulate our first group sentence, “Poor communication is the lack of ability to articulate to and interpret information from other Health Care Professionals (HCPs)”, which then tied in closely with our second sentence: “Negative attitudes towards other HCPs leads to a breakdown in communication.” As Koubel and Bungay (2010) showed, this is key for any multidisciplinary approach to have any sort of success. Taking an interdisciplinary approach to the question in hand, social work provides some useful analogues. ‘Social workers form partnerships with people: helping them to assess and interpret the problems they face, and supporting them in finding solutions. They have to know how the law works and be fully up to speed with the social welfare system. They will liaise regularly with other professionals – teachers, doctors, nurses, police, lawyers – acting on behalf of the people they are working with.’ (http://www.socialworkandcare.co.uk) Furthermore, as Brayne and Carr (1999) point out,’social workers are the creation of government; government is therefore accountable to the public for their work and obliged to regulate their activities. Second, social workers as caring professionals are themselves accountable to their users and to the public at large.’ (p.6) The same is very much true of healthcare professionals, and interprofessional relationships need to be understood in this context. There is a duty not only to provide the patient with the best care possible, but also to deliver value for money for the taxpayer. Accordingly, interprofessional relationships need to be fostered to deliver the most efficient and effective care possible.
What exactly does this involve? Of course, in the professional arena, job roles are to a certain extent prescribed by job titles. However, within the stress of the workplace, roles can become muddled and confused. Accordingly, one of our major tasks involved role definition. It is not simply enough to be clear with one another: practitioners need to define their roles and act accordingly. As Skott (2001) notes, ‘Professional nursing care is formed and carried out in a social cultural process. The discipline of nursing should study narrative communication to understand how individual and collective levels are connected in experiences of sickness and cure.’ (p.249) Nonetheless, Brereton (1995) has shown that there are still a great deal of holes in the critical thinking towards communication in nursing care: ‘The theory-practice relationship and the use of communication and interpersonal skills in nursing have been recurrently identified as issues causing concernâ€¦there appears to be a reliance on mentors to assess student progress and determine whether they have knowledge underpinning practice. Classroom teaching was recognized as idealistic but the divisions in participants’ opinions led to difficulty in determining whether a theory-practice gap actually exists.’ (p.314).
As a group, we all came to the conclusion that one of the key aspects of IPE is avoiding stereotypes. This was viewed as a fundamental basis for the following points:
It is important to value each professions individual contribution to overall patient welfare.
Varying perspectives exist, but any barriers must be overcome in order to promote holistic care.
Pre conceived notions of any member of the Multi disciplinary team need to be challenged.
Hierarchical states of mind have no place when a multi disciplinary team is working towards service user goals.
Whilst communication and stereotyping avoidance may seem like natural bedfellows, it was interesting to be exposed to a group which arrived with preconceived notions of how the nursing profession worked. Whilst my experience of frontline care is limited, my brief experiences have shown that stereotyping is endemic. This may range from physicians making certain judgements about the role or usefulness of nurses, or even vice versa, but throughout the conference, it became clear that attitudes such as these had no place within the professional world of HCPs. Not only do they create a negative, hostile atmosphere, but they also prevent HCPs from doing their job properly, and ultimately, pose a threat to the treatment of patients.
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In many ways, learning about IPE has been a natural development from the direction my studies were already taking. Anyone interested in nursing is, almost by definition a communicator, as it is a profession in which discussion, listening, and mutual understanding are key. Nonetheless, the things I have learnt from IPE have helped me to understand previous experiences better.
Reeves (2001) looked into the ’15-month project which evaluated the effectiveness of interprofessional education (IPE) for first and second year medical, nursing and dental students on a community-based placement’, using a ‘process-based’ approach which tracked the education and social processes connected to IPE. Such an approach has helped overcome some of the problems of using before-and-after designs.’ (p. 269) He found that community-based IPE placements were deeply beneficial in aiding student’s development, as the on-the-job nature of the tasks they faced forced them to adapt on the spot, often needing to adapt with the help of other HCPs. In my experience this was also the case. When I was helping geriatric patients who were acutely ill, I found that IPE skills became increasingly important. Leff et al (2005) note that ”Acutely ill older persons often experience adverse events when cared for in the acute care hospital’ (p.798) Given the anxiety caused to elderly acutely ill patients, any efforts that could be made to accommodate them should be encouraged, and accordingly, the research is both worthwhile and timely. Whilst much literature exists regarding home nursing for end of life care, it is relatively sparse for elderly, acutely ill patients. Zarit (2004) in particular, using the case of disabled patients facing end of life care, note that ‘family members provide a considerable amount of the care for people with terminal illnessesâ€¦and family caregivers must be recognized as an essential part of the treatment team. By clearly recognizing this role, physicians and other health care providers encourage caregivers to be more confident about their abilities to care for their loved ones.’ (p.170). Zarit goes on to argue that the role of family carer is not only beneficial to the part played by the healthcare professionals, it can also be a cost-effective way of giving patients the best palliative care that they need. He even argues that patient survival rates can be affected by paying close attention to family members at the front-line of care. Thus, he recommends that ‘a psychologist or other health care professional familiar with end-of-life care included as part of the treatment team. Although time and effort are required, these strategies may help caregivers provide the care they want to and provide better home care at a reduced risk to their own health.’ (p.170). Furthermore, as Leff et al go on to point out, ”Patients, but not caregivers, had increased satisfaction with hospital-at-home care, and there was some evidence that substitutive models may be cost- effective. However, with some exceptions, most of these models would be difficult to distinguish from augmented skilled nursing services, community-based long-term care, or home-based primary care services in the United States.’ (p.798)
As we can see, there are clearly a number of benefits associated with care at home. However, for the caregiver, such situations can also create a raft of potential problems. Whilst most academics agree that the influence of the family is generally a positive one, not much critical thinking has been devoted to what role the family play in allowing HCPs to perform their job as they should. Outside of the hospital environment, the family’s role is much greater, and often, in my experience at least, they feel that this entitles them to a greater degree of say in the patients care. Whilst I would generally agree with this, I had one experience in particular which made me question this. Because of the increased role of the family in this case, they felt that they “knew best” about how to care for their acutely ill family member. However, there was evidence to suggest that they were not delivering the right level of care. Since returning home, the patient’s condition had deteriorated, and there was a strong argument to be made for readmission into hospital, something the family were completely against. Whilst the physician in charge was willing to watch and see how the situation developed, the critical care nurse was pressing for readmission, the difference in opinions shows the power dynamics between the physician and nurse and has been noted without in-depth discussion between the two, created a barrier to effective collaboration (Manias & Street 2000). However, the family was a low-income family, and as such, used to receive visits from social workers. Accordingly, there was a great deal of IPE needed to deal with the situation. For example, whilst the social worker was not responsible for the health of the patient, and were visiting the family on other grounds, they were consulted on what they thought was occurring under the family’s supervision. This involved the nurse in charge communicating with the social worker, an interdisciplinary approach that necessitated different public sector workers working alongside each other. The interaction between the nurse and social worker showed a co-ordinated effective collaboration between HCP’s to provide a service to improve the quality and decision making process of patient care (Spry 2006).
However, there were also certain problems at our end. The physician in charge of the patient seemed unwilling to get actively involved. He was well-known to be a poor communicator, and seemed more involved in other aspects of his work than dealing with the patients, particularly when they were no longer in the hospital. However, since nothing could be done without his authority, it was frustrating for myself and the nurse to get anything done with him dragging his feet. Likewise, although the social worker was very willing and able to perform their job, they felt put upon when discussing any problems that fell without their remit. As such, it was left to myself and the nurse in charge to orchestrate managing the problem. Cheek and Rudge (1994) look closely at the socio-aspects of nursing ‘to deconstruct the power relations implicit within the socio-political context of the health care arena in which nursing operates.’ (p.583) They found that women’s health and nursing practice were ‘exemplars of the limiting effects of such discourses.’ (p.583) Seeing the reaction the female nurse’s inquiries, it certainly felt that her sex was a limiting factor on how she could get stuff done. The conference was very clear in that one of the major points of IPE was to avoid stereotypes. One of the largest stereotypes is that all nurses are women, and it felt like, the physician in particular, was labouring under some outdated view of nurses that was close to the era of Florence Nightingale than the present day.
Of course, gender stereotyping works both ways. McDonald and Bridge (1991) found that ‘Nurses planned significantly more ambulation, analgesic administration, and emotional support time for the male patient, despite the presence of individuating information. More accurate, effective nursing care is possible when nurses are aware of the effect of gender stereotyping on nursing care.’ (p.373) However, in this instant, it very much felt like the opinion of the nurse in charge was being undermined due to her sex. Although the patient was eventually readmitted, it wasn’t done without much bureaucratic leg-dragging, and I was left feeling that this was a poor example of interdisciplinary care. It could have been improved by more willingness of those in charge to define roles clearly, avoid stereotypes, and place the care of the patient at the forefront of their concerns. I hope that in my future career I am able to learn from this, and apply the things I have learnt to an array of challenging real-life situations.
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