Interprofessional working (IPW) in health and social care is essential for effective service provision and is a key driver of modern healthcare. In a changing and more pressured working environment, health and social care professionals need to be partners in delivering services, embracing collective accountability, be flexible and adaptable and have shared goals in integrating care around service users (Fletcher 2010a, Pollard et al, 2010).
According to Tope and Thomas (2007), analysis of policies from as early as 1920 in health and social care have recommended professional collaboration, improved communication and teamwork to improve outcomes for service users. There have been similar recommendations in government policy since this time (Tope and Thomas, 2007).
High profile investigations since 2000 highlight deficiencies in IPW across health and social care. Inadequate communication between professionals in cases of the Bristol Royal Infirmary Inquiry (HM Government 2001), the Victoria Climbie Inquiry Report (Laming, 2003), and The Protection of Children in England: A Progress Report (Laming, 2009) have caused nationwide concern beyond the professions and services involved, causing a frenzy of media comment and public debate. Core recommendations are for professionals to improve communication between agencies, to have an ethos based around teams and working together and to improve professional accountability. The investigations provide evidence that collaborative working can only improve outcomes and underpins the real need to find out how best to develop a work force that can work together effectively (Leathard, 1994, Anderson et al, 2006 and Weinstein et al, 2003). Policy also recommends putting service users at the forefront of care and coordinating services across the authorities, voluntary and private sector organisations (DoH, 1997, DoH, 2000a, DoH, 2000b, Doh, 2001a, DoH 2001b, DoH 2001c, DoH, 2002a, DoH, 2006, DfES, 2006, HM Government 2004, HM Government 2007).
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Literature suggests that IPW improvements begin in interprofessional education (IPE) (DoH 2000b, DoH 2002b, Fletcher 2010a, Freeth et al 2002, Higgs and Edwards 1999, HM Government, 2007 Reynolds 2005,). IPE has been defined as learning which occurs when "two or more professions learn from and about each other to improve collaboration and quality of care" (CAIPE, 1997). The need to produce practitioners who are adaptable, flexible and collaborative team workers has focused attention on IPE, which aims to reduce prejudices between professional groups by bringing them together to learn with and from each other to enhance understanding of other professional roles, practice contexts and develop the skills needed for effective teamwork (Barr et al. 2005; Hammick et al. 2009, Parsell et al, 1998).
At our interprofessional conference, we worked in teams of mixed student professionals. We introduced ourselves, our disciplines and our course structures, elected a chair and a scribe and set about to complete our tasks. Cooper et al (2001) identify one of the benefits of IPE as understanding other professional roles and team working. In their study, they found evidence to suggest that early learning experiences were most beneficial to develop healthy attitudes towards IPW (Cooper et al, 2001). None of the members of my group knew what a social worker did and I explained my training and professional role to them. McPherson et al (2001) describe how a lack of knowledge of the capabilities and contributions of other professions can be a barrier to IPW.
In our discussions, we talked about our preconceived ideas. Social workers were described as 'hippies' and doctors described as 'arrogant'. Leaviss (2000) describes IPE as being effective in combating negative stereotypes before these develop and become ingrained. Atwal (2002) suggested that a lack of understanding of different professionals' roles as well as a lack of awareness of the different pressures faced by different team members could make communication and decision making problematic. The conference provided an opportunity for us to interact with each other and was conducive to making positive changes in intergroup stereotypes (Barnes et al, 2000, Carpenter et al, 2003). Barr et al (1999) describe how IPE can change attitudes and counters negative stereotyping. The role play exercise gave us an understanding of differing pressures faced by each professional.
Our team worked well together, taking turns to let each other speak, listening, challenging appropriately when needed and creating our sentences by the end of the conference. I feel that our friendly and motivated characters made communication and thus teamwork easy in the group. Weber and Karman (1991) found that the ability to blend different professional viewpoints in a team is a key skill for effective IPW. Pettigrew (1998) emphasises that the ability to make friends in a group of other professionals can reduce prejudice and encourage cooperation in future IPW. We agreed that teamwork was essential to IPW and can assist in the development and promotion of interprofessional communication (Opie, 1997). We felt that IPE allowed us to teach each other while encouraging reflection on our own roles (Parsal et al, 1999).
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We were very clear on how we worked as a group and effective as meeting our tasks and I feel we reached the Tuckman's performing stage (Tuckman 1965). Baliey (2004) describes team members who are unable to work together to share knowledge will be ineffective in practice. Although, there is an argument that this is more likely to happen in teams where the concept of IPW is new and team members lack skills to understand the benefits of IPW or adopt new ways of working (Kenny, 2002). Being in our second year of study and having all had experience of working in an interprofessional setting, we were very motivated at the conference and in achieving our objectives. It is noted that personal commitment is important for effective IPW (Pirrie et al, 1998).
We acknowledged the issue of power in our professional social hierarchies. In our role play exercise, we found that we all looked to the doctors first for management of the service user's treatment and they commanded the most respect. We agreed that medicine was the most established out of all the healthcare professions (Page and Meerabeau, 2004, Hafferty and Light, 1995) and that other professions have faced challenges in establishing status (Saks, 2000). I felt this was especially relevant to social workers who have recently extended their professional training to degree status to bring it in line with other professions. Reynolds (2005) suggested that hierarchies within teams could contribute to communication difficulties; for example, where input from some of the team members were not given equal value. Leathard (1994) describes that rivalry between professional groups especially in terms of perceived seniority are a barrier to IPW. The Shipman Report (2005) noted the importance of ensuring all team members are valued, recommending less hierarchy in practice, more equality among staff, regardless of their position. We talked about valuing and respecting each other's professional opinion. Irvine et al, (2002) discuss how IPW can break the monopoly of any single profession in providing sole expert care, promoting shared responsibility and accountability. We discussed understanding, supporting and respecting every individual in the workplace to promote diversity and fairness.
We also concluded that institutions and differing professional pressures could be a barrier to IPW. Having previously worked in an interprofessional HIV team for Swansea NHS Trust, I found that team members were given priorities from their managers which impacted on their availability to attend team meetings. Wilson and Pirrie (2000) suggest that a barrier to IPW can be a lack of support from managers and the workplace structure. Drinka et al (1996) describe how during times of work related stress, individuals can withdraw from IPW. We acknowledged that institutional support would be essential to effective IPW. Dalrymple and Burke (2006) discuss that different professionals have different priorities, values, pressures and constraints, obligations and expectations which can lead to tension, mistrust and go on to cause to discriminatory and oppressive practice in IPW.
In light of the above learning, we all felt that IPW had occurred naturally in our first year placements, where it was considered the norm in our working environments and where the concept was understood and encouraged. The conference had highlighted some of the barriers to IPW and we will take this knowledge into our practice settings.
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How would you take what you have learnt about IP working into practice?
The conference highlighted some key issues about IPW that I will take into practice. One of the most significant developments in health and social care policy in recent years has been the move away from the professional being the expert with the power and knowledge to the patient centred care with professionals applying their knowledge to the needs and rights of the service user (Barrett et al, 2005). The social model of care identities issues of power in the traditional medical model approach to care and looks at how dependency on the professional can be a side effect of the helping relationship and be disempowering for service users (Shakespeare, 2000). Informing, consulting with and incorporating the views of service users and carers is critical to effective interagency interprofessional practise. There is a drive in recent policy for service users and carers to be engaged in service provision and the recent white paper Liberating the NHS (HM Government, 2010a), calls for more autonomy for service users, making them more accountable through choice, being able to access services that are transparent, fair and promote power and control over decisions made.
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"Nothing about me without me " ( HM Government, 2010a, page 13) is a commitment that will shift power from professionals to service users, a huge change in current culture. The service user is the central vision, a team member involved in decisions made about their care, transforming the NHS to deliver better joined up services, partnerships and productivity (HM Government, 2010)
My learning has reiterated the importance of service user involvement and I have reflected on ways to implement this in practice. In previous employment, I helped to run a patient public involvement group at the HIV service, Swansea NHS Trust. This enabled service users to give feedback and make suggestions for improvements (i.e. having evening nurse led clinics, introducing the home delivery of medication). In my experience, service users were actively involved in shaping services in their communities and it was very successful. In my practice, I will continue to value the service user as part of the interprofessional team as well as encourage this practice in my places of employment. In my placement at a supported housing charity for young mothers, ways to achieve service user involvement were being introduced. One of my roles was to carry out a questionnaire with the aim of getting feedback and empowering the service users. Reflecting on this, I can now see how valuable this exercise was and I will continue to see the value in gaining service user feedback and always aim to do this in practice. I discussed this with my group and this added to our learning.
Informal unpaid carers, the voluntary and private sector are also essential team players and the value of their contribution is being acknowledged increasingly as the success of an interprofessional workforce (Tope and Thomas 2007). In my role within the HIV service, Swansea NHS Trust, I coordinated an interprofessional team and ran a support group for African women living with or affected by HIV in conjunction with social services and the Terrence Higgins Trust. I understand the value that the third sector organisations can be for service users, often filling gaps in statutory services. The Terrence Higgins Trust were able to provide funding for activities as well as support sessions, training opportunities and counselling. Social Care Institute for excellence (2010) in a response to the white paper, Liberating the NHS (HM Government, 2010a) discuss how around 90% of direct social care services are delivered in the private and voluntary sector. The Joseph Rowntree Foundation, a social policy research and development charity, discuss that the state is withdrawing from many welfare functions and increasingly relying on the voluntary sector to fill gaps in care (Joseph Rowntree Foundation, 1996). The recent strategy document, Building a Stronger Civil Society (HM Government, 2010b) discusses how integration with the voluntary sector will be essential to meet the challenges faced by the health and social care provision. The report focuses on our society being able to access wider sources of support and encourage better public sector partnerships, shifting the power from elites to local communities. The government are also keen to support and strengthen the sector and promote citizen and community action (HM Government, 2010b) .
My learning has made me aware that future teams will include professionals across all sectors and communication with these sectors will be essential to our professional roles. Working with the voluntary and private sector as well as statutory services, will require skills to acknowledge different agencies' focus on care. Petrie (1976) acknowledges that each profession holds a direct focus to care and it can be challenging to communicate.
Laming (2003) called for the training bodies for people working in medicine, nursing, housing, schools, the police etc to demonstrate effective joint working in their training. I feel that it would be useful in the future to incorporate more of these professional groups in IPE conference. Fletcher (2010a) discussed how he would hope this could be achieved in future IPW programmes at UWE. I feel that the addition of these extra professions would really add to the learning.
Fletcher (2010b) discusses the central dilemma in ethics between health and social care professionals about having a different focus and the best angle for patient care. These value differences can cause conflict (Mariano, 1999). I feel, in practice, it will be important to take time to find out what each agency/ professional does and I will always remember that in IPW, we have a common goal - providing a good service for the service user. Leathard (2003) identities that what people have in common is more important than difference, as professionals acknowledge the value of sharing knowledge and expertise.
In my practice, I will uphold professional responsibility and personal conduct to facilitate respect in IPW. Carr (1999) explained that the professional has to be someone who possesses, in addition to theoretical or technical expertise, a range of distinctly moral attitudes and values designed to elevate the interest and needs of service user above self interest. According to Davis and Elliston (1986), each professional field has social responsibilities within it and no one can be professional unless he or she obtains a social sensibility. Therefore, each profession must seek its own form of social good as unless there is social sensibility, professionals cannot perform their social roles (Davis & Elliston, 1986). The conference highlighted the benefits of professional codes of ethics, setting of standards for our professional work, providing guidance as to our responsibilities and obligations and obtaining the status and legitimacy of professionals (Bibby, 1998). I feel that is in important to always uphold our values and ethics to create respect in our communities and with this comes respecting each other's roles. I believe that shared values will underpin this in practice. Darlymple and Burke (2006) discuss that we have a shared concern that the work we do makes society fairer in some small way and we have a commitment to social justice. I feel that IPE has facilitated respect and mutual understanding across our professions. It has made me aware of the importance of professional development, about how we are part of the wider team of health and social care services and how our common values can underpin effective partnership working. It reinforces that collaboration is required as not one profession alone can meet all of a services (Irvine et al. 2002).
My social work degree is a combination of theory and practical learning. It is through combining this learning and by reflecting on my experiences throughout the course, that will set my knowledge base, allow me to relate theory to practice, allow me to test my ideas and thinking while identifying areas that need further research becoming a reflective practitioner (Rolfe & Gardner, 2006 and Schon, 1983). As a group we discussed that there we all value continued professional development, reflection and awareness and personal responsibility for our learning (Bankert and Kozel 2005). It is this that we agreed we would carry forward as we start our working careers.
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