Exploring power in interprofessional education

As we know, IPE is considered a key mechanism in enhancing communication and practice among health care providers, optimizing participation in clinical decision making and improving the delivery of care. An important, though under-explored, factor connected to this form of education is the unequal power relations that exist between the health and the social care professions. In a study which analyzed data from the evaluation of a large multi-site IPE initiative, we used Anne Witz's model of Professional Closure to explore the perspectives and the experiences of participants and the power relations between them. Findings from this study really highlighted how professionals' views of interprofessional interactions, behaviours and attitudes tend to either reinforce or attempt to restructure traditional power relationships within the context of an IPE initiative.

For more information read: Baker, Egan-Lee, Martimianakis, Reeves – Journal of Interprofessional Care, Vol. 25, pages 98-104

Appreciative inquiry within interprofessional education: how it overlooks the influence of social structures

Appreciative inquiry (AI) is a relatively new approach to initiating or managing organizational change that is associated with the ‘positiveness’ movement in psychology and its offshoot positive organizational scholarship. Rather than dwelling upon problems related to change, AI encourages individuals to adopt a positive, constructive approach to managing change. In recent years, AI has been used to initiate change across a broad range of public and private sector organizations. In a recent interview-based study which explored how AI was employed as a change agent for implementing an IPE initiative across a number of health care institutions we found a strong resonance and fit for AI both among the health and social care professionals who participated in this initiative. Numerous individuals commented on the enthusiasm and energy AI engendered, while praising its ability to enhance their working lives and interprofessional relationships. Yet a number of difficulties were also reported. These focused on problems with the translation of the AI process into achievable structural level (e.g. professional, cultural) changes. Based on these findings, we go on to argue that the use of AI can overlook a number of structural factors, which will ultimately limit its ability to actually secure meaningful and lasting change within health care.

(Scott Reeves, Editor-in-Chief)

For more information read: Dematteo & Reeves – Journal of Interprofessional Care, Vol. 25, pages 203-208 

Interprofessional simulated learning and sociological fidelity: Part 2

As noted in the last blog entry (see May 2, 2011), the use of interprofessional simulation based on psychological conceptions of non-technical skills tends also to emphasise the individual as the site of the ‘problem’ and ‘solution’ to communication and collaboration.  As a result, there appears to be a disconnect between the theoretical and methodological approach underpinning simulation – that emphasises individual skill acquisition – without adequately acknowledging the subsequent complex clinical context in which individual practitioners must perform their newly acquired collaborative skills. One could also posit that current interprofessional simulated learning brings the notion of interprofessionalism back to an issue of  'correcting' the individual to become more 'team' oriented and ‘collaborative', thereby exacerbating culturally held, highly valued and behaviorally expressed notions of individualism which can exist within some professions.  This would seem fundamentally in tension with the premise of interprofessionalism which is a relational one.  It is not just grounded within uni-dimensional ideas of effective communication, but within an understanding of one's role in relation to others that are pertinent to a given health care task, with an appreciation of the context in which it occurs.

The application of a sociological approach can also encourage a reconsidering of the notion of ‘non-technical’ (collaborating, negotiating and communicating) skills, which within the simulation literature are usually demoted to ‘soft’ and secondary to clinical skills.  Not only are collaborating and negotiating processes essential to effective interprofessional practice, they are also complex technical activities in their own right. They involve the integration of a complicated range of skills, attitudes and behaviours, which require a firm understanding as to how factors such as imbalances of authority and influence, differing educational backgrounds, disparate ways of constructing professional identity, gender and socio-economic inequalities, can affect and often undermine interprofessional interactions.  

It seems therefore that whilst the simulation literature is acknowledging the importance of using an interprofessional approach, the best way to incorporate such an approach and empirically study its impact on collaboration, teamwork and patient care, is still unknown. 

Whilst recognising the issues affecting interprofessional collaboration in healthcare are complex, historical, and culturally and socially engrained, we strongly believe that such issues must be addressed if meaningful and relevant team-focused, rather than individually-focused, training programs are to become a reality.  Incorporating the ever-present, but seldom explicitly addressed sociological issues (e.g. power, hierarchy, professional boundaries, gender) into interprofessional team training simulations will certainly be no easy task.  Operationalizing concepts which are complex and nuanced will be challenging, but if our ultimate goal is to improve interprofessional collaboration in clinical practice to enhance patient care, then this is a necessary next step.  

The introduction of ‘sociological fidelity’ will inevitably have many implications for the design and practice of interprofessional simulated learning.  Undoubtedly, scenarios will become more complex to produce.  As a result, rich qualitative data gathered from various clinical settings will be needed to ensure that the interprofessional scenarios are truly contextual and provide an effective reflection of the lived realities of different professionals.  The aim of such scenario development is to reveal and explore real life interprofessional tensions, hierarchies and boundaries, and thus facilitators will need to anticipate potential consequences of sometimes difficult discussions which may emerge during the enactment of the scenarios.  Despite these additional challenges, the use of sociological theory in the development of interprofessional scenarios, combined with careful assessment and evaluation, will improve the quality of interprofessional simulation-based education. 

(Scott Reeves, Editor-in-Chief)

For more information read: Sharma, Boet, Kitto & Reeves – Journal of Interprofessional Care, Vol. 25, pages 81-83.

Interprofessional simulated learning and sociological fidelity: Part 1

Poor interprofessional communication and teamwork are now well recognised as significant contributors to adverse events in healthcare.  These ‘non-technical skills’ are particularly pertinent in high-hazard areas such as obstetric settings, operating rooms, emergency departments and intensive care units. Recognition of the magnitude of these teamwork issues has led to calls for improved interprofessional training in many areas of healthcare, which has resulted in an increase in a range of team-based simulation activities over the past few years. 

Simulation is a technique that allows the imitation of various aspects of patient care, and includes human simulation, mannequin-based simulation, and virtual reality.  Its use in medicine has been steadily expanding over the past ten years, often forming part of the CRM (Crisis Resource Management) model, based on principles originally developed in the aviation industry.  Most of the current simulated training programs involve experiential learning and rely on a clinical scenario which normally involves a high stress critical incident.  Learners work together to manage the scenario in the most appropriate fashion.  Such training aims to enhance ‘non-technical’ skills such as teamwork and interprofessional communication – both of which have been identified as significant contributors to error in healthcare[Lewis, 2007 #2753].  Simulation aims to allow learners the opportunity to manage critical incidents in a ‘realistic’ environment without the compromise of patient safety. 

The notion of simulation fidelity is considered to be the degree to which the simulated learning activity replicates ‘reality’, and is routinely linked to a prevailing assumption that the more ‘high-fidelity’ the simulation, the more ‘effective’ the learning experience.  The notion of high-fidelity is however problematic for a number of reasons.  For example, several studies using the same simulation approaches may refer to its fidelity differently depending on the context in which the learning takes place, and the skills are taught.  

At present, there is a particular stress on the importance of the notion of psychological fidelity (e.g. the degree to which the learner perceives the simulation to be believable) as the most essential requirement for effective interprofessional learning.  It has been argued that psychological fidelity can reproduce increased levels of individual stress and improve recall of information and its contextual application.  Although manipulating psychological fidelity by, for example, the addition of additional ‘stressors’ into a scenario may create more ‘realistic’ simulation scenarios, the simulation literature continues to overlook the importance of sociological factors such as hierarchy, power relations, interprofessional conflict and professional identity, which are now well-known to affect interprofessional communication, collaboration and teamwork.  

The use of a sociological approach can allow one to see why employing CRM principles, an almost universal approach in interprofessional simulated teamwork training may be considered problematic.  As noted above, CRM was developed in an aviation context, and is based on the premise that a ‘culture of safety’ can be nurtured by encouraging a collective sense of agency, and that flattening hierarchy ensures that all team members are comfortable in voicing their opinions, concerns and recommendations.  Through applying a sociological understanding to this area one can see that the use of CRM principles ignores important socio-economic factors affecting interprofessional health and social care teams. 

(Scott Reeves, Editor-in-Chief) 

For more information read: Sharma, Boet, Kitto & Reeves – Journal of Interprofessional Care, Vol. 25, pages 81-83.