Multiprofessional education to stimulate collaboration: a circular argument and its consequences.

The current developments in healthcare are unprecedented. The organization of health care is complex. Collaboration is essential to meet all the healthcare needs of patients and to achieve coordinated and unambiguous information. Multiprofessional education (MPE) or multidisciplinary training (MDT) seems a logical step to stimulate teamwork. However, collaboration and MPE are wrestling with the same problems: social identity and acceptance.

Background

Developments in healthcare are immense. The possibilities to treat patients with severe illnesses are growing as is the body of medical knowledge, pharmaceutical treatments and advanced technologies. The size and complexity of healthcare have increased proportionally. In the beginning of the 19th century hospitals knew only two different health care professions: medicine and nursing. Nowadays more than 600 different health care professionals work in hospitals, including a variety of therapists, technicians, economists, social workers and even clowns. The impact of the increasing possibilities of healthcare, social developments and developments in the health professions have created many roles, leading to new professions. The scope of healthcare being too broad for one profession to have an overall view, there is a need for extensive specialization not only in medicine and nursing, but also for therapists and technicians. And with the realization of vertical function differentiation the need for collaboration increases. Collaboration is essential to cover all the healthcare needs of patients and to ensure alignment of care and unambiguous information to patients. In order to achieve that coordination and responsibilities have to be clear and this means that professionals should be aware of the contribution to the healthcare process of all the different professionals involved. This is a tall order. For a start it is hard to obtain a good overview of the work of different groups of professionals. Moreover collaboration has been shown to be complicated and working in a team is by no means easy. Traditionally healthcare workers belong to their own professional groups, each with its own culture and its own standards and values.

Multiprofessional education (MPE) or multidisciplinary training (MDT) seems a logical step to stimulate teamwork. The potential benefits are the fostering of team spirit, mutual understanding and respect, and improved communication [1]. Communication problems are one of the main causes of errors in healthcare [2]. But despite incentives from the government to stimulate MPE, successful implementation remains difficult to achieve [3].

Influenced by the national patient safety programmes, MDT, and crew resource management in particular, is gaining in popularity, although so far it seems to be restricted to acute care settings.

Multiprofessional education (MPE) and Multidisciplinary training (MDT)

The World Health Organization (WHO) defines MPE as the process by which a group of students (or workers) in health related fields and with different educational backgrounds are learning together during certain periods of their education [4]. Interaction is considered important to achieve collaboration in promoting health, preventing and curing disease, rehabilitation and other health-related services [5]. The chance of students socializing unilaterally in their specific domain of health care is becoming smaller [6].

The last decade has seen the introduction of MPE programmes, aimed at introducing students to the skills and expertise of other professions during their training in order to foster a more cooperative and collaborative approach to healthcare. The concept of MPE features interactive learning as part of interprofessional learning.

The term multiprofessional is used to denote cooperation of health professionals from three or more different health professions. The difference between interprofessional learning and multiprofessional learning is purely numerical. Interprofessional means two professions, multi-professional means more than two.

MDT is used in education and training in different professional disciplines which have a subject in common, which they all approach from their own professional perspective. The aim is to stimulate collaboration, including communication, situational awareness, problem solving, decision making and teamwork [7].

The MDT approach is characterized by each discipline within the team working towards its own discipline-related goals. Team members work within the boundaries of their professional practice: progress is formally discussed at team meetings, and effective communication is considered vital.

Bottlenecks in collaboration

Collaboration is a dynamic interprofessional process in which two or more health professional make a commitment to interact authentically and constructively to solve problems and to learn from each other in order to accomplish identified goals, purposes or outcomes [8]. Successful collaborative practices are those in which patients easily move back and forth between providers and situation dictates.

Collaboration is widely regarded as useful and desirable. Nevertheless, it is hard to attain. Team members see themselves as representatives of their own discipline rather than as members of a collaborative team. There is rivalry between professional groups, such as different medical specialties, particularly when resources are limited. Who is the lead clinician and who gets the credit?

Moreover, professional groups are known to have different moral and ethical philosophies of care. The paternalistic approach of cure-oriented health professionals versus the approach of public health and social advocates are examples. The traditional power relations between professions in health care must also be recognized, because they influence interprofessional practices. Tradition and role and gender stereotypes are further obstacles to collaboration. Professions and occupations cannot be understood simply in terms of the current balance of social relations. Account should also be taken of structures and practices that have their roots in past patterns of social relations [9].

The image of nursing has its roots in the Victorian age, the period of Florence Nightingale. Nurses were expected to lovingly and humbly devote themselves to the health and well-being of others, without any thoughts of professional autonomy [10]. In hospitals nurses were expected to follow the directions of physicians. Nursing also was perceived as women’s work. Unlike today physicians were exclusively male and nurses were female. Medicine has often been seen as a leading example of how an occupation can raise itself. The contemporary position of medicine as a profession is still one of the most powerful ones of all occupations [11]. Although nursing has experienced a radical transformation due to higher levels of education, emancipation, independent practice and new roles like that of nurse practitioner, some nurses still have a low self image. And low self image has a damaging influence on the image of the profession. Despite the existence of many successful nurse–physician collaborative practices, tradition and stereotypes often have a powerful impact on successful collaboration in groups [12].

Social Identity Theory is a diffuse but interrelated group of social psychological theories concerned with when and why individuals identify with, and behave as part of, social groups, adopting shared attitudes to outsiders [13]. It is also concerned with what difference it makes when encounters between individuals are perceived as encounters between group members. Social Identity Theory is thus concerned with both the psychological and sociological aspects of group behaviour. In sociology, a group is usually defined as a collection of humans who share certain characteristics, interact with one another, accept expectations and obligations as group members and share a common identity [14].

People derive their social identity from the group to which they belong. Who am I and who am I in relation to others? What do I have in common with others and how am I different? People aspire to a positive social identity, which is based on a favourable result of comparisons between the group to which one belongs and other related groups. There are several ways in which social identity can be changed. An individual can try to become a member of another social group with a higher status. In that case, the status of the original group does not change. Groups can try to change their status as well. A group can seek competition with another group by showing the irrationality of the differences between them. This strategy is aimed at emancipation of the whole group.

Collaboration and the formation of a new team can be favourable for professionals with a low image, but unfavourable for professionals of high status. The latter will stay with their group and be reluctant to accept new members from a different background. They expect no profit from collaboration for themselves. Confusion about the scope of practice of other disciplines can be one of the consequences.

There are, however, numerous incentives for nurses, physicians and other health professionals to collaborate. Several studies have demonstrated improved patient outcomes (lower mortality rates, reduced length of stay) with collaborative practice [15].

Failure to communicate and to collaborate affects patients and clinicians’ job satisfaction. Lack of collaboration can be a source of stress to nurses [16]. In addition failure to collaborate may contribute to inefficiencies in the delivery of health care. But despite the obvious advantages of collaboration, social identity seems to be an insurmountable barrier to successful collaboration. Collaboration is seen as a good thing, but not as obligatory.

Bottlenecks in Multiprofesisonal education (MPE) and Multidisciplinary training (MDT)

In the Netherlands there are a few examples of MPE, although they do not fully meet the WHO definition. At the University Medical Center in Groningen, students in dental medicine and students in oral hygiene collaborate throughout their education, especially during skills training [17]. The educational concept that is used in this example of MPE is patient oriented and problem based learning. Another example has been realized at the University of Applied Sciences of Arnhem and Nijmegen. Students of eight different healthcare programmes are offered the same study programme in communication and collaboration skills. An example of MDT is multidisciplinary team training (crew resource management) which is provided at the University Medical Center Groningen.

The problems of the above-mentioned educational programmes seem to be the same. Every discipline appears to have its own language. Some disciplines describe patient problems as problems in functioning, while other disciplines describe them as diseases or self-care problems.

Interprofessional practice is seen as more efficient and therefore a source of cost reduction. An inherent contradiction is that interprofessional education, if done well, implies problem-based learning and other innovative approaches, and these are expensive [18]. The organization of MPE is complicated and time consuming. Teachers are not motivated to invest in MPE, because they have other priorities and they are not optimistic about the effects. Most teachers have a background in healthcare and know how difficult the practice of health care can be. Would it really help to stimulate collaboration? MDT is hard to organize as well. In spite of careful scheduling, sessions often have to be cancelled due to the absence of some team members who have unexpected obligations in patient care.

Another problem of MPE is that students appear to be not really interested in the information for other disciplines [19]. They have a low regard for interprofessional activities, which they consider diversions from their real professional preparation. Medical students attend nursing courses in their first year, as part of the development of their professional attitude. During the course they are taught how to handle intimacy. Some of them had to be persuaded to attend the lessons. They are, they say, training to become doctors not nurses. Some professionals want to protect their knowledge and are unwilling to share it with other disciplines. As a result they are not prepared to accept students from other disciplines. An example is nurse practitioners who are not admitted to classes for junior doctors.

And with these last arguments a vicious circle becomes visible. Problems with social identity are not only a barrier to collaboration; they are equally a barrier to improvement of collaboration through MPE and MDT. Collaboration and MPE and MDT are also hindered by the fact that they are optional. Despite evidence that collaboration leads to better patient outcomes and MPE leads to better collaboration, MPE is still not obligatory [1], [3], [4], [5], [7].

Conclusion and recommendations

Although collaboration is crucial in today’s complex healthcare system, it is very difficult to achieve. One of the main problems is social identity. Professionals are afraid to lose their status when they collaborate with professionals of lower status. They are unable to identify with a team composed of several kinds of professionals. But they are also in a position to hide behind their professional group. Collaboration is optional.

MPE and MDT can stimulate collaboration, but are hampered by the same problems of social identity. MPE in itself is not sufficient to stimulate collaboration. MPE, MDT and collaboration need the same interventions. A common purpose could be the basis for collaboration and joint educational programmes. This purpose is quality of care and tangible patient outcomes, such as lower mortality rates. Collaboration needs to be the new standard in health professional practice and education. Not as an option but as a regular component. Not the professional group but the team should become the social group from which professionals derive their status. Every contribution to further this goal is welcome.

The authors

Dr. P.F. Roodbol, PhD, is head Wenckebach Institute, University Medical Center Groningen, the Netherlands; lecturer of Nursing Hanze University of Applied Science Groningen, the Netherlands.