Over the last two decades in the United Kingdom (UK) there has been an increasing emphasis by the government on collaborative care, interprofessional working, and partnerships between the health and social care services (Department of Health [DOH] 1989, 1990, 1997., 1998, 2001). It is widely argued that collaborative working between the services enables professionals to achieve cost effective and patient-focused community care (Higgins, Oldman, & Hunter,1994; Leathard, 1994) The changing practices and priorities towards community care provision have brought to the fore the importance of issues surrounding professional identity and relationships between practitioners. Notably at practice level, joint working between community nurses and social care services appears to create situations where professional identities and traditional roles are no longer prescribed but are actively worked out and negotiated between those who are involved in the care of a client (Fournier, 2000; Gelman et al., 2000; King & Ross, 2003). Depending on the demands of the situation this may mean in practice that some practitioners have to modify their roles and redefine what it means to them to be a nurse or a social worker. Such situations may create difficulties between some practitioners in terms of conflict over roles and professional boundaries (Biggs, 1997).

Earlier studies and findings from our own research (Higgins et al., 1994; King, Ross, Firth, & Arevalo, 1999) have highlighted that many of these difficulties have arisen through misunderstandings over the roles of others and the ways that other practitioners may approach client care (Biggs, 1997). This lack of understanding may be attributed (at least in part) to the different ways that practitioners (and services) work within the community, so that individual practitioners have little personal contact with others – especially those from outside their profession. For instance, many community nurses do not work the same hours or on the same site as social care staff; and therefore, much of the contact and negotiation is made through telephones or messages left on answer machines (King et al., 1999). Hence there is little opportunity to ‘get to know’ how others work and to develop effective interprofessional relationships.

One way to promote working relationships between practitioners is through integrated learning programmes at different stages of training, from undergraduate education to post-qualification courses. At present many centres in the UK are developing and piloting programmes to cultivate a multi-professional approach to working (Barr, 2002; Whittington, 2003). However, providing multi-professional practice placements is complex and difficult to set up. Also, traditional classroom learning is known to be limited and does not readily reflect the complexities that may arise through interprofessional working (Stuart, 2002). Therefore, the challenge for educationalists and teachers is to provide situations where student practitioners from different professions do more than sit side by side in the classroom. Teaching methods need to encourage students to share their own viewpoints with others, as well as recognise and accept the value of other professionals’ approaches to client care. Beyond the classroom, professional development programmes need to provide learning tools that will help practitioners to reflect upon their interprofessional relationships. This should enhance collaborative working and encourage innovative thinking about new ways of providing care that are not restricted by traditional professional and service boundaries.

In this article we introduce a technique that seeks to encourage and enable health and social care practitioners to reflect upon interprofessional relationships and practice. We will describe a case illustrating the technique, and conclude by discussing its potential use in research, teaching, and professional development.

The Challenge

So how can we encourage students and practitioners to reflect upon their working relationships and share their different perspectives of care? From our own research (King et al, 1999; King & Ross, 2003) and classroom experiences we found that some professionals had difficulty reflecting upon the complexities of their roles and interprofessional relationships when they were not in their practice setting. What seemed obvious to them when they were actually in their practice setting was difficult for them to describe when they were in a classroom setting. For instance, when discussing the challenges of interprofessional working, there was a tendency for practitioners to reflect upon the ‘known’ structural difficulties and they would provide textbook answers, rather than consider alternative ways that may enhance and change individual practice.

Generally, one of the obstacles to overcome is the difficulty in articulating how one feels or and interacts with others. Phenomenology provides a theoretical account of this experience. Merleau Ponty (1962) asserts that much of our involvement with our social world is "pre-reflective." We act in the context of particular circumstances, and our past experiences; only afterwards do we (sometimes) reflect on what we have done (Butt, 2004). Thus interactions amongst health and social care professionals may become set in patterns that are rarely subject to critical consideration. It may only be when practitioners are experiencing significant difficulties with other professionals that they will reflect and consider how relationships and communication may be improved. In the light of this, how do we encourage practitioners to reflect upon and describe their ‘everyday’ relationships and roles in their practice?

A Solution

In finding a solution to this challenge we wanted something that would actively engage students as well as something that would enable them to describe what it meant to be a particular kind of practitioner. We drew upon constructivist phenomenological interview methods used in personal construct psychology (Hargreaves, 1979; Salmon, 1994). We adapted these interview techniques and designed an exercise that would enable students and practitioners to reflect on and describe their experience of an everyday joint (collaborative) working event, as well as to consider ways to improve their working relationships. The technique may be used in research, teaching, and professional development relating to interprofessional working. Approval for a wider research project, of which the research presented in this article was a part, was obtained from the National Health Service Local Research Ethics Committee and the School Research Degrees Committee in the School of Human and Health Sciences.

Briefly, there are two phases to this exercise. First, we utilise Hargreaves’ social network method (1979) to elicit an account from participants of the people they interact with in a given situation and how they perceive their working relationships. The participant is asked to reflect upon a work-related scenario of his or her own choice. For instance this may be a current joint working situation involving the long-term care of a patient in the community, or a recent team project that involved other practitioners. Then the person is asked to write the names (initials) or job titles of those involved, including their own name, in their chosen scenario upon arrow-shaped cards. They then place these upon a large sheet of paper in whatever pattern they feel describes their working relationships. Although care is taken not to lead the participants, it may sometimes be necessary to provide further clarification of the task. We may suggest, for example, that the person might indicate how closely they work with a colleague by the proximity of the cards, and the quality of their relationships by the direction. Once the participant is clear on the task, they are left alone for ten minutes to prevent further discussion during this process. On the facilitator’s return, once the person has finished organising the pattern, the cards are traced onto the paper for a permanent record. Then, they are asked to describe their situation and explain the position of the cards. For example, we may ask, "why have you placed this card here and those there?"

The second stage involves the ‘Salmon Line’ a technique developed by Phil Salmon (1994) to help people focus on how change may be achieved. The facilitator and participant select what is known in construct psychology as a ‘bipolar construct’ (Kelly, 1955). Examples of such constructs could be ‘friendly-unfriendly’, ‘good communication-poor communication’, or ‘helpful-obstructive’. Often the choice of construct is drawn from important themes that emerge from the discussion of the visual layout; or the choice might be influenced by the aims of a particular research project or teaching session. On the back of the paper a dimensional line is drawn between the poles of the chosen construct, for example:

‘daily contact’---------------------------------------------------------‘no contact’

The person is asked to place the arrow-shaped cards along the line in relation to others to give reasons for their present card positions, their ideal positions, and how they might facilitate improvement in their relationships – symbolised by moving arrow-shaped cards towards the desired pole of the Salmon Line.

The value of this particular method lies in its flexibility, whereby the person is able to move the cards along the dimension as alternative strategies and possibilities are considered. To illustrate the flexibility and usefulness of this technique we will now briefly present one case from an ongoing research study of interprofessional working in health and social care. Here the researcher (AR) is interviewing a district nurse team leader using the reflective exercise. The interview took place in the person’s practice area and demonstrates how this technique might be used in a one-on-one teaching situation or for clinical (professional) development. The complexity and the number of relationships described by the district nurse reflects the situations often experienced by both students and practitioners in the community. To preserve the anonymity of the participant and her client, all personal and place names have been replaced with pseudonyms.

Case Study

Maxine

Maxine is a 33-year-old female who has worked for nine years as a district nurse (a specialist community nurse) in a busy rural community in northern England. Currently she is based in a GP (family doctor) practice. She shares her job (working three days a week) with another district nurse and provides nursing support for a GP’s patient caseload. Maxine’s work brings her into contact with a variety of hospital and community services. For those who are unfamiliar with the different services that are provided in the community within the UK – and the different job titles used - we have provided a brief explanation of those described in this paper (Figure 1).

The interview took place one afternoon in the staff room of the general practice where she worked. Maxine had chosen a fairly quiet period in the day of the practice so we would not be disturbed.

The Scenario

After explaining the nature and purpose of the reflective exercise, the researcher (AR) issued Maxine twelve arrow-shaped cards and a large sheet of paper, and left her for ten minutes to decide upon a joint working scenario. Upon AR’s return Maxine had chosen her case, was seated on the floor, and was well into organizing her pattern of relationships. AR sat with Maxine on the floor whilst she enthusiastically explained details as she added cards to the growing design. The final layout is shown in Figure 2.

Figure 2. Maxine's inter-professional layout

DN: District nurse team OOHDN: Out of Hours district nurse team POD: Podiatrist HCM: Home care manager (social services) HCA: Home care assistant (social services) Diab Liaison: Diabetic Liaison Nurse (Specialist hospital nurse) GP: General Practitioner (family doctor) RP: Rehabilitation/Physiotherapy team

The scenario Maxine had chosen was a highly complex, dependent case, which involved many services. The patient (whom we will call Ray) was a man in his late thirties, with multiple sclerosis and diabetes. Ray was immobile, incontinent, and required assistance for all his personal care. Social services homecare staff were involved in providing the personal hygiene care required for his day-to-day living; and the community nurses were there to monitor the diabetes and to ensure there were no complications as a result of his immobility.

On the back of the layout sheet AR drew a dimensional line placing, ‘poor team working’ at one end of the line and ‘good team working’ at the other. Maxine then placed her arrow-shaped cards along the dimensional line according to how well she worked with others (Figure 3). Again AR invited her to explain the reasons for her card positions and asked her how she could facilitate improvements in some of her relationships.

Figure 3. Maxine's Salmon Line

REHAB: Rehabilitation services (Physiotherapists and occupational therapists) GP: General Practitioner (Family doctor) DIAB: Diabetic nurse (Hospital specialist nurse) HCA: Home care assistant (Social services) LS: Loan stores manager (provides equipment) MC: Mattress Co-ordinator (provides specialist equipment) HCM: Home care manager (Social Services) DN: District nurse team OOHDN: Out of hours district nurse service POD: Podiatrist

Analysis

Following the exercise (which was audio-taped) the data were analysed using a style of thematic analysis called ‘template analysis,’ in keeping with a phenomenological methodology (King, 2004). This style of analysis enables the researcher to identify key points or themes and cluster them into broad themes and lower codes that provide the depth on specific issues (see King, 2003, for a web-based introduction to the technique). It is not possible to examine all the themes that emerged from what was a very rich interview. Instead, to illustrate the approach, we will present findings relating to the higher order theme ‘interprofessional relationships’ and its sub-themes (see Figure 3).

Interprofessional Relationships

Teamwork

From the data it was clear that teamwork is very important to Maxine, who is very keen to be seen as part of a team. This may be partly attributed to her job-sharing, as she is reliant on the others within the team to maintain continuity of her role. Note that on the layout she does not include herself as an individual but as part of the district nurse team. During the discussion she noted:

The most important thing is keeping good relations going and trying to understand each others’ commitments and trying not to get into that way- "this is my role and this is your role." We are working as a team. We need to go as a team and I’ve been in a team which I feel I am very much [a part of], the social services, podiatry and sort of rehab specialist nurses we always go [to assess] together.

In spite of working in the same practice and being in constant touch with the GPs, she regards herself as not having the same teamwork relationship with them as with her community nurse colleagues as noted in the following quote:

With GPs we are working hard [to develop a team relationship], for the last nine years we have been working. We never seem as a proper team, they are not a team are they?

So how does she define good working team relationships? In what ways was it not working here? Let us look at how she describes her ‘good’ relationships and what good teamwork means to her.

The first example describes a closeness of working together where boundaries between roles begin to blur. Those with whom she works very well are those in one sense willing to go ‘the extra mile,' those who are willing to cross their role boundaries and respond swiftly to the situation. This is shown in her comments about the home care manager, Adam:

Adam went in on the Monday morning to move his [the patient’s] bed out so the hospital bed could be delivered and put straight in. If you haven’t got a social worker who works well with you like that the whole thing falls apart! I don’t think it’s really his job to go and move a bed out of the way –there isn’t anyone else out there!

Going that extra mile and showing commitment also means to Maxine giving up personal time. Note that the podiatrist is placed toward the positive pole of "good joint working" on Figure 3. She explained how both she and the podiatrist were willing to give up personal time to miss a Christmas party, in order to respond to a client.

Recognition and respect for expertise.

Other relationships which Maxine held in high regard were with the mattress coordinator and the loans store manager. Maxine describes herself as having a ‘fantastic’ relationship with the mattress coordinator. Her comment below shows how she values the mattress coordinator’s knowledge and expertise in sorting out her problems:

The mattress coordinator she is worth her weight in gold; we work fantastic together. Yeah I say, ‘I’ve got a problem with a pressure sore have you got anything?’ - If she doesn’t know it I know its not available.

Problem sharing.

The final example below, illustrates the meaning and benefits of good teamwork for Maxine. Here she highlights her contrasting experiences with the hospital acute services and social workers. As a result of her regular meetings with social services she has developed what she calls a closer relationship and understanding, where they share each other’s demands and problems at the meetings, noting:.

They [social care assessors and home care staff] tell us what the demands have been put on their services and what the latest thing they have been told, what they can do and can’t do, and we let them know what the demands and what the problems we’re having, so it’s understanding...

This is in contrast with the hospital acute services where she describes there is little contact with staff and poor communication between wards and the community, hence a lack of problem sharing and little understanding of each other’s roles. Furthermore she feels that hospital staff lack understanding of how patients are managed in the community, and believes that the staff concerns do not go beyond the ward. Maxine described how she would be the one to ring the ward for more details of a patient or to try and explain to ward staff about the awkwardness of Friday afternoon discharges, which do not give community staff time to coordinate their services.

The Salmon Line enabled Maxine to reflect upon her relationships with the different staff groups, particularly upon how she could improve her relationships with the hospital staff, moving towards the construct pole ‘good team working.’ One change she suggested was for community nurses to each ‘adopt’ a hospital ward and make regular visits to it. She felt that this would give both sets of staff the opportunity to get to know each other and the different ways that they worked.

Usefulness of the Reflective Exercise

We noted earlier how we found this technique to be useful in three areas: research, clinical development and for teaching purposes. We will deal with these subjects in turn.

Research

Using this approach, Maxine was able to provide the researcher with a detailed account of her interactions with other professionals. This helped us, as ‘outsiders,’ to grasp the complexities of the community nurse’s role within a joint working event. From our experience of other projects in this area, we feel confident that the techniques employed here facilitated the elicitation of a more thorough account than we might have obtained using traditional semi-structured interviews. Specifically, the layout and Salmon Line encouraged Maxine to consider a wider range of co-workers than she might have without the use of these reflective tools. For example, the conversation tended to focus upon those whom she had intense relationships with. These would be practitioners placed at ends of the dimension scale, where relationships were very positive or where relationships were significantly poor. However, AR was able to prompt Maxine concerning those practitioners who fell between the extremes and say ‘what about this person or team?’

In the ongoing research project from which the example of Maxine was drawn, participants commonly reported that the exercise helped them to recognise the stereotypes they held about other professions they worked with, and enabled them to begin to question them. They often recognised that rather than simply complaining and waiting for "things to get better," they could devise ways of taking an initiative themselves to improve relationships. For example, one district nurse suggested she could "invite herself" to case conferences in the acute sector that involved her patients, with the result that ward staff would get to know her and her perspective on patient care (and vice versa).

Clinical Development

Maxine’s account frequently went beyond the chosen scenario, which seemed to serve as a springboard for discussing other issues and other situations, brought to her mind through completing the task. Maxine herself stated that she found the layout revealing and was amazed at the complexity of her involvement with other practitioners. She also found the task useful in taking an overview of very complex cases that needed input from may other practitioners. She went on to say how she would like to use this method to help her organise care with other team members. Significantly, through this technique Maxine became aware of how she might improve relationships with other practitioners, particularly those from the hospital services. For instance, she noted she might visit the ward on a regular basis (adopt a ward) and spend time with particular practitioners to gain an understanding of how they work.

Teaching

Subsequent to the use of this technique in research interviews, we and our colleagues have employed it on a number of occasions as a classroom exercises. In one example, it was incorporated in a module on collaborative working for post-registration nurses undertaking a specialist qualification in community nursing. Students presented scenarios from their own working experience to their peers, using the layout and Salmon Line, with the teacher acting as a facilitator. So far this has proved fruitful with students presenting complex interprofessional situations to other students. We found that it enabled students to engage in critical reflective evaluations at every stage of the process, from choosing a joint working scenario, to reflecting on how they believed other practitioners defined their roles and relationships within the chosen event. The activity created debates and discussions amongst the students and prompted them to consider alternate strategies and different ways of working when approaching problems they were experiencing at work. We had positive feedback from the students who participated in this exercise. One student district nurse commented on how the experience had led her to question her relationships with other professionals:

It made me think about relationships we do have with people. If it’s not working and why we don’t have the communication rather than just accepting it- ‘well we never get over to them’ or ‘we don’t speak to them’ It made me think 'well yes, I will phone them I will contact them’. (Student district nurse)

Conclusion

We have found this approach to examining experiences of collaborative working valuable in both research and teaching. The tools are versatile and powerful, and appear to be highly acceptable to the professionals we have used them with. In future we would like to extend the use of the approach to the everyday practice of professionals working in multi-disciplinary settings. For example, as part of team development activities, members could utilise visual layouts to share how they perceive the different relationships within a team. As in Maxine’s example, the Salmon Line could be used to explore alternative actions to improve relations, and consider ways to facilitate their relationships toward achieving their identified goals. We would also be keen to see the approach extended to a wider range of research and teaching settings in health and social care

Authors

Angela Ross, BSc (Hons) Psychology, RN, RM
E-mail: a.ross@hud.ac.uk

Angela is a qualified general nurse and midwife and has practised in London and West Yorkshire, United Kingdom. Following her graduation from the University of Huddersfield, Angela joined the Primary Care Research Group as a research assistant and later as a PhD student. She has been involved in a number of primary care research projects within the region and has taught community nurse students concerning interprofessional working. At present, Angela is completing her thesis 'Professional Identities, Interprofessional Relationships and Collaborative Working.' In addition, she works part-time as a clinical development facilitator at a local hospital.

Nigel King, BA (Hons) Social Psychology, PhD, CPsychol
E-mail: n.king@hud.ac.uk

Nigel is a Reader in Psychology at the University of Huddersfield. He has written widely on organisational innovation and change, especially in health and social care settings, and on the use of qualitative methods in applied psychology. He has extensive research experience in primary care settings, and is currently Director of the Primary Care Research Group at Huddersfield. Recent research topics include developments in community palliative care, the use of self-help materials for depression, and interprofessional working in health and social care.

Jan Firth, RN, DN, Dip.N(Lon), CertEd, M.Ed., DNT
E-mail: j.firth@hud.ac.uk

Jan is a qualified district nurse by profession and has practised in West Yorkshire, United Kingdom. Jan joined the University of Huddersfield in 1988 and has maintained her interests in primary care through membership of various committees, research, and teaching and development links with service colleagues. She has written and led a number of courses, including BSc (Hons) Health with Community Studies, and BSc (Hons) Community Specialist Practitioner, and is a founder member of the school Primary Care Research Group. She also conducted the nurse prescribing course for local district nurses and health visitors. Jan became Head of the Department in 2001, and oversees a range of programmes in community and primary care and health studies at both undergraduate and postgraduate levels. At present, Jan is on a part-time secondment as primary care educator at the Yorkshire Medical Deanery at Leeds University. This role helps her with developing interprofessional education with in primary care in the practice setting.

Barr, H. (2002). Interprofessional education today, yesterday and tomorrow. Higher Education Academy Centre for Health Sciences and Practice, Occasional Paper 1. Available: www.health.heacademy.ac.uk/publications/occasionalpaper

Whittington, C. (2003). Learning for collaborative practice with other professions and agencies. London: Department of Health. Retrieved February, 15, 2004, from www.dh.gov.uk/assetRoot/04/03/48/31/04034831.pdf