Lingard, Lorelei PhD; Vanstone, Meredith PhD; Durrant, Michele RN, MSc; Fleming-Carroll, Bonnie RN (EC), MN, NP-Paeds; Lowe, Mandy OT Reg (Ont), MSc; Rashotte, Judy RN, PhD; Sinclair, Lynne PT Reg (Ont), MA; Tallett, Susan MB BS, FRCPC, MEd
With the advent of interprofessional care,1,2 new questions about leadership and teamwork have arisen. How should responsibility be shared and power differentials mitigated? How has the physician’s role changed?3 How do health care teams view these dimensions of their work? Without insight into these issues, we can’t know how best to educate physicians and other clinicians regarding their responsibilities on collaborative teams.
The growing body of literature on interprofessional care emphasizes the essential nature of collaboration4 and contains a strong discourse of partnership, shared leadership, and team interactions that are horizontal, relational, and situational.5–8 Some articles even equate the terms “member” and “leader.”5,9 Long and colleagues10 have named this orientation “clinical democracy,” a term that emphasizes the collective ownership of goals11 and decision making. Although this model of interprofessional practice may be enacted in different ways on different teams, it generally calls for sharing power on the basis of knowledge and experience rather than roles.12 Rather than following distinct leaders, team members work together interdependently, relying on each other’s expertise to accomplish goals and carry out tasks.13
This model is echoed in the Canadian Interprofessional Health Collaborative’s Interprofessional Competency Framework, which suggests that team leadership ought to change according to the requirements of each situation.14 This discourse has also been taken up within medicine. The Royal College of Physicians and Surgeons of Canada,15 for example, instructs physicians to learn to work in partnership with other providers, to reflect on the function of the interprofessional team, and to demonstrate leadership where appropriate.
Some research has examined interprofessional practice and leadership more critically, analyzing the historical, economic, political, and social professionalization challenges to collaboration.16,17 This work acknowledges the factors influencing power differentials to be outside the control of the team’s professionals, making collaboration difficult18 or even undesirable.3 These external factors may contribute to the dissonance sometimes observed between articulated desires for collaboration and actions that undermine those desires.19
To better understand the role of “physician leadership” in the evolving landscape of collaborative health care, we looked at how five interprofessional health care teams perceived and demonstrated leadership in their daily practice. We report our findings in this article.
In this study, we used a multiple instrumental case study research design embedded within ethnography, which facilitates the exploration of complex, real-world phenomena.20 After receiving research ethics approval from the review boards at three teaching hospitals affiliated with two universities in urban Ontario, Canada, we asked clinical and educational leaders in each hospital to identify interprofessional clinical health care teams with reputations for strong collaborations and managerial/administrative support. We purposively selected five teams, which represented the specialties of brain injury, complex care, mental health, oncology, and stroke, and which were located within rehabilitative, pediatric, and adult health care sectors. We invited all members of those teams to participate. Participants included physicians, nurses, physical and occupational therapists, speech language pathologists, dietitians, child and youth workers, social workers, and psychologists. For stylistic ease, we will refer to the participants who were not physicians as “clinicians,” a term that reflects the centrality of their roles to patient care.
From January 2008 through June 2009, we iteratively collected and analyzed data, both within each team study and across the team studies,20 which were spread out over several months (only the third and fourth team studies overlapped significantly in time). Research assistants, trained in qualitative techniques and without preexisting relationships with any of the teams, observed each team’s work during daytime hours for three to six weeks, in blocks of 1 to 3 hours; across all five teams, they observed 139 hours of team interaction. Over the course of observation, the teams experienced a natural degree of instability due to rotating learners and staff schedules. These observations took place during team meetings, team rounds, consultations, and while shadowing individual team members. During these activities, the research assistants captured ethnographic data about the team members’ daily tasks, their interactions with other colleagues and patients, and team dynamics. Learners on the teams were observed when they interacted with staff team members, but they were not shadowed or interviewed.
While embedded in the workplace, the research assistants approached individual team members to request interviews. Of the 54 members of the five teams, 46 were interviewed using a semistructured guide, which we refined for each interview on the basis of observational data. We broadly explored the theme of leadership, asking participants about the roles of each of their team members, congruencies and conflicts between roles, and who they perceived to be the leader(s) of the team. We probed their responses with follow-up questions that drew on the observational data. The interviews were audio-taped and transcribed verbatim.
As a member-checking mechanism, a qualitative research technique used to elicit participants’ discussion of preliminary findings and seek further insider insights to refine interpretations, we held focus groups for each team, which were audio-taped and transcribed verbatim, with all interested and available team members.
We analyzed data using a constant comparative thematic approach, comparing categories across teams, within teams, and by type of health care professional.21 Our analysis was iterative, beginning with line-by-line coding, proceeding to focused coding, and evolving to produce categories that responded to these codes. Individuals on the research team conducted the analyses, meeting in small groups to compare approaches before refining the categories to share with the research team as a whole.
Amongst a number of recurrent themes that arose in our analysis, team leadership emerged as a dominant issue, consistently across all teams. Its importance was signaled both by its recurrence in field notes and by the enthusiasm exhibited by interviewees as they discussed topics such as professional status, hierarchy, collaboration, and decision making. Leadership in the five teams took different forms; however, each team demonstrated a tension between the ways in which they discussed leadership with us (in interviews and group sessions) and the ways in which they actually enacted leadership in daily practice or talked about it amongst themselves.
Although the physicians and clinicians we interviewed all acknowledged the hierarchical nature of the broader health care system, they differed in their perceptions of leadership within their own teams. The physicians tended to compare themselves favorably to the wider institution, characterizing the leadership structures of their teams as democratic and nonhierarchical. The clinicians, in contrast, tended to describe the assumption of physician leadership and the presence of a medical hierarchy, although they often discussed ways in which all team members, including physicians, worked against this hierarchy. Clinical expertise and decision making were two points of tension between the explicit and implicit constructions of leadership and hierarchy.
Both physicians and clinicians recognized that hierarchies are reified by institutional factors in the health care system, such as the requirement, currently under review,22 for physician referrals to enable other professionals to work with patients. Psychologist 3 (Team 2) remarked: “The physicians are on top, undeniably. Although they are trying to not have that hierarchy, my referrals come from them.” Although clinicians felt that these hierarchies influenced the way their own teams worked together, some physicians, such as Physician 4 (Team 1) and Physician 3 (Team 5), thought that their own teams avoided those hierarchical influences.
This is an unorthodox team. Leadership is not preordained, but shared by the team members…. We are all in it together. You really need humility to do this work and, because of this, it destroys hierarchical levels.
Sometimes people’s previous experiences can be one of the biggest obstacles. If they come from an environment which is much more hierarchical, … it is harder to make the adjustment.
Despite the physicians’ denial of hierarchies on their own teams, our observational notes revealed many instances of physicians behaving in hierarchical ways. For example, a representative note from Team 1’s clinical rounds reported that “the conversation was dominated by the physicians, mostly Physician 1 and Specialist Physician 1.” A detailed confirmation of this kind of behavior came from the patient care coordinator, a nurse on Team 2, who recounted during an interview that nurses sometimes feel disrespected by physicians.
Every two weeks [the physicians] have their rotation, so every time a physician is on again, they rely heavily on the nurses for patient updates. This is really hard on the nurses because they have to take a lot of time to provide this information to the doctors. I don’t understand why they don’t read the charts. It’s like they don’t want to because then they’re responsible if there’s a mistake. It’s very (pause) passive–aggressive. If something isn’t done, or it’s done improperly, they’ll blame the nurses, but they won’t actually come out and say it directly. They’ll say things like “oh, you told me this,” and of course, the nurses can’t really say anything, so they end up feeling very frustrated…. The physicians are good at getting clinical information they need regarding patient care, but the nurses don’t feel like they’re respected.
In contrast to the physicians, the clinicians unequivocally reported the existence of hierarchical structures on their teams. According to Speech Language Pathologist 1 (Team 2), “the physicians are on top. People like to pretend it isn’t that way, but it’s the way that it is.” However, many clinicians simultaneously credited physicians they worked with making efforts to disable this hierarchy. One such effort involved the use of inclusive language, appreciatively noted by Clinical Manager 1, a nurse working on Team 5.
Everybody calls everybody by their first name here. That’s not so common in other areas. If you go to [other site], it’s “Dr. So-and-So.” I think you’ll find that in most hospitals it’s “Dr.,” whereas here it’s first names.
The physicians also reported using strategies to disable hierarchies, as illustrated by Physician 4, Team 1.
I have been on other wards where there are multidisciplinary rounds, but the only ones talking are the physicians. The others are just sitting there and not contributing. It’s quite troubling. I’ve been in other situations where the physician will say “my patient” or “my team.” Here we don’t use that language…. We try to lead by example and we start off with introductions on a first-name basis. The language of how you talk to each other is very important and we need to role-model this.
These quotations reveal the different meanings given to these efforts by the physicians on one hand and the clinicians on the other. The physicians offered the examples as evidence of the progress their teams had made in comparison with other wards, whereas the clinicians brought them up to show how, despite best efforts, the hierarchical social reality remained pervasive and intractable.
The physicians often cited respect for clinical expertise as a reason for their teams being nonhierarchical: “There are no hierarchies on this team. It is all about expertise and what everyone brings” (Physician 1, Team 2). Physicians and clinicians alike all acknowledged that each team member has an area of clinical expertise to contribute and an area of clinical jurisdiction to be respected. While shadowing Nurse Practitioner 1 on Team 1, a research assistant observed Physician 2 deferring to the expertise and authority of Social Worker 1 in securing community resources.
Physician 2 enters a patient’s room and is informed by the patient’s caregiver and Nurse Practitioner 1 that the family is upset with the lack of progress that Social Worker 1 (who is not present) is making on securing community resources necessary for discharge. Physician 2 reads the papers Nurse Practitioner 1 is making notes on and states that he has spoken to Social Worker 1 already, and he is not able to do any more than Social Worker 1. He adds that he cannot do it as well as she can. He says Social Worker 1 “can work magic sometimes.”
However, in other instances, physicians were reluctant to defer to another professional’s clinical expertise, as illustrated in this exchange regarding the readiness of a particular patient for discharge, which took place during Team 3’s rounds.
Physiotherapist 4: Recommend discharge for [date]. Referred to outpatient physio.
Physician 2: Is her wound healed?
Nurse 6 and Physiotherapist 4 both: Yes.
Physician 2: I’ll have to check the wound.
As this excerpt suggests, having germane expertise did not always translate into the authority to make independent clinical decisions. The data we collected from observations and interviews made it clear that physicians on all teams had more decision-making authority than clinicians. This authority was often linked to the perception, held by both physicians and clinicians, that physicians had a higher level of medical-legal accountability for patient care. As Nurse Practitioner 1, Team 1, explained, “I think we all have leadership roles, with respect to our expertise, but it all comes down to the physicians who are ultimately responsible.”
This dynamic of physicians’ superior authority to make clinical decisions manifested in different ways. Physician 3 (Team 5) implicitly acknowledged the tension between his espousal of clinical democracy and his retention of decision-making authority by discussing the ways in which his team differentiated between “team decisions” and “leadership decisions.”
We all know when we can argue with each other and when the decision making needs to be separated out. In a crisis or critical situation, where we can’t do things by committee, there need to be decisions made quickly. So [we need] the ability to shift from “we’re all working together in a collaborative way” to points in time when there needs to be leadership and critical decisions made. We understand when those situations occur.
The decision-making authority of physicians was a common point of discussion in interviews with clinicians and was observed to be strongly engrained and well understood across all teams. The process of decision making revealed professional hierarchies by distinguishing between those who can offer input (all team members) and those who actually make the decisions (usually the physicians). Clinicians felt assured that their opinions and expertise were taken into consideration. As Social Worker 2 (Team 2) remarked, “I feel [the physicians] listen to everyone’s opinion. All of us can speak freely at our weekly team meetings.” But at the same time, they knew quite clearly that they were not the final decision makers. “At the end of the day, I’m not a doctor. They make the decisions” (Social Worker 1, Team 2). And they acted accordingly, as observed in this informal exchange about discharge readiness between Occupational Therapist 1 and Nurse 5 from Team 3.
OT1: From the physio and OT perspective, he can go, so it’s for the physician to decide.
RN5: His wife already got the Vancomycin [prescription drug requiring intravenous injection].
OT1: OK. So he can go after the PICC [peripherally inserted central catheter] if the physicians say.
RN5: I have to talk to Dr. 2.
Some clinicians spoke about the ways in which decision-making privileges entrenched a hierarchy between team members. According to Psychologist 2 on Team 5,
We probably have the most extensive training in mental health, psychology. But psychiatry are the ones that have admitting and discharging privileges. So if I feel very strongly that a client should be discharged, or not be discharged, I nonetheless have to make my case to psychiatry. So admitting and discharge privileges inherently build in a hierarchy.
For some clinicians, the difference in authority did not conflict with the idea of every team member’s equal value in the decision-making process. OT1 on Team 3, for example, described his contribution as one part of the clinical puzzle. Others were less sanguine, particularly those clinicians, like Psychologist 2 on Team 5, who had encountered situations in which they felt well qualified to make a decision without a physician’s input.
The physicians and clinicians in the five interprofessional teams we studied perceived team leadership, particularly in the sense of a professional hierarchy and its influence on decision making, differently.23 Furthermore, although the physicians claimed to eschew leadership roles in their teams’ functioning, their observed behavior and reports from their clinician colleagues belied such claims. Clearly, physicians on interprofessional teams experience a tension between two values: They embrace the philosophy of clinical democracy but, more often than not, act on a philosophy of hierarchical leadership. In this discussion, we explore the circumstances that combine to produce this situation.
The rise of interprofessional care has been accompanied by widespread acceptance of a philosophy of shared leadership6 on health care teams. “Clinical democracy,” as Long and colleagues10 have named this philosophy, is predicated on power that is distributed not on the basis of traditional social hierarchies but, instead, on whose expertise is relevant in a specific clinical situation.12 This notion has become a legitimate part of competency frameworks, both interprofessional14 and profession-specific,15 suggesting that all caregivers, if they are to be considered competent, must understand how to collaborate and share power. Why, then, do the five highly collaborative, interprofessional teams in our study still experience such tension regarding these issues? One answer, according to Whitehead, is that physicians, by necessity, operationalize this philosophy of democracy and cooperation within broader systems that not only support, but may in fact demand, their privileged status.3 Faced with this double bind—asked to share power, but forced to embody a privileged role—physicians may say one thing, but do another. To explore this provocative explanation for our findings, we briefly consider three of the broader systems that support physicians’ privileged status: the education system, the health care delivery system, and the medical-legal system.
The education system
Under normal circumstances in Canada and the United States, physicians, particularly specialist physicians, complete at least six years of education and training after obtaining an undergraduate degree. This educational commitment, large when compared with that of other health professionals, is seen by some as justification for physicians’ superior decision-making privileges.24 This justification loses some sway as education requirements for other health professionals increase. Clinical doctorates will be implemented by 2015 for American nurses in advanced nursing practice roles25 and are being considered for physiotherapists as well.26 Canadian physiotherapists and occupational therapists already require a master’s degree.27
During education and training, socialization shapes the practitioner’s professional identity. Professional socialization and prevalent discourses condition physicians to envision themselves as leaders of health care teams.3,28–30 The enduring dominance of medical knowledge31 in clinical decision making32 further contributes to the perception that interprofessional collaboration occurs at an uneven negotiating table.33
Many physicians have begun to reject their status as omniscient, all-powerful professionals,29,34 but relics of that role remain, interfering with interprofessional teamwork. For example, Nugus et al35 found evidence that physicians have been socialized to believe that they are expected, when working with other health professionals, to evaluate their colleagues’ input and determine the extent to which it should be taken into consideration. Clinicians’ education, too, may reinforce perceptions of medical dominance, socializing them to defer to physicians. As has been described in the 1960s and again more recently,32,36,37 physicians and nurses wage daily power struggles; as clinical apprentices observe this complex dance, they “acquire implicit and powerful cultural knowledge of professional roles and relationships.”38
Health care system
Regulatory, institutional, and funding structures of the health care system perpetuate a hierarchical structure of health professions, placing physicians at the top.39 No matter how democratic or egalitarian a particular health care team is, it still operates within larger organizational structures that challenge nonhierarchical interprofessional relations.40 In Canada, for example, a physician’s referral is required to get funding for many services and equipment and to admit or discharge patients. Fee-for-service compensation formulas may discourage collaborative practice. The Ontario Health Insurance Plan remunerates physicians only for services provided to patients; it does not cover collaborative activities such as interprofessional team meetings where many patients are discussed.41 These hospital, health care delivery, and insurance systems, by privileging physicians’ knowledge and requiring that they green-light services from other health professionals,17 consolidate medical power42 and institutionalize physicians’ leadership of health care teams.
In Ontario, physicians are licensed to perform all but 1 of 13 controlled acts—significantly more than other regulated health professionals.43 This has the effect of enshrining physician autonomy to operate independently from the team, but, in exchange for this autonomy, physicians may assume higher levels of liability.10 The regulation of exclusive scopes of practice may act as an obstacle to clinical democracy in an interprofessional team setting by compartmentalizing services39; overlapping scopes of practice may be a more effective way to encourage collaboration.30,44
The medical-legal system
Many participants in this study and others20 perceived physicians as shouldering more legal or professional liability; this reasoning was often used to justify their superior decision-making authority.24 Exploring the dynamics of interprofessional medical-legal liability is outside of the scope of this article, and very few Canadian court decisions have addressed the liability of interprofessional health care teams, but two legal issues may help explain the participants’ perception of greater physician liability. First, Canada’s legal system does not recognize unincorporated teams as entities that can be sued.45 Liability is examined on a case-by-case basis, with fault assigned to specific individuals and entities, although multiple providers may be found jointly negligent.46 Second, physicians and other health care providers have different legal relationships with hospitals, which may assume vicarious liability for negligent acts committed by their employees. Although courts assess the existence of an employee–employer relationship in each case,47 they have traditionally found nurses to be employees of hospitals,47–49 whereas physicians are often, but not always, considered independent contractors.50,51 As independent contractors, physicians must bear any liability for what occurs within the context of their practice.
Although these factors appear to support the sense that physicians have more legal accountability for (and therefore more clinical authority over) medical decisions, there is a change afoot in the legal landscape. With the rise in interprofessional work, Canadian courts are working with liability in a different way,45 recognizing that team members are entitled to rely on each other to practice to their own standard of care.52 All regulatory colleges in Ontario now require their members to maintain professional liability insurance as a condition of registration.52–54 This wider distribution of responsibility may remove some barriers to interprofessional practice.45,55
Although physician leadership is not problematic in and of itself, we have found that it raises issues within interprofessional teams. Tensions arise, both between physician and clinician, and between the emerging discourse of clinical democracy and the well-engrained incentives for keeping structural hierarchies in place. Fortunately, these tensions open doors to discussion and reflection about the nature of leadership and collaboration. Openly acknowledging and confronting the challenges may enable interprofessional teams to address specific issues and improve their collaborative practices.
On a macro level, addressing the issue of interprofessional collaboration will require a broad and multifaceted approach, which will involve dialogue within and across professions, as well as with patients and their families and with regulatory, governmental, and academic institutions. Because the context within which qualitative data are collected is essential to their interpretation, we recognize that our findings are not generalizable. Context is particularly important in this study because of our emphasis on specific institutional and medical-legal systems. Research in other educational, health care, and medical-legal contexts can only add to our understanding of leadership in team settings and may suggest initiatives that help interprofessional teams better collaborate and more deftly navigate the tensions between the old ways and the new.
Acknowledgments: The authors wish to thank the institutions and individuals who participated in the research reported here.
Funding/Support: This work was funded by a grant from the Health Force Ontario Interprofessional Care/Education Fund (agreement no. ICEF0708014).
Other disclosures: None.
Ethical approval: Ethical approval was granted at all institutions at which this research was conducted.
Previous presentations: This material was presented as an oral abstract at the Canadian Conference on Medical Education, May 2009.
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