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Are We All on the Same Page? A Discourse Analysis of Interprofessional Collaboration

Haddara, Wael, MD; Lingard, Lorelei, PhD

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doi: 10.1097/ACM.0b013e3182a31893
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Abstract

Interprofessional collaboration (IPC)—the idea that health care is best conceptualized and practiced as a team activity—has grown in popularity to the point of becoming accepted “common sense.” In the practice setting, IPC has grown up alongside changes in health care delivery, particularly the move away from single-practitioner models and patient–provider dyads, to team-based delivery of care.1,2 Its influence in the educational domain is unquestionable, evident both in competency frameworks identifying it as an essential competency3–5 and in calls for interprofessional education (IPE), which together represent a fundamental pedagogical shift emerging in many health professional curricula.

A quick scan of the scholarly literature confirms the emergence of IPC over the past few decades as a topic for thriving scholarly discourse. Today (June 7, 2013), a single PubMed search using the terms interprofessional collaboration and medical education retrieved 319 articles from the past five years alone, while a search of the term interprofessional collaboration through a corpus of millions of digitized books via Google Ngrams6 revealed a sixfold increase over the last 40 years. With this growth has come the development of scholarly institutions dedicated to IPC, such as peer-reviewed research journals (e.g., Journal of Interprofessional Care) and policy initiatives.7

Although IPC’s status is not in question, its definition and characteristics are the subject of ongoing debate.8–11 Medical researchers, educators, and authors have advanced multiple models and frameworks,8–12 not always with reference to—or resonant with—one another. Further, although IPC implementation in health care delivery and health professions education has moved ahead regardless of questions of ontology, implementation is often fraught with tension, and outcomes remain ambiguous.13,14 This situation has led us to our research questions: Is there clarity on the idea of IPC? And if not, what does that mean for its adoption into physician training?

Method

We used the methodology of critical discourse analysis (CDA) to explore these questions. Epistemologically, CDA takes knowledge to be socially constructed and perpetuated, and it explores instances of spoken and written language to understand how these influence what persons within a sociopolitical and cultural context understand as, or consider to be, “known.”15(p39) CDA probes the question of how some knowledge claims are beyond dispute at particular historical moments, and it pays particular attention to the contradictions within and among discourses that become visible when the probing of this “common sense”16 occurs. Those contradictions manifest as “irregularities” and—where the construction of the social world changes altogether—as “ruptures.” Beyond simply describing the patterns of discourse, CDA is also concerned with understanding what institutions or concepts (“objects”) gain legitimacy and power as a result of particular discourses.17,18

Specifically, we draw on Michel Foucault, who treated the history of knowledge/ideas as serial rather than progressive. Rather than viewing the history of ideas as a stepwise progress through which ideas are refined and improved, Foucault (and others) argued that there are “ruptures” in the conception of “truth” over time. For example, ruptures, rather than a progression in the “truth,” characterize the history of the understanding of “madness,” which changed from possession by evil spirits to social deviance and today to a chemical imbalance. But even within a single conception of the “truth” there may be irregularities; differences and tensions arise from how an idea is conceived and knowledge constructed. Like Foucault, we have examined how the truth around IPC has changed over time, specifically through the lens of irregularities and ruptures. This Foucauldian orientation to the study of ideas has proven fruitful both for questioning the origins of long-standing ideas in health care19 and for tracing the development of emerging ones.20 Others have used a Foucauldian orientation to explore questions of direct and indirect relevance to the domain of IPC, including the history of medical competency frameworks,21 the idea of reflective practice,22 the emerging role of nurses in health promotion,23 and the epistemological limits on nurse–physician collaboration.24

A Foucauldian CDA requires gathering and studying an archive of texts “neither entirely linguistic, nor exclusively material”15(p86) that together constitute a discourse; in other words, the texts should be reflective of the social world the discourse is constructing. The archive includes statements, objects, institutions, practices, and traditions that collectively make—or are made possible by—a discourse. Its delineation poses a major methodological decision because its size must not only be manageable but also allow for sufficient depth that discourses can be meaningfully identified and characterized. As Foucault25(p146) pointed out, the “archive of a society … cannot be described exhaustively; or even, no doubt the archive of a whole period.” Foucault himself undertook archeological examinations drawing on both extensive25,26 and limited27 archives.

We limited our archive in four ways. First, we limited the archive to published, peer-reviewed literature. Although “statements” in the Foucauldian sense are limited neither to written texts nor to published literature, the published literature represents a domain within which individuals, ideas, and methods interact, and it is, therefore, a defensible research starting point. Second, we limited the archive to nurse–physician IPC in order to focus on what is arguably the dominant interprofessional axis in modern health care. Furthermore, Foucault highlights the importance of considering statements in their context, and nurse–physician relationships are arguably unique given that the historical relationship between these two professions predates the emergence of some other professions now participating in the health care workplace. Third, the archive includes literature from the 1960s through December 2011, a time frame chosen both for convenience and relevance. Demographic changes and the technological advances of the mid-late 1950s strongly influenced the current health care system in Canada and the United States, such that, although a discourse analysis can be informed by a longer historical lens, limiting the starting period for the current analysis to the 1960s allows for analysis of a historically connected period.28 Fourth, the archive is limited to U.S. and Canadian, and to a lesser extent British, texts. Although we do not consider these countries to be homogenous, they do share similarities of medical and training culture, and a degree of cross-pollination in their IPC literatures allows for constructing a meaningful archive. Finally, we excluded literature relating to IPE and items dealing exclusively with gender conflict. Both of these areas constitute distinct discourses in themselves and deserve separate treatment.

To compile our archive, we conducted a search in PubMed and CINAHL using an expansive search strategy developed with the help of a librarian. We initiated our search in November 2010 and continually updated it through December 2011 using the terms “interprofessional relations,” “interdisciplinary communication,” and “collaboration” both as subject headings and as key words. One researcher (W.H.) reviewed titles and abstracts. He retrieved full papers (articles, reports, letters, commentaries, etc.) if they fell within the limits described above and if they related to the theory, conceptualization, or implementation of IPC. Sampling in CDA research is not intended to be exhaustive; rather, it continues until stable description of discourses is achieved.29 In CDA, a comprehensive archive is not the goal, and the size of the archive is less salient than the insight afforded into the question; thus, the sufficiency of the sample is judged by the richness of the characterization of the discourse(s) that emerges from the analysis.30

CDA has been called an approach rather than a fixed method,31(pp1,145) in part because of its resistance to formulaic rules for analysis.30,32(p249) Nevertheless, researchers should articulate their analytic methods. We drew largely on the method of Wodak and Meyer.16(pp53–56) We defined our discourse plane as published, peer-reviewed texts with the above-mentioned delineations (primarily from the United States and Canada, dealing with nurse–physician collaboration, dating from the 1960s through 2011, etc.). We noted the peculiarities of each particular paper including the journal, the authors’ affiliations, and the genre (e.g., research report, descriptive article, letter). We processed the texts using an iterative analytic process in which we examined texts for themes, truth statements about IPC, objects enabled, and language used. We analyzed the texts for irregularities, ruptures, and transformations until a stable description of the various discourses emerged. One researcher (W.H.) read each text in the archive. Then, during regular meetings, the principal author (W.H.) and a second researcher (L.L., an education researcher familiar with IPC) discussed patterns emerging from the analysis. These discussions aimed to distinguish the patterns that constituted discourses through identifying and refining the truth statements, language, and objects produced by and linked to the emergent themes. These researchers explored questions about the interactions between these discourses through revisiting the texts themselves. They also undertook additional literature searches to further validate the presence of the discourses identified.

Results

The papers we retrieved included empirical studies, systematic reviews, conference proceedings, editorials, and commentaries. Our final archive consisted of 188 texts, the earliest published in 1965 and the most recent in 2011.

The fundamental insight from our analysis is that, over the last 50 years, the term “interprofessional collaboration” has not signified the same thing to all who use and apply the term. Different discourses of IPC exist and result in different truth statements, objects, and language. The two major discourses to emerge from our analysis are the “utilitarian” and “emancipatory” discourses (Table 1). We describe below the recognizable features of each discourse, including the truth statements each embodies, the objects each creates, and the language each employs. We also illustrate the spectrum that exists within each discourse and the nuances possible within its truth statements. Importantly, although these two discourses are distinct, they are not mutually exclusive; in fact, a subset of our archive invokes both. Finally, we do not imply that these discourses are the only discourses of IPC in published literature nor that all literature on IPC contributes to or exists within one or both of these discourses.

Table 1
Table 1:
Emancipatory and Utilitarian Discourses Within the Peer-Reviewed Literature on Health Care Delivery and Medical Education Interprofessional Collaboration (1960–2011)

Utilitarian discourse

Truth statements.

The central truth statement in the utilitarian discourse is that IPC is necessary because it produces better patient care and improves patient outcomes. A related but less overt truth statement is that the utility of IPC can and should be demonstrated through positivist, experimental research; hence, IPC is a valuable innovation only if it can be empirically shown to improve “outcomes,” ideally through randomized controlled trials.

Language and objects.

The utilitarian discourse is evident in the emergence of formalized interactions between organized medicine and nursing groups, which create the conditions for new language and objects to emerge. Such interactions include proceedings and recommendations from conferences cosponsored by the American Medical Association and the American Nursing Association (starting as early as 1964). The titles, objectives, and content of each of the conferences cast IPC within a utilitarian framework: the 1965 conference, for instance, was titled “Nurse–physician collaboration toward improved patient care.”33

These conferences were followed by the establishment (in 1972) of a National Joint Practice Commission (NJPC) to promote “quality health care.” The principal objectives of the NJPC further promoted the utilitarian discourse of IPC by instigating a number of hospital “demonstration projects” that implemented and reported the benefit of IPC practices.34–44

In line with this positivist ethos of “demonstration,” a body of literature has emerged breaking collaboration down into characteristics or mechanics, testing its association with clinical outcomes, and tracing causality through studies aimed at distilling the “necessary” aspects of collaboration for improved outcomes. Bates,34,45 an early and influential researcher in this field, set the tone for language in this discourse by emphasizing “effective team functioning” and “the importance of physician–nurse relations to patient care.” Indeed, the very use of the term “demonstration” in the NJPC’s original demonstration projects suggests that a utility or benefit is to be demonstrated and that, in the absence of such demonstration, IPC could be abandoned.

In line with this language, a central object enabled by the utilitarian discourse is the IPC interventional trial. The early interventional trials, failing to conclusively demonstrate “impact,” spurred the refinement and implementation of additional trials, each seeking to demonstrate the utility of IPC more conclusively, often through a better trial design. Prominent examples include Knaus and colleagues,36 who reported that predicted mortality was inversely correlated to self-reported “coordination of care” in intensive care units. This influential report (cited 1,329 times by June 7, 2013, according to Google Scholar) encouraged further efforts to demonstrate the links between IPC and “hard” patient outcomes.37–39

In the last 10 years (2002–2011), 22 randomized controlled trials of IPC were indexed in PubMed, of which more than a third were published in the last two years. The proliferation of interventional trials has produced another object of the utilitarian discourse: measurement tools designed to track the relationship among IPC practices and system and patient outcomes.3,46

As the interventional trial and its measurement tools have proliferated, another object, with its associated language, has emerged: the systematic review of IPC, published as early as the 1960s42 and continuing unabated.47 The systematic review is a powerful example of how a discourse creates objects through its truth statements and how these objects, in turn, consecrate the discourse by defining acceptable knowledge. Using language such as “rigor,” “methodological quality,” and “evidence,” systematic reviews reinvest the interventional trial with power even as they critique the vast utilitarian literature made up of hundreds of published studies. The authors of a recent Cochrane review deemed only five studies “valid,” and all five of these are interventional trials,44 themselves a function of the utilitarian discourse of IPC.

In summary, the utilitarian IPC discourse constructs the process of team practice in the clinical setting as a tool for better health care outcomes. In doing so, the utilitarian discourse enables certain objects and language and legitimizes particular forms of knowledge as acceptable.

Emancipatory discourse

Truth statements.

The central truth statement in the emancipatory discourse is that IPC is necessary because it is a means to diminish medical dominance. This truth statement is situated in the premise that health care delivery has long been compromised by the dominance of physicians and the medical paradigm. Hence, common among all the papers evidencing the emancipatory discourse is a leveling of the professional field away from the dominance or leadership of medicine.

Language and objects.

Like the utilitarian discourse, the emancipatory discourse enables certain language and gives rise to specific objects. In the textual archive, this discourse is strongly represented in particular genres such as opinion pieces, editorials, sociologic works, and qualitative research centering on individual experiences.

Whereas the language within the utilitarian discourse is relatively uniform, the language in the emancipatory discourse covers a wide spectrum. At one end, papers have a tone of confrontation, hostility, or militancy, and they use language consistent with this tone. The common genre at this end is the editorial or opinion piece,48 marked by exclamatory or imperative statements. These papers characterize medicine–nursing relations as rooted in “deception, paternalistic hostility and blatant sexism,”49 and they describe medicine as having “an ethic of domination,”50(p39) as promoting “subservience and [the] second class status of nurses,”51(qtd p729) and as generally acting dictatorially toward other nonmedical, health professions.52,53

To illustrate, Friedson’s 1970 sociological description of “medical dominance” in the division of health care labor has had broad uptake, engendering “a body of literature … exploring the structural components contributing to the subordination of the allied health professions.”54(qtd p173) Although this language is less hostile, it retains a confrontational flavor in its explicit challenge of the distribution of power across the professions. Arising from the body of work at this end of the spectrum is the assertion of the notion of IPC as a tool for “flattening the hierarchy” in health care.8,11,55–57

Not all texts in the emancipatory discourse take as strong a stance as those at the confrontational end of the spectrum. One highly influential paper that straddles the continuum between confrontation and conciliation is Stein’s58 “Doctor–nurse game,” in which Stein describes the interaction between nurses and physicians as a classic game with specific rules. The game metaphor still implies confrontation, but it portrays a less oppositional stance than metaphors of “domination” and “liberation.”

At the opposite end of the emancipatory discourse spectrum, the language becomes more neutral, invoking less antagonism and less personal investment. Empirical papers are the most common genre at this end of the emancipatory spectrum; most papers explore IPC through primary research, including interviews and fieldwork, or through concept analyses.9,10,24,59 Power remains a central theme in these texts, which construct IPC as overcoming a power differential; however, their overall tone is more declarative and descriptive than imperative and exclamatory. One author, Rose,60 provides an example of the former, more descriptive tone in a review of the definitions of IPC. She writes that IPC “implies sharing, partnership, interdependency, but also power. Many barriers to successful interprofessional collaboration exist, including problematic power dynamics.”60(p6)

Texts at the nonconfrontational end of the emancipatory spectrum are much less overt about the issue of power leveling, but it is often convincingly portrayed nonetheless. For instance, the term “nonhierarchical” suggests an emancipatory stance without invoking the potential resistance associated with the language of dominance and liberation. In fact, texts taking this more subtle stance often use the concept of nonhierarchical working relationships without ever explicitly mentioning the group that must give up power for such relationships to be possible: medicine. In her analysis of Baggs and Schmitt’s61 original use of “nonhierarchical” to define an element of IPC, Taylor55(p66) notes:

It is immediately apparent that whilst patients and nurses gain from collaborative practice according to this summary, doctors are not mentioned. It seems feasible that Baggs and Schmitt have either assumed that the medical staff will focus upon better patient outcomes as reason enough to support collaboration, or that they have marginalized the medical staff.

Objects created within this emancipatory IPC discourse are distinct from those in the utilitarian IPC discourse, even if they share superficial similarities. For example, literature reviews are present at this end of the emancipatory spectrum, but they differ importantly from those falling within the utilitarian discourse. Literature reviews classified as emancipatory characterize a flat hierarchy as a sine qua non of IPC, almost irrespective of the empirical findings of the review.8,11,55 For example, Taylor55 reviewed the literature for definitions of IPC and reported little empirical evidence indicating that common definitions of IPC included a purported benefit for patient outcomes; nevertheless, she uses the little evidence supporting this definition to uncritically define IPC as a “nonhierarchical” working arrangement for doctors and nurses.

The emancipatory discourse has produced other objects besides peer-reviewed papers. One is the “shared leadership model,” a model for administering clinical units that draws on both nursing and physician leadership.62 Another is the “magnet hospital” designation,63–67 granted by a nursing accrediting body to hospitals deemed exceptional, as measured by, among other factors, their collaborative work structures. Finally, the emancipatory discourse enabled its own set of measurement tools, rooted in ideas of hierarchy and power. One example is the Jefferson Scale, developed by Hojat et al,68 which is based on an “attitudes towards nursing” survey and the culture, organization, and management in the intensive care unit.69

In summary, the emancipatory discourse constructs IPC as a corrective for the domination of nursing by medicine. The papers falling within the emancipatory discourse represent a spectrum, ranging from opinion pieces and editorials that employ imperative, exclamatory, and confrontational language to papers that use empiricist approaches, nonconfrontational language, and a more covert positioning of the power-leveling agenda.

Discussion

We have identified two prominent discourses in the literature on IPC—utilitarian and emancipatory—each of which constructs IPC in different ways and makes possible certain objects and language.

The utilitarian discourse is expressed through randomized trials, before-and-after comparisons, meta-analyses, measurement tool validations, and systematic reviews. It gives rise to the language of “outcomes,” “evidence,” “proof,” and “utility” in relation to IPC. This language signals the epistemological stance of positivism, which makes possible the search for truth. Consistent with the Foucauldian conception of power/knowledge, this discourse legitimizes and delegitimizes certain knowledge, by setting standards of “rigor” and “validity” for interventions.

Interestingly, as the utilitarian discourse constructs IPC as a tool to achieve better-quality care, scholars drawing on this discourse can investigate the “truth” of such claims, opening up the possibility of concluding that IPC is not effective at producing better patient care. Recently, the authors of a systemic review asked, “What is so great about collaboration?”70 suggesting that the positivist stance of the utilitarian discourse may carry within it the seeds of its own demise.

The emancipatory discourse constructs IPC as a means of empowering health professions that are traditionally subordinate to medicine in the health care division of labor: namely, in our review, nursing. This discourse emphasizes the issue of power and the goal of flattening the power hierarchy; it elaborates its own set of objects such as “shared leadership models” and tools for “measuring” IPC that are rooted in theories of conflict and power. Epistemologically, the stance of this discourse is critical and constructivist: IPC is viewed as being able to reshape a social reality in need of radical change.

Our results suggest an intriguing answer to the question that motivated this study: No, there is no clarity on what constitutes IPC. At a minimum, the presence of two dominant discourses suggests that we health care practitioners and medical educators may not all be talking the same language, or sharing the same purposes, when we invoke the term “interprofessional collaboration.” Even more concerning, our purposes may be in direct conflict, and our progress stymied unless we expose this conflict for critical reflection and debate.

Interestingly, almost 30 years ago, in an historical analysis of health care teams, Brown1 pointed to the presence of different types of language used to describe teams. Although he does not characterize these in terms of discourses, nor trace their impact in terms of producing truths, objects, and language in health care, he does make the following observation which resonates with our findings: “It may take the discussants quite some time to realize that a multilevel transaction actually took place during team talk and that neither party fully understood or agreed with the other.”1 Brown’s point—that we may be talking at cross-purposes and not realizing it—is hammered home in a recent review by Lurie and colleagues,71 who assessed medical education’s progress in measuring the competencies. In discussing the failure of attempts to measure the Accreditation Council for Graduate Medical Education (ACGME) competencies in a robust and valid manner, Lurie et al conclude that the question at stake is not so much the nature of the psychometrics as it is the nature of the constructs themselves, which medical educators are trying to measure. They argue that these constructs (e.g., professionalism and collaboration) are the product of political and social compromises between disparate forces—that, in essence, they do not objectively exist but are ideas whose definitions are dictated by societal forces, and that it is no wonder that physician educators struggle to create valid measurement tools to capture these ideas. Our analysis of the two dominant discourses underpinning IPC offers rich insight into the very problem Lurie and his coauthors have identified.

Our results also show that the relationship between the utilitarian and emancipatory discourses is neither a developmental trajectory—one does not replace the other in time—nor a simple binary opposition. Rather, as Hodges72 found with the discourses of competency, and as Martimianakis and Hafferty73 discovered with the discourses of global physician competency, the two IPC discourses we identified interact in various and complicated ways. For instance, papers at the less confrontational end of the emancipatory spectrum may be infused with utilitarian language; that is, they may emphasize the power-leveling aspects of IPC while suggesting associations between power leveling and benefits for patient care.

The findings of this CDA suggest that clinicians and educators involved in IPC initiatives may find acknowledging the existence and legitimacy of both discourses useful. Likewise, they may find value in considering the underlying societal forces that inform each of them. Consciously asking, Are we all on the same page? may help articulate and negotiate the tensions that currently underpin—and limit—IPC efforts.

Our work focused on a specific body of literature, mostly nurse–physician interactions in Canadian, U.S., and British contexts. These discourses may not be as dominant—or other discourses may be foregrounded—in a textual archive that includes literature from outside these three places and that extends beyond nurse–physician collaboration. Also, undoubtedly, our appreciation of these discourses would be refined by the inclusion of a more varied corpus of artifacts, including interviews with IPC leaders, organizational vision documents, and—most interesting perhaps—the architectural and technological structures that have grown up around IPC in recent decades.

Notwithstanding these limitations, however, our results raise important and pressing questions for health professional practitioners and educators. What “version” of IPC do existing training programs purport to teach—a utilitarian or an emancipatory one? To what extent does the CanMEDS Collaborator role3 or the ACGME systems-based practice competency74 reflect a utilitarian or emancipatory discourse—or both? Are we physician educators clear on which kinds of collaborative practices (those oriented towards utility or those oriented towards emancipation) we are trying to assess when we complete the collaborator dimension on in-training evaluation reports for trainees? Specifically, given the pervasiveness of 360-degree assessments and the use of feedback-dependent in-training evaluation forms, do we truly agree on what is being assessed? And, perhaps most pressing given its enormous popularity in current health professional curricula, how does IPE reflect these two discourses? When educators from nursing, medicine, pharmacy, social work, and other health professional programs sit down together to design and implement IPE initiatives, how are the two IPC discourses interacting, visibly and invisibly, and how does this interaction shape the nature and eventual success of IPE?

Our discourse analysis opens up the possibility that these are not straightforward, self-evident conversations, and that, when multiple discourses are in play, those using them need to attend to their intersection and their impact on the educational practices that emerge.

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