How and where clinicians exercise power: Interprofessional relations in health care
Introduction
At least until the 1980s, medicine maintained a relative position of autonomy from external evaluation, while wielding authority over other occupations in the health division of labor (Willis, 2006). In terms of authority and status, in the English-speaking countries, at least, medicine has largely resisted attempted incursions into its scope of practice, and largely retains its power base (e.g., Allsop, 2006, Bourgeault and Mulvale, 2006, Boyce, 2006). In the sphere of localized interaction, where this study lies, communication has been shown to be terse and uni-directional (Reeves et al., 2009), and collaboration by autonomous clinicians has been shown to be selective, happening on a case-by-case basis, largely at the discretion of medicine (e.g., Salhani & Coulter, 2009). The patterns that constitute such power have been framed as “medical dominance” (Freidson, 1988[1970], Willis, 2006).
To enhance patient outcomes, reduce burgeoning costs of providing health care and to compensate for staff shortages, governments and health services in Australia, the UK and elsewhere, have created incentives for establishing teams, sharing roles, power and responsibility for care, comprised of clinicians from various occupations (e.g., NHS Executive, 1998). The desire for collaboration has been framed as interprofessional learning (IPL) and interprofessional practice (IPP) (e.g., Braithwaite et al., 2007).
The progress of patient pathways through a health service requires coordination, or management (Komet, 2001). This study uniquely deals with the tension between the perceived need for patient management, and calls for patient care to be delivered collaboratively (e.g., Gröne & Garcia-Barbero, 2001). Collaboration is a process of positively communicating among clinicians to address client needs (following Abramson & Mizrahi, 2003). A key component of collaboration is the relative autonomy of clinicians over their scope of practice to deliver patient care. We define patient management as the coordination of patient care. It inevitably involves the use of power. Relatively few studies have focused on the in situ interactions among clinicians in different occupations (e.g., Reeves et al., 2009). Therefore, we appeal to a more nuanced interpretation of power than typically afforded by medical dominance, which emphasizes conflict (Lewis, Heard, Robinson, White, & Poulos, 2008). Power can be diverse and distributed, rather than uni-directional and static, and can be negotiated and used tactically and strategically (de Certeau, 1984), as has been demonstrated in health care (Salhani & Coulter, 2009). Power is a competency that can be viewed as positive, productive and cooperative (Hartsock, 1983), in contrast to a zero-sum, competitive interpretation of power, characterized by discussion of the re-distribution of power (e.g., Fitzgerald, Mark, & McKee, 2007). Accordingly, our study elaborates a distinction between “competitive power” and “collaborative power”.
An alternative perspective on health systems to the conflictual emphasis of medical dominance, and that aligns with a disbursed and situated notion of power, is the perspective that the health system is a “negotiated order”. Strauss, Schatzman, Ehrlich, Bucher, and Sabshin (1963) argued that the way treatment and care are organized only partly derive from “rules” and the unfolding pathology of the patient, but are also the product of continual negotiation, in interaction, by the players involved in the exercise of agency and the simultaneous creation of a relatively stable hospital “order” (Strauss et al., 1963).
Negotiated order reflects the central tenets of the theory of symbolic interactionism, outlined below, and was tailor-made to characterize social life in health services. Social orders include structural influences on relations between professions, such as the broader institutional and policy framework (Martin, Currie, & Finn, 2009). In the relatively structured environment of a workplace, new staff enter communities which have relatively stable orders in terms of roles and identities (Strauss et al., 1963). Actors choose from a repertoire of what are acceptable actions and responses, befitting role expectations, under particular circumstances. These constitute patterns of influence, or power, over them of which they might not be aware. What they choose to say or do may resist or challenge this pattern, expanding the repertoire, but also possibly expanding the conditions of influence over their fellow interactants, and themselves in other times and places. Such influence extends even to those outside of their sphere of interaction but part of interconnected discursive communities (Katovich & Maines, 2003). Because the character and extent of mutual influences interaction is often unknown, negotiated orders of power can exist in spite of the benevolent attitudes or intentions of individual actors (Nugus, 2008).
Previous studies have engaged a negotiative perspective on the ordering of health care. The association between professions and their work – their “jurisdictions” – are actively negotiated to deliver a patterned order of role relations in an interdependent system (Abbott, 1988). The development and even the definition of teams, their internal distributions of power, and boundary demarcation between occupations and teams, are dynamic, contextual and negotiated (e.g., Allen, 1997, Griffiths, 2008). Broader patterns of inequality and domination have been found and reinforced in self-monitoring teams (Barker, 1993), constituted in interactions within teams, and are sourced from and have consequences beyond the immediate interactive environment (Finn, 2008).
In this study we aimed to discern how clinicians exercise power. Previous studies have engaged a negotiated order perspective to examine health occupational relations (e.g., Reeves et al., 2009). A negotiated order perspective is uniquely engaged in this study to account for the possible co-existence of agency and structural influences, evident in competitive and collaborative power. Having been examined in a limited range of settings, the interactive, negotiated orders of health care need to be tested across a variety of health care settings (Reeves et al., 2009). The settings offered by a whole health system are systematically diverse. Therefore, if negotiated order is to account for the way power is exercised, it needs to be tested across multiple settings to show whether or not the exercise of either competitive or collaborative power manifests in a particular pattern across various settings of a health system.
Section snippets
Methods
The data for this study were derived from a multi-method action research project investigating IPL and IPP across a health system, tertiary education providers and professional organizations. The study was conducted within a politically bounded Australian state/territory and was conducted by external researchers (Braithwaite et al., 2007, Greenfield et al., 2010). The current study presents data from the benchmark audit of IPL and IPP within the health services, conducted in 2008.
The research
Modes of patient management
The exercise of power was associated with patient management, and was different from acute to community settings. Patient management across settings aligns with variations in the use of competitive and collaborative power across the health system. Patient management involves guiding patients through the following phases in their care trajectories: presentation or referral to a service; assessment; diagnosis; admission; treatment; engagement for advice or shared care of clinicians from various
Discussion and conclusion
This study contributes a unique exposition of negotiated order across different but comparable sites. Health care staff are part of a negotiated order which is maintained, reinforced, and sometimes challenged, in interaction (Strauss et al., 1963). The significance of combining a multi-setting study across a bounded health service with a negotiated order perspective was to show the co-existence of competitive and collaborative power in health services. While a medical dominance perspective
Acknowledgement
This research was supported under Australian Research Council’s Linkage Projects funding scheme (project number LP0775514).
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