Medical Education 1992, 26, 4 2 7 4 2 8
Editorial Int erprofessi onal edwcation Given the challenges faced by the many different professionals who work in health and community serviccs, good collaboration bctwccn them might be assumed, if only for mutual support. It is, of course, often achicvcd, but daily experience and systematic studies alike suggest that this is not always so. For instance, a primary care study involving pairs of general practitioners and district nurses, from a national sample, showed that only 20% of them were working in ‘partial’ or ‘full’ collaboration. Thcsc were the upper two levels of a five-point scale defining degrees of collaboration. In the same study the figure for pairs of general practitioners and health visitors was 11% on the same scale (Gregson et al. 1991). It is a widespread assumption that education about the work of other professions and education together can contribute to better collaboration between their members. Woodhouse & Pengelly, in a recently published book (1991), describe a 3-year experiment in education together. O n behalf of the Tavistock Institute of Marital Studies, they conducted workshops in one of the home counties for groups derived from mixcd disciplines (gencral practitioners, hcalth visitors, marriagc-guidance counsellors, probation officers and social workers). The group members were cstablishcd workers, as aware as any others of thc nccd to collaboratc. Thc workshops concentrated on marital problems. Their objcct was to study working partncrships between practitioncrs from different disciplincs and from different agcncics, alongside their capacity to rcspond to
marital conflict or related family problems as these aflktcd their primary tasks. The rnethod of these workshops was derived from one long familiar to gcneral practitioners in ‘Balint’ groups - the presentation of a problem case by an individual worker experiencing difficulty; discussion; follow-up in repeatcd discussions within a group whose members have come to know and trust each other. The difference was in the special emphasis on couples in conflict and, above all, the frequent need in this context to collaborate with people in other professions. It is the difficulty and avoidance of collaboration which stand out in the cases described in this book. Barriers to collaboration arc of many sorts ignorance, different trainings, different languages, different purposes and different status, expressed through tasks or pay. Woodhouse & Pengelly’s work points to something more fundamental, but more difficult for people to reveal or even recognize - the barrier created by uncertai.nty, insecurity and anxiety arising in the course of their essential work. These feelings the inevitable experience of anyone dealing with people 1.n trouble - and defences set up against them, often unconsciously, can and do distort their dedings with colleagues. Paradoxically, the more stressful the primary task with patients and clients, the more difficult is collaboration; impediments operate at all levels of the system involved - personal, working group and the larger organization or profession. Marital problems or child abuse, intrinsically matters of conflict, raise anxiety in professional worker:s with unusual frequency, along with disagreement about what actions should be taken. They illustratc particularly clcarly the difficulties of collaboration. But the same sort of difficulties arise in many other ‘clinical’ contexts. If thcsc are common experiences for all who work directly with patients or clients, they
Correspondence: Dr John Hordcr, T h e Centre for the Advancement of Interprofessional Education in Primary Health and Community Care, Department of Social Science and Administration, The London School of Economics, Houghton Street, London WC2A 2AE, UK.
427
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Ed i t o ri n I
rcsonate also within the professional bodies which educate and support them. Practitioners may turn to them when they feel inadequate o r uncertain in their professional identity. But professional bodies educate and support only their o w n . Their established cultures embody forms of defence against the predominant anxiety inherent in the tasks of each. Separate professional educations are the rule. They havc not always, o f course, ignored the need to reconimend collaborative behaviour. But this is not enough to prevent defensive reactions when individual professionals feel inadequate o r when members o f a professional group sense a threat to their corporate identity. Separate educations are more likely to promote such reactions than prevent them. These authors describe one experiment in education together. There arc many others in this country. Their distribution and some o f their characteristics were identified 4 years ago by the Institute of C o m m u n i t y Studies, o n behalfofthe Centre for the Advancement o f Interprofessional Education (Shakespeare et a!. 1989; Horder 1992). Most wcrc small and brief, but one intcrprofessional M S c course (at Exeter) had a duration o f 2 years. This is n o w no longer the only comparable large initiative. A new survey is needed because interest in interprofessional education has been increasing (a repetition o f the survey is being planned). What is also needed n o w is evidence whether these initiatives - particularly the niajor experinients - help to bridge the gaps o r prevent gaps
from forming, which separate cducations havc helped to create. Do they succeed in changing professional attitudes o r the behaviour of employing organizations, increasing collaborative behaviour o r benefitting patients and clients? Existing evidence is inadequate. While in no doubt about the advantages of‘ interprofessional education for experienced practitioners, Woodhouse and Pengelly conclude that neither this nor better procedures will prove sufficient to improve collaborative practice unless agencies develop ways of managing inescapable anxiety less defensivcly .
References Grcgson B . A . , Cartlidgc A. 8: Bond J . (1991) Iriferprc+ssiona/ Educatiori iw Prirnary Health Carc 0 p n i . s afioris. Occasional Paper 52. Royal College of General Practitioners. London. Horder J. (1992) A national survey which needs to bc repcated. journal ~!fIrirrrproic.ssiorin/Care 6, ( 5 7 1 Shakespeare H . , Tucker W. 8: Northovcr J . (1989) Report o f a ,Vatiorin/ Sirrury (iti Irircrpryfissiorral Edrrcatiori irr Primary H d h C u r r . (Obtainable from the Centre for the Advancement of Interprofessional Education in Primary Health and Comniunity Care at the London School of Economics, London WC2A 2AE.) Woodhouse D. & I’engelly P . (1991) Arixiety arid r k c Dyriamics cf Co//ahoratiori. Aberdeen University Press, Aberdeeii. Distributed by Karnac (Books) Ltd, 56-58 Gloucester Road, London SW7 4QY,
UK. DlIJOI IN Hol?DEI
Editorial Int erprofessi onal edwcation Given the challenges faced by the many different professionals who work in health and community serviccs, good collaboration bctwccn them might be assumed, if only for mutual support. It is, of course, often achicvcd, but daily experience and systematic studies alike suggest that this is not always so. For instance, a primary care study involving pairs of general practitioners and district nurses, from a national sample, showed that only 20% of them were working in ‘partial’ or ‘full’ collaboration. Thcsc were the upper two levels of a five-point scale defining degrees of collaboration. In the same study the figure for pairs of general practitioners and health visitors was 11% on the same scale (Gregson et al. 1991). It is a widespread assumption that education about the work of other professions and education together can contribute to better collaboration between their members. Woodhouse & Pengelly, in a recently published book (1991), describe a 3-year experiment in education together. O n behalf of the Tavistock Institute of Marital Studies, they conducted workshops in one of the home counties for groups derived from mixcd disciplines (gencral practitioners, hcalth visitors, marriagc-guidance counsellors, probation officers and social workers). The group members were cstablishcd workers, as aware as any others of thc nccd to collaboratc. Thc workshops concentrated on marital problems. Their objcct was to study working partncrships between practitioncrs from different disciplincs and from different agcncics, alongside their capacity to rcspond to
marital conflict or related family problems as these aflktcd their primary tasks. The rnethod of these workshops was derived from one long familiar to gcneral practitioners in ‘Balint’ groups - the presentation of a problem case by an individual worker experiencing difficulty; discussion; follow-up in repeatcd discussions within a group whose members have come to know and trust each other. The difference was in the special emphasis on couples in conflict and, above all, the frequent need in this context to collaborate with people in other professions. It is the difficulty and avoidance of collaboration which stand out in the cases described in this book. Barriers to collaboration arc of many sorts ignorance, different trainings, different languages, different purposes and different status, expressed through tasks or pay. Woodhouse & Pengelly’s work points to something more fundamental, but more difficult for people to reveal or even recognize - the barrier created by uncertai.nty, insecurity and anxiety arising in the course of their essential work. These feelings the inevitable experience of anyone dealing with people 1.n trouble - and defences set up against them, often unconsciously, can and do distort their dedings with colleagues. Paradoxically, the more stressful the primary task with patients and clients, the more difficult is collaboration; impediments operate at all levels of the system involved - personal, working group and the larger organization or profession. Marital problems or child abuse, intrinsically matters of conflict, raise anxiety in professional worker:s with unusual frequency, along with disagreement about what actions should be taken. They illustratc particularly clcarly the difficulties of collaboration. But the same sort of difficulties arise in many other ‘clinical’ contexts. If thcsc are common experiences for all who work directly with patients or clients, they
Correspondence: Dr John Hordcr, T h e Centre for the Advancement of Interprofessional Education in Primary Health and Community Care, Department of Social Science and Administration, The London School of Economics, Houghton Street, London WC2A 2AE, UK.
427
328
Ed i t o ri n I
rcsonate also within the professional bodies which educate and support them. Practitioners may turn to them when they feel inadequate o r uncertain in their professional identity. But professional bodies educate and support only their o w n . Their established cultures embody forms of defence against the predominant anxiety inherent in the tasks of each. Separate professional educations are the rule. They havc not always, o f course, ignored the need to reconimend collaborative behaviour. But this is not enough to prevent defensive reactions when individual professionals feel inadequate o r when members o f a professional group sense a threat to their corporate identity. Separate educations are more likely to promote such reactions than prevent them. These authors describe one experiment in education together. There arc many others in this country. Their distribution and some o f their characteristics were identified 4 years ago by the Institute of C o m m u n i t y Studies, o n behalfofthe Centre for the Advancement o f Interprofessional Education (Shakespeare et a!. 1989; Horder 1992). Most wcrc small and brief, but one intcrprofessional M S c course (at Exeter) had a duration o f 2 years. This is n o w no longer the only comparable large initiative. A new survey is needed because interest in interprofessional education has been increasing (a repetition o f the survey is being planned). What is also needed n o w is evidence whether these initiatives - particularly the niajor experinients - help to bridge the gaps o r prevent gaps
from forming, which separate cducations havc helped to create. Do they succeed in changing professional attitudes o r the behaviour of employing organizations, increasing collaborative behaviour o r benefitting patients and clients? Existing evidence is inadequate. While in no doubt about the advantages of‘ interprofessional education for experienced practitioners, Woodhouse and Pengelly conclude that neither this nor better procedures will prove sufficient to improve collaborative practice unless agencies develop ways of managing inescapable anxiety less defensivcly .
References Grcgson B . A . , Cartlidgc A. 8: Bond J . (1991) Iriferprc+ssiona/ Educatiori iw Prirnary Health Carc 0 p n i . s afioris. Occasional Paper 52. Royal College of General Practitioners. London. Horder J. (1992) A national survey which needs to bc repcated. journal ~!fIrirrrproic.ssiorin/Care 6, ( 5 7 1 Shakespeare H . , Tucker W. 8: Northovcr J . (1989) Report o f a ,Vatiorin/ Sirrury (iti Irircrpryfissiorral Edrrcatiori irr Primary H d h C u r r . (Obtainable from the Centre for the Advancement of Interprofessional Education in Primary Health and Comniunity Care at the London School of Economics, London WC2A 2AE.) Woodhouse D. & I’engelly P . (1991) Arixiety arid r k c Dyriamics cf Co//ahoratiori. Aberdeen University Press, Aberdeeii. Distributed by Karnac (Books) Ltd, 56-58 Gloucester Road, London SW7 4QY,
UK. DlIJOI IN Hol?DEI
