http://informahealthcare.com/jic ISSN: 1356-1820 (print), 1469-9567 (electronic) J Interprof Care, 2014; 28(3): 206–211 ! 2014 Informa UK Ltd. DOI: 10.3109/13561820.2014.890580
THEMED ARTICLE
Securing intersubjectivity through interprofessional workplace learning experiences Stephen Richard Billett Education and Professional Studies, Griffith University, Brisbane, Australia
Abstract
Keywords
Effective interprofessional work is premised on high levels of shared understandings (i.e. intersubjectivity) among those who are co-working. In particular, when quick or seemingly spontaneous responses are required for urgent or immediate action, what is termed as ‘‘shared intuition’’ is highly desirable. Much of the required intersubjectivity can arise ordinarily through everyday healthcare collaborations, such as through joint problem-solving. Yet, a concern is how best to develop these capacities in circumstances when co-working is temporary, fleeting and partial, and also when the goals to be achieved are ambiguous and uncertain, and the processes indeterminate. To achieve the kinds and levels of intersubjectivity required for these non-routine forms of care and intermittent interprofessional working, therefore, likely requires particular curriculum and pedagogic interventions within practice settings. These interventions may be used to shape the organisation and sequencing of experiences for interprofessional work through which can arise a foundation of shared understanding of concepts, procedures and values. Yet, to assist the articulation, sharing, appraising and elaborating shared disciplinary and personal-professional positions, values and procedures, specific pedagogic interventions may also be required, albeit their exercise being embedded in co-working practices in healthcare work activities.
Co-working, experiences, interprofessional working, inter-psychological processes, inter-subjectivity, shared intuition, workplace learning
Providing healthcare is often inherently interprofessional work. It frequently requires physicians, nurses and other health professionals to work together collaboratively and effectively in addressing patient needs. Sometimes, this collaboration is in routine healthcare provisions, where roles and relationships are as well-defined as the procedures being enacted. In other circumstances, such as emergency medicine, intensive care, trauma, etc., however, co-working occurs under conditions that are dynamic, where goals and processes are non-routine, unclear, multi-parted and outcomes are unpredictable. Also, in these circumstances, those co-working can also constantly change, as some staff will be engaged only fleetingly, and may have their time distributed across numbers of patients. Therefore, this collaboration is often temporary; comprising combinations of interprofessional engagements extending across occupational hierarchies and distinct professional cultures (Hall, 2005). Such working arrangements are not adequately explained by concepts such as communities of practice (Lave & Wenger, 1991) as there are limited opportunities to form and sustain such a community. Participation is based on other premises than progression to full-participation in a community of practice. Yet, regardless of these complexes, attempts to improve the capacities for interprofessional now appear warranted. The evidence is beginning to suggest that key healthcare goals, such as the effective organisation of care, arise from collaboration (Reeves, Correspondence: Stephen Richard Billett, Education and Professional Studies, Griffith University, Brisbane, Australia. E-mail: s.billett@ griffith.edu.au
Received 14 January 2013 Revised 29 January 2014 Accepted 29 January 2014 Published online 26 February 2014
Goldman, Burton, & Sawatzky-Girling, 2010; Reeves, Perrier, Goldman, Freeth, & Zwarenstein, 2013). Manser (2009) similarly concludes that improvements in healthcare performance are more likely based on better communication, co-ordination and inclusion, than on enhanced clinical skills. That is, through improving co-working capacities. Categories of these capacities include: (i) personal qualities and commitment of staff; (ii) communication within the team; and (iii) development of creative working methods that are contingent upon and relational to the qualities of collaborative practices (e.g. Molyneux, 2001; O’Keefe, McAllister, & Stupans, 2011). This evidence suggests that initial and continuing healthcare professional education should include experiences that focus on or emphasise developing capacities required for effective interprofessional work, and these educational provisions warrant being guided by robust macro and micro level precepts and concepts (Reeves & Hean, 2013). One such micro-level explanation is that high levels of intersubjectivity (i.e. shared understandings) are required amongst co-workers. This is particularly the case when quick or almost spontaneous responses (i.e. informed intuition) are needed, such when urgent action is required and where preempting co-workers’ actions may be critical. Therefore, high levels of intersubjectivity need to be secured for co-working in healthcare, and potentially extends to ‘‘shared intuition’’. That is, engendering intersubjectivity amongst those who are co-working to the extent that interprofessional care can be spontaneous, optimising conscious decision-making and correctly pre-empting how co-workers will need to act effectively. Here, the focus is on how to achieve these outcomes through using work activities and interactions as platforms for
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Introduction
History
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this professional development. Therefore, whereas the focus for initial and continuing professional education are usually about sustaining individuals’ occupational competence, securing career advancement or changing occupations, here the concerns and processes go beyond individual performance. Instead, they emphasise securing intersubjectivity as a means to improve co-working so that those almost spontaneous decision-making and action can occur and effectively. Yet, this is a tough developmental outcome to achieve. It is most likely secured through workplace activities and interactions where intersubjectivity can be promoted and interventions enacted to augment that development collectively as healthcare workers engage in co-working activities, including joint problem-solving. Taking up Reeves and Hean’s (2013) invitation to furnish theoretical premises for advancing interprofessional education, the proposition advanced in this article is that intersubjectivity is required for effective co-working and is reciprocally developing through this co-working. In advancing this case, the central role of intersubjectivity in co-working is elaborated first, followed by an account of how these attributes arise inter-psychologically (between social partners). Next, a framing of how this development can be understood within the context of interprofessional care is presented. Then, a set of curriculum and pedagogic practices that can be enacted in healthcare workplaces are advanced as means for securing these outcomes.
Conceptions: intersubjectivity, interpsychological and workplace experiences Intersubjectivity is defined by Rogoff (1990, p. 71) as ‘‘shared understanding based on a common focus of attention and some shared presuppositions that form the ground for communication’’. Earlier, Trevarthen (1980, p. 530) defines it more inclusively as ‘‘both the recognition and control of cooperative intentions and joint patterns of awareness’’. These two definitions are helpful, albeit focussing on understanding and awareness. Yet, intersubjectivity also extends beyond conceptual knowledge to shared procedural capacities and also values (i.e. shared ways of undertaking tasks and achieving common goals. Therefore, whilst shared understandings and awareness are essential and powerful foundations for effective co-working, they need to be complemented by shared procedures (i.e. how to do things) and dispositions (i.e. values, beliefs, interest). This is not to say that nurses need the same kinds and levels of understandings, procedures and beliefs as doctors, for instance, but that they share common procedural capacities and values required for effective inter-professional work. Securing intersubjectivity of these kinds does not necessarily require educational interventions, although in some circumstances these may be required (see below). It comprises an ordinary process of cognition and, one not restricted to humans. Whether referring to the ontogenetic virtualisation that baby and mother Orang-utans engage in when negotiating access to breast milk (Tomasello, 2004), apprentices’ learning through actively observing and imitating what and how skilled tradespersons perform (Singleton, 1989) or children securing the ambiguous process of trying to get a cookie (Baldwin, 1894), there is commonly an active process of comprehending what goals and processes direct others’ actions. Indeed, necessarily, much of engagement is about securing intersubjectivity. Newman, Griffin, and Cole (1989) noted that if individuals developed understandings in uniform ways from what they experience socially, there would be little need to communicate. Yet, because common understanding does not happen, we need to communicate with others to engage in socially-shaped activities. Indeed, key social constructivists Berger and Luckman (1967) note that there is no guarantee that
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what is suggested by the social world would be either projected in unambiguously or taken up in common ways. Hence, securing intersubjectivity is central to everyday human activity and is central to activities such as co-working. Perhaps this is never more than for interprofessional care, particularly when immediate joint decision-making and responses are required. Yet, its development requires both access to what needs to be learnt and a willingness to engage with it and in what can be contested working environments (Salhani & Coulter, 2009). Yet, everyday processes of interaction amongst humans provide opportunities for building intersubjectivity (Rogoff, 1990). They can provide a nuanced awareness of why co-workers have particular conceptions and preferred actions. Intersubjectivity also does not have some endpoint of complete shared understandings. It comprises an ongoing process through which similarities, commonalities and distinctive conceptions of knowledge and knowing can be made accessible, shared and comprehended. Nurses spending significant times with particular patients may come to know their sensitivities, concerns and reactions, in ways that fleeting visits from medical specialists may not, yet whose specialist knowledge provides insights that may not be apparent through nurses’ informed observation of patients. Consequently, the process of co-working permits these elements of intersubjectivity to be developed and elaborated through everyday acts of engagement, collaborative and shared activities and interactions. Moreover, it is vital when humans engage in co-working activities where misunderstandings and inconsistencies can have significant consequences, such as in healthcare. Therefore, as with Reeves and Hean’s (2013) call for better theorisations for interprofessional education, the same applies for the learning that comprises intersubjectivity, and these may most readily found broadly within psychology accounts. Inter-psychological processes informing intersubjectivity Intersubjectivity can most likely be best explained as arising through inter-psychological processes: those between individuals and social and brute worlds beyond them (Billett, 2006a). The majority of the knowledge individuals need to learn for engaging in socially derived purposes and practices, such as healthcare, come from outside of individuals: beyond the skin, so to speak (Wertsch & Tulviste, 1992). That knowledge arises and is transformed through history, culture, society and situations and is learnt by engaging (i.e. inter-psychologically) in occupational activities, with artefacts and more informed others (Billett, 2003). Intersubjectivity arises in similar ways. Through focused engagement with others, shared understanding, awareness and nuanced understanding about subjects’ positions and preferences arise and become refined and honed through their articulation, appraisal and ability to assess causal responses. The development of intersubjectivity needs to be seen as an interdependent and relational interpsychological process (Billett, 2006a). It is interdependent because the social world projects needs human actors need to understand its norms and enacts its practices (for instance, for healthcare to be practiced and further developed) and the actors need what the social world provides for them to learn about and practice that occupation. Without individuals’ constructive processes the social world would remain stagnant and moribund (Berger & Luckman, 1967). Therefore, there is interdependence between the person and the social world that underpins both learning and the remaking of cultural practices. However, that interdependence is relational. What for one individual will be a compelling and transformative learning experience, for another it might be quite routine, leading to reinforcement of what is known. Therefore, just as trainee doctors might find confronting the emergency room activities
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in large metropolitan hospital on a Saturday evening, the senior residents have become quite accustomed to the outcomes of behaviour (e.g. drunkenness, violence) which shapes their work on these evenings. Therefore, the same social experience or suggestion is construed and constructed (i.e. learnt) relationally by individuals. Therefore, interpsychological processes are not set and predictable, as with behavioural or automatic responses – they are situationally based and person-dependent. Therefore, subjectivity arises through both what learners experience and how they come to know or make sense of those experiences. Intersubjectivity arises through opportunities for subject’s constructions to be articulated, justified and shared. Given that, it is useful now to consider how intersubjectivity arises and can be promoted through workplace experiences. Workplace learning experiences: affordances and engagement Securing intersubjectivity associated with interprofessional work most effectively arises through opportunities for co-working. Importantly, when individuals engage in and complete work activities, two other legacies or changes arise. First, through engaging in work activities, individuals come to change what they know and do. This is called learning. It occurs continuously across our lives and is not reserved for or privileged by interludes in educational institutions or their programs. Sometimes, the learning that co-occurs with working can be quite incremental. For instance, through healthcare worker’s learning arising through refining and honing what they know or what they do or, what they value in their work activities (Billett, 2001a). In other circumstances, that learning can be transformational through engaging in activities which are wholly novel to these workers. These experiences open up or expose them to concepts, practices or values which are quite novel for them: new learning arises. Put simply, through engaging in goal-directed work activities and interactions, learning of different kinds arises (Billett, 2001a). However, not all of that learning might be described as being positive, ideal or even desirable. Bad habits, ill-informed practices can be learnt, as well as knowledge that empowers and extends what these workers come to know. Moreover, access to opportunities and support will be mediated by workplace relations and contestations both intra and interprofessionally (Salhani & Coulter, 2009). Hence, individuals’ learning of different kinds arises through everyday work activities and interactions as shaped by the particular sets of experiences that are afforded by the workplace settings in which they engage. Importantly, this work and learning necessarily co-occurs as workers engage in goal-directed occupational activities and interactions. It likely co-occurs most optimally when there are opportunities for individuals to articulate and justify their positions, and subject them to others’ appraisals. These opportunities arise through joint problem-solving, in everyday work practices, albeit sometimes augmented by particular kinds of intentionally organised experiences. Engagement in goal-directed activities, where goals need to be considered and identified as do the procedures for securing those goals such as addressing patients’ care can be a source of such learning, as in handovers, for instance. In this way, joint or co-working provides opportunities for perspectives and decisions to be articulated, appraised and decided upon. These activities also often provide the opportunity for monitoring the consequences of those decisions and actions, thereby providing bases for making causal associations and for refining and honing the procedures to be deployed. The second kind of change that co-occurs through individuals undertaking work activities is the remaking of professional practice. Professions are dynamic and continually evolve as
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requirements for their practice change (Billett, 2006b). They are also manifested in particular ways in specific circumstances which are subject to and respond to the workplace’s circumstances, actors, and changing work practices and technologies. Essentially, this remaking arises through practitioners engaging in occupational activities and interactions at a particular point in time and response to particular actors’ needs, activities and interactions. This is the process through which society sustains itself and is advanced (Scribner, 1985). Therefore, as healthcare practitioners engage in their daily work they are learning and also engaging in the process of remaking and transforming their occupational practice. When engaged in collaboration there is the prospect of bringing about the kinds of changes that systematic reviews of interprofessional education are emerging (Reeves et al., 2010, 2013). Therefore, for instance, the move now to have interprofessional care as a key element of health work generally requires collaboration by practitioners who may have previously been separated by traditions of practice, professional cultures and workplace hierarchies. This co-working may lead to this remaking of healthcare practice, through these new working arrangements. To further explain how intersubjectivity arises occurs in workplace settings, two interrelated concepts may be informative: affordances and engagement (Billett, 2001b). Affordances refer to the degree by which individuals are invited to participate and learn in a social setting. That is, granted the access to, engagement in and support when engaging in work activities and interactions. Affordances can be high, with individuals being included, guided and supported in their learning and provided with opportunities to learn new knowledge, and reinforce and hone what they have learnt through opportunities to practice and engage with more informed partners. Alternatively, in contested or fragmented work environments affordances can be quite low and limited in their invitational qualities. For instance, limited access to practice, short periods of time within clinical settings, being ignored or intimidated by co-workers and others are instances of low affordances that potentially restrict the extent of individuals’ learning, or in this instance generating intersubjectivity. It is also important to be reminded that particular categories of learning are likely to be generated by specific kinds of experiences. Hence, the kinds of experiences that workers are permitted to participate shapes what they learn. You cannot become effective with specific procedures (i.e. taking a temperature, auscultation, taking patients’ histories) without opportunities to practice, rehearse and by guided by experts. Hence, learning about other workers’ preferences or disciplinary positions or conceptions warrants experiences that require them to be articulated (i.e. stated). Therefore, workplaces afford a range of activities and interactions that, by degree, assist learning of different kinds and in different ways. The great prospect of interprofessional care is to afford rich learning experiences through its enactment. However, beyond affordances are bases by which individuals to elect to engage with what is afforded them. Even the most welcoming and supportive of the workplaces might be rejected by workers who are uninterested in engaging with and learning what is being afforded them. Conversely, through their efforts and tenacity, highly active and engaged individuals may be able to overcome the limitations of low workplace affordances (Billett, 2001b). Importantly, therefore, how individuals elect to engage in activities and interaction from which they might learn and secure intersubjectivity is central to those processes. Put plainly, this engagement and learning is partially person-dependent. What for one individual is a welcoming workplace, for another it might be construed as having low affordances. Studies of learning at and for work identify the centrality of learner agency through their engagement in goal-directed activities (just doing it),
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observation and listening (just being there), how they engage with more informed workers (i.e. direct guidance) and also utilising opportunities for practice to refine, hone and extends what they know (Billett, 2001a). Perhaps the most commonplace process of securing these outcomes across human history for occupational purposes is mimesis: observation, imitation and rehearsal. This process should not be dismissed as mindless mimicry. Instead, it comprises an active interpsychological process that humans use to comprehend, predict and act (Byrne & Russon, 1998). Indeed, it requires the capacity to come to understand empathically what the others will do and for what reasons, and then react to their actions. Yet, these are personally mediated. For interprofessional working and learning, the quality of participants’ engagement will be essential in providing opportunities for securing the kinds and levels of intersubjectivity required for co-working. It is particularly necessary for developing intersubjectivity in co-workers from distinct professional, with different roles and particular sets of concerns to be able to articulate and share their conceptions, values and procedures. This is particularly the case when there is the need to develop shared intuition: a level of intersubjectivity that allows more spontaneous and collaborative responses from co-workers. As proposed earlier, this kind of capacity can be developed through co-workers engaging in routine activities on a regular basis through interprofessional work. However, it is far more difficult to achieve when the co-working situation is temporary, interrupted, disjointed and partial. From the above, it can be seen that much of intersubjectivity with arise through everyday processes of individuals interactions with each other and the greater the extent and duration of that interaction, the more likely high levels of intersubjectivity will be achieved. However, given the particular need to promote high levels of intersubjectivity to secure shared intuition, the concern is that these may not be achieved through everyday interactions alone. These factors, plus the potentially diverse backgrounds and specialism’s of co-workers suggest there is a need for there to be structured experiences to support that development.
Curriculum and pedagogic practices promoting intersubjectivity To consider the intentional promotion of intersubjectivity it is helpful to consider two long-standing concepts albeit for these particular purposes: curriculum and pedagogic practices. Curriculum refers to the ‘‘course to follow’’ or ‘‘pathway of experiences’’ through which individuals learn. These concepts are highly consonant to learning through practice (Billett, 1996), including the kinds, sequence and duration of practice-based experiences comprising the workplace curriculum. Therefore, considerations for the organisation and ordering of experiences for the purpose of developing high levels of intersubjectivity can be associated with these curriculum practices. Beyond these orderings, are pedagogic practices that augment experiences such as those provided through engaging in co-working. In particular, where knowledge cannot easily be made accessible, openly articulated or shared, there may be a need to utilise particular pedagogic practices to promote that accessibility, articulation or sharing. There are also personal epistemological dimension. A key aspect of interprofessional working within professional development is that experienced healthcare practitioners, unlike novices, will have senses of selves or subjectivities associated with their occupations. Such subjectivities are important when engaging in shared and dialogic processes. It is difficult to form collaborative ties when one is unsure of one’s professional identity (Dombeck, 1997; Sims, 2011). The principles associated with engaging with workers from other professions and
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disciplines and, in the circumstances where this co-working needs to occur and use of specific pedagogic practices are discussed below. Curricula practices If not already occurring, it is necessary to secure opportunities for those who are to co-work to engage in working interprofessional. Some consideration might be given here to providing experiences, initially, where inter-professional engagement is incremental so that capacities such as intersubjectivity can be developed productively. For instance, this co-working might commence in activities that are routine. Such activities are often less demanding and urgent, yet may well provide a foundational experiences for interprofessional working through which shared relations, understandings and subjectivities are initially developed. Hence, aspects of interprofessional working which are frequently conducted might first be used as bases for developing intersubjectivity, including having access to more that on professional perspective. These affordances may well occur before individuals attempt to work interprofessionally in circumstances where levels of patient acuity, emergency or uncertainty are higher. Hence, as noted work activities such as when cases are reviewed, the planning and organisation of patient treatments, etc., may well provide initial co-working situations to secure levels of intersubjectivity. Then, increasingly, interprofessional working can be extended into work situations which are more critical and acute, and which require shared understandings to be applied effectively and consistently. There is nothing particularly novel here. This progression is a standard principle for curriculum planning and enactment (i.e. develop foundational knowledge and within learners’ readiness to progress). In practice-based curriculum, the progression is from engagement in activities that can tolerate the consequences of errors through to those activities where error cost is greater (Lave, 1990). This sequencing of experiences provides for incremental engagement and development of opportunities for developing capacities for interprofessional tasks that are openended and not predictable in advance. Yet, such co-working will comprise engaging in non-routine activities for some participants. The development of shared intuition requires lengthy periods of such co-working, including opportunities for the sharing of perspectives about and intended procedures for actions. These experiences need to be of sufficient duration to provide opportunities to understand, appraise and even predict others’ responses. However, beyond providing access to and sequencing of interprofessional working. Instead, there is a need to augment these experiences in maximising their contributions including permitting implicit understandings to be made explicit and subject to elaboration. These are the key purposes for the use of pedagogic practices. Pedagogic practices As foreshadowed, a key for pedagogic practices is to assist those collaborating to articulate their dispositions, values, goals and procedures so that co-workers can be understand, appraise with worth and compare and critiqued the approaches adopted. For instance, there are processes such as handovers, morbidity and mortality meeting or case discussions that permit the development of shared understanding to arise as part of healthcare practice. One potentially helpful example here is the use of handovers, by health-care workers to brief the incoming shift. A common practice in these handovers is to discuss: (i) the patient, (ii) their condition, (iii) their treatments, (iv) how they are responding to those treatments and (v) then making a prediction or prognosis about their progress. Through these activities, dialogues often
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occur and these can be encouraged further. As the case of each patient is addressed, particularly in the move from description about patient, conditions, treatments, to discussion and dialogue about their responses and prognosis, rich opportunities arise for the articulation of perspectives, goals and preferred procedures, and their justification. These routine workplace activities provide ongoing bases to build and develop further intersubjectivity, including new understandings about co-workers’ perspectives, and particular emphases. Then, there are practices such team objective structured case examinations (TOSCEs) (Gordon et al., 2013) and interprofessional objective structured clinical examinations (iOSCE) (Simmons et al., 2011) with the potential to provide the same kind of experiences and outcomes. Such experiences can even be augmented by the use of instructional media of different kinds. Simulated activities such as the use of videos of events within TOSCEs can play an important role in preparing and assisting healthcare practitioners to co-work (Gordon et al., 2013). These authors note the salience of using practice based experiences, such as joint case study notes, as a means to develop intersubjectivity. The process of articulating both conditions and the preferred treatments provides insights into particular subject or professional positions and their justifications. Consequently, the provision of an engagement in such activities can progressively be used to generate high levels of intersubjectivity. Yet, there may well also be a need for experiences that explicitly draw out preferences, emphases and justifications across a range of professional and disciplinary perspectives engaged in co-working which may be inhibited by inter-personal or interoccupational tensions. Given the occupational hierarchies existing in the healthcare sector, it may be necessary for practitioners to be prompted to review and change their conceptions and positions. This process may require facilitation in circumstances where entrenched hierarchies and professional cultures or professional or hierarchies resist being articulated, and subject to appraisal and engagement.
Concluding comments It has been proposed here that a key foundation for effective interprofessional care is developing high levels of intersubjectivity amongst professionals. Particularly in circumstances where immediate tasks are required to be enacted with only limited time for conscious and deliberate decision making, levels of shared intuition are likely to be helpful. Intersubjectivity arises ordinarily through individuals communicating, interacting and working together. Yet, it may not be sufficient simply to allocate individuals to interprofessional working arrangements and allowing them to progress autonomously. It may be necessary, instead, to order engagement in particular kinds of activities to promote intersubjectivity and shared intuition through interprofessional working. That is, building on co-working in authentic healthcare activities and augmenting these with experiences that permit joint problems-solving and having experiences that press participants into articulating and sharing their decision-making processes. These permit co-workers can engage in a considered and critical ways in understandings about other kinds of workers’ motivations, decision-making and practice preferences, whilst being cushioned from workplace hierarchies or power relations. Through these kinds of practices greater levels of intersubjectivity can be generated, perhaps even to the level where shared intuition can be experienced and developed.
Declaration of interest The authors report no conflicts of interest. The authors alone are responsible for the content and writing of this article.
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THEMED ARTICLE
Securing intersubjectivity through interprofessional workplace learning experiences Stephen Richard Billett Education and Professional Studies, Griffith University, Brisbane, Australia
Abstract
Keywords
Effective interprofessional work is premised on high levels of shared understandings (i.e. intersubjectivity) among those who are co-working. In particular, when quick or seemingly spontaneous responses are required for urgent or immediate action, what is termed as ‘‘shared intuition’’ is highly desirable. Much of the required intersubjectivity can arise ordinarily through everyday healthcare collaborations, such as through joint problem-solving. Yet, a concern is how best to develop these capacities in circumstances when co-working is temporary, fleeting and partial, and also when the goals to be achieved are ambiguous and uncertain, and the processes indeterminate. To achieve the kinds and levels of intersubjectivity required for these non-routine forms of care and intermittent interprofessional working, therefore, likely requires particular curriculum and pedagogic interventions within practice settings. These interventions may be used to shape the organisation and sequencing of experiences for interprofessional work through which can arise a foundation of shared understanding of concepts, procedures and values. Yet, to assist the articulation, sharing, appraising and elaborating shared disciplinary and personal-professional positions, values and procedures, specific pedagogic interventions may also be required, albeit their exercise being embedded in co-working practices in healthcare work activities.
Co-working, experiences, interprofessional working, inter-psychological processes, inter-subjectivity, shared intuition, workplace learning
Providing healthcare is often inherently interprofessional work. It frequently requires physicians, nurses and other health professionals to work together collaboratively and effectively in addressing patient needs. Sometimes, this collaboration is in routine healthcare provisions, where roles and relationships are as well-defined as the procedures being enacted. In other circumstances, such as emergency medicine, intensive care, trauma, etc., however, co-working occurs under conditions that are dynamic, where goals and processes are non-routine, unclear, multi-parted and outcomes are unpredictable. Also, in these circumstances, those co-working can also constantly change, as some staff will be engaged only fleetingly, and may have their time distributed across numbers of patients. Therefore, this collaboration is often temporary; comprising combinations of interprofessional engagements extending across occupational hierarchies and distinct professional cultures (Hall, 2005). Such working arrangements are not adequately explained by concepts such as communities of practice (Lave & Wenger, 1991) as there are limited opportunities to form and sustain such a community. Participation is based on other premises than progression to full-participation in a community of practice. Yet, regardless of these complexes, attempts to improve the capacities for interprofessional now appear warranted. The evidence is beginning to suggest that key healthcare goals, such as the effective organisation of care, arise from collaboration (Reeves, Correspondence: Stephen Richard Billett, Education and Professional Studies, Griffith University, Brisbane, Australia. E-mail: s.billett@ griffith.edu.au
Received 14 January 2013 Revised 29 January 2014 Accepted 29 January 2014 Published online 26 February 2014
Goldman, Burton, & Sawatzky-Girling, 2010; Reeves, Perrier, Goldman, Freeth, & Zwarenstein, 2013). Manser (2009) similarly concludes that improvements in healthcare performance are more likely based on better communication, co-ordination and inclusion, than on enhanced clinical skills. That is, through improving co-working capacities. Categories of these capacities include: (i) personal qualities and commitment of staff; (ii) communication within the team; and (iii) development of creative working methods that are contingent upon and relational to the qualities of collaborative practices (e.g. Molyneux, 2001; O’Keefe, McAllister, & Stupans, 2011). This evidence suggests that initial and continuing healthcare professional education should include experiences that focus on or emphasise developing capacities required for effective interprofessional work, and these educational provisions warrant being guided by robust macro and micro level precepts and concepts (Reeves & Hean, 2013). One such micro-level explanation is that high levels of intersubjectivity (i.e. shared understandings) are required amongst co-workers. This is particularly the case when quick or almost spontaneous responses (i.e. informed intuition) are needed, such when urgent action is required and where preempting co-workers’ actions may be critical. Therefore, high levels of intersubjectivity need to be secured for co-working in healthcare, and potentially extends to ‘‘shared intuition’’. That is, engendering intersubjectivity amongst those who are co-working to the extent that interprofessional care can be spontaneous, optimising conscious decision-making and correctly pre-empting how co-workers will need to act effectively. Here, the focus is on how to achieve these outcomes through using work activities and interactions as platforms for
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this professional development. Therefore, whereas the focus for initial and continuing professional education are usually about sustaining individuals’ occupational competence, securing career advancement or changing occupations, here the concerns and processes go beyond individual performance. Instead, they emphasise securing intersubjectivity as a means to improve co-working so that those almost spontaneous decision-making and action can occur and effectively. Yet, this is a tough developmental outcome to achieve. It is most likely secured through workplace activities and interactions where intersubjectivity can be promoted and interventions enacted to augment that development collectively as healthcare workers engage in co-working activities, including joint problem-solving. Taking up Reeves and Hean’s (2013) invitation to furnish theoretical premises for advancing interprofessional education, the proposition advanced in this article is that intersubjectivity is required for effective co-working and is reciprocally developing through this co-working. In advancing this case, the central role of intersubjectivity in co-working is elaborated first, followed by an account of how these attributes arise inter-psychologically (between social partners). Next, a framing of how this development can be understood within the context of interprofessional care is presented. Then, a set of curriculum and pedagogic practices that can be enacted in healthcare workplaces are advanced as means for securing these outcomes.
Conceptions: intersubjectivity, interpsychological and workplace experiences Intersubjectivity is defined by Rogoff (1990, p. 71) as ‘‘shared understanding based on a common focus of attention and some shared presuppositions that form the ground for communication’’. Earlier, Trevarthen (1980, p. 530) defines it more inclusively as ‘‘both the recognition and control of cooperative intentions and joint patterns of awareness’’. These two definitions are helpful, albeit focussing on understanding and awareness. Yet, intersubjectivity also extends beyond conceptual knowledge to shared procedural capacities and also values (i.e. shared ways of undertaking tasks and achieving common goals. Therefore, whilst shared understandings and awareness are essential and powerful foundations for effective co-working, they need to be complemented by shared procedures (i.e. how to do things) and dispositions (i.e. values, beliefs, interest). This is not to say that nurses need the same kinds and levels of understandings, procedures and beliefs as doctors, for instance, but that they share common procedural capacities and values required for effective inter-professional work. Securing intersubjectivity of these kinds does not necessarily require educational interventions, although in some circumstances these may be required (see below). It comprises an ordinary process of cognition and, one not restricted to humans. Whether referring to the ontogenetic virtualisation that baby and mother Orang-utans engage in when negotiating access to breast milk (Tomasello, 2004), apprentices’ learning through actively observing and imitating what and how skilled tradespersons perform (Singleton, 1989) or children securing the ambiguous process of trying to get a cookie (Baldwin, 1894), there is commonly an active process of comprehending what goals and processes direct others’ actions. Indeed, necessarily, much of engagement is about securing intersubjectivity. Newman, Griffin, and Cole (1989) noted that if individuals developed understandings in uniform ways from what they experience socially, there would be little need to communicate. Yet, because common understanding does not happen, we need to communicate with others to engage in socially-shaped activities. Indeed, key social constructivists Berger and Luckman (1967) note that there is no guarantee that
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what is suggested by the social world would be either projected in unambiguously or taken up in common ways. Hence, securing intersubjectivity is central to everyday human activity and is central to activities such as co-working. Perhaps this is never more than for interprofessional care, particularly when immediate joint decision-making and responses are required. Yet, its development requires both access to what needs to be learnt and a willingness to engage with it and in what can be contested working environments (Salhani & Coulter, 2009). Yet, everyday processes of interaction amongst humans provide opportunities for building intersubjectivity (Rogoff, 1990). They can provide a nuanced awareness of why co-workers have particular conceptions and preferred actions. Intersubjectivity also does not have some endpoint of complete shared understandings. It comprises an ongoing process through which similarities, commonalities and distinctive conceptions of knowledge and knowing can be made accessible, shared and comprehended. Nurses spending significant times with particular patients may come to know their sensitivities, concerns and reactions, in ways that fleeting visits from medical specialists may not, yet whose specialist knowledge provides insights that may not be apparent through nurses’ informed observation of patients. Consequently, the process of co-working permits these elements of intersubjectivity to be developed and elaborated through everyday acts of engagement, collaborative and shared activities and interactions. Moreover, it is vital when humans engage in co-working activities where misunderstandings and inconsistencies can have significant consequences, such as in healthcare. Therefore, as with Reeves and Hean’s (2013) call for better theorisations for interprofessional education, the same applies for the learning that comprises intersubjectivity, and these may most readily found broadly within psychology accounts. Inter-psychological processes informing intersubjectivity Intersubjectivity can most likely be best explained as arising through inter-psychological processes: those between individuals and social and brute worlds beyond them (Billett, 2006a). The majority of the knowledge individuals need to learn for engaging in socially derived purposes and practices, such as healthcare, come from outside of individuals: beyond the skin, so to speak (Wertsch & Tulviste, 1992). That knowledge arises and is transformed through history, culture, society and situations and is learnt by engaging (i.e. inter-psychologically) in occupational activities, with artefacts and more informed others (Billett, 2003). Intersubjectivity arises in similar ways. Through focused engagement with others, shared understanding, awareness and nuanced understanding about subjects’ positions and preferences arise and become refined and honed through their articulation, appraisal and ability to assess causal responses. The development of intersubjectivity needs to be seen as an interdependent and relational interpsychological process (Billett, 2006a). It is interdependent because the social world projects needs human actors need to understand its norms and enacts its practices (for instance, for healthcare to be practiced and further developed) and the actors need what the social world provides for them to learn about and practice that occupation. Without individuals’ constructive processes the social world would remain stagnant and moribund (Berger & Luckman, 1967). Therefore, there is interdependence between the person and the social world that underpins both learning and the remaking of cultural practices. However, that interdependence is relational. What for one individual will be a compelling and transformative learning experience, for another it might be quite routine, leading to reinforcement of what is known. Therefore, just as trainee doctors might find confronting the emergency room activities
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in large metropolitan hospital on a Saturday evening, the senior residents have become quite accustomed to the outcomes of behaviour (e.g. drunkenness, violence) which shapes their work on these evenings. Therefore, the same social experience or suggestion is construed and constructed (i.e. learnt) relationally by individuals. Therefore, interpsychological processes are not set and predictable, as with behavioural or automatic responses – they are situationally based and person-dependent. Therefore, subjectivity arises through both what learners experience and how they come to know or make sense of those experiences. Intersubjectivity arises through opportunities for subject’s constructions to be articulated, justified and shared. Given that, it is useful now to consider how intersubjectivity arises and can be promoted through workplace experiences. Workplace learning experiences: affordances and engagement Securing intersubjectivity associated with interprofessional work most effectively arises through opportunities for co-working. Importantly, when individuals engage in and complete work activities, two other legacies or changes arise. First, through engaging in work activities, individuals come to change what they know and do. This is called learning. It occurs continuously across our lives and is not reserved for or privileged by interludes in educational institutions or their programs. Sometimes, the learning that co-occurs with working can be quite incremental. For instance, through healthcare worker’s learning arising through refining and honing what they know or what they do or, what they value in their work activities (Billett, 2001a). In other circumstances, that learning can be transformational through engaging in activities which are wholly novel to these workers. These experiences open up or expose them to concepts, practices or values which are quite novel for them: new learning arises. Put simply, through engaging in goal-directed work activities and interactions, learning of different kinds arises (Billett, 2001a). However, not all of that learning might be described as being positive, ideal or even desirable. Bad habits, ill-informed practices can be learnt, as well as knowledge that empowers and extends what these workers come to know. Moreover, access to opportunities and support will be mediated by workplace relations and contestations both intra and interprofessionally (Salhani & Coulter, 2009). Hence, individuals’ learning of different kinds arises through everyday work activities and interactions as shaped by the particular sets of experiences that are afforded by the workplace settings in which they engage. Importantly, this work and learning necessarily co-occurs as workers engage in goal-directed occupational activities and interactions. It likely co-occurs most optimally when there are opportunities for individuals to articulate and justify their positions, and subject them to others’ appraisals. These opportunities arise through joint problem-solving, in everyday work practices, albeit sometimes augmented by particular kinds of intentionally organised experiences. Engagement in goal-directed activities, where goals need to be considered and identified as do the procedures for securing those goals such as addressing patients’ care can be a source of such learning, as in handovers, for instance. In this way, joint or co-working provides opportunities for perspectives and decisions to be articulated, appraised and decided upon. These activities also often provide the opportunity for monitoring the consequences of those decisions and actions, thereby providing bases for making causal associations and for refining and honing the procedures to be deployed. The second kind of change that co-occurs through individuals undertaking work activities is the remaking of professional practice. Professions are dynamic and continually evolve as
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requirements for their practice change (Billett, 2006b). They are also manifested in particular ways in specific circumstances which are subject to and respond to the workplace’s circumstances, actors, and changing work practices and technologies. Essentially, this remaking arises through practitioners engaging in occupational activities and interactions at a particular point in time and response to particular actors’ needs, activities and interactions. This is the process through which society sustains itself and is advanced (Scribner, 1985). Therefore, as healthcare practitioners engage in their daily work they are learning and also engaging in the process of remaking and transforming their occupational practice. When engaged in collaboration there is the prospect of bringing about the kinds of changes that systematic reviews of interprofessional education are emerging (Reeves et al., 2010, 2013). Therefore, for instance, the move now to have interprofessional care as a key element of health work generally requires collaboration by practitioners who may have previously been separated by traditions of practice, professional cultures and workplace hierarchies. This co-working may lead to this remaking of healthcare practice, through these new working arrangements. To further explain how intersubjectivity arises occurs in workplace settings, two interrelated concepts may be informative: affordances and engagement (Billett, 2001b). Affordances refer to the degree by which individuals are invited to participate and learn in a social setting. That is, granted the access to, engagement in and support when engaging in work activities and interactions. Affordances can be high, with individuals being included, guided and supported in their learning and provided with opportunities to learn new knowledge, and reinforce and hone what they have learnt through opportunities to practice and engage with more informed partners. Alternatively, in contested or fragmented work environments affordances can be quite low and limited in their invitational qualities. For instance, limited access to practice, short periods of time within clinical settings, being ignored or intimidated by co-workers and others are instances of low affordances that potentially restrict the extent of individuals’ learning, or in this instance generating intersubjectivity. It is also important to be reminded that particular categories of learning are likely to be generated by specific kinds of experiences. Hence, the kinds of experiences that workers are permitted to participate shapes what they learn. You cannot become effective with specific procedures (i.e. taking a temperature, auscultation, taking patients’ histories) without opportunities to practice, rehearse and by guided by experts. Hence, learning about other workers’ preferences or disciplinary positions or conceptions warrants experiences that require them to be articulated (i.e. stated). Therefore, workplaces afford a range of activities and interactions that, by degree, assist learning of different kinds and in different ways. The great prospect of interprofessional care is to afford rich learning experiences through its enactment. However, beyond affordances are bases by which individuals to elect to engage with what is afforded them. Even the most welcoming and supportive of the workplaces might be rejected by workers who are uninterested in engaging with and learning what is being afforded them. Conversely, through their efforts and tenacity, highly active and engaged individuals may be able to overcome the limitations of low workplace affordances (Billett, 2001b). Importantly, therefore, how individuals elect to engage in activities and interaction from which they might learn and secure intersubjectivity is central to those processes. Put plainly, this engagement and learning is partially person-dependent. What for one individual is a welcoming workplace, for another it might be construed as having low affordances. Studies of learning at and for work identify the centrality of learner agency through their engagement in goal-directed activities (just doing it),
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observation and listening (just being there), how they engage with more informed workers (i.e. direct guidance) and also utilising opportunities for practice to refine, hone and extends what they know (Billett, 2001a). Perhaps the most commonplace process of securing these outcomes across human history for occupational purposes is mimesis: observation, imitation and rehearsal. This process should not be dismissed as mindless mimicry. Instead, it comprises an active interpsychological process that humans use to comprehend, predict and act (Byrne & Russon, 1998). Indeed, it requires the capacity to come to understand empathically what the others will do and for what reasons, and then react to their actions. Yet, these are personally mediated. For interprofessional working and learning, the quality of participants’ engagement will be essential in providing opportunities for securing the kinds and levels of intersubjectivity required for co-working. It is particularly necessary for developing intersubjectivity in co-workers from distinct professional, with different roles and particular sets of concerns to be able to articulate and share their conceptions, values and procedures. This is particularly the case when there is the need to develop shared intuition: a level of intersubjectivity that allows more spontaneous and collaborative responses from co-workers. As proposed earlier, this kind of capacity can be developed through co-workers engaging in routine activities on a regular basis through interprofessional work. However, it is far more difficult to achieve when the co-working situation is temporary, interrupted, disjointed and partial. From the above, it can be seen that much of intersubjectivity with arise through everyday processes of individuals interactions with each other and the greater the extent and duration of that interaction, the more likely high levels of intersubjectivity will be achieved. However, given the particular need to promote high levels of intersubjectivity to secure shared intuition, the concern is that these may not be achieved through everyday interactions alone. These factors, plus the potentially diverse backgrounds and specialism’s of co-workers suggest there is a need for there to be structured experiences to support that development.
Curriculum and pedagogic practices promoting intersubjectivity To consider the intentional promotion of intersubjectivity it is helpful to consider two long-standing concepts albeit for these particular purposes: curriculum and pedagogic practices. Curriculum refers to the ‘‘course to follow’’ or ‘‘pathway of experiences’’ through which individuals learn. These concepts are highly consonant to learning through practice (Billett, 1996), including the kinds, sequence and duration of practice-based experiences comprising the workplace curriculum. Therefore, considerations for the organisation and ordering of experiences for the purpose of developing high levels of intersubjectivity can be associated with these curriculum practices. Beyond these orderings, are pedagogic practices that augment experiences such as those provided through engaging in co-working. In particular, where knowledge cannot easily be made accessible, openly articulated or shared, there may be a need to utilise particular pedagogic practices to promote that accessibility, articulation or sharing. There are also personal epistemological dimension. A key aspect of interprofessional working within professional development is that experienced healthcare practitioners, unlike novices, will have senses of selves or subjectivities associated with their occupations. Such subjectivities are important when engaging in shared and dialogic processes. It is difficult to form collaborative ties when one is unsure of one’s professional identity (Dombeck, 1997; Sims, 2011). The principles associated with engaging with workers from other professions and
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disciplines and, in the circumstances where this co-working needs to occur and use of specific pedagogic practices are discussed below. Curricula practices If not already occurring, it is necessary to secure opportunities for those who are to co-work to engage in working interprofessional. Some consideration might be given here to providing experiences, initially, where inter-professional engagement is incremental so that capacities such as intersubjectivity can be developed productively. For instance, this co-working might commence in activities that are routine. Such activities are often less demanding and urgent, yet may well provide a foundational experiences for interprofessional working through which shared relations, understandings and subjectivities are initially developed. Hence, aspects of interprofessional working which are frequently conducted might first be used as bases for developing intersubjectivity, including having access to more that on professional perspective. These affordances may well occur before individuals attempt to work interprofessionally in circumstances where levels of patient acuity, emergency or uncertainty are higher. Hence, as noted work activities such as when cases are reviewed, the planning and organisation of patient treatments, etc., may well provide initial co-working situations to secure levels of intersubjectivity. Then, increasingly, interprofessional working can be extended into work situations which are more critical and acute, and which require shared understandings to be applied effectively and consistently. There is nothing particularly novel here. This progression is a standard principle for curriculum planning and enactment (i.e. develop foundational knowledge and within learners’ readiness to progress). In practice-based curriculum, the progression is from engagement in activities that can tolerate the consequences of errors through to those activities where error cost is greater (Lave, 1990). This sequencing of experiences provides for incremental engagement and development of opportunities for developing capacities for interprofessional tasks that are openended and not predictable in advance. Yet, such co-working will comprise engaging in non-routine activities for some participants. The development of shared intuition requires lengthy periods of such co-working, including opportunities for the sharing of perspectives about and intended procedures for actions. These experiences need to be of sufficient duration to provide opportunities to understand, appraise and even predict others’ responses. However, beyond providing access to and sequencing of interprofessional working. Instead, there is a need to augment these experiences in maximising their contributions including permitting implicit understandings to be made explicit and subject to elaboration. These are the key purposes for the use of pedagogic practices. Pedagogic practices As foreshadowed, a key for pedagogic practices is to assist those collaborating to articulate their dispositions, values, goals and procedures so that co-workers can be understand, appraise with worth and compare and critiqued the approaches adopted. For instance, there are processes such as handovers, morbidity and mortality meeting or case discussions that permit the development of shared understanding to arise as part of healthcare practice. One potentially helpful example here is the use of handovers, by health-care workers to brief the incoming shift. A common practice in these handovers is to discuss: (i) the patient, (ii) their condition, (iii) their treatments, (iv) how they are responding to those treatments and (v) then making a prediction or prognosis about their progress. Through these activities, dialogues often
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occur and these can be encouraged further. As the case of each patient is addressed, particularly in the move from description about patient, conditions, treatments, to discussion and dialogue about their responses and prognosis, rich opportunities arise for the articulation of perspectives, goals and preferred procedures, and their justification. These routine workplace activities provide ongoing bases to build and develop further intersubjectivity, including new understandings about co-workers’ perspectives, and particular emphases. Then, there are practices such team objective structured case examinations (TOSCEs) (Gordon et al., 2013) and interprofessional objective structured clinical examinations (iOSCE) (Simmons et al., 2011) with the potential to provide the same kind of experiences and outcomes. Such experiences can even be augmented by the use of instructional media of different kinds. Simulated activities such as the use of videos of events within TOSCEs can play an important role in preparing and assisting healthcare practitioners to co-work (Gordon et al., 2013). These authors note the salience of using practice based experiences, such as joint case study notes, as a means to develop intersubjectivity. The process of articulating both conditions and the preferred treatments provides insights into particular subject or professional positions and their justifications. Consequently, the provision of an engagement in such activities can progressively be used to generate high levels of intersubjectivity. Yet, there may well also be a need for experiences that explicitly draw out preferences, emphases and justifications across a range of professional and disciplinary perspectives engaged in co-working which may be inhibited by inter-personal or interoccupational tensions. Given the occupational hierarchies existing in the healthcare sector, it may be necessary for practitioners to be prompted to review and change their conceptions and positions. This process may require facilitation in circumstances where entrenched hierarchies and professional cultures or professional or hierarchies resist being articulated, and subject to appraisal and engagement.
Concluding comments It has been proposed here that a key foundation for effective interprofessional care is developing high levels of intersubjectivity amongst professionals. Particularly in circumstances where immediate tasks are required to be enacted with only limited time for conscious and deliberate decision making, levels of shared intuition are likely to be helpful. Intersubjectivity arises ordinarily through individuals communicating, interacting and working together. Yet, it may not be sufficient simply to allocate individuals to interprofessional working arrangements and allowing them to progress autonomously. It may be necessary, instead, to order engagement in particular kinds of activities to promote intersubjectivity and shared intuition through interprofessional working. That is, building on co-working in authentic healthcare activities and augmenting these with experiences that permit joint problems-solving and having experiences that press participants into articulating and sharing their decision-making processes. These permit co-workers can engage in a considered and critical ways in understandings about other kinds of workers’ motivations, decision-making and practice preferences, whilst being cushioned from workplace hierarchies or power relations. Through these kinds of practices greater levels of intersubjectivity can be generated, perhaps even to the level where shared intuition can be experienced and developed.
Declaration of interest The authors report no conflicts of interest. The authors alone are responsible for the content and writing of this article.
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