Social Identity Theory (SIT) postulates that individuals naturally favour their own ‘in- group’ over the other ‘out-group’. It highlights the power of perceived attributes of
groups to affect relations and group dynamics, whether or not the attributes actually reflect reality (Tajfel et al. 1971; Turner 1999; Hean at al. 2006b; Michalec et al.
2013)11. In line with the underlying principles of SIT, IPE studies have demonstrated that during interprofessional interactions, group participants favour their own identity and establish their identities through comparing attributes of their own and other groups (Mandy et al. (2004); Hean et al. 2006a and b; Lidskog et al. 2008; Michalec et al.
2013). Professional identification, while psychologically beneficial to individual and organisation (Tajfel and Turner 1979; Leavitt et al. 2012) has a potential downside, insofar as it generates social categorisation with subsequent stereotyping (Turner 1999).
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Collectively, these power-driven dynamics can create a major source of conflict on interprofessional teams (Lidskog et al. 2008).
In their small qualitative study (n=16) investigating perceptions among student nurses, occupational therapists and social workers’ about their own and other professions, Lidskog et al. (2008) argue that members from different professions, engaged in IPW on an interprofessional training ward (IPTW), attempted to reinforce their own positive ‘in-group’ identity, rather than yield to the development of an interprofessional identity. The concern for IPW relates to a resulting conflict, which Lidskog et al. (2008) believes could affect the delivery of quality patient/client care. These findings build upon earlier assertions by Mandy et al. (2004), who found that the podiatry and physiotherapy students in their qualitative study (n=34), used more negative adjectives to rank the ‘out-group’. It also lends support to the claims by Hean et al. (2006a) who, in their large quantitative study involving students from 10 frontline and non-frontline professions (n=1256), recognised that the natural consequence of professional identity, that is, social categorisation and subsequent stereotyping12, presented a major source of barriers and conflicts in IPW relationships. In a later study, Michalec et al. (2013) reported significant ‘in-group favouritism’ (pg. 206) among first year students of medicine, nursing, pharmacy, occupational therapy, physiotherapy, and couple and family therapy (n=638). In line with SIT, the study participants clearly desired to view the group to which they aspire to in a positive light (Taifel 1971). These students also presented with a strong, positive commitment to their own professions which Michalec
12 Professional stereotyping as a key concept underpinning the study will be considered fully in section
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et al. (2013) believed somewhat idealistic, given the early stage of student training with limited healthcare experiences.
It is clear these psychological processes, that are usually subconscious, can be potentially problematic for shared learning and collaborative teamwork. However, even more problematic is that strong professional identity produces professional boundaries and tribalism among the healthcare professions. The concept of ‘tribalism’ has become a metaphor symbolic of the distinctions and allegiances attributed to healthcare professional groups (Atkins 1998; Baldwin 2007; Carlisle et al. 2004; Reynolds 2007; Baker et al. 2011; Bell and Allain 2011; Timmons and East 2011). Tribalism, coupled with a sense of ‘belongingness’ to the traditions that represent the healthcare occupations, results in individual professions becoming territorial or protective of what they consider to be their own professional ‘turf ’ (Baker et al. 2011). These relations of power can greatly interfere with an individuals’ ability to learn in a shared learning context, and are most problematic for the effective achievement of interprofessional working between healthcare professionals (Baldwin 2007; Baker et al. 2011). IPE aims to address these issues through increasing understanding of professional roles and boundaries, and through engendering respect for the value and expertise contributed by other professions (Thistlethwaite and Nisbet 2007). Furthermore, it is expected IPE has the potential to dismantle destructive traditional hierarchical structures embedded within the culture of healthcare delivery (Michalec et al 2013). However, power comprises a multidimensional phenomenon that can impact relationships between healthcare professionals in terms of territory, authority, status or influence (Baker et al. 2011) and studies suggest these power-related dynamics pose a major challenge for IPE to attain the aforementioned goals.
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In their qualitative study that aimed to explore the impact of power relations on IPE (n=132), Baker et al. (2011) found strong professional identity had the potential to obstruct the goals of IPE through reinforcing traditional power relations among qualified healthcare professionals, instead of dissipating them. The participants appeared to protect their sense of professional identity when interacting during IPE, which in turn appeared to inhibit their ability to learn collaboratively. Baker et al.
(2011) also observed that strong professional identity led to tension on teams when it came to interprofessional decision-making and team leadership. Physicians reinforced their traditional power status, seeing themselves as the leaders and decision-makers, whilst nurses, pharmacists, dieticians and social workers were seen as more akin to taking on a more ‘holistic approach’ to care (pg.100). Some physicians viewed the longer training in their professions as justification for adopting a dominant role on the interprofessional team. Perhaps these attitudes are rooted in the uni-professional, traditional culture of physician training, which as Hall (2005) asserted, is orientated towards adoption of decision making and leadership roles.
Baker et al’s’ (2011) study was relatively comprehensive using a reasonably large sample size for a qualitative study. However, there are limitations to which the authors refer. There is sample bias insofar as the study only used participants who volunteered. It would have been most insightful to glean the perspectives of those who declined participation. This is a frequent problem in IPE studies as participation is largely voluntary unless IPE activities happen to be part of the existing curriculum. This means that those who choose to participate potentially have a greater vested interest in IPE for some reason. Baker et al (2011) note that on the basis such a ‘complex array of issues’
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emerged about the role of power in IPE, more research is needed to examine this further (pg. 103).
Baker et al. (2011) also asserted that rather than finding common ground between healthcare professional attitudes to each other, attitudes towards IPE can be articulated through a type of ‘protectionism’ whereby it becomes more important to prioritise one’s own professional identity rather than find mutual goals and understandings. Perhaps, this is symptomatic of a scenario suggested by Atkins (1998), whereby healthcare professionals, having been socialised into the culture of their individual professions, experience a sense of loss and grief when they perceive that their cultural group boundaries could be under threat. A further point of interest among these findings by Baker et al. (2011) saw some medical staff appearing to see IPE as a potential threat to their professional status; whereas paradoxically, non-medical staff appeared to view IPE as a way to improve their status within the healthcare professions. Since higher status is generally attributed to medicine more so than any other professions (Timmons and East 2011), it could well be that non-medical participants experienced a sense of heightened status through their association of learning with the medical group.
Problems for IPW relating to tribalism and professional boundaries are recognised among HEI educators and relevant stakeholders, and it is encouraging to find there is recognition among these agents for change for IPE to combat these potentially destructive forces (Carlisle et al. 2004; Ryan 2010). Carlisle et al. (2004) used focus group interviews to glean perspectives from a combination of participants representing students, clinical and academic staff, and patient/clients (n=34), to investigate the feasibility of introducing IPE in undergraduate programmes, and to illuminate potential challenges and advantages of IPE for students, patient/client s and HEI’s. Tribalism,
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impermeable professional boundaries, and what was described as ‘interprofessional jealousy’ among disciplines, emerged from the discussions (pg. 548). The participants viewed the establishment of IPE as a way forward for cultural change.
Similar concerns have been expressed in Ireland. In a small qualitative Irish study, Ryan (2010) explored the perspectives of leaders in healthcare education (n=8) regarding the importance of IPE development in Ireland. Tribalism and problems relating to professional boundaries again emerged within the discussions as an issue for effective IPW and a barrier to IPE. It was interesting to note the educators reported tribalism in particular among medical students, who were reported to embrace a sense of superiority over other professions. Ryan et al. (2010) strongly recommended early IPE to prevent stereotyping, prejudice and entrenchment of positions of superiority among students, and criticised the Irish National Healthcare Education agenda for not giving enough priority to the implementation of IPE.