The collegial attitude is actualised when clinicians are mutually confident that each individual is offering a unique, unmistakable contribution towards the team purpose. The traditional stereotypical images that have impeded collegial interactions between doctors and nurses (Campbell
Heider & Pollock, 1 987) have been broken. Kerfoot ( 1 989) suggests collegial
relationships involve interactions between individuals who occupy both equal and unequal status. Equality in organisational life, more often than not, concerns the subtle, and not so subtle, power relations that influence attitudes and behaviour associated with a gender-influenced hierarchy (Morgan, 1 997) . In this study equality, hierarchy/non-hierarchy, respect, skill, and expertise are indicative of the collegial attitude.
Perhaps because the participants in this study were predominantly female, equality was understood differently from the commonly accepted meanings. The health services have a long history of relationships built on male values and male dominance. In this research, many of the participants were females who were introducing new cultural values and approaches into a previously male-dominated arena. Traditional assumptions were examined in interdisciplinary relationships:
I think one of the difficulties with that system is that the old medical system that the medical school pertained was incredibly patriarchal. Usually two consultants "owned" a ward and all of the staff on it! They "owned" their charge nurse and their nurses. The only strength there was that usually there were a couple of consultants and junior staff and the charge nurse and they had morning tea together . ... I
think the system meshed because there were these disgusting ceremonies like the morning tea that was made by junior nurse but ordered by the charge nurse! The tea was poured and handed to the consultants! No one wanted that to continue. But what got thrown out was a structure of respon�ibility . . . the consultants were listening to the charge nurses and woe betide them if they didn't! The junior staff listened to the charge nurses because the consultant said, "If you upset my sister you'll get a D for this run!" It was hierarchical but at least there was a structure. Now that seems to have been lost in teams because there are multiple consultants and people don't have morning tea together! (Emily, Int. 94, p . 1 5 1 0)
Traditional authoritarian interactions founded on paternal benevolence continue in some places today, blocking the development of a collegial attitude. Kenny and Adamson ( 1 992) report that the majority of health professionals do not feel that doctors understand the work of other health professionals, or regard them as equals. Historical social interactions still persist to some degree:
When I first went to the hospital I always remember the frrst meeting of the executive. The general manager at the time was a typical doctor. I was introduced to a couple of people and then I introduced myself to a couple of professors. Well! They looked absolutely astounded at a person doing that! And we all sat down and the general manager turned to me ahd said, "I'll have a cup of tea, thank you!" And I said, "Well I'm sure you know how to make a cup of tea, feel free to get one. Don't we all get our own cups of tea here? I'm not the typical matron that seiVes you all". I got up, got my cup of tea, and sat down. They did the same and as they were sitting down I
said, "I didn't know you had handmaidens in this organisation".
They were very uncomfortable. . . . I refuse to be a handmaiden. It was the typical stereotype - that the director of nursing would seiVe all the others. Well! I wasn't going to do that! We've moved on since those days! (Lilly, Int. 86, p. 1397)
Myths surrounding male-female relationships are breaking down slowly as service structures change and women move into higher management positions. As responsibilities are restructured, many health professionals are learning to explore habitual ways of thinking as they interact with others in a collegial way. Respectful collegial interactions evolve if the team recognises the need for balanced - equal - contributions:
That word equality is an awkward word really because it brings in all sorts of connotations about the hierarchy of systems and of professionals. It's to do with stereotyping and some professions are seen to be much more superior in the sense of comparing them to others. To me, equality is really about being able to work together with mutual respect. The people identify each other's role and place within that team and respect that . . . . That is what makes you equal. It is not that your responsibilities are equal or training, or skill. That is varied. But I'm just as good as they are. The trouble is there is an awful lot of historical stereotyping that goes on. I think the health
system is changing incredibly fast and I don't think people's
perceptions are changing at the same speed. It is probably up to us to forge the understanding. (Sophia, Int. 8 1 , p. 1 0 1 8)
But, thinking changes slowly and the collegial attitude emerges over time. It is a two-way process dependent on positive interactions between people functioning as a team. Women, conditioned culturally to see themselves as offering less in the medical hierarchy, gradually learn to sense the wealth of experience they offer.
In this study, a supportive team environment promoted deconstructive
thinking that prompted colleagues to re-examine taken-for-granted
assumptions and beliefs. Colleagues empowered colleagues by drawing the person in, and respecting individual strengths, until the fullness of a team place was completely appreciated:
That helps us with our own image of ourselves. I have come to
recognise that I have got something to offer to this team. I do know
what I am talking about. I am a specialist. And I suppose that is
reassuring my position in the team - yes, I should be there. And, I should be accepted by the team, for what I am and the knowledge
and skills I bring. I think of everybody in the team as being equal.
Lots of people put doctors on a pedestal, and think that they are better than everyone else but I think everyone has something specific to offer in this team. And we are all treated as equal and what we say
in discussion is considered. I think we need to appreciate people for
what they are, what they do, and what they bring to the team.
(Rhonda, Int. 4 1 , p. 503)
Acknowledging individual value sometimes requires a redefinition of the self. It was evident that, many team members, trained to place the doctor at
the top of the management pyramid, struggled to think of the self being as
coequal with colleagues. More used {Q social divisions where open
recognition of individual contribution is rare, many did not actively seek equal opportunity in teams. If traditional expectations persisted the collegial attitude was affected. Interactions were especially difficult when one professional group tried to dominate others:
She works in close collaboration with the medical practitioners and is working as an equal colleague. Equal, but different . . . . And that's the way I see nursing working in the future. They need to have the knowledge and the expertise to work in that way. And I believe that many nurses do work like that but they are not recognised for it and they themselves may be part of that. They don't recognise their
worth. . . . It is important they learn how to become articulate about that and feel a good professional self-esteem about that because they cany a lot of responsibility. But talking about the team that functions really well, you can only do that when you are of equal ability and you get back to that equality thing again and being seen as having some sort of equality. You can be different but equal. And where that works between nursing and the medical profession it just works superbly. And I guess we've all had experience of that sort of thing. And where that isn't so you feel compelled to say "Now look here! What you're expressing is a view I don't share with my own profession. Could we not just come a bit closer on this?" (Diane, Int.
1 1 , p. 146)
Different viewpoints originate in professional education and the confidence
and proficiency engendered therein (Jolley & Brykczynska, 1 993). Many
nurses and some therapists have been trained vocationally. Well trained to respond to practical situations, they are less well prepared to question
decisions or to think outside the box. These people needed encouragement
to break the stereotypical images and to engage in pluralistic dialogue:
And I think one of the things we have developed, as a style is that all members are treated equally . . . And whatever level of the so-called hierarchy you are . at, people are expected to make equal contributions in terms of the numbers of presentations they make. They are all to attend. So, they're forced to do things that they've never done before. I think people have been facilitated to blossom because we've set the standard high, at whatever level they're at. And they don't feel in any way inhibited from reaching any heights that they could, or wish to. We don't say you have to reach that, but we give you all the opportunities, and see what happens . . . . And, again, you are talking about having carefully selected people in whom you see that potential. (Alice, Int. 20, p. 290)
Equality is ambiguous. Hegyvary ( 1 990) believes that underlying the collegial attitude is the subtle expectation that total agreement is required.
Equality does not exclude debate, although pluralistic dialogue is more
likely when clinicians respect each other as equals. When individuals value each other differences are more readily explored:
In this team I think we all have equal roles in so much as without
the bit that the others do, we wouldn't function as well. So we are equal in so much as we· have separate things to dol Professionally, we're not equal. Academically I'm not equal to them. There's no question there. Is a doctor equal to a nurse? What does it mean? I
don't see doctors and nurses as equal. I would rather say I am equal to a district nurse. Am I equal to a midwife? It wouldn't enter my
head to put myself as equal to them because I am different. I have a
completely different role to play. In my eyes a physiotherapist is equal to an OT but they play different parts and come together and they do work well together. If you look at who is equal you have to look at what we do. It starts with your own self-value (Marilyn, Int.
1 2 , p. 169)
Those who did not value themselves and their work appeared to be unusually sensitive to stereotyping based on unchecked assumptions,
regardless of competence or professional contribution. However,
experienced clinicians do retain power; albeit informally:
I think it depends on what areas you are working in, I very much feel that we are all equal here On the surgical wards we're not seen to be as important as the surgical teams . . . But, the teams don't undermine physio or occupational therapy. They're interested in it. It's just a different focus. And the surgeons weren't very good at asking the occupational therapy and physiotherapy opinion. There wasn't the pressing need there so that [therapy] wasn't in such a high esteem as it is here. But that's not to say that it was negated. We just went and did our thing. We didn't say what we were doing. We just did it. Here, the doctors are very much into therapy. (Carmel, Int. 47, p. 553)
The collegial attitude carries rights, obligations, and responsibilities. In the small teams members worked together to meet service needs and made real efforts to dialogue with colleagues about decision making, even if their input was limited by experience. But, in the large ward team, the collegial attitude was harder to establish because there was a fme line between having confidence in colleagues or checking out the validity of their input:
People have different levels of training and different expertises with that training. My notion of equality is that your opinion is respected and acknowledged. When you get people who are skilled and experienced you feel more comfortable about their opinion and you never question it . . . . Or, if you do, it's more a drawing out of the detail. If it's somebody who's inexperienced, I'm always wondering if
they've done enough? And there will always be some dissonance in what my opinion might be versus what they are telling me. . . . When I've been to see the patient my observations may not have been the same. If it was an experienced person then I would accept the judgement and say, 'Well, I was wrong". If it was a junior person then I would feel more anxious because it's going to effect the
outcome of what we can do with this patient. . . . They are not all equal, are they? People's backgrounds, their level of intellect - it's different . . . But they all have something to contribute that will help this person. If you've been consistent, and you're reliable, and competent, then you will get respect. And, if you stuff something up, you lose it. (George, Int. 33, p. 342)
Equality and respect build up over time as team members know each other
better and learn to trust each other. Respect certainly facilitates pluralistic
dialogue:
Respect is a personal thing. People generally respect other people that they know, get on with, and have worked quite a bit with. Or they build it up . . . . It's very, very important to have a voice. And that's part of being respected. Being respected is being heard and listened to . . . . And it's not just having a voice, it's also having a voice that will be received in a certain way. It's attitudes. It's people's attitudes. (Lee, Int. 45, p. 528)
Respectful attitudes towards colleagues cannot be assumed. Manion et al. ( 1 996) claim that respect means treating people with dignity and fairness unconditionally. They argue that treating team members with consideration is a basic human requisite. Respect is also about regard and value. In this study, clinicians valued highly knowledge and competence. Theoretically, there is no place for practitioners with poorly, developed skills in a specialist team, yet they still appear. Once again, though clinicians who have not kept up with changes in knowledge and technology are a liability, they continue to be tolerated, albeit unsympathetically:
This specialty is still in the medical model of care. A lot of the registered nurses are not up-skilling here . . . . Doctors are very clear about which nurses they'd trust . . . Some registered nurses are perceived as experts and then there are those they were wary of to the extent that they don't like them looking after their patients. Opinion is based on the nurse's interaction with the doctor. Nurses would ring the doctor just to give panadol even though we have standing orders to give panadoll It coloured their involvement in the interdisciplinary activity. . . . When we all got together some colleagues were embarrassed by what they saw as silly, twittering remarks. . . . Perhaps they are not acknowledging overtly the lack of skill . . . . You can't manage an interdisciplinary team where people don't have expert knowledge. With some registered nurses - you have this conundrum where they've been trained for thirty years, but they are still novice practitioners . . .. (Ann, Int. 3, p. 29)