When exploring the concept and definitions of interprofessional working it is important to acknowledge that issues surrounding professionalism are closely associated and underpin an emerging theoretical framework of interprofessional working. Salhani and Coulter (2009) suggest that the idea of interprofessional collaboration means that professional boundaries among healthcare professionals are in fact flexible. This implies that an interprofessional approach means that the traditional characteristics of professions (autonomy, codification of knowledge, professional values and boundaries (Abbott 1988, Freidson 1988), professional jurisdiction and identity, self-regulation and professional territorialism (Axelsson & Axelsson 2009) are challenged by this approach to working.
The current definitions of interprofessional working have been derived from the widely agreed definition of interprofessional learning: when two or more professions learn with, from and about each other to improve collaboration and the quality of care (CAIPE 2002). It is, however, important to distinguish between interprofessional learning and interprofessional working. Lewy (2010) suggests that one of the key underpinning differences is that interprofessional learning provides an environment in which structured opportunities are put in place to facilitate the transfer of professional knowledge and where team processes and working are developed in a structured and more formal way. It could be argued that interprofessional learning takes place in a more controlled environment, than that of a clinical environment. Whereas interprofessional working is seen when professionals work together both informally and formally in response to patient healthcare needs (Lewy 2010). Headrick et al. (1998) suggested that in fact interprofessional working can be thought of as a spectrum of activity, with more loosely co-ordinated effort of collaboration at one end and more tightly organized teams of work at the other. Ovretveit’s et al. (1997) offer a definition of interprofessional working that focuses on communication and cooperation as strategies for achieving a common goal, highlighting the relationships between professional groups, while Leathard (1994) focuses on the sharing of resources, skills and responsibility and suggests that the interdependence of the team members can provide a better service if the various professionals worked alongside but independently of each other. Carrier and Kendall (1995, p. 18) have perhaps constructed a definition which conveys the depth and breadth of the tasks associated with interprofessional working: interprofessional working implies the sharing of knowledge; respect for the individual autonomy of different professional groups and administrators; the surrender of professional territory where necessary; and a shared set of values concerning appropriate responses to share definitions of need. Unsurprisingly the authors admit that professions are likely to find this an ambitious and demanding agenda.
Barriers to interprofessional working
Some key barriers to interprofessional working have been clearly identified in the literature. McPherson et al. (2001) suggests that barriers preventing interprofessional working include a lack of knowledge of the capabilities and contributions of other professionals, and existing rivalries and resentments amongst healthcare professionals about professional boundaries and territories. This, he suggests is compounded by the wide range of stakeholders with their own aims, objectives, priorities and values in establishing different allegiances, not only to the team, but also to their professional groups (Firth-Cozens 2001). McPherson et al. (2001) also identify that there are concerns amongst healthcare professionals that interprofessional working will lead to a blurring of differences between professions, just at a time when non-medical professions are still struggling to establish themselves as ‘true professions’ with a body of discreet, specialized and unique knowledge. Thus, Lewy (2010) suggests that professions are more interested in emphasizing the differences between professions rather than ‘sharing’ knowledge and skills which may be perceived as a threat to their professional status rather than as an opportunity. According to Abbott (1988) all professions are striving for ‘jurisdiction’ over their field of work, suggesting dominance over other professions within the same field and clear boundaries against those professions. The medical profession has also voiced concerns over the safety issues associated with task substitution and true interprofessional working and recommend that doctors retain their central role within health care (Yong 2006). This is despite a Cochrane review which found that nurses could successfully substitute for medical roles in particular circumstances in primary care (Laurent et al. 2005)
Task and role substitution
Task substitution is defined as allocation of clinical responsibilities to lesser or more narrowly trained healthcare professionals with or without medical supervision (Yong 2006, p. 27). Task substitution directly contributes to role substitution when aspects of a previously defined role are undertaken by another professional usually a non-medical practitioner. It could be argued that aspects of task and role substitution have been informally embedded within the NHS for many years. For example as nurses contribute to a 24-hour working shift pattern and allied healthcare professions presently do not, many nurses are expected to take on elements of allied healthcare professionals work such as physiotherapy tasks out of hours and at weekends. It is also interesting to note that task and role substitution is associated with negative descriptors in the literature while generally interprofessional working is associated with positive descriptions. Arguably, the foundation of this finding may be found in the traditional characteristics surrounding professional identity particularly in health (Baxter & Brumfitt 2008) where professional groupings, allegiances and underlying philosophical approaches have been identified to be very important to individual health professionals. Thus being seen to ‘substitute’ for aspects of a different professional role is perceived to be an inferior or less worthy characteristic of a professional group.
The terms interprofessional working and role or task substitution seem to be used interchangeably throughout policy and Department of Health literature, however, it is important to be able to differentiate the two concepts when examining the policy context in more detail to understand the evolution in healthcare and more specifically emergency care.
Brook and Crouch (2004) suggest that in emergency departments during most of the twentieth century, there was clear demarcation between the roles of nurse and doctor, where patients received a consultation and examination for diagnostic purposes by doctors who would prescribe treatment and delegate its provision to nurses. However, whilst this may have been the official truth, unofficially there is evidence to suggest that nurses particularly had been expanding their role quietly for some time.
Hughes (1988) in his study undertaken within a ‘casualty’ department in the 1980s found that the distinctive features of ‘casualty’ nursing were found to replicate the findings of Stein (1967) in their increased involvement in decision-making affecting diagnosis and treatment and the flattened hierarchy found in ‘casualty’ departments when compared to wards. He also observed that the medical dominant relationship was weakened by the informal interactions of the nursing staff with the medical staff, the form of subtle cues to medical staff, the heavy work demands associated with the triage function of the department, the potential urgency of treatment and the short-term nature of most medical appointments all increased the nurses’ influence within the department and on nursing and medical relationships. Further ethnographic work in emergency care settings has confirmed that informal boundary blurring between medicine and nursing has been prevalent for many years. Annandale et al. (1999) found that it fell to the senior nursing staff to harness the unpredictability so the workload could be accommodated within the resource constraints. This resulted in the nurses organizing the work of the medical staff and taking on task substitution roles such as suturing and cannulation to speed up the flow of patients through the department and try to reduce bottlenecks in the process.
Newer roles began to develop such as the extended scope physiotherapist (ESP): a physiotherapist who has additional skills in assessment, diagnosis and management (McClellan et al. 2006). Evaluation of these newer roles is ongoing but early studies demonstrate that there are high levels of patient satisfaction associated with the introduction of these roles into emergency and urgent care settings (McClellan et al. 2006). Some emergency departments found that despite the development of these new roles, difficulties were still being experienced in recruiting enough staff to manage the patient attendances in a timely fashion, and the model of service delivery by physician’s assistants (PAs) as in the USA was adopted. PAs are health professionals with a generalist medical education that allows them to work in a variety of settings. They work under the supervision of a senior doctor. The profession emerged in the USA in the 1960s and is now being adopted by other countries such as the UK to address workforce gaps in medical specialties (Farmer et al. 2009). Interestingly the Scottish BMA (2008) published a position paper on this emerging profession and identified specific issues concerning the role; around value for money, impact on medical training, professional standards and regulation and integration into clinical teams, while praising and supporting the role of the nurse practitioner because they saw this as an expansion of a current role rather than a new role, which was viewed as a more positive approach.
Pollard (2010) suggests that one of the most important features of successful projects which address new ways of delivering a service is one in which a profession takes on and incorporates the tasks of a different professional group. From the evidence examined so far it emerges that the most successful non-medical role in terms of longevity and positive evaluation is that of the ENP (Dunn 1997, Sakr et al. 1999, 2003, Lin et al. 2002, Brook & Crouch 2004). This role has developed from experienced nurses taking on a substitution role that was and still is carried out by junior doctors. Because the role has become well established in emergency care over the past 25 years and developed to address a specific deficit in the workforce, evaluations have taken place which have identified a high level of patient satisfaction and an ability of ENPs to work safely within protocols (Grummisch & Lowe 2007, Carter & Chochinov 2007, Keating & Thompson 2008) There now appears to be a general acceptance of the role within emergency care (Benger & Hoskins 2005, Carter & Chochinov 2007) most importantly by medical colleagues (in terms of encroaching on traditional medical boundaries of minor injury care). The scope of practice within this workforce has gradually been developing and expanding to meet service delivery needs, and now the role has moved away from protocol driven care towards evidenced based care, which it could be argued carries much more risk along with independent prescribing status. With the expansion in scope has come the ability for ENPs to develop the skills to see the more ‘unpopular’ patient presentations and this may be part of the reason why the role expansion has now been accepted with relatively little ongoing resistance from medical colleagues. Incongruously, ENPs are now experiencing a reversal in roles and there is now an expectation and requirement that they will teach junior doctors about the management of minor injuries and illness. Adapting Headrick et al. (1998) concept of a spectrum of interprofessional activity it could be argued that the similar concept of a spectrum of activity can be applied to the range of healthcare roles from task substitution to interprofessional working (with role substitution sitting somewhere between the two) when plotted on a scale. Using this theoretical framework (see Figure 1) it can be observed that as the ENP role has become established it has moved along the spectrum of task and role substitution towards one of interprofessional working as other professions begin to understand and accept their role and the specific knowledge. This professional group is now claiming this area of work as their own, and as a consequence ENPs are being seen to contribute towards successful service delivery and interprofessional working.
There are however, identifiable disadvantages to the development of this role. Of particular note in the literature is the concern raised that senior nurses are being removed from the experienced nursing workforce in emergency care and are taking their knowledge and leadership away from the day-to-day running of busy emergency departments and thus diluting the nursing skill mix (Yong 2006). Coupled with this is the potential fear that future ENPS will identify that there is little or no financial reward for undertaking extensive further education and additional responsibility that the role now demands. In addition, where once the role attracted senior nurses who wanted to work more attractive hours, the need to meet growing demand for services out of hours has meant that the service provision has extended and ENPS are now working increasingly unsocial hours. While job satisfaction is a key reason for senior nurses to take on the ENP role, in the future ENPs may become a more mobile workforce when they become increasingly questioning of the prospect of undertaking increased responsibility with no financial award, and working increasing unsocial hours with no clear career progression.
Whereas there is less experience and evaluation of new roles such as the extended scope physiotherapist, there are some themes emerging from the literature. In the case of the extended physiotherapist it could be argued that their role expansion in emergency care has developed in a more interprofessional way mainly because the role brings profession specific expertise to emergency care (McClellan et al. 2006). However, if this role expands further it seems that the role extension could in fact move back along the spectrum towards task substitution as the ESP takes on tasks such as venepuncture and wound management. Positively, this will mean less ‘hand offs’ in care for patients but conversely could mean a perceived dilution of their well-defined and accepted expertise and knowledge by the rest of the workforce.
The physician’s assistant role was specifically developed as a role substitution function within the team (Farmer et al. 2009). Positively, when the role is clearly understood, it seems that the evidence suggests that the role is accepted and ‘owned’ by doctors. This may be in some part due to the use of similar language, values and socialization based around a medical model of learning and working (Axelsson & Axelsson 2009). The role has developed with obvious boundaries and the PA is directly responsible to a medical practitioner. It may be the case in the future that PA roles become so integrated into teams that they begin to claim specific professional knowledge as their own. However, without professional registration in the UK, it is unlikely that this will occur in the foreseeable future.
This different approach to delivering redefined models of care would suggest that healthcare roles are being encouraged towards a model of being based on competence rather than professional identity, in that occupation alone does not determine who conducts these tasks (Cameron & Masterson 2003). Miller (2004, p. 152) argues that the call for collaboration across professions in health care has come at a time when ‘many professionals feel threatened by a loss of identity and autonomy are struggling to maintain a professional role’ and may explain some of the resistance to expansion of roles and a more integrated approach to the concept of interprofessional working within teams. Catto (2005) acknowledges that the exclusivity of medical knowledge and skill is being broken down and suggests that this should not be seen as a diminution of medicine but rather a strengthening of health care. The emphasis in recent UK government policy is to prepare all healthcare students for interprofessional working in order to be able to be flexible and to be able to substitute for roles traditionally undertaken by other occupational groups and the ability to move across traditional role boundaries so that the delivery of care is patient centred rather than task or individual specific. While the underpinning concept is laudable, such flexibility, centred on role substitution and role design can present a challenge to healthcare professionals accustomed to established patterns of professional roles and professional boundaries and professional socialization (Pollard 2010) particularly in teams and professions where a hierarchy in the team is the normal and established approach to delivering a particular service.