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Thursday Review: “Relationships of power: implications for interprofessional education”

Teaching health care providers how to collaborate between disciplines is considered an important mechanism for enhancing communication and interprofessional practice (IPP) among professionals, optimizing staff participation in clinical decision making, and improving the delivery of patient care1, 2, write Lindsay Baker, Eileen Egan-Lee, Maria Athina “Tina” Martimianakis and Scott Reeves.

Their article in the Journal of Interprofessional Care answers a big, glaring question: if there are such big advantages to “interprofessional practice”, why can it be so difficult to get professionals in different areas to collaborate?

The short answer, the authors argue, is self-interest. They give a summary of the academic discussion surrounding this almost guild mentality in medicine:

Professional groups engage in a process of “closure” to establish a monopoly over specific areas of knowledge and expertise in order to effectively secure economic reward and status enhancement.3 These are commonly referred to as “professional projects”.

As the model4 indicates professions interact as organized bodies with traditions, strategic orientations and a desire to protect and advance their members’ interests. In this article, we explore professionals’ perceptions of power within an [interprofessional education] context…

For example, Ellen D. Baer discusses some nurses and advocates for nursing jockeying for its position early on the existence of nursing as a profession.

Baker et al. show that the theory matches up with what all kinds of health care professions have to say.

Physicians […] feel threatened by a potential loss of power, loss of autonomy, loss of income, and loss of prestige [and] that interprofessionalism is just another word for further diluting the quality of work that a physician has previously enjoyed. (Physician 1).

A lot of nurses here in inpatient settings probably feel disempowered […] Nurses come to work wanting to make a difference […] and when you get here you realize, “oh this is the way it’s done and this is what’s expected of me”, you kind of lose that drive (Nurse 6).

Especially with the divide between OT and PT like that’s the biggest one because everyone thinks that we’re all the same, so most of it is trying to show them the differences between what we do. (Physical therapist 2).

The authors point out that just like Physician 1 feared, interprofessional education can have the reverse affect of increasing competition amongst professions. If various professions are educated and socialized to protect their profession’s status, deliberately introducing the idea of sharing decision-making is only going to heighten everyone’s awareness of what they have to lose.

Although it’s never made explicit, the authors hint at a three-tiered pecking order in health care:

  1. physicians
  2. nurses
  3. “allied health” providers, i.e., everybody else

As you can imagine, when everyone is talking about what control they have to lose or want to gain, almost no one is talking about the patient’s needs. If IPP and joint decision-making has any hope of making it off the page and into medical practice, the narrative has to be re-framed around the needs of the patient.

Physicians are worried that after they’ve been in school for twenty years and are ultimately legally liable for healthcare decisions, they’re going to lose control, which means a loss of autonomy. Nurses are worried that physicians see themselves as leaders, and are deferred to even in matters of the operational and working culture of the clinical environment. “Allied health” professionals are worried that no one — physicians most of all — knows what their skills and roles are.

In his book The Power of Habit, Charles Duhigg5 discusses a clinical culture which refused to collaborate and which produced some very public medical errors:

The critical issue at Rhode Island Hospital was that the nurses were the only ones giving up power to strike a truce. it was the nurses who double-checked patients’ medications and made extra efforts to write clearly on charts; the nurses who absorbed abuse from stressed-out doctors; the nurses who helped separate kind physicians from the despots, so the rest of the staff knew who tolerated operating-room suggestions and who would explode if you opened your mouth. … The [operational] truces at Rhode Island Hospital were one-sided. So at those crucial moments—when, for instance, a surgeon was about to make a hasty incision and a nurse tried to intervene—the routines that could have prevented the accident crumbled…

As the informal middle of the pecking order, nurses have an important function in any clinical setting. Since Rhode Island Hospital’s procedures and some of its personnel have been overhauled, the hospital has received accolades from the National Coalition on Health Care, the American College of Surgeons, and the Beacon Award. Duhigg details what the hospital’s operations are like now:

In 2010, a young nurse named Alison Ward walked into an operating room to assist on a routine surgery. She had started working in the OR a year earlier. She was the youngest and least experienced person in the room.

“Okay, final step,” [the surgeon] said before he picked up his scalpel. “Does anyone have any concerns before we start?”

The doctor had performed hundreds of these surgeries. He had an office full of degrees and awards.

“Doctor,” the twenty-seven-year-old Ward said, “I want to remind everyone that we have to pause before the first and second procedures. You didn’t mention that, and I just want to make sure we remember.”

It was the type of comment that, a few years ago, might have earned her a rebuke. Or ended her career.

“Thanks for adding that,” the surgeon said. “I’ll remember to mention it next time.

“Okay,” he said, “let’s start.”

Duhigg uses several other examples from outside healthcare to discuss how organizations can improve performance and safety through collaboration: Creating successful organizations isn’t just a matter of balancing authority. For an organization to work, leaders must cultivate habits that both create a real and balanced peace, and, paradoxically, make it absolutely clear who’s in charge.

There’s nothing wrong with physicians being a leader and being the final decision-maker in medical matters. What’s needed is a shift in the articulation of the problem: for example, physicians can’t be with their patients all the time, observing symptoms and reactions.

In the same way, nurses can’t be expected to oversee the treatment and therapy of every patient in every way. That’s where occupational therapists, physical therapists, nutritionists, social workers, and the rest of a clinical staff comes in.

Like Duhigg says, balancing authority — making it clear who is in charge of what — is a great way of keeping people off of one another’s toes. In addition, as he says, paradoxically, it’s necessary to make sure everyone knows who makes decisions and who is authorized to voice an opinion or an observation.

If the problem is re-framed away from professional security and pecking order onto the needs of the patient, every health care provider that comes into contact with the patient is a potential resource for information about the patient.

Baker et al. quote and an occupational therapist in such a situation:

Once someone has had their medical condition cleared … the physician wants them out of the hospital whereas … we would have concerns, yeah their pneumonia is cleared but … their safety is at risk if they go home.

If an OT is authorized to question a physician’s decision to release a patient, it’s necessary to make sure that the question is framed as a genuine question, and not as an affront to the decision-making capacity of the physician in charge. Because, while a physician may be correct that somebody who went to say, occupational therapy school for three years and I have been in school for twenty years … we are not in the same boat, that doesn’t mean the OT has nothing to say about the issue.

Far from having to negotiate with every Tom, Dick and Harry, as doctors fear, if, in this example, the OT might ask a genuine question: “Are you concerned that if the patient is released now, even though their pneumonia is cleared they might be at risk?” Faced with this decision, a physician — with the help of other healthcare providers — can find a course of action with the patient’s best interests in mind.

It’s possible to collaborate in a manner that respects everyone’s autonomy, skill, training, and ability in their own discipline while focusing on the best care of the patient.


The article reviewed: Baker, Lindsay, Eileen Egan-Lee, Maria Athina “Tina” Martimianakis, and Scott Reeves. “Relationships of Power: Implications for Interprofessional Education.” Journal of Interprofessional Care 25, no. 2 (March 16, 2011): 98–104.

1 Curran, Vernon. Interprofessional education for collaborative patient-centered practice research synthesis paper. 2008. Baker et al. list the paper as being accessed from This link is broken, but the same paper seems to be available at ResearchGate.

2 Reeves, Scott, Merrick Zwarenstein, Joanne Goldman, Hugh Barr, Della Freeth, Marilyn Hammick, and Ivan Koppel. “Interprofessional Education: Effects on Professional Practice and Health Care Outcomes.” In Cochrane Database of Systematic Reviews, edited by Scott Reeves, CD002213. Chichester, UK: John Wiley & Sons, Ltd, 2008.

3 Freidson, Eliot. Profession of Medicine: A Study of the Sociology of Applied Knowledge. Dodd, Mead & Co. 1970.

4 The authors make extensive use of: Witz, Anne. Professions and Patriarchy. Routledge, 1992.

5 Duhigg, Charles. The Power of Habit: Why We Do What We Do in Life and Business. Random House, 2012.

Featured Image: “Conflict (Chess II)” by Flickr user Cristian V, used under a CC BY-ND 2.0 License