Towards an ethos of interdisciplinary practice
BMJ 1995; 311 doi: https://doi.org/10.1136/bmj.311.7000.305 (Published 29 July 1995) Cite this as: BMJ 1995;311:305
- Mike Nolan
Anyone browsing through the nursing journals over the past few months will have noticed that the profession seems to be undergoing sustained and quite unprecedented change. While change characterises the health care environment in general, several factors seem to have impinged on nursing and exacerbated an already fraught situation.
On the one hand there are dire warnings of the potential impact of “multiskilling,” whereby unqualified and minimally trained personnel are undertaking activities previously deemed to be the province of nurses. Indeed in the United States such workers seem to be already moving into quasi-medical territory and are suturing wounds, injecting intravenous drugs, and inserting catheters.1 Paradoxically, in Britain there are concurrent accounts of the potential benefits, particularly for junior doctors, of nurse practitioners completing a similar range of tasks.2
Although some experts feel that the development of the nurse practitioner will also benefit nursing, there are those who argue that such an initiative is of questionable value and does little but reinforce the traditional “handmaiden” relationship, with the nurse now cast in the role of “technical functionary.”3 In considering alternatives, others assert that nursing's future lies outside acute care, in such domains as health promotion, which is seen to offer “truly infinite scope” for professional growth and development.4
Against this backcloth Castledine suggested that nursing is currently in the throes of an identity crisis, initiated and sustained by the scale and pace of technological, economic, and scientific change in the NHS.5 To consider the likely impact of such factors on the delivery of health and social care and the role of the nurse in the next century the chief nursing officers for England, Northern Ireland, Scotland, and Wales convened a group of nursing leaders and other professional colleagues in May 1993. The report of their deliberations outlined several potential scenarios based on the premise that there is, and will continue to be, a shift in the balance of health care away from institutional provision and towards community care, coupled with an increasing emphasis on chronic illness.6 The net effect of this, it was argued, was that the ecological balance between all those involved in health and social care would be disturbed and that traditional roles and responsibilities would need to change.
Parkin has argued that the current state of flux has resulted in several occupational groups seeking to “lay claim to territories of ambiguous ownership in health care,” with a consequent heightening of traditional power struggles, a tension exacerbated by the emergence of consumerism so that challenging professional opinion is now seen as normative rather than deviant.
Much has been written over recent years about multidisciplinary teamwork, and terms such as collaboration and participation have proliferated, with a growing emphasis now on the involvement of patients and carers. For example, a recent report by the Royal College of Physicians addressing issues of equity in service provision for older people stated, in respect of decisions about admission to residential care, that informed choices by patients should always predominate.8 Unfortunately, such fine sentiments are rarely realised, often because differing professional groups do not share a common understanding of the relevant issues.9 If this situation is to improve then the diversity and complexity of the health care environment must be acknowledged more fully, reinforcing the fact that no profession has hegemony across all contexts. Such an acknowledgment has a particular impact on the interface between medicine and nursing.
Relation between medicine and nursing
Castledine suggested that the relation between medicine and nursing can be summarised by three viewpoints10:
* Nursing is an autonomous discipline, independent of medicine
* Nursing is inextricably linked to and largely dependent on medicine
* Both medicine and nursing are part of a continuum in which cure and care have a reciprocal relationship, with the relative emphasis shifting depending on context.
While these models may be oversimplifications, they are useful heuristic devices. Some professionals doubtless subscribe to the first or second approach, but I contend that the third approach represents the only viable model for the future.
Few would argue with the fact that the medical model is the most appropriate, and indeed the one of choice, when cure is possible.11 The application of such an approach, however, is counterproductive in chronic illness. Yet despite the growing importance given to the health needs of individuals with such conditions12 interventions are still largely characterised by the use of treatments derived from acute care.13 True progress will not be made until there is a fundamental reconceptualisation of the meaning of some terms—such as rehabilitation and the role that various groups play in the process. There are encouraging signs that this debate has begun, at least in respect of older people,8 and that it is widening to include health promotion and recognition that outcomes of care extend beyond the objective and must concern satisfaction with life and health. It therefore seems ironic that such factors receive only tacit recognition in the perceived aims of important services for older people, such as care in day hospitals.14
Professional reductionism is the tendency to restrict the legitimate focus of attention to an area consistent with a given professional paradigm.15 All professional groups engage in such activity, to the detriment of genuine collaboration and service innovation. Indeed this is probably one of the primary reasons that multidisciplinary working has often remained simply rhetoric.
From multidisciplinary to interdisciplinary care
Recently it has been possible to discern a subtle shift in emphasis away from multidisciplinary care towards interdisciplinary care. The concept of multidisciplinary care is based on the premise that health care is delivered by a team, each member of which has a different professional training and brings different skills to bear.16 The main task is therefore to coordinate the team effort. Interdisciplinary care, although not denying the importance of specific skills, seeks to blur the professional boundaries and requires trust, tolerance, and a willingness to share responsibility.9 Although such sentiments may sound trite in the current climate—which is more conducive to maintaining than dismantling barriers to collaborative working—trust, tolerance, and a willingness to share responsibility are what is needed.
During periods of rapid change there are always those who seek solace in the past. Within the present context, however, maintaining the status quo is simply not a viable or even sensible option. Rose tinted reflections on a better, albeit probably largely, mythical past do little to point a constructive way forward. In fact the nature of professional relationships in health care has changed. The lessons of the past are there to be learned but cannot be built on by reifying what has gone before. Rather it is time for constructive debate and some clear thinking to facilitate interprofessional dialogue. Such dialogue requires agreed definitions as to purpose and intent, free of much of the current rhetoric. While “pseudo-managerial gibberish”17 may indeed abound, its existence is indicative of a potent set of forces that will feed on, rather than be countered by, verbiage and unsubstantiated opinion.
In a recent critique of the seemingly endless reports detailing a vision for nursing in the year 2000 and beyond, Smith stated that what is needed is the development of a nursing profession that consists of “well educated, articulate, and assertive practitioners … who use their hands, hearts, and heads.”18 This is only likely to be achieved when there is a wider appreciation that the balance between these latter three ingredients must be flexible and shift in response to the health care environment in which we operate. Therefore while hands and hearts will always play an important part in nursing, the development of critical thinking is also essential.
As nursing produces its well educated, articulate, and assertive practitioners there is evidence that they are becoming increasingly disaffected with the commonly held view of the profession, particularly the perceptions of some medical colleagues.19 It is to be hoped that the disparate views in this issue of the BMJ will pave the way towards the level of continuing, well informed, and constructive debate that is necessary for enhanced interdisciplinary care.