Getting health professionals to work togetherBMJ 2000; 320 doi: http://dx.doi.org/10.1136/bmj.320.7241.1021 (Published 15 April 2000) Cite this as: BMJ 2000;320:1021
There's more to collaboration than simply working side by side
- Celia Davies, professor of health care
Doctors and nurses work together every day. But is there more to working together than making sure that the work of the one profession dovetails with that of the other? Is there really any content in the “co” words, so popular in government policy documents—coordination, collaboration, and cooperation?
Researchers are beginning to understand what working together can achieve. The settings are different—how work groups in the private sector can perform better, 1 how democracies can involve people more directly, 2–4 how conflict can be resolved5—but the message is the same. Working “together” rather than working “alongside” can energise people and result in new ways of tackling old problems. We have had glimpses of this in patient participation in the NHS. We know much more than we did even five years ago about giving lay people the support and information they need to have a meaningful dialogue with managers and clinicians and to make an input into how services are run. We need to encourage real “conversations” at work—ones that start to create a dialogue between people who have not yet understood what they can achieve in common.6
It's the differences that matter
What characterises the new models of collaboration is the recognition that it is not what people have in common but their differences that make collaborative work more powerful than working separately. Working together means acknowledging that all participants bring equally valid knowledge and expertise from their professional and personal experience. Affirmations, acknowledgment, and recognition are important, but it is the questions and challenges that arise from the differences that are vital. A diverse group can arrive at a place no individual and no like-minded group would have reached. When, for example, a social services department decided to bring people with learning difficulties into the heart of its evaluation of quality, staff realised how inaccessible and unnecessary some of their jargon had become. The direct comments of those in residential care about what would help them in their day to day lives gave a simpler and more motivating starting point for change.7
The same kind of thinking is at work when theorists of leadership urge a move from transactional to transformational approaches. A transactional leader has a strong sense of direction and comes to an agreement with subordinates about what each will do to make a reality of a given vision. A transformational leader is at the centre of a network, allowing a vision to emerge from the dialogue.8
What does it take to create the conditions for working together in the new collaborative model? 9 10 Firstly, participants have to welcome challenge. They need to be confident enough to face the unfamiliar, respectful and trusting enough to listen openly to others. Secondly, there must be ground rules. Inequalities of power can make it near impossible for the less powerful membersof a group to speak out. Appointing a facilitator and arranging a premeeting to help a minority viewpoint get expressed are ways of organising to redress the balance. Another technique that has been used by teachers when invited speakers withopposing views are addressing a class is to set up a facilitated dialogue. Instead of a traditional debate, where speakers with opposing views defend their own position and attack their opponents', such a dialogue is designed to explore different perspectives, values, and goals and encourages pupils to respect different perspectives on a controversial issue.11 Collaboration sometimes works spontaneously when established experts arebrought together as strangers on a working group or task force. More often, dialogue has to be deliberately encouraged.
There are good reasons why doctors and nurses are not far along this road. Traditionally the profession of medicine created doctors who were self reliant and independent. It emphasised expertise, autonomy, and responsibility more than interdependence, deliberation, and dialogue. The ritual humiliations of medical training that instil individual mastery of knowledge help to maintain this. So too do the expectations of patients and colleagues.
Nursing traditions have been different, emphasising hierarchy and bureaucratic rule following. Even if these have diminished, along with deference to doctors, nurses still work “around” others. Individually, nurses and doctors may strive to overcome the lingering images of their professions, but there is a weight of tradition, including a tradition of genderthinking, 12 to contend with. Nursing is no more conducive to collaborative working than is medicine. Both need to change if a collaborative model is to work.
Support comes from strange quarters. The new National Institute for Clinical Excellence refers to “health professionals” rather than singling out any one group. It acknowledges that no one who works alone can stay at the forefront of knowledge given the speed of organisational and clinical change.13
Just how ready are nurses and doctors to work together in a new way? Is it any accident that collaboration between patients and professionals springs more readily to mind than collaboration between the professions? The tales that nurses and doctors each tell about the other when they are outside work and “among friends” suggest that there is still some way to go.