Professional Documents
Culture Documents
Correspondence: Dr. Scott Reeves, Faculty of Medicine, Centre for Faculty Development, University of Toronto, St. Michael’s Hospital, Toronto,
Ontario, Canada. E-mail: scott.reeves@utoronto.ca
98
RELATIONSHIPS OF POWER 99
enhancement (Freidson, 1970). These are commonly WITZ’S MODEL OF PROFESSIONAL CLOSURE (1992)
referred to as ‘professional projects’.
Friedson’s work offered a critical turning point in thinking Witz’s model defines and discusses the relationships
about professions, as traditional accounts of professions between four types of closure strategies: exclusionary,
tended to stress their functionality, universalism and demarcationary, inclusionary and dual closure (see
neutrality. Other sociologists have extended Friedson’s Table I). As such, this model can be regarded as helpful
analysis. For example, Larkin (1983) argued that a key part in understanding the relationships between professions.
of the professionalization of occupational groups was the These strategies are arranged into four quadrants; the left-
licensing of their practice through their connections with the hand side, which is concerned with intra-professional power
state. Without this formal link, granting the right to a relations, and the right-hand side, which is concerned with
monopoly of practice, Larkin argues that an occupation interprofessional power relations (Figure 1).
cannot successfully achieve professional closure and its social As the model indicates professions interact as
and economic rewards: organized bodies with traditions, strategic orientations
and a desire to protect and advance their members’
A profession’s relationship with the state [. . .] is fundamental. interests. In this article, we explore professionals’ percep-
Occupations that attempt to secure for themselves the two tions of power within an IPE context and therefore
dimensions of professionalism – market control and social
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Exclusionary Exclusionary strategies involve a downward use of power by a dominant profession in order to control entry to their
profession and create a monopoly over their skills and knowledge.
Inclusionary Inclusionary strategies are used by subordinate professions to challenge exclusionary strategies and involve an
upward push of power in order to achieve entry into the ranks of the dominant profession.
Demarcationary Demarcationary strategies involve a downward use of power by a dominant profession in order to control
boundaries between related professions to secure their position of power on the professional hierarchy.
Dual closure Dual closure strategies are used by subordinate professions in response to demarcationary strategies and involve
a two-way use of power:
. Usurpationary strategies push upward and are used not to gain entry to the ranks of the dominant profession,
but to challenge demarcationary strategies and change the structure of the hierarchy.
. Exclusionary strategies push downward and are used to secure their place in the hierarchy.
centre in North America. The initiative was funded by a local issues related to power. On-going discussion about the
government agency to develop and deliver a series of IPE emergent themes with the other authors (T.M., S.R.) resulted
activities which would foster knowledge, awareness and skills in an agreement to look at potential theories which could help
for interprofessional collaboration (IPC) among the staff us understand these data. After reviewing the sociological
working in (and across) the participating organizations. literature, Witz’s model of professional closure was selected as
While the commissioned evaluation was focused on one framework to help understand how power impacted IPE
describing processes and outcomes related to the varied IPE experiences. To confirm the findings from the secondary
activities, power emerged in the initial analysis as a analysis, an additional 37 transcripts (selected by the process
significant theme within the data. A secondary analysis of outlined above) were read by two researchers (L.B., E.E.L.).
a subset of the data was undertaken to explore these issues
in greater depth. Ethics and quality
Ethical approval for this study was obtained from Research
Context Ethics Boards at all participating institutions. A number of
The IPE initiative involved a coordinated effort among the techniques were used to ensure the quality of this work. For
health science disciplines at a single university and its example, as noted above, selection of transcripts was
affiliated teaching hospitals and research institutes. Speci- undertaken by a researcher not involved with the initial
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fically, it involved six educational and clinical institutions analysis. Two researchers reviewed, coded and agreed upon
who collaborated to develop and deliver a series of IPE the nature of the emergent themes from the secondary
activities. Six separate programmes which offered a range of analysis. Themes generated by the two researchers were
interprofessional experiences were piloted across several discussed and agreed by all authors. Additional transcripts
clinical institutions. Each program was aligned with the were read to ensure the secondary analysis resonated more
specific goals of their institution however their overall widely across the dataset (Lincoln & Guba, 1985).
visions were the same: to create organizational structures
for new channels of communication to enhance student Findings
learning and ultimately patient care; to help prepare Our findings are organized into two sections. The first
hospital environments for future student IPE placements; section illustrates how the various health and social care
For personal use only.
to train staff to actively practice IPC; and to identify role professions perceive and experience power relations. The
models for IPC and new IPE facilitators. second section explores how the perception of these power
relations may have affected participation in this IPE
Data collection initiative.
The overall evaluation of this initiative involved multiple
methods of data collection including interviews with Perceptions and experiences of power
program leaders, facilitators, and learners. Participation in In the following sections, we describe the general environ-
the evaluation was voluntary and a total of 132 individuals ment in which most health and social care professionals
from a variety of professions agreed to be interviewed. A work and interact on a daily basis. Power relations are
semi-structured interview protocol was developed which discussed in the context of professional training and
aimed to explore participant perceptions and experiences of socialization, interprofessional awareness, and determinants
the programs. Interviews were digitally recorded, tran- of team climate.
scribed, and anonymized.
Professional training and socialization
Analysis Our data indicated that individuals felt that socialization
As noted above, while not an area of focus for the through their training affected the way different health
evaluation, during the initial analysis, issues of power professional groups viewed themselves. In general, physicians
imbalances amongst the professions emerged as a key perceived themselves as ‘leaders’ and ‘decision makers’ in
theme. To explore this area in more depth, a separate health care while nursing, therapists and other professions (e.g.
analysis was subsequently undertaken with a sub-set of 25 pharmacists, dietitians, social workers) saw themselves as ‘team
transcripts. This subset of transcripts was sampled members’ who tend to adopt a holistic approach to care. The
purposefully for representation from a range of different following quotes show how professional identity may cause
health and social care professions, specifically, dietetics, tension in the context of interprofessional decision-making:
medicine, nursing, occupational therapy, pharmacy, phy-
sical therapy, speech and language therapy and social Once someone has had their medical condition cleared . . . the
work. To overcome the potential bias with transcript physician wants them out of the hospital whereas . . . we [because
selection (i.e. selecting only those which contained many of our holistic approach] would have concerns, yeah their
pneumonia is cleared but . . . their safety is at risk if they go
references to power), all transcripts were selected by a
home (Occupational therapist 1).
researcher who was not involved in the data collection or
initial analysis.
All selected transcripts were read iteratively by A number of physicians also referenced the number of
two researchers (L.B., E.E.L.) and were re-analyzed to explore years of training and the degree of monetary investment
they made towards becoming a professional which seemed difference [. . .] and when you get here you realize, ‘oh this is the
to justify a hierarchical division of labor with them in a way it’s done and this is what’s expected of me’, you kind of lose
that drive (Nurse 6).
dominant position. In the following quote, this physician
described his colleagues’ response to this issue:
Also affecting team culture was the notion of medical
Like a lot of physicians thought, I killed myself and destituted dominance in team decision-making processes. This
myself for years to achieve the training . . . and you’re telling me dominance was perceived to be difficult to counteract by
now that I am going to . . . have to negotiate with every Tom, many of the nurses, therapists and social workers who felt
Dick and Harry. You know like somebody who went to say,
that they should have input in the direction of patient care
occupational therapy school for three years and I have been in
school for twenty years . . . we are not in the same boat . . . (- within their areas of expertise. The difficulty was often
Physician 4). attributed to their working conditions. In busy, high-
pressured clinical contexts like the emergency room, some
The legal responsibility of physicians for patients also of the nurses described the need to defer to the physician
appeared to legitimize physicians’ status in the health due to a ‘lack of time’ or ‘responsibility’, thereby reinforcing
professional hierarchy. Both medical and non-medical traditional interprofessional hierarchical arrangements.
professions noted that ‘ultimately they were liable’ (physi-
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You wait to see which resident [junior physician] joins you or Furthermore, several participants indicated that IPE
which staff person [senior physician] joins you and then you helped them feel more valued and respected, improving
decide how your team’s going to function around them rather their job satisfaction and retention:
than welcoming a new health care member to your team. (Social
worker 1).
Better for the patients and better for the team. Better for staff. A
In addition, the frequent rotation of junior and senior good team allows for a real opportunity for openness and
physicians, it was felt, undermined the stability of the team, understanding and respect and it’s like good learning. People learn
well in an environment that’s open and accepting. (Social worker 4).
leading to feelings of disempowerment for other members:
A lot of nurses here in inpatient settings probably feel While nurses, therapists and social workers appeared to be
disempowered [. . .] Nurses come to work wanting to make a united in describing the potential benefits of IPE and
perceptions of their medical colleagues, they also appeared Physicians [. . .] feel threatened by a potential loss of power, loss of
to engage in a form of ‘elbowing’ behaviour. It appears that autonomy, loss of income, and loss of prestige [and] that
interprofessionalism is just another word for further diluting the
the aim of this activity was to carve out their own quality of work that a physician has previously enjoyed.
professional niches. This strategy could be seen as an act (Physician 1).
as a ‘boundary setting’ and involved defending the
uniqueness of their professions:
In this context, poor physician participation was regarded
Especially with the divide between OT and PT like that’s the by some nurses, therapists and social workers as proble-
biggest one because everyone thinks that we’re all the same, so matic because perceptions of medical ‘apathy’ towards IPE
most of it is trying to show them the differences between what we appeared to compound historically entrenched hierarchical
do. (Physical therapist 2).
relationships amongst these professions.
and not excluded in the planning and delivery of this description of a North American environment in which
initiative: health and social care professions work and interact on a
daily basis. These findings highlight how different profes-
My boss and I didn’t want to lose out on this piece [involvement sional groups perceive and experience power, and how these
in the IPE initiative] because, I mean we don’t have a voice to perceptions contribute to maintain the traditional hierarchy
begin with [. . .] and when we don’t get a voice things happen and of these professions. Our findings also outline varying
nutrition and dietitians are always left out. (Dietitian 1).
perceptions and responses to an IPE initiative that was
introduced into this environment.
In contrast to other professionals, physician involvement in Witz’s model of professional closure can help us
this IPE initiative was limited. This lack of engagement was understand these findings in more depth. As noted above,
For personal use only.
perceived as apathy by numerous participants: this model describes how professions engage in various
closure strategies in order to stake claims to resources and
The two doctors that came, it was great to have them but, you opportunities and control boundaries (see Figure 1). More
know it was a very small percentage of the group because specifically, it highlights how dominant occupational groups
certainly in any hospital setting, if you don’t have the doctors on can engage in demarcationary strategies as a means to
board it is hard to move forward with some things, so it would
control the boundaries between subordinate occupations to
have been good to have more involvement from them. (Physical
therapist 4). maintain an advantage over them. For example, historically,
medicine has played a crucial role in defining the areas of
competence of other health professions such as midwifery
One possible reason for physicians’ lack of engagement in and nursing, often referred to as ‘caring professions’ (e.g.
IPE could be linked to their concerns about its lack of Hugman, R. 1991). In response, Witz argues that these
empirical rigor: ‘caring professions’ engage in the dual closure strategy of
usurpation as a way to resist and challenge the dominance
I found in some of the [IPE] presentations where things were of other professions, especially medicine, and exclusion
touted as best practice or numbers were given, there wasn’t a lot strategies as way to protect and demarcate the scope and the
of evidence behind those claims. Being used to medical rounds, if boundaries of their work and relative position in the health
you were going to present you would have to have more data
[evidence] to back your claims. (Physician 5).
professions division of labor. The model thus captures the
two-way exercise of power within a hierarchy of relation-
ships among professions.
Other participants however felt this ‘lack of proof’ argument Examining our findings using this model illustrates how
as a convenient excuse to not engage in IPE, as this nurse interprofessional interactions within an IPE context can be
explains: seen to mirror closure strategies. These interactions can
serve to reinforce traditional power relationships and thwart
Going back to the philosophy, where is the proof? Where is the efforts to develop more collaborative approaches to care.
proof that this works? Where is the proof becomes a convenient For example, professional socialization prompted physi-
defense mechanism for not changing, to not embarking on cians in our sample to acknowledge that some of their
something new. (Nurse 5).
medical colleagues view their profession-specific training,
knowledge and skills as more ‘valuable’ than that of the
The data suggested that another possible reason for other professions. This belief could translate into a lack
physicians’ lack of engagement in IPE could be related to of knowledge about the roles and the responsibilities of their
a perceived threat to its dominant position in the health colleagues from nursing and social work, for example,
professional division of labor: leading to poor interprofessional interactions.
Exploring current relations through this particular the closure strategies identified in our data and the groups
theoretical lens helps to set the stage for understanding which appeared to employ them.
why some professions are particularly ‘attracted’ to and The situation we have outlined above can create a
engage in IPE. Our data indicated that IPE was regarded as tension: while participation in IPE may lead to a range of
an opportunity for improving the conditions of work for perceived gains for some professions it may also lead to
many of the professional groups in this study. As a result, it perceived losses, increased competition and friction
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means to legitimize the potential clinical and scientific relating to this phenomenon were therefore limited in
contributions that other professions can offer to delivering nature. Nevertheless, the complex array of issues that did
care. In practice, however, projecting the notion of equality emerge from these data suggests that the role that power
was not enough to address power imbalances within the plays in IPE requires much further study.
delivery of IPE that stem from the regulatory and work
arrangements of each profession as well as the historically
entrenched attitudes of whose knowledge and skill ‘really’ CONCLUSION
matters.
Our data also indicated that physicians were largely In this article we indicated how perceptions, attitudes and
absent from many of the IPE experiences. They were activities of professionals within an IPE context can serve to
commonly perceived to be the ‘decision makers’ in the reinforce traditional hierarchical relationships amongst
clinical setting, and therefore in a more influential position them. Although the professionals in our sample were all
to effect change than their non-medical colleagues. This engaged in IPE, we found that their motivations and levels
made their absence from IPE problematic, and could be of engagement were linked to their respective professiona-
considered a demarcation strategy (Witz, 1992) to protect lization projects. For example, in this study physicians
their position of authority in the health care hierarchy. noted that some of their medical colleagues regarded IPE as
The complexity of dual closure strategies (Witz, 1992) a potential threat to their professional status, while non-
also came through in our data set. In addition to engaging medical professionals saw it as an opportunity to improve
in IPE as a usurpation strategy, some professions (e.g. their standing within the health professions. These attitudes,
occupational therapy, physical therapy, speech and language it appeared, were expressed through a type of protectionism
therapists) also engaged in exclusionary strategies as a way where it mattered more to foreground one’s own profes-
to create and protect boundaries around their own sional identity than to find common ground.
professional turf. Historically, these professions have been While institutions have invested significant effort and
‘clustered together’ into a homogenous group of health care resources in designing interprofessional curricula, little
providers (sometimes referred to ‘allied health’) on the basis attention has been given to attitudes, perceptions and
of not being nurses or physicians, a position which arguably practice that reproduce hierarchies amongst professions and
negates the unique status and contributions to patient care can affect team functioning. IPE as presented in this article,
for each of these professions. As noted above, within our while based on notions of collaboration and teamwork, can
data, there was some form of ‘elbowing’ activity, undertaken have the reverse affect of increasing competition amongst
to delineate boundaries that differentiate their scopes of professions, like the ‘elbowing’ phenomenon we saw emerge
practice from each other and to secure their own position in between the ‘allied’ professions. We also indicated that
the health care hierarchy. Table II provides a summary of when professionals engage in IPE they bring along their
respective attitudes and perceptions of each other and can Curran, V. (2008). Interprofessional education for collaborative patient-
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