Journal of Interprofessional Care, 2011, 25: 98–104 Ó 2011 Informa UK, Ltd.

ISSN 1356-1820 print/1469-9567 online DOI: 10.3109/13561820.2010.505350

Relationships of power: implications for interprofessional education
Lindsay Baker1, Eileen Egan-Lee1, Maria Athina (Tina) Martimianakis2 and Scott Reeves1,3–5
1

Centre for Faculty Development, Faculty of Medicine University of Toronto, St. Michael’s Hospital, 2Department of Paediatrics, University of Toronto, 3Li Ka Shing Knowledge Institute, St Michael’s Hospital, 4Wilson Centre for Research in Education, University Health Network, and 5Department of Psychiatry, University of Toronto

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Interprofessional education (IPE) is considered a key mechanism in enhancing communication and practice among health care providers, optimizing participation in clinical decision making and improving the delivery of care. An important, though under-explored, factor connected to this form of education is the unequal power relations that exist between the health and the social care professions. Drawing on data from the evaluation of a large multi-site IPE initiative, we use Witz’s model of professional closure (1992) to explore the perspectives and the experiences of participants and the power relations between them. A subset of interviews with a range of different professionals (n ¼ 25) were inductively analyzed to generate emerging themes related to perceptions of professional closure and power. Findings from this work highlight how professionals’ views of interprofessional interactions, behaviours and attitudes tend to either reinforce or attempt to restructure traditional power relationships within the context of an IPE initiative. Keywords: Interprofessional education; power; professional closure; hierarchy; faculty development

INTRODUCTION Interprofessional education (IPE) is commonly invoked by policy makers internationally and nationally as a key mechanism to address current and emerging human health resource issues (Ontario Ministry of Health and Long Term Care, 2007; World Health Organization, 2006) such as recruitment, retention and satisfaction of health and social care providers. Specifically, IPE 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 care (e.g. Curran, 2008; Reeves et al., 2008). To date, the IPE literature has focused primarily on programme descriptions and outcomes, reporting changes in

learners’ attitudes, knowledge and skills (Barr Koppel, Reeves, Hammick, & Freeth, 2005; Hammick, Freeth, Koppel, Reeves, & Barr, 2007). As a result, the literature has often overlooked the complex array of underlying factors related to this type of education, such as the broader organizational priorities, and the workforce arrangements (funding, regulations, etc.) that affect the ability of individual professions to engage in IPE. While some authors have begun to explore such underlying factors in relation to IPE (e.g. Cooper, Braye, & Geyer, 2004; Hean et al., 2009), the unequal power relationships that exist between all health and social care professions, and underpin their interprofessional activities and interactions, are rarely examined. Power, it has been argued, is the ability or capacity to act or to exercise influence (Lukes, 1970). As such, it has many dimensions (gender, race, class, knowledge, etc.) which can impact interprofessional relations. A small number of IPE studies are beginning to offer some insight in the nature of interprofessional relationships (e.g. Barker & Oandasan, 2005; Cole & Crichton, 2006; Kvarnstrom, 2008), however, power is only alluded to, and rarely explored in-depth. Instead, this phenomenon is more commonly (and more comfortably) discussed in terms of authority, status, territory or influence. The most significant contributions to the study of power have been provided by the sociological literature, which has helped illuminate the issue of power relations by studying the historical evolution of the health and social care professions (e.g. Abbott, 1988; Freidson, 1970; Martimianakis, Maniate, & Hodges 2009; Reeves MacMillan, & van Soeren, 2010). According to these studies, the development of professions as distinct occupations has been based on different professionalization projects aimed at securing and protecting exclusive areas of knowledge and tightly regulating entry and work practices for the aim of economic, social and political advantage. 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

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

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demarcationary. As the model indicates professions interact as organized bodies with traditions. As such. Usurpationary strategies push upward and are used not to gain entry to the ranks of the dominant profession. METHODS This article draws upon qualitative data generated from the evaluation of a multi-site IPE initiative based in a large urban Table I. Strategies of closure: A conceptual model (Witz. . Without this formal link. OF POWER 99 WITZ’S MODEL OF PROFESSIONAL CLOSURE (1992) Witz’s model defines and discusses the relationships between four types of closure strategies: exclusionary. Definitions of professional closure strategies. J Interprof Care Downloaded from informahealthcare. and the right-hand side. we explore professionals’ perceptions of power within an IPE context and therefore discuss demarcationary and dual closure strategies (the right-hand side of the model).] is fundamental. 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. Other sociologists have extended Friedson’s analysis. 1970). Friedson’s work offered a critical turning point in thinking about professions. which is concerned with interprofessional power relations (Figure 1). 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.RELATIONSHIPS enhancement (Freidson. Larkin argues that an occupation cannot successfully achieve professional closure and its social and economic rewards: A profession’s relationship with the state [. which is concerned with intra-professional power relations. . These are commonly referred to as ‘professional projects’. Larkin and others by illustrating the complex relationship between various closure strategies employed by different health and social care professions. Occupations that attempt to secure for themselves the two dimensions of professionalism – market control and social mobility generally seek to establish a legal monopoly through licensure by the state. . granting the right to a monopoly of practice. 4). . These strategies are arranged into four quadrants. as traditional accounts of professions tended to stress their functionality. (p. inclusionary and dual closure (see Table I).com by University of Toronto on 02/11/11 For personal use only. strategic orientations and a desire to protect and advance their members’ interests. p. this model can be regarded as helpful in understanding the relationships between professions. Larkin (1983) argued that a key part of the professionalization of occupational groups was the licensing of their practice through their connections with the state. universalism and neutrality. Exclusionary Inclusionary Demarcationary Dual closure 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. Exclusionary strategies push downward and are used to secure their place in the hierarchy. Witz’s (1992) conceptual work on professions extends further the early work undertaken by Freidson. Dual closure strategies are used by subordinate professions in response to demarcationary strategies and involve a two-way use of power: . 48). 1992. but to challenge demarcationary strategies and change the structure of the hierarchy. For example. Ltd. Ó 2011 Informa UK. Figure 1. the lefthand side. In this article.

Interviews were digitally recorded. E. . as noted above. . Two researchers reviewed.). Data collection The overall evaluation of this initiative involved multiple methods of data collection including interviews with program leaders. Additional transcripts were read to ensure the secondary analysis resonated more widely across the dataset (Lincoln & Guba. BAKER ET AL. while not an area of focus for the evaluation. and to identify role models for IPC and new IPE facilitators. we [because of our holistic approach] would have concerns. A number of techniques were used to ensure the quality of this work. To overcome the potential bias with transcript selection (i. specifically. yeah their pneumonia is cleared but . transcribed. On-going discussion about the emergent themes with the other authors (T. In general. E. While the commissioned evaluation was focused on describing processes and outcomes related to the varied IPE activities.e. during the initial analysis. Participation in the evaluation was voluntary and a total of 132 individuals from a variety of professions agreed to be interviewed. it involved six educational and clinical institutions who collaborated to develop and deliver a series of IPE activities. occupational therapy. awareness and skills for interprofessional collaboration (IPC) among the staff working in (and across) the participating organizations. The following quotes show how professional identity may cause tension in the context of interprofessional decision-making: Once someone has had their medical condition cleared . . and anonymized. dietetics. we describe the general environment in which most health and social care professionals work and interact on a daily basis. and learners. physical therapy. all transcripts were selected by a researcher who was not involved in the data collection or initial analysis. pharmacists. . The second section explores how the perception of these power relations may have affected participation in this IPE initiative.R. physicians perceived themselves as ‘leaders’ and ‘decision makers’ in health care while nursing. power emerged in the initial analysis as a significant theme within the data.100 L. Power relations are discussed in the context of professional training and socialization. J Interprof Care Downloaded from informahealthcare. and determinants of team climate. to train staff to actively practice IPC. A secondary analysis of a subset of the data was undertaken to explore these issues in greater depth.) resulted in an agreement to look at potential theories which could help us understand these data. Perceptions and experiences of power In the following sections. The initiative was funded by a local government agency to develop and deliver a series of IPE activities which would foster knowledge. an additional 37 transcripts (selected by the process outlined above) were read by two researchers (L.) and were re-analyzed to explore issues related to power. Themes generated by the two researchers were discussed and agreed by all authors. medicine.M.E. speech and language therapy and social work.B. After reviewing the sociological literature. Ethics and quality Ethical approval for this study was obtained from Research Ethics Boards at all participating institutions.com by University of Toronto on 02/11/11 For personal use only.g.L. S.B. their safety is at risk if they go home (Occupational therapist 1). centre in North America. All selected transcripts were read iteratively by two researchers (L. selecting only those which contained many references to power). A semi-structured interview protocol was developed which aimed to explore participant perceptions and experiences of the programs. A number of physicians also referenced the number of years of training and the degree of monetary investment Journal of Interprofessional Care . the physician wants them out of the hospital whereas . selection of transcripts was undertaken by a researcher not involved with the initial analysis. This subset of transcripts was sampled purposefully for representation from a range of different health and social care professions. Each program was aligned with the specific goals of their institution however their overall visions were the same: to create organizational structures for new channels of communication to enhance student learning and ultimately patient care. issues of power imbalances amongst the professions emerged as a key theme. Context The IPE initiative involved a coordinated effort among the health science disciplines at a single university and its affiliated teaching hospitals and research institutes. For example. a separate analysis was subsequently undertaken with a sub-set of 25 transcripts. coded and agreed upon the nature of the emergent themes from the secondary analysis. 1985). Six separate programmes which offered a range of interprofessional experiences were piloted across several clinical institutions.L. dietitians. interprofessional awareness. therapists and other professions (e.E. To explore this area in more depth. social workers) saw themselves as ‘team members’ who tend to adopt a holistic approach to care. Witz’s model of professional closure was selected as one framework to help understand how power impacted IPE experiences. . pharmacy. Specifically.. To confirm the findings from the secondary analysis. Findings Our findings are organized into two sections.. Analysis As noted above. Professional training and socialization Our data indicated that individuals felt that socialization through their training affected the way different health professional groups viewed themselves. nursing. .. to help prepare hospital environments for future student IPE placements. facilitators. The first section illustrates how the various health and social care professions perceive and experience power relations.

This lack of understanding surrounding scopes of practice was perceived by many participants as a possible disregard for. . and devaluing of. . The difficulty was often attributed to their working conditions. . . Determinants of team culture Our data indicated that physicians were in large part regarded as ‘setting the tone’ of the local team culture both with their actions and their attitudes. Both medical and non-medical professions noted that ‘ultimately they were liable’ (physician 3) if things went wrong. . several participants indicated that IPE helped them feel more valued and respected. . .] so we try to explain what our roles are. .g. Furthermore. Dick and Harry. and you’re telling me now that I am going to . improving their job satisfaction and retention: Better for the patients and better for the team. pharmacists. therapists and social workers lamented. . the frequent rotation of junior and senior physicians. why are we waiting for physicians to develop a culture? We need to develop a culture and then let the physicians know what that culture is and be part of it. nor did they appear to have learned this informally in their daily practice. . you kind of lose that drive (Nurse 6). Ltd. a way for them to gain some control over their clinical environment: I think there is some encouragement in this cultural shift to go ahead anyway and to say. IPE was perceived by nurses. Interprofessional awareness Many of the nursing and therapist participants made frequent references to physicians’ lack of interprofessional awareness. Participation in IPE In this section we explore how participation in this IPE initiative was affected by the power relations between professions. occupational therapy school for three years and I have been in school for twenty years . . . we are not in the same boat .com by University of Toronto on 02/11/11 For personal use only. . In addition. Many nurses. For example.] good [. then hopefully [. and social workers often became involved in IPE for a number of personal and professional benefits. You know like somebody who went to say. ‘oh this is the way it’s done and this is what’s expected of me’. People learn well in an environment that’s open and accepting. that’s [. It was felt that this lack of knowledge created a burden on the system with what many of the nurses and therapists described as ‘inappropriate consultations’: They [physicians] come onto the floors and they consult us inappropriately [.RELATIONSHIPS they made towards becoming a professional which seemed to justify a hierarchical division of labor with them in a dominant position. thereby reinforcing traditional interprofessional hierarchical arrangements.] Nurses come to work wanting to make a Ó 2011 Informa UK. (Physician 4). . leading to feelings of disempowerment for other members: A lot of nurses here in inpatient settings probably feel disempowered [. I killed myself and destituted myself for years to achieve the training . While nurses.] In the future if there is this IPE in school. The data indicated that many nurses. highpressured clinical contexts like the emergency room. (Social worker 4).] they will be coming in with an appreciation with knowledge of what the different professionals do. social workers) as a pathway for empowerment. OF POWER 101 difference [. In busy. that many of their medical colleagues (even those in junior positions) had the potential to determine their local working culture: You wait to see which resident [junior physician] joins you or which staff person [senior physician] joins you and then you decide how your team’s going to function around them rather than welcoming a new health care member to your team. therapists and social workers who felt that they should have input in the direction of patient care within their areas of expertise. therapists and social workers appeared to be united in describing the potential benefits of IPE and . Our data also suggested that an important reason these participants engaged in IPE was linked to gaining respect for themselves (individually) and their profession as a whole. (Social worker 1). (Occupational therapist 2). In the following quote. . it was felt. . therapists. other professions. . A good team allows for a real opportunity for openness and understanding and respect and it’s like good learning. dietitians. therapists. . . In the following data extract an occupational therapist discusses her optimism that the use of IPE in medical school will lead physicians to respect and value other health professions: When the physician in charge or the senior resident demonstrates respect for the other professionals on the team. Better for staff. have to negotiate with every Tom. They often expressed frustration that many physicians had neither received adequate orientation about the scopes of practice of other health professional groups during their extensive training. . but then it’s just that daily on-going re-education (Occupational therapist 3). (Social worker 3). J Interprof Care Downloaded from informahealthcare. and other professionals (e. some of the nurses described the need to defer to the physician due to a ‘lack of time’ or ‘responsibility’. this physician described his colleagues’ response to this issue: Like a lot of physicians thought. Also affecting team culture was the notion of medical dominance in team decision-making processes. undermined the stability of the team.] and when you get here you realize. The legal responsibility of physicians for patients also appeared to legitimize physicians’ status in the health professional hierarchy. however. This dominance was perceived to be difficult to counteract by many of the nurses.

This lack of engagement was perceived as apathy by numerous participants: The two doctors that came. you know it was a very small percentage of the group because certainly in any hospital setting. there wasn’t a lot of evidence behind those claims. It appears that the aim of this activity was to carve out their own professional niches. One possible reason for physicians’ lack of engagement in IPE could be linked to their concerns about its lack of empirical rigor: I found in some of the [IPE] presentations where things were touted as best practice or numbers were given.] feel threatened by a potential loss of power. and exclusion strategies as way to protect and demarcate the scope and the boundaries of their work and relative position in the health professions division of labor. professional socialization prompted physicians in our sample to acknowledge that some of their medical colleagues view their profession-specific training. Managers. 1991).102 L. I mean we don’t have a voice to begin with [. The data suggested that this ‘elbowing’ activity also extended to their participation in the IPE initiative. our findings provide a general description of a North American environment in which health and social care professions work and interact on a daily basis. if you were going to present you would have to have more data [evidence] to back your claims. . . therapists and social workers as problematic because perceptions of medical ‘apathy’ towards IPE appeared to compound historically entrenched hierarchical relationships amongst these professions. knowledge and skills as more ‘valuable’ than that of the other professions. Journal of Interprofessional Care In contrast to other professionals. More specifically. Our findings also outline varying perceptions and responses to an IPE initiative that was introduced into this environment. J Interprof Care Downloaded from informahealthcare. and loss of prestige [and] that interprofessionalism is just another word for further diluting the quality of work that a physician has previously enjoyed. Being used to medical rounds. The model thus captures the two-way exercise of power within a hierarchy of relationships among professions. (Dietitian 1). Witz’s model of professional closure can help us understand these findings in more depth. (Physician 5). physician involvement in this IPE initiative was limited. . medicine has played a crucial role in defining the areas of competence of other health professions such as midwifery and nursing. . (Physical therapist 4). leading to poor interprofessional interactions. seeing IPE as a vehicle with which to gain respect. it highlights how dominant occupational groups can engage in demarcationary strategies as a means to control the boundaries between subordinate occupations to maintain an advantage over them. this model describes how professions engage in various closure strategies in order to stake claims to resources and opportunities and control boundaries (see Figure 1). Other participants however felt this ‘lack of proof’ argument as a convenient excuse to not engage in IPE. Examining our findings using this model illustrates how interprofessional interactions within an IPE context can be seen to mirror closure strategies. perceptions of their medical colleagues. These findings highlight how different professional groups perceive and experience power. Witz argues that these ‘caring professions’ engage in the dual closure strategy of usurpation as a way to resist and challenge the dominance of other professions.g.] and when we don’t get a voice things happen and nutrition and dietitians are always left out. Hugman. especially medicine. In this context. In response. As noted above. (Physical therapist 2). loss of autonomy. These interactions can serve to reinforce traditional power relationships and thwart efforts to develop more collaborative approaches to care. if you don’t have the doctors on board it is hard to move forward with some things. for example. BAKER ET AL. they also appeared to engage in a form of ‘elbowing’ behaviour.com by University of Toronto on 02/11/11 For personal use only. Physicians [. to not embarking on something new. and how these perceptions contribute to maintain the traditional hierarchy of these professions. wanted to ensure their professions were represented and not excluded in the planning and delivery of this initiative: My boss and I didn’t want to lose out on this piece [involvement in the IPE initiative] because. poor physician participation was regarded by some nurses. (Physician 1). This strategy could be seen as an act as a ‘boundary setting’ and involved defending the uniqueness of their professions: Especially with the divide between OT and PT like that’s the biggest one because everyone thinks that we’re all the same. as this nurse explains: Going back to the philosophy. This belief could translate into a lack of knowledge about the roles and the responsibilities of their colleagues from nursing and social work. where is the proof? Where is the proof that this works? Where is the proof becomes a convenient defense mechanism for not changing. For example. so it would have been good to have more involvement from them. so most of it is trying to show them the differences between what we do. R. loss of income. DISCUSSION As presented above. often referred to as ‘caring professions’ (e. For example. (Nurse 5). it was great to have them but. The data suggested that another possible reason for physicians’ lack of engagement in IPE could be related to a perceived threat to its dominant position in the health professional division of labor: . historically.

while nonmedical professionals saw it as an opportunity to improve their standing within the health professions. While this study offers some illuminating insights into the nature of how power is perceived between professions involved in an IPE initiative. it could be argued that IPE represents a type of usurpation strategy (Witz. devaluing of IPE. Our data also indicated that physicians were largely absent from many of the IPE experiences. there was some form of ‘elbowing’ activity. The situation we have outlined above can create a tension: while participation in IPE may lead to a range of perceived gains for some professions it may also lead to perceived losses. For example. some professions (e. pharmacists. They were commonly perceived to be the ‘decision makers’ in the clinical setting. IPE may offer a means to legitimize the potential clinical and scientific contributions that other professions can offer to delivering care. For this reason. The complexity of dual closure strategies (Witz. it nevertheless has a number of limitations. projecting the notion of equality was not enough to address power imbalances within the 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’ matters. it appeared.com by University of Toronto on 02/11/11 For personal use only. CONCLUSION In this article we indicated how perceptions. while based on notions of collaboration and teamwork. within our data. in this study physicians noted that some of their medical colleagues regarded IPE as a potential threat to their professional status. 1992) also came through in our data set. like the ‘elbowing’ phenomenon we saw emerge between the ‘allied’ professions. increased competition and friction amongst others. speech and language therapists) also engaged in exclusionary strategies as a way to create and protect boundaries around their own professional turf. and therefore in a more influential position to effect change than their non-medical colleagues. and therefore did not capture the perspectives of those who declined participation. undertaken to delineate boundaries that differentiate their scopes of practice from each other and to secure their own position in the health care hierarchy. insights gained from data relating to this phenomenon were therefore limited in nature. little attention has been given to attitudes. the complex array of issues that did emerge from these data suggests that the role that power plays in IPE requires much further study. Ltd. as the study was not originally designed to examine perceptions of power. These professions may therefore engage in IPE with the aim to enjoy a similar status and autonomy as their medical colleagues. Closure strategy Dual closure/usurpationary Dual closure/ exlusionary Demarcationary Group Nursing and ‘Allied health’ ‘Allied health’ Physicians Examples Participating in interprofessional education Vocalizing uniqueness of their profession. IPE projects the notion that all professions have equally important roles to play in the delivery of care. these professions have been ‘clustered together’ into a homogenous group of health care providers (sometimes referred to ‘allied health’) on the basis of not being nurses or physicians. securing a voice in IPE Lack of engagement with IPE. We also indicated that when professionals engage in IPE they bring along their . attitudes and activities of professionals within an IPE context can serve to reinforce traditional hierarchical relationships amongst them. For example. and could be considered a demarcation strategy (Witz. In practice. we found that their motivations and levels of engagement were linked to their respective professionalization projects. physical therapy. in a highly evidence-based setting where medicine has traditionally defined best practice. Summary of closure strategies from data. While institutions have invested significant effort and resources in designing interprofessional curricula. the closure strategies identified in our data and the groups which appeared to employ them. and other professions (e.g. 1992) for nursing. perceptions and practice that reproduce hierarchies amongst professions and can affect team functioning. however. 1992) to protect their position of authority in the health care hierarchy. occupational therapy. This made their absence from IPE problematic. In addition to engaging in IPE as a usurpation strategy. were expressed through a type of protectionism where it mattered more to foreground one’s own professional identity than to find common ground. Table II provides a summary of Ó 2011 Informa UK. Historically. In addition. Nevertheless.g. Although the professionals in our sample were all engaged in IPE. a position which arguably negates the unique status and contributions to patient care for each of these professions. IPE as presented in this article. this study only included those individual professionals who volunteered to participate in the IPE initiative. As noted above. As a result. therapists. Our data indicated that IPE was regarded as an opportunity for improving the conditions of work for many of the professional groups in this study. social workers). participation from power positions Exploring current relations through this particular theoretical lens helps to set the stage for understanding why some professions are particularly ‘attracted’ to and engage in IPE. J Interprof Care Downloaded from informahealthcare. can have the reverse affect of increasing competition amongst professions. These attitudes.RELATIONSHIPS OF POWER 103 Table II.

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