Professional boundary crossing and interprofessional knowledge development
Professional boundary crossing and interprofessional knowledge development
Abstract and Keywords
The chapter points at the growing need for different welfare professions to collaborate and coordinate their services in order to respond to service users’ complex needs. To solve complex cases doctors, social workers and therapists often need to develop professional knowledge and skills that facilitate inter-professional collaboration. However, multi- or inter-professional services can give rise to demarcation problems and competition between professions. Using data from child welfare services in Finland and Norway, the chapter examines problems connected to the development of multi professional services that involve inter-professional boundary crossing and knowledge development.
A significant trait of modern societies is the increased organisational specialisation of welfare services, which in turn has resulted in increased professionalisation, that is, a greater number of professionals involved in the production of welfare services (Meads and Ashcroft, 2005). This growing specialisation and professionalisation, which on one hand has led to more advanced services, has also resulted in fragmentation and need for coordination between services in order to provide adequate and holistic efforts when responding to service users’ complex needs (Arnkil and Seikkula, 2015). Today the service delivery system is faced with problems concerning the division of labour, coordination of services, maintenance and development of staff competence, and improvement of service effectiveness and outcomes. Specialisation often necessitates collaboration between different actors in order to achieve a comprehensive view of citizens’ complex problems.
The aim of this chapter is to examine how interprofessional knowledge is developed when crossing boundaries, illustrated by two cases in social work in the domain of child welfare in Norway and Finland. We have chosen these two cases to provide analytic description of innovative knowledge production processes in professional practices and the complex boundary crossings involved. The two cases represent the field of child and youth welfare, a field that is under much pressure both on a national and on an international level.
There is an obvious need for developing multi- or interprofessional services that address complex problems effectively. By way of example, (p.116) doctors, social workers and other welfare professionals in the welfare services need to find new ways of collaborating to be able to solve complex cases. To ensure optimal outcomes for service users in an uncertain, evolving environment, it is necessary to enhance professional knowledge and skills in boundary crossing and increase efforts to adapt to change. These challenges certainly involve European welfare states and highlight the ultimate purpose: ‘to assure universal coverage of high quality comprehensive services that are essential to advance opportunity for health equity within and between countries’ (Frenk et al, 2010), mentioning improved team work and decreased professional tribalism as important issues.
It is claimed that the prevalence of difficulties of children and young people is high, and that 15-20% of all children have psychiatric problems that influence their level of functioning (NOU, 2009, p 18). International research show that serious behavioural problems (‘conduct disorder’) comprise 1.5-3.4 % of all children (five times as many boys than girls) (Barton and Parry-Jones, 2004, p 1632). No matter which numbers are utilised and which problems identified, child and youth welfare is characterised by uncertainty, complexity and unpredictability. Hence, a significant number of children will need interprofessional provision and support in an attempt to prevent serious problems for children at risk and their families as well as to limit the need for increasing resources in a long-term perspective.
Our interest in these cases is to examine the boundary activities in knowledge development of interprofessional practices. Interprofessional practices imply complex networks of relationships and they go beyond the more contemporary forms of coordination and thus form an interesting ground for managing and creating knowledge across boundaries. The first case, on initial collaboration with young people at risk, is a Finnish research and development project where different professionals from various sectors conceptualise their role, and the help and support given to young people at risk, and form a model aimed at improving the initial collaboration practices. The other case, concerning young children with attention deficit hyperactivity disorder (ADHD)/Asperger syndrome, is a Norwegian research and development project that focuses on how professionals discuss their conception and responsibilities in dealing with families and children in need for the purpose of improving services and facilitating organisational change. Both these projects serve as examples of crossing boundaries and reflect the growing need of developing interprofessional practices and achieving knowledge about how these processes develop over time. A transitional framework, developed by Michel Callon (1986), (p.117) is used for the analysis. He developed this framework while studying the anchorage of scallops in the Mediterranean area, a framework that was retrospectively (and inductively) created on basis of different sorts of meetings and exchanges (including negotiations), and adjustments among the actors in the case study. He found that four key questions needed to be addressed in order to scrutinise the elements of the complex process. The first concerns problematisation: it is important identify the issue and phenomenon that require a solution and to ask how the problem is identified by the different actors. The second concerns the degree to which the different actors are invested in the solution to the issue and how they conceptualise their roles and responsibilities. The third focuses on visions. Here it is crucial to analyse how the different actors see their role in a new setting, and how they can be encouraged to change and create new visions. The fourth concerns the anchorage of new working models and the types of ally mobilised. Although the framework as such has not been developed within the context of interprofessional practices but within that of scientific research, it is applicable to other settings (Star and Griesemer, 1989) and provides a tool for structuring and pinpointing the places and phases where boundary activities are formed. It also helps with focusing on which boundary activities are important for the development of shared knowledge and where critical pitfalls may be found. Wenger’s concept of community of practice (Wenger, 1998) serves further as an analytical approach to analyse more deeply the multilateral and dynamic boundaries in how professionals may or may not/can or cannot/choose or choose not to cross professional boarders in order to attend to the mutual project of the community of practice. Hence, the concept of community of practice goes beyond professional boundaries and analyses how the professionals in the projects cross boundaries in order to create interfaces for collaboration and knowledge development.
Collaborative practice and boundary crossings
In the literature on interprofessional collaborative practice there is still some confusion surrounding the motivations behind this process as well as the definitions used. The processes of specialisation, professionalisation and fragmentation are part of the societal development framing the welfare services, both nationally and internationally, and there has been a demand for collaboration over the past 25 years (Barr et al, 2005). Abbott (1988) reminds us that these processes are also involved in framing the professional jurisdiction, that is, the link (p.118) between a profession and its work regarding professional control over knowledge and skills connected to tasks and contexts. But the same conditions that necessitate collaboration can also hamper interaction because of demarcation problems and competition between different professions – so-called professional tribalism. Even though the focus has been on collaboration for a long time, it seems that there is great confusion in the use of terms of interprofessional collaboration and little empirical evidence for the efficacy of interprofessional work or for how interprofessional knowledge is being developed in boundary-crossing practices. As Seaburn and colleagues (1996, p 23) have noted, ‘A culture of collaboration does not just happen. It must be formed and fashioned by many hands.’
The World Health Organization’s Framework for action on interprofessional education and collaborative practice (WHO, 2010) defines collaboration as follows: ‘Collaborative practice happens when multiple health workers from different professional backgrounds work together with patients, families, carers and communities to deliver the highest quality of care (p 7)’. This comes close to Payne’s definition of ‘the open team’ (2000), ‘the professional and multiprofessional teams and the network of people we link with in the community and teamworking and networking as an integrated form of practice’ (p 5). The definition allows for inclusion of professionals and service users, as well as organisations such as agencies and units/departments. It also focuses on the main desirable outcome of collaboration – an integrated practice. The importance of integration lies in its capacity to relate to the demands of the environment and to meet people’s multiple needs, that is, those of various target groups for social work, such as children and families. The term ‘open team’ indicates that the team’s boundaries are transparent and blurred, in order to allow the members to adapt to the situation of the service user, the development of his/her situation, the need for changing competence and services and so on. All in all, the definition attends to the complex and dynamic interaction between various actors and services and moreover the collaboration process.
The very idea and language of interprofessional practice implies boundaries. These complex networks of relationships offer different possibilities for thinking about self and others. When talking about interprofessionalism, Abbott (1988) sees boundaries as closed doors, claiming that professionals struggle and compete for maintaining jurisdiction and distribution of tasks and that this is a way of controlling professional knowledge and hence creating boundaries for exclusion. Wheatley (2005), on the other hand, sees boundaries as places of meeting and exchange rather than a self-protective wall. We usually (p.119) think of boundaries as the means to define separateness, defining what is inside or what is outside. But in living systems, boundaries are quite different. They can be the places where new relationships take form, exchange and grow. This is also well illuminated in the Callon’s case study on the anchorage of scallops and what he observed during the process. Similarly, Wenger (1998) looks at boundaries multilaterally; boundaries may serve as sources for misunderstandings, disagreements and conflicts causing communication problems, but may also be viewed as interfaces for contact and interaction that may promote coordination, in other words spaces for integration and knowledge development. Hence, boundaries represent places where collaboration may be created and organised and may have the potential for hampering as well as supporting coordination, knowledge development and change. Concepts have been developed to more thoroughly explicate the multidimensionality of boundary crossing, such as boundary practices (Wenger, 1998), boundary objects (Star and Griesemer, 1989; Wenger, 1998), and knowledge managing across boundaries (Carlile, 2004), as which we shall discuss further.
Examining collaborative practices in social work
In looking at the boundary crossings of interprofessional collaboration, we provide an analytical description of two case studies of knowledge development processes applying Callon’s (1986) framework. We have both been involved in these case studies as researchers and supervisors, and here we attempt retrospectively to capture the spaces and objects that either form barriers or facilitate development.
The case studies
‘Systemic work with young people at risk’ was a research and development project on how professional groups and organisations deliver help and support to young people at risk and how they together work on ways to improve initial collaboration practices with this group of citizens. The two-year research and development project (Söderström and Backman, 2012) was organised to develop new collaborative working models within a broad network of people from different institutions and professions, such as schools, day care, healthcare, family counselling and child protection. An overarching goal was to develop a service user-oriented, systemic collaboration model with the prevailing structural and organisational forms as it (p.120) standpoints. This assumed developing knowledge in a dialogic approach and involving frontline practitioners within the development work.
‘Together for children and young people’ was a research and development project that focused on how professionals understand and discuss their perception and responsibilities in dealing with families and children in need in order to improve services and facilitate organisational change (Elvik and Willumsen, 2011). The project was organised to ensure the goal of coordinated services for children with psychiatric difficulties and behavioural problems such as ADHD/Asperger syndrome. Considerable disagreements regarding responsibility/accountability for this target group, particularly between health and child welfare services, were registered in the municipality. Schools and psychiatric services were involved occasionally when necessary. Although internal procedures existed, these were not sufficient to clarify responsibility in actual cases. The characteristics of this group of young people, close to 18 years of age, were significant psychiatric difficulties and functional disabilities, with implications for parental care and fulfilling school work. Hence, these young people and families’ needs were complex and challenging to professionals in terms of understanding their situation and their struggles. In order to work systematically to improve the coordination/integration of services for this target group, an external supervisor was invited to discuss actual cases.
Investment of actors
We were interested in analysing the degree to which relevant actors were invested in solutions to these difficult cases and how they conceptualised their roles and responsibilities. At the start the professionals in the different domains were all overwhelmed by the challenges of the child and youth welfare services and found that there were too many obstacles to finding help and sustainable solutions for young people and their families. Which services were most relevant was an open question, hence causing confusion between social workers from health and child welfare services respectively. Moreover, there was little knowledge on the division of labour, what other professionals’ roles and tasks were. For instance, teachers involved in these cases would come into contact with the children in school, but had few dealings with their parents. Their understanding of their role was one of advice without the possibility of intervention, leading to a lot of frustration and also mistrust towards other welfare professionals.
(p.121) The professionals used quite a bit of time to clarify the primary problem because this would give the direction for which service had to take responsibility. At the same time, the problems were so complex that it was not easy to identify just one. Dealing with young people and their families within conflicting frames caused discussion, confusion, frustration and also power struggles between collaborating partners. The professionals represented health, education and childcare services, and each assumed their own assessment of the young people and their families. From the start, the professionals were caught in different administrative silos, albeit governed by the same municipality. This results in an emphasis on administrative power struggles, which in turn may lead to the avoidance of responsibility. The organisational boundaries seemed thus to form an uncomfortable place. The danger of silos is that they may become isolated from the practices they are supposed to connect (Wenger, 1998; Bihari Axelsson and Axelsson, 2009). This often leads to fragmentation and multi-professional collaboration that implies mechanical coordination with a low degree of integration and the lack of potential for the development of novel interventions (Willumsen, 2009).
Translating meanings may be seen as an externalisation process that adds to addressing differences across the different domains as well as being a prerequisite to learning processes that examine ways of thinking (Nonaka, 1994). But while different interests are often revealed they can also create barriers to developing shared meanings. Callon (1986) focused on dwelling thoroughly on different interests and saw this stage as crucial in arriving to a careful analysis of the problematics at hand. Hence, this stage involves negotiating interests and making trade-offs between actors (Wenger, 1998; Carlile, 2004) and may involve revealing power interests and moving beyond the ‘here and now’.
Just initiating collaboration seemed a mountainous effort for the professionals and almost an impossible task. Emotional elements played a key role in discussing these issues, and either facilitated or inhibited collaboration. Interestingly, the professionals described the problematics of collaboration as ‘out there’, as something that was not concretely contained by the professionals themselves. In acknowledging the emotional and practical experiences of professionals, Strauss (1993) pointed out the importance of interaction at every level, ranging from the most collective to the most individual. This relationship between the individual and the collective is also a crucial building block to open up for broader visions of change.
As long as professionals suggest what others should do, and resist committing to and taking responsibility, they keep themselves out of (p.122) the collaboration process. Arnkil and Seikkula (2015) claim that it is when professionals see themselves as part of the hopelessness that they can begin to see the process from a personal perspective. Taking the position of an outsider prevents one from looking for plausible solutions. Solutions are often ‘smaller’ and simpler than when looking from an outside position. The systemic perspective was pervasive in the Finnish case and encompassed a view that changes in the system are possible through changing one’s own behaviour and thinking.
To deal with processes with different interests implies identifying boundary objects, objects that are ‘common enough to more than one world to make them recognisable’ (Star and Griesemer, 1989, p 393). Carlile (2004) points out that under these circumstances domain-specific knowledge may need to be translated and transformed to effectively share and assess knowledge at the boundary. Hence, the central collaborative task is the translation of each other’s perspectives.
Working with difficult issues
When analysing a complex and dynamic field, such as interprofessional collaboration, it is important to acknowledge the process and the length of time as well as the different levels involved. These comprise the personal level (professionals and service users participating in collaboration), and organisational the level, for example, organisations, units and sections. We were interested in looking at how professionals created opportunities and how they worked with difficult issues.
Ways of dealing with problematic issues were facilitated through regular working seminars and learning forums led by supervisors. The working seminars were planned collaboratively with actors and project leaders. They covered theoretical knowledge on interprofessional collaboration, systemic approaches, dialogic methods and user perspectives. Learning forums were created to provide support for testing new ideas for pilot units and the networks around them. Because of the different organisational settings of the cases involved, these learning fora were different. The Finnish project focused on border-crossing learning forums, whereas the Norwegian project aimed to create a ‘learning organisation’ to facilitate systematised improvements and implementation in the municipality as a whole. In the community of practice approach, these could be seen as boarder activities and boarder objects, including different levels of learning, personal, collective and peripheral learning. The Finnish case had different learning forums for the professionals involved, with a professional (p.123) group leader functioning as a moderator. The moderator helped the group to deliberate on their own positions and occupational roles.
Both of the projects built their reflections on concrete and challenging client cases. In the Norwegian case, the supervision meetings started with the presentation of a client case. During these reflections, the participants could explain, elaborate on and examine nuances in their views, ask questions and clarify their thoughts and perceptions. There was also a focus on clarifying roles and responsibilities. In the Finnish case, there was in the beginning a resistance to discussing challenging cases openly and in participating in developing new forms of collaboration. A lot of work was needed to create and manage boundary objects. One essential element in the process was the translation of each other’s perspectives. Star and Griesemer (1989) claim that the central cooperative task of social worlds is a key process in developing and maintaining coherence across intersecting worlds. Translation needs to include learning phases. This was made possible through a learning model based on critical reflection of client cases developed by Ray Pawson (2008). This systemic and reflective model helped with the acknowledgement and acceptance of the different roles and responsibilities of each professional. It also encouraged a commitment to developing a new working model.
The peripheral learning elements were made possible through seminars for members of the project team and other interested persons in the municipality, including plenary sessions on relevant topics and interprofessional group discussions. The supervisor in the Norwegian project was responsible for a presentation on the theory of collaboration in seminars, which constituted a mutual framework for the supervision meetings. In the Finnish case, the issues and themes were driven by the needs of the units and their networks and were based on the concrete and daily experiences of the professionals. In the Norwegian case, the supervisor had a strong translator and gatekeeper role. She took part in supervision meetings at the health and social centres and participated in the project group at an administrative level. She provided information on activities and progress and pointed out areas for improvement. She also presented written information summarising points for improvement to be discussed by the project group, which were followed up by the project management and extended to other parts of the organisation/municipality. Some of the ‘improvement points’ were introduced as main topics for mutual discussion at the seminars.
In the beginning there seemed to be a lack of communication between the partners due to the absence of a common framework. (p.124) Much work was made on creating boundary objects. In everyday life, we constantly deal with artefacts that connect us in various ways to practices we do or do not belong to, claims Wenger (1998). It seemed that the ‘not-knowing’ element in both projects produced a boundary that both shut and opened doors. Opening these doors leads to more than just information transmission – in both cases, partners worked intensively on dialogues and reflection, allowing space for experiences and values, and thus creating a sense of a shared belonging. Bhaskar and Danermark (2006) point out in their work on interdisciplinary collaboration that meaning is formed through interactive communication. This includes being open to conflicting discussions, just as Callon points out. This was well illustrated in the reflective discussions in both cases with room for thought and talk that allowed for transformations in ways of understanding context.
What type of boundary crossing was taking place?
Establishing boundary practices
In both projects there was an urge to improve services and develop new forms/models of collaboration to integrate efforts more efficiently. Both projects were establishing boundary practices (Wenger, 1998), that is, organising fora and meeting places for mutual engagement, building and maintaining relationships between insiders and outsiders and developing a repertoire to address conflicts, reconcile perspectives and approaches and find resolutions. Such boundary practices may over time develop a community of practice that goes beyond administrative and professional boundaries, in order to engage in productive activities that imply negotiating diverging meanings and approaches, such as in collaborative work with children and families.
One example from the Norwegian case concerned a family with multiple problems where the professionals from municipality and psychiatric units were frustrated and felt that team meetings were a waste of time. The case coordinator wanted to discuss the family in the supervision meeting and it was decided to organise the following team meeting as part of the supervision process. This was a way of establishing a boundary practice whereby all the professionals involved could participate in mutual reflections. The coordinator conducted the meeting as usual, and the supervisor was allowed to interrupt and reformulate questions and ask for elaborations. The meeting turned out to be a ‘live’ performance of communication and problem solving, where the participants had the opportunity to explain and give reasons (p.125) for their perceptions and actions. Several questions were clarified and a plan for follow-up was agreed, resulting in a positive outcome for the family. The professionals thought they had learned from each other, were able to give each other positive feedback and commented that the family had been kept in centre of the discussion. Hence, the combination of reflection and establishing a boundary practice turned out to be fruitful. In the long term, it is important to encourage the establishment of boundary practices, because they may serve as starting points for tailoring combinations of services for particular service users. Additionally, members develop a repertoire of knowledge and skills when they share their knowledge, in terms of assessing each other’s domain-specific knowledge as well as developing common knowledge to better understand the challenges they face when trying to work across professional and agency boundaries (Carlile, 2004).
Wenger acknowledges the importance of peripheral experiences. The ability to have multiple levels of involvement is an important characteristic, one that presents opportunities for learning both for outsiders and for communities, claims Wenger (1998, p 117). The projects in our study were both encouraged to communicate with broader networks and the seminars provided space for reflection both outside and inside the communities.
Creating boundary objects
Although boundary practices may serve as spaces for collaborative work, there is no guarantee that collaboration will happen. The participating members may have to create boundary objects, that is, objects that serve to coordinate the perspectives of various constituencies and practices for some purpose (Star and Griesemer, 1989). In most services, boundary objects are already in place, such as mutual records/files, computer systems containing standardised information, manuals and reports. However, these devices may not necessarily ensure specific tasks in collaborative work. For instance, in Scandinavia, the Individual Plan (IP) (Kjellevold, 2013) has been established as a legal framework for the coordination of services and may be regarded as a boundary object. Still, only a small amount of the estimated population has an IP. The reconstruction of the practices during supervision showed us that the creation of additional boundary objects, such as forms/templates for supervision, reports of activities and references to relevant literature, need to be worked on in order to improve communication.
Creating boundary objects may also be regarded as a management tool in order to connect functions and tasks with relevant communities of (p.126) practice in order to facilitate shared practice. In this sense the boundary object may go beyond professional jurisdictions and require a process of translation between each form of partial jurisdiction (Wenger, 1989). Additionally, the boundary object may go across administrative silos to support mutual initiatives. Both boundary practices and boundary objects influence the participants’ attitudes and whether they choose to cross boundaries in order to create interfaces for collaboration and knowledge development.
But boundary objects are not always a question of concrete tools but of shared artefacts. When looking back at the knowledge development process, participants in both of our case studies emphasised trust. Trust was an importance ingredient in the working process and formed an essential boundary object. Trust enabled creativity and courage to try new working forms. Working together on real cases had an impact on the groups at an emotional level. Trust towards others in the group enabled participants to give constructive criticism to others without excluding themselves from the process. The common ground started to take form as common concepts, and terminology enabled boundary crossing. Instead of concentrating on professional boundaries, the object of the practice, the child and the family became important. This gave room for another dynamic in the interaction with the professionals and a new form of knowledge building.
Encouraging boundary spanners
Bridge builders or boundary spanners play a key role in the process of establishing boundary practices and creating boundary objects. According to Wenger (1989), such actors have experience in multiple work practices and are able to transfer some element of one practice to another, also called brokering. The focus is on the relationship between a community of practice and the external environment, across boundaries and between practices, a complex process that include influencing the development of a practice, addressing conflicting interests, facilitating transactions and enabling learning between practices. Boundary spanners demonstrate particular competence in greasing the wheels between professionals and organisations by facilitating dialogue and negotiating goals and meanings regarding inherent conflicts across boundaries (Oliver, 2013).
In our case studies we noticed several examples of boundary spanning. The leaders of the reflective teams, whether supervisors or educators, are perhaps the most evident boundary spanners, although their productivity depends much on communications and negotiations (p.127) between the different actors. Sometimes these involve power struggles, as with one of the groups in the Finnish case. However, boundary spanners are not only an issue of competencies but of doing, thinking and saying, and these characteristics may differ in different contexts.
One could say that a variety of contributions from professions and organisations are needed, which implies differentiation, as well as the unified efforts necessary to achieve integration. Oliver (2013) emphasises the importance of acknowledging and valuing difference in terms of culture, role and focus. One could say that value creation emerges through experiences and interpretations of values inherent in work practices. All professions have their own ethical values and code of ethics of how to do good practice (Molander and Terum, 2008), but they come alive in practice in collaboration with the user. Hence, values are wedded to actions in practice, and these came to light when the practitioners reflected on real cases. Boundary spanners were often needed to translate this domain-specific knowledge.
Conclusion: readiness for complexity?
The growing trend towards the development of boundary crossing and interprofessional services has been particularly common between the health and social sectors. The aim of this chapter has been to explore how interprofessional knowledge is developed when crossing boundaries, illustrated by two cases in the field of child welfare from Norway and Finland. The chapter points to the necessity to build knowledge development on existing knowledge, routines and values. Sustainable changes are not about ‘shaking it all up’ or ‘turning everything upside down’, rather, questions of values are embedded and acted out in concrete situations. Questions about interests and values in professional working life are present when practitioners encounter, and when their values and visions are included in, organisational change processes. Practitioners’ values and visions provide guidelines for what may reasonably be changed and what may be preserved. The chapter also acknowledges that practitioners’ access to knowledge development processes is vital for both desired change and competence development.
Together these workings are still not enough, as they need to be contextualised, confined and grounded through different organisational and network levels. Change requires organisation-level measures in order to support new working models. Accordingly, practices call for commitment from organisations’ management. Knowledge development, however, calls for moving beyond information transmission and management by focusing on the relational dimension (p.128) and by highlighting reflexive analysis and deliberation about values and interests in practice (see also Nowotny, 2003). The cases scrutinised in this chapter may form an illustrative example on how professionals in the welfare field initiate new ways of working in practice on the basis of their values, and these new ways may contain potential for an extension of being and doing.
Analytically we found it intriguing to use the conceptual framework of community of practice and the interrelations between different boundary concepts, which managed to open up the phenomenon on interprofessional collaboration. We also found Callon’s careful (1986) analysis of the problematics at hand as important, as it reveals power interests and may serve as an iterative framework within which actors may assess each other’s knowledge.
All in all, we found the approach ‘dialectical, emphasising the relationships of each part to each other and to the whole’ (Worrall, 2010, p 13). We feel that the illustrative case studies reflected the importance of carefully managing the creation, crafting, meaning and representation of boundary practices and objects, as well as the role of boundary spanners, in providing a high level of coherence in interprofessional practice.
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