Interprofessional

Communication in Health
and Social Care
Theoretical Perspectives on Practical Realities
Edited by
Stephanie Fox · Kirstie McAllum · Leena Mikkola
Interprofessional Communication in Health
and Social Care
 Stephanie Fox • Kirstie McAllum
Leena Mikkola
Editors

Interprofessional
Communication in
Health and Social Care
Theoretical Perspectives on Practical Realities
Editors
Stephanie Fox Kirstie McAllum
Department of Communication Media & Communication Department
Université de Montréal University of Canterbury
Montreal, Canada Christchurch, New Zealand

Leena Mikkola
Faculty of Information Technology and
Communication Sciences
Tampere University
Tampere, Finland

This work was supported by Université de Montréal and Tampere University.

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 Stephanie: First and foremost, we dedicate this book to our readers. You have
been top of mind for us for many moons! Next, to engaged communication
scholars working across disciplinary and paradigmatic boundaries in health and
social care contexts. You inspire us! Finally, from the “kid” to Sami Antaki, for
having me report on interviews with such a variety of people at the McGill
University Health Centre all those years ago; it opened my eyes to the importance
of interprofessional work and solid writing.
Kirstie: To Mary and John Hartigan. Your creative and care-full
interprofessional work has been an inspiration.
Leena: To all those health and social care professionals I have been privileged to
collaborate with. Your work is invaluable.
 Foreword

Communication is essential to every aspect of interprofessional work. Yet, we

still need to better understand how communication is intertwined with the
myriad challenges and practical realities that health and social care providers
face when working together. Most often in interprofessional literature and
practice, communication’s role is understood as effective and timely informa-
tion sharing between relevant individuals. This conception of communication
is important, as many problems stem from ineffective information exchange.
Indeed, health and social care systems serve diverse populations, and language
or cultural barriers can, and frequently do, impede communication between
health and social care providers and service users (patients/clients). A lack of
coordination and collaboration among health and social care professionals, in
both education and practice, leads to fragmented communication, which
results in incomplete or inconsistent information sharing. This lack of coordi-
nation and collaboration then affects how openly health and social care provid-
ers communicate about, and with, service users. Often communication is
hindered or obstructed by the outdated or inefficient information systems with
which health and social care professionals are working.
However, we must add to this instrumental understanding of communica-
tion as information exchange to better understand other dimensions of inter-
professional work. It is well known that a lack of clarity about the roles and
responsibilities of health and social care professionals leads to not only miscom-
munications but also a lack of accountability within what are assumed to be
homogenous teams. Likewise, it is frequent in health and social care teams that
poor communication results from a lack of understanding of professional dif-
ferences (and, in many cases, of professional similarities). Interprofessional cur-
ricula and professional trainings often address the need for professionals to be
able to communicate their roles to others. However, communication is also
important in how team roles are worked out, how power asymmetries are navi-
gated, and how complex meanings are negotiated in interprofessional interac-
tions, all of which cannot be explained solely through information sharing.

vii
viii FOREWORD

Another perennial challenge stems from a major shortcoming in health and

social care, namely the inadequate involvement of patients in decisions con-
cerning their care, which frequently leaves the patient with insufficient material
on which to make informed choices about their health and/or social care
needs. Similarly, communication within and between health and social care
systems continues to be inadequate because not all health and social care stu-
dents receive adequate training in professional communication skills.
Inadequate training can result in a poor ability to explain complex health infor-
mation to patients or their colleagues. Moreover, the negative consequences of
poor interprofessional communication training can be compounded by the
reality that in busy health and social care environments, there may be limited
time for informed communication. These time constraints can contribute to
emotional and psychological fallout, such as stress and burnout, now so fre-
quently observed in the workforce.
In every setting, there will always be health and social care professionals who
are resistant to change, such as the problems with adopting checklists and find-
ing ways to hinder their integration. Other communication challenges can arise
from the way in which health and social care professionals understand and use
the word “interprofessional.” Still, others derive from how these professionals
behave in interprofessional settings and the different ways they use language in
communicating within and across their professions. Clearly, the importance of
communication to interprofessional work cannot be underestimated. Yet con-
ceptual tools in the interprofessional literature are still limited.
This edited book introduces, describes, and explains many of the critical
theoretical and practice issues related to interprofessional communication
(some of which are outlined above) and that must be addressed in curricular
and health and social care reforms. The education of health and social profes-
sionals has been remiss in its approach to teaching the skills necessary to com-
municate between professionals – it is to be hoped that educators and
practitioners will pay close attention to the suggestions provided in this edited
book and develop opportunities to carry this vision into not only classrooms,
but also into clinical practice contexts.
Unique in the field, the book brings communication and management
scholars together with interprofessional researchers, educators, and practitio-
ners to offer a nuanced exploration of the ways that communication shapes and
influences interprofessional collaboration. Chapters in the book examine com-
munication’s vital role in information transmission in practices such as case
management and interorganizational patient transfers as well as in different
stages along the patient’s care trajectory. However, the book also explains com-
munication’s role in other aspects of interprofessional care, beyond sharing
information, such as negotiating and understanding roles and giving voice to
patients and their families in interprofessional interactions.
The first section of this book introduces interprofessional practice and the
various ways that interprofessional communication can be conceptualized,
 FOREWORD ix

from dominant functionalist understandings of communication as information

transmission to social constructionist understandings of negotiated orders as
viewed through the lens of communication in teams and in interprofessional
collaborative care, which do not necessarily call on the same approaches.
The utility of these different conceptions is mapped onto a continuum of
interprofessional practices, and clarifications are offered for frequently used (and
perhaps just as frequently misunderstood) terms to describe different forms of
interprofessional working together. This section also describes frameworks cur-
rently used to teach interprofessional competencies, including communication.
The second section of this book explores fundamental processes and dynam-
ics of interprofessional communication that are relevant across clinical con-
texts. These include sensemaking as a communicative explanation of the
complex and interdependent work of shared practice, thus expanding instru-
mental notions of interprofessional communication as information transmis-
sion. Communication is a social process that shapes relationships and as such
can foster or harm the wellbeing of collaborators. As a social process, the dia-
lectal tensions inherent in interprofessional collaborative communication can
be seen in a variety of ways, including power relationships in health and social
care teams; the specific language used in communicating in small cultures (and
the plethora of acronyms this occasions) and the deeply intercultural nature of
professionality. These tensions make a strong impact and require health and
social care professionals to be both professional and interprofessional. Relatedly,
the question of interprofessional communication competence, which continues
to be a matter of considerable debate, is turned on its head, proposing that
competence is not (only) an individual skill but rather a shared accomplishment
that must always be collectively worked out.
The third section of this edited book examines interprofessional communi-
cation in specific practices and contexts of care, for example, in efficient and
coherent case management in the interorganizational integration of care; in the
communication practices that foster patient- and family-centered care in com-
plex clinical settings, including the NICU, primary care when collaborators do
not speak the same language, and survivor care in oncology. The particularities
of rural trauma care teams are considered through the lens of the communica-
tion style of collaborators.
A final note. Institutional dialogue can set up differential power and status
relations in interactions involving a variety of health care professionals. The way
that health and social care organizations frequently refer to health professions
speaking of “medicine, nursing, and allied health professions,” thereby dimin-
ishing the status and autonomy of the professions lumped together as “allied
health,” is one asymmetry perpetuated by language use. Such asymmetries cre-
ate situations in which nonverbal cues and contextual nuances play a significant
role in erecting interprofessional communication barriers that must be over-
come in order to develop a well-functioning interprofessional care-providing
or learning environment.
x FOREWORD

Addressing the many complex challenges addressed in this edited book

requires a holistic approach that includes, for example, interprofessional com-
munication training programs both on campus and in practice settings; the
implementation of effective interprofessional communication strategies; and
the use of technology to facilitate information exchange within health and
social care systems. Such endeavors can promote a culture of open interprofes-
sional communication and collaboration that is essential to overcome the chal-
lenges addressed in this book. By considering context, language variation,
power dynamics, nonverbal communication, and identity, individual health and
social care professionals can enhance their interprofessional communication
skills and contribute to more effective and inclusive interprofessional collabora-
tion. Interprofessional communication is, and will continue to be, a vast topic
of concern for theorists, educators, and practitioners.

Vancouver, BC, Canada

John H. V. Gilbert
 Acknowledgments

Many authors and editors create long lists of people who inspired their think-
ing, encouraged them to launch out, helped them write their books, and
enabled their efforts to come to fruition. Those we work with, those we teach,
those we interact with in interprofessional health and social care contexts, and
those we love have all contributed immensely to this book’s development. Yet,
our collective work emerged primarily from a series of events that spurred our
thinking, our decision making, and, ultimately, our collaborating: publisher
emails asking for book proposals; hallway conversations with colleagues and
students; and more sporadic meetings at international conferences where we
discussed research, intervention, and practitioner and student needs.
When Kirstie sat down for a cup of tea in Stephanie’s office in 2021, she
mentioned that a publisher had approached her to see if she wanted to submit
a book proposal. “What a great idea,” Kirstie reflected, “but after a year of
surviving pandemic-induced online teaching, I’ve decided that 2021 has to be
my ‘Year of No (to New Things).’ Maybe next year can be the ‘Year of the
Book?’” The cogs were set in motion. Stephanie decided that a book about
interprofessional communication would be a fascinating project. Moreover, it
would be especially relevant in light of the rapid transformation of health and
social care practices; demographic shifts as the population ages and comorbidi-
ties become more complex; developments in interprofessional education; and
the increased attention that health and social care workers have received
post-2020. Stephanie discussed the “Book Project” with Leena at the annual
conference of the International Communication Association in Paris, in May
2022, and Kirstie and Leena talked over lunch (and a glass of excellent French
wine) before it ended. Stephanie spent part of her sabbatical working with
Leena in Tampere, Finland, in the second half of 2022. In-person meetings
matter, and they make amazing things happen.
We launched a call for chapters that would explore interprofessional collabo-
ration from a communication perspective, mobilizing our professional net-
works and personal contacts with researchers working on these issues. Thank

xi
xii ACKNOWLEDGMENTS

you to all those who responded with enthusiasm, and best of all, with a short
chapter proposal, which allowed us to create a rich, nuanced overview of the
dynamics and challenges of interprofessional communication in health and
social care contexts. Around the same time, Stephanie touched base with col-
leagues in the interprofessional field at the University of British Colombia,
Canada, to ask for feedback on issues that they thought were essential to
include in the book. We learned much from their feedback. After incorporating
their insights, we submitted our official book proposal to Palgrave. We were so
grateful to the book’s anonymous reviewers for their comments and encour-
agement. One reviewer wrote: “An important aspect of this volume is the
sophisticated conceptualization of the communicative process; such a concep-
tualization is missing from most work on interprofessional communication.
Much of the work relies on a simplistic view of communication; the more
sophisticated focus is a key strength of the proposed book.” Our second
reviewer noted that we would need to work hard to make communication’s
complexity accessible to practitioners and students in health and social care and
interprofessional programs. And, indeed, we and the authors of each chapter
did work very hard to make the book accessible, based on the maxim that there
is nothing so practical as a good theory. To this end, we incorporated vignettes
that would illustrate how theories played out in varied health and social care
contexts. We created callout boxes that defined key terms and explained and
synthesized complex concepts.
It has been a joy working with the author or group of authors of each chap-
ter. Your engagement with interprofessional practice, responsiveness to ques-
tions and suggestions, and attentiveness to deadlines were exemplary. We
learned so much from you! We were so excited about making your work widely
available to practitioners, students, and researchers studying interprofessional
communication in health and social care settings that we wanted the book to
be open access. We are extremely grateful to the Social Sciences and Humanities
Research Council of Canada (Insight grant 435-2020-1274), the Fonds de
recherche du Québec-Société et Culture (Relève professoral grant 2021-­
NP-­282893), and the Tampere University Library, Finland, for their financial
support, which allowed us to do so.
And now, we start an impossible-to-be-exhaustive list of those who have
prodded us to think better and differently about interprofessional communica-
tion: John Gilbert; Isabelle Gaboury and Mylaine Breton from Université de
Sherbrooke; Lorelei Lingard; Marie-Thérèse Lussier; François Cooren, Daniel
Robichaud, and Boris Brummans at the Groupe LOG at the Université de
Montréal; Emmanuelle Careau; Andrea Meluch; Joshua B. Barbour; Matthew
Koschmann; the researchers at Montreal’s Centre for Research and Expertise
in Social Gerontology (CREGÉS); the graduate students of the Labo de
recherche engagée (labengage.org) at the Université de Montréal; Heli
Parviainen; Sanna Laulainen; Pirjo Lindfors; the researchers and practitioners
at the interdisciplinary health and social care research consortium MOTIIVI of
 ACKNOWLEDGMENTS xiii

Tampere University, Tampere University of Applied Sciences, University of

Eastern Finland, and the Wellbeing Services County of Pirkanmaa; and
Laurianne Piette, Alice Carter, and the anonymous reviewers at Palgrave. Many
thanks to you all. Merci beaucoup. Kiitos.
 Contents

Part I Introduction to Interprofessional Communication   1

1 How
 to Conceptualize Communication in Interprofessional
Practice  3
Stephanie Fox, Kirstie McAllum, and Leena Mikkola

2 Communication
 and Effective Interprofessional Healthcare
Teams 25
Gary L. Kreps

3 Interprofessional
 Communication: A Continuum of
Intentions and Practices 41
Emmanuelle Careau and Stephanie Fox

4 Rethinking
 How Communication Is Taught as an
Interprofessional Competency 59
Marlène Karam and Isabelle Brault

Part II Fundamental Processes and Dynamics of Interprofessional

Communication  81

5 Sensemaking
 in Interprofessional Communication 83
Nina Lunkka, Ville Pietiläinen, Ville Kivivirta, and Sanna Laulainen

6 Foregrounding
 the Relational Dimensions of Interprofessional
Collaboration: A Communication Perspective 97
Kirstie McAllum, Stephanie Fox, Laura Ginoux, and Léna Meyer

xv
xvi Contents

7 Dialectical
 Tensions in Interprofessional Relationships:
Understanding Relational Dialectics Theory in Health
and Social Care Teams115
Leena Mikkola, Maija Peltola, and Julie Apker

8 Negotiating
 Power Relationships in Interprofessional
Health Care Groups133
Allison L. Noyes

9 Building
 Blocks and Weaving Threads: An Intercultural
Communication Framework for the Study of Professional
Identity Construction in Interprofessional Collaboration in
Health Care149
Malgorzata Lahti and Karoliina Karppinen

10 Shared
 Communication Competence: Moving Beyond the
Individual in Interprofessional Communication165
Tessa Horila

Part III Interprofessional Communication in Specific Contexts

and Practices 183

11 Case
 Management as a Structural Condition for Effective
Interprofessional Communication185
Yves Couturier, Stephanie Fox, Paul Wankah, and Julie Martin

12 Improving
 Family-Centered Care through High-Reliability
Interprofessional Collaboration in the NICU199
Cassidy S. Doucet and Joshua B. Barbour

13 Interprofessional
 Teamwork in Oncology: Patient-Centered
Perspectives and Survivorship Care Planning215
Laura E. Miller

14 The
 Interprofessional Team as an Emergent Structure of
Participation: A Case Study on Primary Care Visits of
Unaccompanied Foreign Minors231
Letizia Caronia and Federica Ranzani
 Contents  xvii

15 Independent
 Mindedness, Patient Safety, and
Interprofessional Communication within Rural Trauma
Medicine Teams253
Theodore A. Avtgis

16 Reflections
 on Future Directions271
Stephanie Fox, Leena Mikkola, and Kirstie McAllum

Author Index279

Object Index281

Subject Index283
 Notes on Contributors

Julie Apker (PhD, Communication) is Professor of Communication and

director of graduate studies in the School of Communication at Western
Michigan University (USA). Her areas of research specialization include inter-
professional communication in health teams, patient-provider interactions,
provider stress and burnout, and qualitative research methods.
Theodore A. Avtgis (PhD, Communication) is an assistant professor at
Western Illinois University and independent consultant specializing in organi-
zational communication processes in general business and health care organi-
zations. He is a co-founder and head trainer of Medical Communication
Specialists. His research focuses on organizational and health communication,
risk and crisis communication, and aggressive communication.
Joshua B. Barbour (PhD, Communication) is a full professor at the University
of Illinois Urbana-Champaign (USA). His research begins with the assumption
that institutional structures such as regulations, laws, and cultural norms create
opportunities, constraints, resources, and contradictions that we exploit and
suffer to solve problems. His research sheds light on practitioners’ strategic
efforts to navigate those structures.
Isabelle Brault (RN, PhD, Public Health) is an associate professor at the
Faculty of Nursing at the Université de Montréal (Canada) and Past President
of the Interfaculty Operational Committee on Interprofessional Education.
Her research focus includes evaluative research on interprofessional education,
collaboration and partnership in care, nursing administration, and clinical
governance.
Emmanuelle Careau (OT, PhD, Experimental Medicine) is Vice Dean of
Professional Development, Pedagogy and Social Responsibility and associate
professor in the Rehabilitation Department of the Faculty of Medicine at
Université Laval (Canada). She is also the former director of the Réseau de col-
laboration sur les pratiques interprofessionnelles en santé et services sociaux

xix
xx NOTES ON CONTRIBUTORS

(Collaboration Network on Interprofessional Practices in Health and Social

Services).
Letizia Caronia (PhD, Education) is a full professor at the Department of
Education, University of Bologna (Italy). Her research interests include lan-
guage, interaction, and culture in institutional as well as ordinary contexts, the
management of knowledge and expertise in (interprofessional) institutional
interactions, and the communicative constitution of everyday and scientific
knowledge.
Yves Couturier (MSW, PhD, Applied Human Sciences) is a full professor at
the Department of Social Work of the Université de Sherbrooke (Canada). His
research expertise is related to integrated services, interprofessional collabora-
tion, and the sociology of professional practices in the field of health and social
services. He is the scientific director of the Primary Care Knowledge Network
(http://reseau1quebec.ca/) founded by Fonds de recherche du Québec-Santé
and the Canadian Institutes of Health Research.
Cassidy S. Doucet (MS, Communication) is a doctoral student at the
University of Texas, Austin (USA). Her research investigates how organiza-
tions and individuals manage risks related to both health and environmental
disasters and how communication factors influence decision-making related to
those risks as well as coping and resilience following a health crisis or disaster.
Stephanie Fox (PhD, Communication) is an associate professor in the
Department of Communication at the Université de Montréal (Canada). Her
research expertise relates to interprofessional communication and collabora-
tion in health and social care organizations. She studies how collaborators navi-
gate and make sense of shared problems across professional and other
boundaries. Her recent work examines the relational dimensions of collabora-
tion, including team care.
John H. V. Gilbert (CM, PhD, LLD, FCAHS) is an emeritus professor at
the University of British Columbia’s Faculty of Medicine, School of Audiology
and Speech Sciences (Canada). His distinctions include being the founding
chair of the Canadian Interprofessional Health Collaborative and a member of
the Order of Canada.
Laura Ginoux (MSc, Communication) is a PhD candidate and lecturer in the
Department of Communication at the Université de Montréal (Canada). Her
research is situated at the crossroads between health communication, intercul-
tural interactions, and organizational collaboration. Her current research
focuses on interactions and knowledge sharing between minority ethnocultural
family caregivers and health professionals.
Tessa Horila (PhD, Communication) is a university instructor at Tampere
University (Finland). Her research expertise is related to the sharedness of
communication competence, group and team communication in both
 NOTES ON CONTRIBUTORS xxi

professional life and higher education, and scientific thinking in the context of
university education in communication.
Marlène Karam (PhD, Public Health) is an assistant professor in the Faculty
of Nursing at the Université de Montréal. Her research focuses on interprofes-
sional collaboration and continuity of care in urgent and primary care and care
coordination by nurses for patients with complex needs. She also teaches
courses in interprofessional education.
Karoliina Karppinen (MA, Communication) works as a PhD researcher and
university teacher at Tampere University (Finland). Her research focuses on
themes that sit at the intersections of interpersonal communication and social
interaction, intercultural communication, and health communication.
Ville Kivivirta (PhD, Administrative Sciences) is Senior Lecturer in Health
and Human Services Informatics at the Department of Health and Social
Management at the University of Eastern Finland. His research focuses on
information and organizing in societies and service ecosystems. His profes-
sional background involves administrative and human resource roles.
Gary L. Kreps (PhD, Communication) is university distinguished professor
and Director of the Center for Health and Risk Communication at George
Mason University (USA). He examines the influences of strategic evidence-
based communication programs and practices on reducing health risks and
enhancing health outcomes, with a focus on promoting health equity in soci-
ety. He is an expert in community-based participatory research, health infor-
mation dissemination, and the effective design and use of health information
technologies.
Malgorzata Lahti (PhD, Communication) is a senior lecturer at the
Department of Language and Communication Studies, University of Jyväskylä
(Finland). Her research interests include interculturality and multilingualism in
professional and academic contexts, critical approaches to intercultural com-
munication, and team interaction across professional contexts, including nego-
tiations of interprofessionality in interprofessional health care.
Sanna Laulainen (PhD, Social Management) is Professor of Social
Management Sciences at the Department of Health and Social Management,
University of Eastern Finland. She is an expert in critical leadership and orga-
nization studies. She has studied organizational citizenship behavior, leader-
ship competencies, and leader-member relations in various contexts in health
and social care.
Nina Lunkka (PhD, Health Administration) is a senior lecturer at the
Department of Health and Social Management at the University of Eastern
Finland. Her research focuses on organizational change processes in health
care settings, which she examines primarily from discursive, narrative, and sen-
semaking perspectives.
xxii NOTES ON CONTRIBUTORS

Julie Martin (MSW) is completing a PhD on organizational change as part of

the doctoral program in gerontology at the Université de Sherbrooke (Canada).
Kirstie McAllum (PhD, Communication) is an associate professor in the
Department of Media and Communication at Te Whare Wānanga o Waitaha |
the University of Canterbury (Aotearoa New Zealand). Her research focuses
on the meanings of non-­standard work, the communicative patterns of col-
laboration and conflict, and compassion and care organizing in multiple health
and social care contexts.
Léna Meyer (MSc., Communication) is a doctoral student at the Université
de Montréal (Canada), working with Stephanie Fox. Her research interests
relate to professional identities in interprofessional interactions in health and
social care contexts, focusing on women’s health and health for women.
Leena Mikkola (PhD, Speech Communication) is an associate professor at
the Faculty of Information Technology and Communication Sciences at
Tampere University (Finland). Her research focuses on interpersonal commu-
nication in social and health care teams and workplaces, but her interests also
include provider-patient communication. In her current research, she concen-
trates on tensions in interprofessional relationships and identity construction.
Laura E. Miller (PhD, Communication) is an associate professor at the
University of Tennessee, Knoxville (USA). Her research interests are at the
intersection of interpersonal and health communication. Her work has exam-
ined health care providers and teams in hospital emergency departments.
Allison L. Noyes (PhD, Communication) is an associate professor in the
Communication Studies Department at Loyola Marymount University (USA).
She specializes in organizational and group communication, health care orga-
nizations, and strategic communication. Her current research focuses on inter-
professional collaboration, organizational power dynamics, care disparities, and
palliative care.
Maija Peltola (MA, Speech Communication) works as a PhD researcher at
Tampere University (Finland). Her research focuses on patient-professional
communication, which she has examined from the perspectives of dialectical
tensions and collaboration as well as critical incidents.
Ville Pietiläinen (PhD, Administration) is Senior Lecturer in Leadership
Psychology at the Faculty of Social Sciences, University of Lapland (Finland).
His professional background derives from human resource management and
human resource development in the private and public sectors. He has studied
topics such as complex organizations, critical leadership, discursive psychology,
and (post)phenomenology.
Federica Ranzani (MS, Education) is a PhD candidate at the Department of
Education, University of Bologna (Italy). She conducts ethnographic,
 NOTES ON CONTRIBUTORS xxiii

video-based research to study language, interaction, and culture in institutional

settings, with a particular focus on primary care and well-child pediatric visits,
and primary care triadic visits of unaccompanied foreign minors.
Paul Wankah (PhD, Health Sciences) is a postdoctoral researcher at the
Institute of Health Policy, Management and Evaluation (IHPME) of the
University of Toronto (Canada). His research expertise is related to integrated
care services, organizational change, interorganizational partnerships, equity-
promoting practices, and interorganizational network governance.
 List of Figures

Fig. 1.1 The transmission model of communication 10

Fig. 1.2 The transactional model of communication 12
Fig. 1.3 The constitutive model of communication 15
Fig. 3.1 Continuum of Collaborative Practices. Reproduced with
permission by the Réseau de collaboration sur les pratiques
interprofessionnelles (RCPI) of Université Laval and the CIUSSS
de la Capitale Nationale 42
Fig. 14.1 Excerpt 1: Problem-presentation phase 240
Fig. 14.2 D looks at the documents held by E 240
Fig. 14.3 D looks at E, E looks at D 241
Fig. 14.4 E visibly turns toward P 241
Fig. 14.5 D stops looking at E and looks at P 242
Fig. 14.6 Excerpt 2: Treatment/Recommendation phase 243
Fig. 14.7 D looks at P 243
Fig. 14.8 D looks at E 244
Fig. 14.9 D looks at E 244

xxv
 PART I

Introduction to Interprofessional
Communication
 CHAPTER 1

How to Conceptualize Communication

in Interprofessional Practice

Stephanie Fox, Kirstie McAllum, and Leena Mikkola

Interprofessional collaboration is a cornerstone of twenty-first century health

and social care due to its potential to improve organizational efficiency and
safety, clinician and care worker satisfaction with their job, and quality of
patient care (World Health Organization 2010). Communication is considered
a key determinant of effective interprofessional collaboration and is described
as a core interprofessional competency for healthcare professionals (IPEC
2023). While policy documents and training materials are full of recommenda-
tions for improving interprofessional communication (e.g., by promoting
active listening and respect, fostering common understanding, developing
trust and role awareness), they seldom elaborate on why these communication
practices can be so challenging. In our view, the complexity of interprofessional
communication remains both under-theorized and under-researched in health
and social care contexts.

S. Fox (*)
Département de communication (Department of Communication), Université de
Montréal, Montréal, Québec, Canada
e-mail: [email protected]
K. McAllum
Department of Media and Communication, Te Whare Wānanga o Waitaha | the
University of Canterbury, Christchurch, New Zealand
e-mail: [email protected]
L. Mikkola
Faculty of Information Technology and Communication Sciences, Tampereen
yliopisto (Tampere University), Tampere, Finland
e-mail: [email protected]

© The Author(s) 2025 3

S. Fox et al. (eds.), Interprofessional Communication in Health and Social
Care, https://doi.org/10.1007/978-3-031-70106-1_1
4 S. FOX ET AL.

This book aims to fill that gap by offering practitioners, policy makers, inter-
professional curriculum builders, and advanced undergraduate and graduate
students in the health professions a broadened theoretical understanding and
rich empirical examples of interprofessional communication across a range of
health and social care contexts. Importantly, this means questioning what it
means for interprofessional communication to be “effective,” in particular, for
complex, collective practices that rely on shared meanings and accountabilities.
Sometimes collaboration and communication are considered as synonymous,
especially when it comes to effectiveness. However, it is important to under-
stand the distinction between the two. Effective collaboration implies collec-
tively accomplishing a shared goal (Lewis 2006), such as coming up with an
appropriate care plan for a difficult problem. On the other hand, the notion of
effective communication implies successful information transmission: sharing
the right information with the appropriate people in a timely manner. This is
very important, especially in contexts such as urgent care. However, it is not
always obvious what the right information is or with whom exactly we should
share information, especially if the situation we are facing is multifaceted and
complex. For this reason, we must also comprehend communication’s role in,
for instance, collectively figuring out the meaning of complex problems.
Therefore, the main goal of this is book is to offer a broad and nuanced
understanding of how communication and interprofessional practice inter-
twine. The book brings communication and management scholars from the
subfields of health, interpersonal, and organizational communication together
with experts in interprofessional education and collaborative practice to pro-
vide theoretical insights and practical examples of interprofessional communi-
cation. The way in which contributors theorize communication varies, yet each
chapter insists on the centrality of communication practices to interprofessional
work. In this way, we offer truly interdisciplinary perspectives on interprofes-
sional communication to better understand and explain the complexity and the
variety of situations where health and social care providers, the recipients of
care, and their family members must collaborate. While the book is aimed at an
international audience, its contributors hail from European (Finland and Italy)
and North American (Canada and the United States, although one moved to
New Zealand since the book went to press) contexts, and the content and
examples are drawn from these Western settings. Before describing the differ-
ent chapters, we lay the conceptual groundwork for the rest of the book by
defining terms that are key to our goals: interprofessional, working together,
and communication.

Defining Key Terms

Understanding what is meant by “interprofessional communication” can be
challenging, in large part because the terminology used for various related con-
cepts is not consistent across the interprofessional literature. For the communi-
cation scholar studying interprofessional collaboration, there may seem to be a
 1 HOW TO CONCEPTUALIZE COMMUNICATION IN INTERPROFESSIONAL… 5

lack of concepts and theories in the interprofessional literature that adequately

describe communication processes and practices. Yet, enhancing collaboration
requires establishing a shared terminology to start with. Therefore, we estab-
lish what we mean by interprofessional collaboration, and we offer three com-
munication models to promote shared understanding of interprofessional
communication.

Describing Interprofessional
Interprofessionality implies a way of working together that occasions the dia-
lectical tension between connection and professional autonomy, a reality that
will be explored in later chapters. The prefix inter denotes both connection
across differences, such as when a nurse collaborates with a social worker, as
well as the continued existence of these differences; the two professions con-
tinue to operate distinctly despite their collaboration. Interprofessional work is
thus inherently dialectical (Moran 2002), necessarily entailing complexity and
tensions, professional identities and interprofessional skills.
Next, a word on the word profession. A profession has traditionally been
understood as a type of work carried out with acquired knowledge and skill,
regulated by a professional body, and implicitly governed by a social contract
that bestows privileges for circumscribed service to the collective (Saks 2021).
The word is also political, as it can be mobilized to elevate the status of certain
occupations and groups of workers (Freidson 2001), an important and some-
times strategic move in the context of the entrenched professional hierarchy in
health care (Abbott 1988; Freidson 1970). However, alongside the contribu-
tions of regulated professionals, today’s health care and social services also
involve the contributions of other workers such as medical secretaries, informa-
tion technology experts, and managers. Therefore, we use the word profes-
sional quite inclusively when referring to teamwork and collaboration in and
across clinical contexts. Moreover, there is increasing attention paid to the
active role of people receiving care and services (Oates et al. 2000; Epstein and
Street 2011).
In healthcare and social service contexts, it is not unusual to hear the terms
interprofessional, interdisciplinary, and multidisciplinary used interchangeably
to describe ways that providers work together. However, scholars who study
and teach such collaboration often prefer the term interprofessional for its spec-
ificity. Twenty years ago, D’Amour and Oandasan (2005) distinguished inter-
professional from interdisciplinary to argue for the importance of
interprofessionality, then a relatively nascent field of study and practice. The
key difference, in their view, is that interdisciplinarity has to do with integrating
knowledge that is fragmented across different established areas of study, such as
the disciplines of biology and chemistry, or even across specialties in medicine,
whereas interprofessionality aims to integrate practices that are fragmented
across established bodies of healthcare and social services work, such as between
the professions of medicine and physiotherapy. It is the integration of different
6 S. FOX ET AL.

clinical practices across professional and occupational boundaries—as well as

the development of shared understanding among collaborators—that interests
us here, and so we also privilege the term interprofessional. Moreover, we
understand interprofessionality in broad terms, to include contributors to care
who may not be governed by a professional order as well as multiagency com-
munication that spans more than one health and social care organization.

Explaining Working Together

Fundamentally, interprofessional practice is about working together. The
World Health Organization (2010) explains that collaborative practice “hap-
pens when multiple health workers from different professional backgrounds
work together with patients, families, carers and communities to deliver the
highest quality of care. It allows health workers to engage any individual whose
skills can help achieve local health goals” (7). Despite the comprehensiveness
of this definition, it does not account for the fact that working together in clini-
cal contexts can take many forms, ranging from a family physician referring a
patient to a specialist for diagnostic tests to a geriatric hospital care team dis-
cussing the complex needs of an older patient with dementia and diabetes who
might need to move from home to assisted living.
Furthermore, as Reeves et al. (2010, 2018) pointed out, the collaboration
and teamwork literature tends to describe teams in a linear fashion, suggesting
that teamwork exists along a continuum of “weak to strong” or “immature to
mature” (e.g., Drinka and Clark 2000). This normative view can obscure
important nuances in the nature of collaborative practice. To remedy this,
Reeves and colleagues proposed a contingency approach to understanding
collaborative practice, one where the form of working together depends on the
situated and contextual needs of the patient or client. More specifically, they
outline four forms of interprofessional working together: teamworking, col-
laboration, coordination, and networking. These forms of working together
vary according to the following six core elements that can affect collaboration.
First, shared team identity is the extent to which collaborators identify or are
identified by others as members of the same team. Second, clarity in roles and
goals indicates how clear each member’s team role is to the other members
(i.e., knowing the professional contributions and scopes of practice of the other
members) and how clear the team’s shared goals are to all. Third, interdepen-
dence refers to collaborators’ mutual need for the others’ contributions to
achieve their individual and shared goals. Fourth, collaborators may be more or
less integrated as a team (i.e., collaborators might constitute a network rather
than a team). Fifth, shared responsibility means the extent to which collabora-
tors are “collectively and mutually accountable for meeting goals and produc-
ing outputs” (Reeves et al. 2010, 40). Finally, team tasks can vary in their
predictability, urgency, and complexity. The authors suggest that these elements
can each be placed on a continuum, for instance, team tasks ranging from
 1 HOW TO CONCEPTUALIZE COMMUNICATION IN INTERPROFESSIONAL… 7

routine and predictable to dynamic and unpredictable. Hence, variations in

each of these six elements inform the four forms of working together that they
identify.
Interprofessional teamworking is the most interdependent of these forms,
with collaborators integrated as a team. They likely share a team identity and
have clarity about roles and shared goals. They also tend to share responsibility
for outputs and outcomes, working in an integrated fashion, where each com-
municates regularly with the others to carry out their profession-specific tasks.
Tasks are often unpredictable, complex, and urgent. An example is an emer-
gency department trauma team, where the team task demands are changeable,
urgent, and may involve a great degree of informational uncertainty, especially
if patients are unable to communicate. The shared goal of providing rapid and
appropriate care in these circumstances requires a high level of integration, an
ability to work interdependently, and a clear understanding of everyone’s role
and how they all fit together. Collaborators are likely identifiable by others in
the hospital as the trauma team.
Interprofessional collaborating is a “looser” form of interprofessional
work than teamwork, where a shared identity and the integration of individuals
is less important. However, accountability is typically still shared between col-
laborators and there is also some degree of interdependence and clarity of roles
and goals. Collaborators work together to achieve a goal. In this form of work-
ing together, tasks are seen as a bit more predictable, and less urgent and com-
plex than with teamworking. Collaborators communicate when needed, even if
only briefly. An example can be found in a primary care clinic where a nurse
practitioner typically sees his own patients independently but may occasionally
need to discuss complex patient care issues with a physician or pharmacist.
Interprofessional coordination is a form of working together that impli-
cates some type of shared identity, but integration and interdependence are
seen as less important than for the previous two forms. Tasks are even more
predictable, less urgent and less complex than with collaboration; collaborators
often work separately to achieve a goal together. Providers must communicate
to share timely information in order to coordinate their different professional
contributions to care, indicating the presence of some level of shared account-
ability between individuals, as well as clarity of roles, tasks, and goals. An exam-
ple given by Reeves et al. (2010) is case management, where a pivotal care
coordinator oversees the articulation of different professional contributions to
care (see Corbin and Strauss 1993).
Finally, interprofessional networking is a form of working together that
has the most informal arrangements as well as changing membership; collabo-
rators might only need to navigate these networks when the need for specialist
expertise arises. Therefore, shared team identity, interdependence, and integra-
tion are seen as even less essential than for coordination. However, tasks are
quite predictable, non-complex, and non-urgent, which Reeves et al. (2018)
suggest means that communication can be asynchronous or synchronous, as
8 S. FOX ET AL.

team members do not need to meet in person. An example might be a family

physician referring a patient to a specialist in the health network for diagnostic
tests, although Reeves et al. (2010) offer the example of a literal network of
providers who share a mutual interest on a care-related topic and meet infre-
quently to discuss, such as in cancer care survivorship.
Overall, the key to the contingency approach is collaborators’ ability to
adapt their form of working together to the needs of the situation. Take for
example providers working together to provide optimal care for a person who
has suffered a brain aneurism. Her initial needs will be complex, very unpre-
dictable, and pressing. At this stage, the intensive care unit team would likely
adopt an interprofessional teamworking approach, constantly communicating
to collectively and continually figure out what is going on and what needs to
be done by whom, thus continually modifying the care plan. As the patient’s
situation becomes more stable and predictable, and her care needs less urgent,
she might be transferred to a rehabilitation ward, where interprofessional col-
laboration would probably be the most appropriate form of working together.
There, collaborators, possibly including the ICU neurologist, might meet daily
to discuss updates to the patient’s situation and care needs, while each profes-
sional contributes to the patient’s care in a parallel fashion. Once the patient is
ready to leave the hospital, the care coordinator will coordinate her discharge
with all the professionals contributing to her care, including the home care
coordinator, if there is one. Down the road, the patient’s primary care provider
might serve as a case manager and will likely communicate on a semi-regular
basis with the interprofessional network of specialists who will monitor the
woman’s health.
As we can see, what is considered the most effective interprofessional form
of interprofessional working together depends entirely on the local situation
and the patient’s needs, hence the notion of contingency! Therefore, the ques-
tion of effectiveness in interprofessional collaboration is not a simple one.
Neither is effective interprofessional communication. We argue that the way we
understand communication—its purposes and what it accomplishes—can vary,
depending on the form of interprofessional work. We explain this in the next
section on how communication is theorized.

Conceptualizing Communication
Communication has been defined as the management of messages for the pur-
pose of creating meaning within and across various contexts (National
Communication Association n.d.; Frey et al. 1991). As the process by which
collaboration and teamwork take place, communication can be understood in
multiple ways, depending on what we choose to emphasize with regard to what
happens when we communicate. Therefore, just like with the different forms of
working together, it is essential to clarify which conceptualization, approach, or
model we mean when we refer to communication. More broadly, learning
about these different approaches to communication broadens and deepens our
 1 HOW TO CONCEPTUALIZE COMMUNICATION IN INTERPROFESSIONAL… 9

understanding of this fundamental process. This is especially important because,

in research on interprofessional collaboration, communication tends more
often than not to be put in a conceptual “black box” (Careau et al. 2014),
where unspoken theoretical assumptions about communication remain
unspecified.
Our aim in this section is to open up this black box and explore different
approaches to communication as well as their assumptions, their usefulness,
and their applicability to clinical contexts and interprofessional practice. Below,
we present three main approaches to conceptualizing communication: the
transmission model, the transactional model, and the constitutive model. The
first two are commonly (if sometimes implicitly) used in health professions cur-
riculum and the interprofessional literature, while the third is currently a pre-
ferred approach in the communication discipline. However, models, theories,
and the approaches they characterize are only able to consider parts of the
social phenomena they aim to describe, explain, and represent. In other words,
they are necessarily reductive and partial. That is why we propose adopting an
agnostic stance with regard to these different conceptualizations, as we believe
each can be useful to our understanding of interprofessional practice, depend-
ing on the questions we are asking. We begin with the model that most people
are familiar with.

The Transmission Model

The transmission model of communication, an information-oriented approach
(Frey et al. 1991), is by far the most commonly referenced understanding of
communication. Typically, it is the model that is referenced, often implicitly,
when we talk about effective or efficient communication. Tracing its tracing
roots to industrial and organizational psychology and to post-positivist science
(i.e., research that focuses on causal relationships between variables; Fairhurst
and Connaughton 2014), it originated in the 1940s in the work of Claude
Shannon and Warren Weaver (1949), two engineer-mathematicians at Bell
Labs who were trying to describe how information can be sent across a tele-
phone line between two people. They decoupled the problem of message
meaning from the process of message transmission. In other words, they were
not interested in how messages come to be imbued with meaning, presuming
instead that the meaning is simply inherent in the message.
They proposed a simple model that views communication as a conduit: An
information source or sender produces and encodes a message into a signal that
is transmitted by a channel to a receiver who decodes it. Shannon and Weaver
focused on the technical problems of communication, which they understood
primarily as noise, which can distort the signal at any point along the way
(Fig. 1.1).
The focus of this model is on the accurate transmission of information from
one person to another, and there are clearly many situations in health care and
social service delivery when the timely and accurate transmission of
10 S. FOX ET AL.

Fig. 1.1 The transmission model of communication

information to the right receiver is important. Take for instance an asynchro-

nous interprofessional communication practice in which a nurse practitioner
sends a patient’s prescription by fax to a pharmacist (yes, this does still happen
in some contexts!), who receives the fax and fills out the prescription. But if the
ink smears as the fax prints out, it will obscure the nurse practitioner’s message,
and we can consider it as noise (i.e., a hindrance to transmission).
This model tells us that communication is successful when a message has
been sent and received; it is therefore considered a linear or one-way model of
communication (Axley 1984). It is useful for describing situations where the
process of information transmission is particularly salient, like when an informa-
tion technology (or channel) such as electronic medical records or an internal
email system is used in interprofessional practice. This approach “sees the world
in terms of inputs, processes, and outputs” (Fairhurst and Connaughton 2014,
9) and its optimal use is when the goal is to understand communication as one
variable among others at work in interprofessional collaboration. More specifi-
cally, it can be understood as a process variable (e.g., the influence of effective
information sharing on rates of medical error) or as a behavioral outcome (e.g.,
“good” communication as a result of trust among collaborators).
One critique of the original model is that it doesn’t account for confirma-
tion of message reception. For instance, the nurse practitioner doesn’t know if
the pharmacist has received and filled the prescription. Therefore, later itera-
tions of this model incorporated the cybernetic notion of feedback, which
describes the process by which the receiver provides information to the sender
about their message reception. This can be particularly important for safe
 1 HOW TO CONCEPTUALIZE COMMUNICATION IN INTERPROFESSIONAL… 11

patient hand-offs. For instance, when an ambulance crew called to treat a

patient with a cardiac arrest are backed up by members of the local fire brigade,
they will give a rapid report of what they have observed (a synchronous com-
munication practice). The firefighting team might repeat back to one of the
paramedics what they have heard, thereby confirming reception of the infor-
mation. If there has been an error, the paramedic might repeat the correct
information (i.e., send another message).
While easy to grasp and very useful for understanding what is going on—or
what went wrong (i.e., a communication “breakdown”)—when information
transmission is the primary concern, the transmission model and its offshoots
have their limitations. A key limitation is that the decoupling of meaning from
the process of communicating ignores interpretation and sensemaking, which
constitute a large part of what happens when we communicate. Messages can
be polysemic, implying that they can have different meanings to different peo-
ple. Therefore, it is imperative that communicators share the same code to
understand messages; this is why the use of professional jargon can be detri-
mental to shared understanding in interprofessional teamwork.
The transmission model is also critiqued for simplifying the complexities of
face-to-face communication. For instance, it does not take into account that
contextual cues, such as speakers’ situated identities and relationships, are
inherently influential to how messages are interpreted. Furthermore, while
the notion of feedback may more accurately represent communication as an
interactive process, the modified interactive transmission model nonetheless
presumes that communication is always sequential, where communicators take
turns at being a sender or a receiver. As we will see in the next section, this is
not necessarily the case.

The Transactional Model

When we are speaking with someone, we pay close attention to how they seem
to be reacting, perhaps a subtle change in expression or posture, and we often
adjust what we are saying or how we are saying it. The communication theo-
rists who developed the transactional model aimed to capture these face-to-­
face interaction dynamics. When Paul Watzlawick and his colleagues (1967)
studied family communication dynamics, they claimed that it is impossible to
not communicate. This is because we are always giving feedback, at least
through our non-verbal behaviour, even if unintentionally. For instance, even a
blank look may be interpreted as being meaningful (Du Pré 2017). Furthermore,
they posited that every communication act has both a content and a relational
component; the relationship of the speakers and their relative identities
influence the content of what is communicated and how it is interpreted. Three
years after Watzlawick, Dean Barnlund (1970) published very similar ideas,
giving the theory its name. He insisted that communication is an ongoing,
two-way process, meaning that communicators are always sending messages
and receiving feedback (i.e., transacting) (Fig. 1.2).
12 S. FOX ET AL.

Fig. 1.2 The transactional model of communication

This model is often taught in health professions communication training,

especially nursing (e.g., Lapum et al. 2020), to promote patient-centred com-
munication, but it is just as relevant to interprofessional communication. The
model focuses on the contextual process of meaning-making—or interpreta-
tion—that occurs in interaction. While the transmission model presumes that
meaning exists in messages, the transactional model’s fundamental premise is
that people make meaning: When we communicate, we reciprocally influence
one another and mutually adjust as we work to agree on and produce meaning.
In this sense, the transactional model is particularly useful for describing situa-
tions where interprofessional collaborators create meaning together, such as an
interprofessional team meeting where care planning is discussed.
Another premise is that context shapes all aspects of how we communicate
and understand one another. As shown in Fig. 1.2, context is multidimen-
sional, and each dimension is salient to interprofessional work. For instance, if
their physical context is loud, crowded, and busy, interprofessional communi-
cators might choose not to discuss sensitive patient information. Likewise,
communication scholars have found the built environment in hospital emer-
gency departments favours “case talk,” typically enacted by physicians talking
about patients and geared towards diagnosis and intervention tasks, over “com-
fort talk,” usually enacted by nurses and oriented to relationally connecting
with and emotionally supporting patients (Dean et al. 2016). Moreover, it is
thought that physical proximity or co-location of communicators facilitates
interprofessional work (e.g., Oandasan et al. 2009).
 1 HOW TO CONCEPTUALIZE COMMUNICATION IN INTERPROFESSIONAL… 13

The psychological context includes our pre-existing attitudes, values, and

beliefs, including the professional mental models we hold, which all influence
our ways of interpreting messages and seeing and framing problems. The psy-
chological context also includes our mental and emotional state, both individ-
ual and collective. Indeed, certain contexts of care are particularly challenging
to well-being and resilience, such as pediatric palliative care or residential long-­
term care facilities during the COVID-19 pandemic; the result can be burnout,
disengagement, and moral distress that inhibit supportive communication
among team members (Fox et al. 2023).
The relational context refers to the interpersonal history and type of rela-
tionship between communicators. For instance, interprofessional team mem-
bers who have worked together a lot may have developed the trust and role
understanding (e.g., Suter et al. 2009) that facilitate easy communication.
They might even use meaning-making shortcuts based on shared experience.
In contrast, in a situation of “plug-and-play” teaming (Faraj and Xiao 2006),
such as an overloaded trauma department that called in support from other
organizations, communicators might not know each other or have any experi-
ence collaborating with one another. Their communication might feel labori-
ous, or they might rely on communication protocols such as checklists rather
than shared experience.
The social context is often thought to refer to implicit norms and rules
about how to communicate, what kinds of messages and feedback are appro-
priate. This includes communicators’ identities and status relative to one
another. For instance, interprofessional communication can be hindered by
status differences among communicators that stem from the professional hier-
archy (Abbott 1988; Freidson 1970). The SBAR communication tool was cre-
ated by the U.S. military to help lower-status members communicate with
higher-status members. Often implemented in hospital settings to facilitate
nurse-physician communication, SBAR stands for the components of a “rec-
ipe” for transmitting one’s message: describe the situation, provide relevant
background information, offer your assessment, and name your recommended
course of action (Haig et al. 2006).
Finally, cultural context is often understood to refer to the social identities
of the communicators, such as their gender, nationality, sexual orientation, and
social class. However, in the context of interprofessional work, we can also add
professional culture, as this influences how communicators approach problems
and one another.
Overall, it should be clear that the transactional model is much more adept
at describing and explaining the realities of face-to-face and technologically
mediated interactions, as well as the situated meaning- and sensemaking that
occurs when we communicate. It certainly sees the decoding process as much
more nuanced and multi-layered than does the transmission model. Yet the
constitutive model goes a radical step further, as we explain in the following
section.
14 S. FOX ET AL.

The Constitutive Model

The fundamental premise of the constitutive model is that communication
does more than serve as the medium for the co-creation of meaning; it pro-
duces—or constitutes—our social world. This proposition is often credited to
communication scholar Robert Craig (1999) who mapped the many subfields
of the fragmented discipline of communication in order to propose the consti-
tutive theory of communication as an overarching metatheory to engage them
all. He proposed that communication is the central activity and driving force in
our social lives and our relationships. The constitutive model is the preferred
approach for many communication scholars today.
What is radical about this proposition is that it takes communication as the
starting point for all other social forces in society, insisting that they are all cre-
ated—or constituted—in and through communicative activity. So, rather than
presuming that context (whether physical, psychological, cultural, relational,
or social) exists prior to and influences in a unidirectional fashion what happens
in interaction between communicators (as the transactional model does), the
constitutive model is primarily interested in how communication is “the pri-
mary constitutive social process” (Craig 1999, 126) by which psychological,
social, cultural, and economic factors can be explained. In other words, social
forces and social structures—including interprofessional collaboration—do not
precede communication; they are established (or constituted) in and through
communication. Moreover, the model explains that the constitutive nature of
communication is ongoing; social realities and contexts are constantly being
constituted, negotiated, challenged, or maintained through our communica-
tive practices in a recursive manner.
The constitutive model as it has been developed in the subfield of organiza-
tional communication is particularly useful for understanding the centrality of
communication to interprofessional collaboration and teamwork. Most inter-
professional literature sees communication from a transmission or a transac-
tional model perspective, for instance, as a core competency for interprofessional
collaborative practice (IECEP 2011). However, the constitutive model pro-
poses something else: Because it sees communication as the origin of all social
connections, it underscores communication’s capacity to create and shape teams
and teamwork. Thus, there can be no interprofessional collaboration, relation-
ships, teamwork, or even health and social care organizations without the com-
munication through which they emerge (see Fig. 1.3). Therefore, this model
suggests we examine communication processes when trying to understand or
effect changes in interprofessional teamwork.
The constitutive approach takes several, very different forms (Boivin et al.
2017; Castor 2024). What they all have in common is the assumption that
communication has generative power; it creates and shapes both context and
communicators. This abstract premise can be somewhat hard to grasp, espe-
cially if we are accustomed to thinking of communication as a tool or a skill.
However, the constitutive approach is extremely useful for explaining why, for
 1 HOW TO CONCEPTUALIZE COMMUNICATION IN INTERPROFESSIONAL… 15

Fig. 1.3 The constitutive model of communication

instance, communicative practices that are considered appropriate in one con-

text might be completely inappropriate in another context, even if the com-
municators are thought to be individually very “skilled.” In other words, it is
helpful for understanding the nuanced negotiation of meaning and identities
that occur in our interactions.
One way of comprehending the constitutive approach is to think of the way
that rules, policies, and the like constrain and contain how communicators
interact. For instance, this is precisely what a checklist is designed to do: It
prescribes an order and a set of topics to be considered in routine interprofes-
sional interactions. However, people frequently challenge, modify, contest, and
negotiate how checklists are integrated into their practice, which suggests that
the meanings they attach to checklists are more or less malleable. By modifying
the meaning of a checklist (for instance, “This checklist is a key to patient
safety!” or “This checklist is a bureaucratic pain in the neck!”), communicators
embrace or reject it. The more people attach a negative meaning to the check-
list, the harder it will be to implement. Conversely, the more people accept a
positive meaning, the easier it is to integrate the checklist into everyday practice
until such time that nobody can imagine working without it, and it becomes a
“structure” that shapes and constrains collaborators’ communicative practice.
In this way, moments of communication can accrue to become constitutive of
“the way we do things here.”
One form of the constitutive approach that we find particularly helpful for
understanding the constitutive force of communication regarding interprofes-
sional working together is McPhee and Zaug’s (2000) four flows theory from
16 S. FOX ET AL.

organizational communication. The theory describes how organizations (i.e.,

teams, units, departments, or institutions) emerge and develop from four inter-­
connected communication processes: membership negotiation, self-­structuring,
activity coordination, and institutional positioning.
Membership negotiation refers to the communication by which an organiza-
tion establishes, maintains, and modifies its relationship to its members. More
specifically, membership negotiation is what brings a team into existence,
because in order to exist, the team must have members. Membership negotia-
tion involves decisions about who is included or excluded from the team, as
well as how new members should be socialized in order to understand how the
team, the unit, the department, and the organization work and the role they
and others will play (e.g., job descriptions, accountability, role clarity).
Membership negotiation also implies negotiation of relative status. Activity
coordination involves organizing what should be done, by whom, where, and
when so that members can complete tasks that they could not accomplish
alone. Self-structuring refers to how the organization, team, unit, or depart-
ment organizes itself, rather than individual tasks: Is the organization or group
hierarchical or participatory? Who has authority and for what? What are the key
values that drive how work gets done? Self-structuring has many practical
implications: This process specifies how members of the organization, the
team, the unit, or the department relate to each other, share information, and
make decisions. Institutional positioning explains how organizational members
explain and coordinate their work with others outside the organization, and
this is implicated in interprofessional networking and inter-organizational
collaboration.
Overall, their four flows theory draws on the idea that, while organizational
and institutional structures enable and constrain those who work within them,
people also have agency or the ability to act intentionally in deciding how to
interpret rules and use available resources, as we illustrated with the checklist
example above. Consequently, through the way they communicate with vari-
ous audiences, organizational members can maintain, change, or disrupt exist-
ing organizational structures such as checklists or professional hierarchy. As
Iverson et al. (2022) notes, “the term flow is a useful metaphor to illustrate
[communication’s] fluid nature and its ability to change that which it con-
tacts” (75).
Later scholarship on the constitutive power of communication added other
important nuances. First, researchers insisted that it is not only individual com-
municators who influence how teams are formed, organized, grow stronger,
and/or fall apart, as the transactional model assumes. Instead, many other
agents—both people and things—make a difference in a situation. An agent
can be understood simply as someone or something that has agency, that is,
that can influence how a given situation unfolds. Agents can include artefacts
(e.g., a care plan or electronic patient record), architecture (e.g., the layout of
a unit or meeting room), texts (e.g., an organizational mission statement,
 1 HOW TO CONCEPTUALIZE COMMUNICATION IN INTERPROFESSIONAL… 17

Table 1.1 Comparing models of communication

Transmission model Transactional model Constitutive model

What Accurate Mutual meaning making Creation of social realities

communication transmission of and interpretation and relationships
enables messages/
information
Issues that are Communication Contextual elements Understanding
important breakdowns that shape how meaning communication as the
(“noise”) making occurs such as basic process through
Feedback to check the physical, which people work
that the sender and psychological, relational,
together
receiver have the social, and cultural Who or what is acting in a
same understanding context communicative event;
of message how these various
“agents” are connected
together
Examples of Safe patient handoffs Communication among Understanding how IP
when the model Avoiding medical members of a team communication shapes IP
is conceptually error where membership collaboration, including
useful often rotates tensions, conflicts,
identities, and so on,
which are co-created by
all the agents involved in
interactions
Limitations of the Doesn’t account for Doesn’t consider that Doesn’t offer a clear
model how messages are context might emerge guide about how to
interpreted in light of from the interaction; pinpoint all the agents
relationships and this approach assumes acting in a situation
contextual cues that context already
exists prior to the
interaction

strategy document, or checklist), as well as gestures, clothing, and people

(Castor 2024). Scholars who adopt a constitutive approach hold that “who or
what is acting is always an open question” (Cooren et al. 2011, 1152) and how
agency will play out in any given situation depends on the context. Second, the
constitutive approach argues that all of these agents’ properties result from the
way they are connected and relate to each other (e.g., how an interprofessional
meeting unfolds can reinforce the professional hierarchy due to the type of
space used for meetings, the people involved, and the agenda that specifies
what will be discussed and in what order). These subtle nuances are important
for a deep understanding of how interprofessional communication and inter-
professional working together are ontologically intertwined phenomena,
beyond the exchange of information (e.g., the transmission model) and
accounting for context (e.g., the transactional model) (Table 1.1).
18 S. FOX ET AL.

Overview of the Chapters

As the chapters in this book will show, communication allows interprofessional
collaborators to accomplish a great many things: ascertain what information
matters in a given context; build, maintain, and repair workplace and personal
relationships; negotiate hierarchy; decide whose voices should be heard and
accounted for during decision-making; coordinate and verify immediate patient
care and longer-term care plans; and work across boundaries. The chapters
explore how communication unfolds in a variety of health and social care con-
texts, including primary care, neonatal intensive care, critical care, emergency
work on ambulances and emergency departments, pediatric care, cancer care,
long-term aged care, and case management. The focus is primarily on team-
working and collaborating, but some chapters also consider coordinating,
while networking is not investigated in depth. Readers will notice that the
authors of each chapter use different words, such as patient, client, consumer,
user, and patient partner, to describe the person receiving care. The vocabulary
they choose is important, as each term communicatively situates the person
receiving (and in some case contributing to) care and the care relationship itself
quite differently. Most chapters include a vignette to illustrate how concepts
and theories play out in practice. The vignettes are also designed to be peda-
gogically useful.
The book is organized into three parts. Part I, including this chapter, pro-
vides the conceptual foundation for understanding interprofessional communi-
cation across a variety of contexts. Chapter 2 by Gary Kreps provides a broad
overview of the field of interprofessional teamwork in health and social care,
and thus helps to contextualize chapters in the subsequent section of the book.
It explains the need for interprofessional teams in healthcare delivery and iden-
tifies classic themes in the healthcare teamwork literature, such as interprofes-
sional team roles, interpreting them from a communication perspective. His
chapter focuses on interprofessional communication practices that help and
hinder effective interprofessional teamwork and identifies common challenges,
such as juggling demands on time, learning how to interact effectively with
other healthcare professionals and patients, navigating knowledge differences,
and productively managing conflict. While emphasizing the importance of
communication as information transmission for shared task effectiveness, the
chapter also introduces the relational and interpersonal dimensions of interpro-
fessional healthcare teams.
Chapter 3 by Emmanuelle Careau and Stephanie Fox maps the different
conceptualizations of communication explored in Chap. 1 to specific types of
interprofessional practice, drawing on a continuum of collaborative practices
that range from parallel to shared practice. Emphasizing the importance of col-
laborators’ intentions and the complexity of the patient’s situation, the chapter
explains how communication can serve as a tool for information sharing in
some situations and be the basis of collective sensemaking in others, such as
shared practice. Hence, this chapter also lays the groundwork for the chapters
 1 HOW TO CONCEPTUALIZE COMMUNICATION IN INTERPROFESSIONAL… 19

that follow. Chapter 4 by Marlène Karam and Isabelle Brault reflects on how
communication is currently taught as a core competency in interprofessional
education (IPE) programs. It presents commonly used frameworks for teach-
ing interprofessional competencies and discusses how each framework envis-
ages communication. It also discusses how patients can be integrated into
interprofessional curricula as well as how IPE might continue to move forward
in the twenty-first century.
The second part of the book explores fundamental processes and dynamics
of interprofessional communication. Chapter 5 by Nina Lunkka, Ville
Pietiläinen, Ville Kivivirta, and Sanna Laulainen explains how a sensemaking
perspective can help health and social care practitioners understand how highly
interdependent interprofessional collaborators develop shared meanings. They
argue that sensemaking is particularly relevant in the presence of situational
complexity, such as integrated care planning for complex cases. Chapter 6 by
Kirstie McAllum, Stephanie Fox, Laura Ginoux, and Léna Meyer explores the
relational dimensions of interprofessional collaboration, and how they have
been conceptualized according to either a task orientation or a relationship
orientation to collaborating. They discuss how lack of trust and limited role
awareness create relational challenges that can derail task-based collaborative
work and how, in contrast, supportive, compassionate communication prac-
tices can build positive interprofessional relationships.
Chapter 7 by Leena Mikkola, Maija Peltola, and Julie Apker continues this
focus on relationships through the lens of relational dialectics theory. They
describe the dialectical contradictions that are inherent to collaborating across
professional boundaries. Most prominent in health and social care contexts are
the contradictions between hierarchy and equality as well as between auton-
omy and connectedness, often producing tensions in interprofessional relation-
ships. It is important to note that contradictions are inherent to interpersonal
relationships, and thus, such tensions may never disappear, yet they can be
managed. Indeed, Mikkola et al. discuss strategies for managing tensions, in
particular for interprofessional teams communicating with patients.
Chapter 8 by Allison Noyes considers the communication challenges associ-
ated with the hierarchical structure of power relationships among the health
professions. Although many believe that creating more balanced power rela-
tionships is crucial for successful interprofessional collaboration in providing
patient care, balancing power among health professionals may be an unrealistic
ideal because hierarchy is deeply embedded in healthcare organizations. This
chapter therefore reframes thinking about professional hierarchy—from a
monolithic absolute to a flexible and negotiable social order that can serve
multiple purposes at different points in the patient care process. It proposes a
communicative framework of interprofessional hierarchy negotiation that can
help us to understand how interprofessional groups can negotiate hierarchical
power relationships in ways that improve collaboration without increasing
conflict.
20 S. FOX ET AL.

Chapter 9 by Malgorzata Lahti and Karoliina Karppinen gives a fresh theo-

retical spin on the question of intersecting professional cultures. Drawing on
theories from critical interculturality and essentialist and non-essentialist con-
ceptions of culture, the chapter proposes that we see professional identities as
social constructs produced and negotiated in communication. The authors
suggest that interprofessional collaboration requires a mindful dance where
collaborators navigate between fixed and fluid notions of professional identity.
Importantly, the chapter argues that the appropriateness of adopting an essen-
tialist, or simplifying and reductive, notion of professional cultures is situation-
ally dependent.
In a similar vein, Chap. 10 by Tessa Horila tackles the question of commu-
nication competence. Existing approaches to communication competence in
teamwork conceptualize competence as an individual quality, which implies
professionals have mastered a set of situational communication skills. However,
Horila contends that communication competence is inherently relational; a
healthcare professional cannot be communicatively competent alone. This
chapter thus proposes a relational and systemic perspective of shared communi-
cation competence, where competence is emergent, relationally constructed,
maintained, and evaluated in communication, and temporally changing. Seen
this way, the theoretical focus of competence shifts from individual capabilities
to joint meaning-making processes.
Part III of the book presents perspectives on interprofessional communica-
tion in specific contexts and with regard to particular interprofessional prac-
tices. Chapter 11 by Yves Couturier, Stephanie Fox, Paul Wankah, and Julie
Martin explains case management as a key person-centered practice in the
interprofessional coordination of care, including multiagency care. After defin-
ing case management and tracing its history, the chapter explains case manage-
ment’s critical role as a systemwide support that promotes continuity of care
across the health and social care network. The chapter describes the communi-
cation challenges associated with case management as well as the potentially
dire consequences when case management is not well implemented.
Chapter 12 by Cassidy Doucet and Joshua Barbour considers the neonatal
intensive care unit (NICU), a context where the difficult, complex, intensive
patient care required makes teamwork more challenging and at the same time
more necessary. These challenges stem, in part, from the need for high-­
reliability communication among professionals who bring differing frames and
scripts for problem solving and who must navigate power and status differences
in their actions. Furthermore, the requirements of family-centered care, such
as collaborative decision making with diverse families, makes interprofessional
teamwork even more demanding. The chapter reviews existing communication
interventions for high reliability interprofessional communication in this con-
text, where institutional, organizational, and family dynamics intersect, and it
discusses how interprofessional teams might address these challenges.
Chapter 13 by Laura E. Miller examines patient-centeredness from a differ-
ent perspective: that of the patient after cancer treatment. The chapter explains
 1 HOW TO CONCEPTUALIZE COMMUNICATION IN INTERPROFESSIONAL… 21

cancer survivorship care and the interprofessional collaboration that is required

across the cancer care trajectory. More specifically, the chapter highlights the
stress of uncertainty that patients face in the post-treatment period (when they
are in remission or no longer receiving active oncology treatment) and the
uncertainty they face in being forced to navigate communication with multiple
specialists over time.
Chapter 14 by Letizia Caronia and Federica Ranzani analyzes primary care
interactions between a general practitioner, an unaccompanied foreign minor,
and an education professional tasked with helping the child. Using conversa-
tion analysis, the chapter illustrates how what we think of as an interprofes-
sional “team” is locally accomplished by collaborators in interaction through
their communicative practices. The authors identify a key interaction pattern
they call “interprofessional attunement.” They demonstrate how collaborators
navigate two potentially conflicting objectives: maximizing information com-
prehension and fostering patient agency.
Chapter 15 by Ted Avtgis explains why specific communication tools
designed to facilitate information transmission and the transfer of patients
between the pre-hospital rural trauma team and the receiving emergency
department hospital staff may fail, due to communication patterns that reduce
interprofessional team members’ ability to work with each other. The chapter
presents the theory of independent mindedness to discuss how the traits of
argumentativeness and aggressiveness can influence interprofessional interac-
tions in rural trauma care. This theory proposes that communicator style, or
how these traits are displayed, can be affirming, contributing to constructive
dialogue and mutual respect, or non-affirming, threatening other collabora-
tors’ self-concept and leading to conflict.
We conclude the book with suggestions for future directions for the study
and teaching of interprofessional communication. It is our hope that this edited
volume will enrich readers’ understanding of the centrality and complexity of
interprofessional communication in health and social care settings. The chap-
ters show that communication is what enables interprofessional collaborators
to transmit patient information, make decisions, solve problems, create shared
meaning, make sense of complicated cases, train new professionals, integrate
patient perspectives, express doubts, and develop positive workplace and inter-
personal relationships, among many other things. Yet, many of the book’s con-
tributions indicate that relying on “more” communication as a way to resolve
problems might be misguided. In addition to its positive potential, communi-
cation has its dark side. It can impede interprofessional collaborators from
working constructively together due to lack of trust, aggressive communicator
styles, and reinforcement of the medical hierarchy when it is unhelpful to do so.
By offering theoretical and practical insights about collaborative communica-
tive practices, the authors provide a set of conceptual tools to help interprofes-
sional teams in varied social and healthcare contexts navigate the challenges of
interprofessional collaboration. So, dive on in.
22 S. FOX ET AL.

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 CHAPTER 2

Communication and Effective Interprofessional

Healthcare Teams

Gary L. Kreps

Introduction
There are numerous complexities to working effectively in healthcare teams.
The challenges to interprofessional coordination are often underestimated and
such coordination demands advanced interpersonal and group communication
skills, as well as sensitivity to professional and cultural differences. There is
limited training for interprofessional teamwork in most health professional
educational programs, with each professional group learning in isolation from
other groups; moreover, healthcare consumers are rarely well prepared to par-
ticipate actively in healthcare teams (IECEP 2011). However, once healthcare
professionals and consumers confront complex healthcare issues, they are
expected to be able to work together collaboratively. This chapter focuses on
explaining how strategic communication can influence group climate, conflict
management, and group decision-making in interprofessional health teams to
promote effective team performance. The chapter is grounded in the relational

This chapter is a modified version of a previously published open-access article and is

reprinted with permission: Kreps, Gary L. 2016. “Communication and Effective
Interprofessional Health Care Teams.” International Archives of Nursing and Health
Care 2, no. 3: 51. https://doi.org/10.23937/2469-­5823/1510051

G. L. Kreps (*)
Department of Communication, George Mason University, Fairfax, VA, USA
e-mail: [email protected]

© The Author(s) 2025 25

S. Fox et al. (eds.), Interprofessional Communication in Health and Social
Care, https://doi.org/10.1007/978-3-031-70106-1_2
26 G. L. KREPS

health communication competence and health outcomes model that describes

the need for collaborative interprofessional health care practices to enhance
health outcomes (Kreps 1988, 2014).

The Need for Healthcare Teams

The modern healthcare system has become exceedingly complex and special-
ized, with a range of different healthcare professionals working together to
help consumers address their health problems. Often the most serious health
threats, such as invasive cancers, heart disease, and HIV/AIDS, demand close
coordination from a variety of different healthcare specialists, such as nurses,
pharmacists, therapists, social workers, surgeons, oncologists, cardiologists,
anesthesiologists, and internal medicine physicians (Bélanger and Rodríguez
2008; Chan et al. 2015; Chisholm-Burns et al. 2010; Farris et al. 2004).
Moreover, the patient and the patient’s personal healthcare support system,
which can include key family members, advocates, friends, and others, also
need to participate actively in making important decisions related to delivery of
care, long-term treatment, and rehabilitation (Kreps 1996). These interdepen-
dent healthcare professionals and healthcare consumers often need to work
together in interprofessional health and social care teams to coordinate their
efforts and to share relevant information needed to provide the best healthcare
services (Kreps 2012).
It is not easy to coordinate the different efforts of all the unique individuals
who comprise interprofessional healthcare teams, even though the team mem-
bers depend upon one another to provide appropriate healthcare services to
achieve the best health outcomes (Grover and Niecko-Najjum 2013; Kreps and
O’Hair 1995). Unfortunately, coordination and cooperation in health care
does not happen automatically. In fact, there are often tremendous problems
with promoting coordination of care in modern healthcare systems (Salas et al.
2012). It takes a lot of work to get everyone participating in an interprofes-
sional healthcare team to work together effectively (Grover and Niecko-­
Najjum 2013).
Team members need to learn how to work together cooperatively, how to
communicate with one another meaningfully, and how to make good health-
care decisions together (Grover and Niecko-Najjum 2013; Salas et al. 2012;
Van et al. 2011; Bajcar et al. 2005; Dieleman et al. 2004). It is critically impor-
tant for team members to share relevant information they possess concerning
the healthcare situation with all of the different members of their team, includ-
ing healthcare providers, administrators, and consumers who are involved, so
they are all on the same page and know what is going on with the patient and
the patient’s treatment plan. Each member of the team is likely to have special-
ized knowledge and experiences relevant to the healthcare situation that can
 2 COMMUNICATION AND EFFECTIVE INTERPROFESSIONAL HEALTHCARE TEAMS 27

help the team make informed healthcare decisions. However, the best ways to
share this specialized knowledge and information may be difficult for team
members to accomplish.
Even when team members are able to share their specialized knowledge
effectively and all the involved team members have been provided with the lat-
est relevant health information, it does not guarantee that the team members
will cooperate with each other in the delivery of care. Each team member will
inevitably have his or her own personal interpretations about the health infor-
mation provided, and each is likely to make different decisions about priorities
for care and the best courses of action based on each person’s unique back-
ground, expertise, and involvement in the case (Van et al. 2011). For example,
a pharmacist is likely to focus on the benefits and risks concerning medications
that may be relevant to the case (Bajcar et al. 2005). A surgeon is likely to have
a different perspective on the case, likely focusing on the different surgical
interventions that may be warranted. Certainly, the patient will have a unique
perspective about treatment decisions related to his or her concerns about the
complexity of different treatments, their potential to address the health prob-
lem, as well as their implications for pain, suffering, length of hospitalization,
rehabilitation, and costs. All of these different orientations to the same health-
care case are legitimate and important to consider in making the best health-
care decisions. Team members can share their different insights and expertise
to help address complex healthcare problems. That is why it is important to
work in healthcare teams.
Sharing relevant information and expertise is a necessary part of developing
effective healthcare teams, but it is not enough to enable them to work well.
Team members need to share information with each other, but they also have
to be able to act on the information shared together to make good, informed
healthcare decisions. This means that each team member has to be responsive
to hearing the perspectives of other team members and willing to be influenced
by the information they share. Furthermore, team members must be able to
make collaborative decisions together that reflect the specialized information
and insights shared within the team (Dieleman et al. 2004). Strategic commu-
nication is needed to enable team members to work together to make informed,
collaborative, and responsive healthcare decisions and this chapter will explore
the conceptual issues involved in such strategic healthcare team communica-
tion (Morgan et al. 2015) (Callout 2.1).
28 G. L. KREPS

Callout 2.1 Communication Challenges in Interprofessional Collaboration

Communication is at the heart of interprofessional collaboration. It is
how interprofessional work gets done and how interprofessional relation-
ships are built, maintained, and repaired. We use communication to do so
many things in health and social care contexts, such as coordinating tasks,
sharing relevant information, creating shared meaning, establishing pri-
orities for care, and making decisions. It is also how we manage profes-
sional boundaries, build and maintain trust, manage group or team
“climate,” deal with conflicts constructively by remaining focused on
competing ideas and possible courses of action, and lead or participate in
interprofessional meetings.
Evidently, the task-based and relationship-oriented work of communi-
cation involves significant challenges. Logistical challenges include diffi-
culties in scheduling meetings where everyone on the team can participate,
not to mention the need for time to read and prepare material needed for
active participation. When we lack awareness of differences in profes-
sional “cultures,” it can make it hard to be receptive to others’ perspec-
tives or to clearly articulate our own, when our perspective seems
“normal” and “right” to us. This can lead to destructive personal con-
flict, lack of respect for others’ professional roles, and poorer decision
making. Another challenge is who should be included in the interprofes-
sional team: Patients are seldom trained to play a role in teams, and sup-
port staff’s specialized knowledge and experience on the ground is often
overlooked.

Roles Performed in Healthcare Teams

There are a variety of important behavioral roles performed by different mem-
bers of interprofessional healthcare teams. Communication is the process
through which team roles are expressed and team goals are achieved. Two
primary team roles are leader and follower roles. Leaders are team members
who exert influence over team activities by providing other team members with
guidance to accomplish specific group goals. Leaders often assign projects and
provide task instructions to other team members. For example, a healthcare
team leader might ask other members to review specific laboratory results to
determine how well patients are responding to treatments. The leader might
provide them with a form to fill out that guides their review of these lab tests
and can be shared with other group members when they meet to make treat-
ment recommendations for the patients. Leaders depend upon members of the
team to follow the directions provided to them (followers), enabling leaders to
influence group process.
Typical team leadership activities include calling for and conducting team
meetings to share information and make decisions, establishing standards for
group interactions, raising topics for team deliberations, assigning
 2 COMMUNICATION AND EFFECTIVE INTERPROFESSIONAL HEALTHCARE TEAMS 29

responsibilities among team members, inviting members to share their indi-

vidual perspectives on different issues under discussion, introducing new and
relevant information to the group, initiating team decision making, and intro-
ducing strategies for implementing group decisions. Leaders are often
appointed and assigned to official leadership roles. These are formal leaders of
healthcare teams. Frequently, the formal leaders of healthcare teams are senior
physicians or the primary provider in charge of the healthcare case that the
team is addressing. Sometimes healthcare teams are also led by senior health
care administrators who are appointed as formal leaders. However, there are
times when different team members also assume informal leadership roles
(sometimes referred to as emergent leaders) based upon their relevant expertise
and experiences concerning the specific issues the team is addressing (Dobson
et al. 2009). These informal leaders help address team issues by leading discus-
sions and decision-making activities on topics about which they are especially
knowledgeable. For example, when discussing the best medication regimen for
a patient, the formal team leader might ask a pharmacist member of the team
to lead the discussion and guide medication decision making (Bates 2009;
Farrell et al. 2013). In another situation, the formal leader might ask a nurse
who has been caring for a specific patient to lead discussion about the ways the
patient has been responding to treatment (Lomax and White 2015). Both for-
mal and emergent leaders need to be skilled communicators to facilitate group
discussions, information sharing, conflict management, decision making, and
implementation of team decisions.
Prominent management theorists Kenneth Benne and Paul Sheets (1948)
described functional and dysfunctional roles that are often performed in groups
by leaders and followers. Functional roles help the group achieve goals, while
dysfunctional goals can distract the team from achieving their goals. Task roles
are functional roles that help facilitate accomplishment of team activities and
responsibilities. These role activities include contributing ideas, seeking rele-
vant information, and providing feedback to other members to help manage
team goal accomplishment. Maintenance roles are another type of functional
role that helps to establish and preserve good interpersonal relations and coop-
eration among team members. Maintenance role communication activities
include expressing support and encouragement, making comments to reduce
tension, and encouraging cooperation. Dysfunctional roles, however, can limit
team progress, and should be minimized to improve group process because
they include overly aggressive and blocking behaviors, such as hostile com-
ments or refusing to respond to others’ requests, that can reduce team effec-
tiveness. Effective interprofessional healthcare team leaders balance task and
maintenance roles, while minimizing the expression of dysfunctional roles.
They try to give all team members an opportunity to communicate, so team
interactions are not dominated by one or a few team members. It is important
to maintain confidentiality of sensitive and private health issues discussed by
the team. It is also important for team members to be receptive to the ideas of
other team members and to treat each other with respect. Failure to follow
these expectations can cause serious impediments to accomplishing group goals.
30 G. L. KREPS

Challenges to Working in Healthcare Teams

There are many challenges to working on healthcare teams. One of the major
challenges is finding the time for busy team members to meet and share infor-
mation. Scheduling of meetings needs to be responsive to team members’
schedules and it is often best to have a standing weekly or bi-weekly meeting
schedule that team members can place on their agendas. Meeting remotely via
conference call or video conferencing can often make it easier to accommodate
team member schedules and travel demands. There are also time demands in
preparing for team meetings, reviewing relevant background materials (patient
charts, lab results, medication information, research findings, etc.) so team
members can stay abreast of the issues under consideration and participate
meaningfully in team deliberations. It is important for each team member to be
committed to actively preparing and participating in team activities.
Another major challenge to working effectively on healthcare teams is learn-
ing how to interact effectively with other healthcare professionals and health-
care consumers. Team members typically come from very different professional
backgrounds, and sometimes have other differences based upon education,
age, gender, and cultural background that can make team interactions compli-
cated. Different healthcare professionals bring unique perspectives, strategies,
and language to examining health care situations. For example, pharmacists,
social workers, surgeons, and nurses are likely to perceive healthcare situations
from their own unique professional backgrounds (Jorgenson et al. 2013a,
2013b). It is important for these different team members to explain their per-
spectives in language and with examples that other team members can under-
stand. It is also important to be receptive to considering the different points of
view that are likely to be expressed by other team members. Even among dif-
ferent branches of medicine (internal medicine, psychiatry, oncology, cardiol-
ogy, surgery, etc.), there are likely to be very different perspectives to addressing
healthcare issues that need to be examined by the team in determining the best
courses of action for addressing health issues.
Healthcare providers and consumers are likely to have very different per-
spectives on healthcare issues, complicating team communication (Kreps
1996). Consumers will have personal concerns about the implications of treat-
ments, such as how painful, debilitating, or expensive they might be. These
concerns will guide their evaluation of different treatment options (Kreps
2012). On the other hand, providers might focus on more instrumental con-
cerns around treatment, such as availability of needed expertise and equipment
and scheduling issues for delivering the treatments. These different consumer
and provider perspectives are all important and need to be considered in mak-
ing the best team decisions. This demonstrates once again how important it is
for different members of the healthcare team (including consumers) to share
their ideas and concerns with the group. Consumer participation on healthcare
teams is crucially important to ensure that the wishes and concerns of patients
are taken into account when making team decisions (Kreps 2012). Sometimes
 2 COMMUNICATION AND EFFECTIVE INTERPROFESSIONAL HEALTHCARE TEAMS 31

the actual patient may not be able to participate actively in healthcare teams
due to their conditions. In these cases, it is important for healthcare teams to
include patient advocates, such as family caregivers, to make sure the patient’s
point of view is included in team deliberations.
In addition, healthcare team members often have to consult with support
staff to effectively deliberate and make good decisions about complex health
issues. This includes clerical, technology, administrative, housekeeping, food
services, security, and other staff members. Support staff often possess special-
ized operational information about patients and health issues. They can con-
tribute important insights into the history and background about the issues the
team is examining, how things are accomplished within healthcare delivery
systems, and what resources and strategies are available to address health issues.
Healthcare teams may also need to enlist the help of key support staff in imple-
menting team decisions. For example, if a decision is made by the healthcare
team to deliver specialized health information about medical procedures to
patients via video to address patient concerns about these treatments, they
probably will have to work with hospital administrative and technology staff
members to find out how to do so. Consulting with support staff can increase
the effectiveness of teams by framing team decisions in the real operational
constraints of the healthcare system and ensuring that decisions can be trans-
lated into actual healthcare system practices (Lemieux-Charles and
McGuire 2006).
There are a number of other challenges to effective interprofessional com-
munication among team members (Chung et al. 2012). Differences in team
members’ professional backgrounds, training, and unique expertise can lead to
different approaches to addressing health issues. These differences can be
understood as unique professional cultures, and team communication can be
seen as a form of intercultural communication (Kreps and Kunimoto 1994;
Solheim et al. 2007). Cultural groups, including professional cultures, socialize
members through ongoing communication and reinforcement to see the world
through the lens of established cultural norms, or rules about how things work
and how members of the culture should behave (Kreps and Kunimoto 1994).
Their professional training orients different healthcare providers to different
key aspects of health care. For example, nurses are educated to focus on deliv-
ering care to patients, physicians are educated to focus on diagnosing and treat-
ing health problems, and pharmacists are educated to focus on the medications
and related therapies needed to address health issues (Kreps 1983). These are
different but complementary parts of healthcare delivery that are all relevant to
healthcare team deliberations. However, sometimes cultural groups do such a
good job socializing their members to accept cultural norms, they tend to
think their areas of focus are the most important and valid, discounting the
importance, or even the validity, of other professional approaches. This ten-
dency to over-value one’s own cultural perspective in comparison to other pro-
fessional cultural approaches is known as ethnocentrism and can be a major
barrier to interprofessional communication in healthcare teams.
32 G. L. KREPS

It is important for team leaders to develop strategies for overcoming ethno-

centrism that stems from intercultural and interprofessional differences. To do
this, the leader must establish a team norm for interprofessional respect and
receptivity. The leader can express interest in hearing different professional
points of view and encourage the expression of different professional perspec-
tives during group deliberations. Team members can also show appreciation
for learning about different relevant approaches to addressing health issues and
describe how the unique perspectives helped lead to responsive team decisions.
In essence, the best healthcare teams demonstrate interprofessional cultural
sensitivity and cooperation (Kreps and Kunimoto 1994).
Another interprofessional communication challenge has to do with sharing
the timely, accurate, and appropriate health information that enables team
members to carefully consider the different aspects of health issues and to make
informed health decisions about how to best respond to these issues. Therefore,
it is one of the most important resources available to healthcare providers and
consumers in making their best health decisions (Kreps 2012). Yet, often, per-
tinent information is not easy to access in complex healthcare situations. It is
thus the job of healthcare team members to seek relevant information, share it
with team members, and use the shared information to analyze the health
issues under deliberation. Sometimes team members have access to relevant
information about a health issue due to their experiences with the issue. For
example, nurses may have noticed changes in the ways that a patient has
responded to treatments over time from direct bedside observations that other
team members might not have access to. Pharmacists might have access to the
history and range of medication prescriptions for a patient that other members
of the team might not have access to. Moreover, the pharmacist might have
access to specialized information that could help identify any potentially dan-
gerous interaction effects across these prescribed drugs. So, team members can
share relevant information based upon their unique experiences with the case
under examination by the team, as well as from their specialized knowledge
about health issues.
However, it is not enough just to share general information about a medica-
tion or therapeutic procedure. The team members must also be able to apply
the relevant health information to the specific health cases under investigation
by the team, asking how the information can be used to address the issue at
hand, what the information might suggest about the best treatment strategies,
potential risks, or opportunities for implementing health decisions. For exam-
ple, in a case where team members are exploring the next therapeutic steps for
addressing a serious health problem for which the treatments being given are
not helping the patient, team members can suggest other evidence-based treat-
ment options that can improve the care for this patient. These treatment rec-
ommendations might be based on team members’ personal expertise, their
knowledge about new available treatments, or even about clinical trials (research
about new treatments) for which the patient may be eligible. Finding and shar-
ing relevant information is a primary goal of the interprofessional healthcare
 2 COMMUNICATION AND EFFECTIVE INTERPROFESSIONAL HEALTHCARE TEAMS 33

team! Team members must not only be ready to gather relevant information,
but they must learn how to carefully encode their messages so that others can
understand their points of view. Encoding is the process of strategically plan-
ning the messages we send to achieve our communication goals. This aligns
with the transmission model of communication discussed in Chap. 1. Team
members need to present their health information clearly, succinctly, and per-
suasively to other team members so the team can determine how to best use
the information to address the health issues under examination (Kreps and
Thornton 1992).
In addition to information provision, it is imperative for team members to
be good listeners so they can evaluate the information other team members
share with them. Listening effectively is not as easy as it may seem, especially
when complicated health information is being shared in interprofessional
healthcare teams (Kreps et al. 1997). Listening is more than just hearing what
others have to say. It involves paying close attention to other team members’
perspectives, considering their points of view carefully, and examining how the
information being provided can be used to address the health issues under
examination by the team. This process of careful, receptive, and analytical lis-
tening is often referred to as active listening. Listening is not just a passive
process of decoding the messages, interpreting the meaning of messages based
upon past experiences, knowledge, and logic, but it also involves letting other
team members know that you have heard and understand them (Kreps and
Thornton 1992). Effective group communicators provide feedback to others
to demonstrate understanding and empathy in health teams. For example,
when a patient member of the health care team explains his or her concerns
about different available treatment options, it is imperative for other team
members to clearly acknowledge the patient’s perspective and demonstrate that
they are taking the concerns expressed seriously in suggesting treatment deci-
sions. This is important for demonstrating respect and empathy (that is, genu-
ine understanding) for the strongly held perspectives of other team members.
As we will discuss in a later section on relationship development in healthcare
teams, the expression of empathy is a critical factor in building relationally
strong and cooperative interprofessional healthcare teams.

Communication and Conflict in Healthcare Teams

One of the major challenges to leading healthcare teams is managing team
conflict, arguing about the merits of different ideas. Conflict is an essential part
of healthcare team processes that lead to good team decisions (Kreps and
Kunimoto 1994). There may be a tendency in groups to muffle conflict because
arguing can be uncomfortable and may make team members feel uneasy.
Sometimes team members just go along with what they think may be the will
of others in the group, rather than arguing for their own ideas. This often leads
to bad decisions, something referred to as groupthink (Kreps and Thornton
1992; Janis 1972). Encouraging team members to express different conflicting
34 G. L. KREPS

ideas is the best way to avoid groupthink and enable the team to explore a
variety of perspectives on a complex health issue.
Conflict can encourage the team to explore and express different ideas and
courses of action, thus preventing premature decisions that might ignore other
important perspectives (i.e., groupthink, Janis 1972). Conflict can be an excit-
ing form of communication because it solicits involvement and attention from
team members, who may feel compelled to search for potential solutions to
expressed conflict, including the development of useful creative compromises
for addressing complex health issues (Kreps and Thornton 1992).
While conflict is exciting, it can also be exhausting for team members.
Indeed, conflict can be dangerous if not managed effectively in healthcare
teams. Often, those who are not skilled at ethical conflict strategies may engage
in angry, hostile, and even violent behaviors that can diminish team process.
One of the primary ethical conflict strategies is to focus on ideational conflict
versus personal conflict. Ideational conflict examines different competing ideas,
perspectives, and points of view, while personal conflict focuses on individual
personalities and manifests in character attacks (Kreps and Thornton 1992).
Personal conflict needs to be avoided in healthcare teams because it alienates
team members, hurts feelings, and undermines cooperative interpersonal
relationships.
Skilled team leaders encourage team members to explore different perspec-
tives without criticizing others for having different points of view. This means
keeping an open mind about the merits of ideas that are different from your
own and looking for opportunities to compromise between different ideas
expressed in healthcare teams.

Interpersonal Dimensions of Healthcare Teams

Perhaps the most basic communication process in building effective interpro-
fessional healthcare teams is the development of effective interprofessional rela-
tionships (Farris 2005). Relationships are the agreements we establish with
others to interact in certain ways to help us accomplish our goals (Kreps and
Thornton 1992). In healthcare teams, we have both task and maintenance
needs for working with other team members. Task needs involve the use of
relationships to accomplish specific tasks, such as information gathering and
decision making in healthcare teams. Maintenance needs involve establishing
comfortable and harmonious interactions with one another, such as expressing
respect, comradery, and cooperation. By developing good relationships with
team members, we encourage them to share information with us, to listen care-
fully to what we have to say, and to treat us professionally. We use good rela-
tionships to establish rapport, trust, and collaboration in teams. When there
are poor relationships between team members, it is difficult to achieve team
goals because team members are not encouraged to cooperate with one
another, to share relevant information, or even to treat one another with
respect.
 2 COMMUNICATION AND EFFECTIVE INTERPROFESSIONAL HEALTHCARE TEAMS 35

Every time we communicate with someone else, our interaction has an effect
on our relationship with that person. Typically, the interaction either helps us
build a stronger, more cooperative relationship (this is referred to as relational
development), or it diminishes the relationship (this is referred to as relational
deterioration). Therefore, it is important for team members to learn how to use
their team communication to build effective team relationships. Once relation-
ships are established, we need to monitor the ways we communicate with one
another to keep our relationship moving in a positive direction. This is referred
to as relational maintenance. This means that the way we communicate in
healthcare teams is very important to building and maintaining effective team
relationships.
Self-disclosure is an important part of establishing effective relationships.
Self-disclosure involves telling others about ourselves, our ideas, and our goals.
Yet, self-disclosure can be risky, because we give up some of our personal pri-
vacy every time we disclose information about ourselves. Self-disclosure works
best for building relationships when it is mutual and reciprocal. Mutual and
reciprocal self-disclosure occurs when both parties who are building a relation-
ship share similar kinds of information with one another about themselves.
Often, we begin by disclosing relatively basic and not very revealing informa-
tion about ourselves, such as our names, our professions, and where we work.
Over time, we can build up to sharing more personal information about where
we live, who we live with, and what we do in our spare time. When we share
personal information incrementally and mutually over time, it is less risky to get
to know one another because we are not opening our privacy barriers alone but
are doing this together.
In healthcare teams, it is important to encourage team members to share
personal information so they can get to know one another, learn about each
other’s backgrounds (especially their areas of expertise), and become aware of
the unique perspectives on different health issues team members possess. As
team members learn more about each other through mutual self-disclosure,
they also begin to feel more connected with one another, and they learn how
to communicate effectively with each other. They learn how other team mem-
bers like to be addressed, how formally they like to communicate, and what
topics and issues are most important to them. They also learn about the kinds
of language they use and the relevant areas of expertise they possess.
Perhaps the most important part of building and maintaining effective rela-
tionships is the use of interpersonal communication to learn about and meet
mutual relational expectations, a process that has been described as the build-
ing of implicit contracts (Kreps and Thornton 1992). Implicit contracts are
mutual agreements we make with one another, which are often unspoken,
about meeting relational expectations about how we want to be treated. These
communication expectations include how we address one another, the kinds of
topics we discuss, the language we use, how we include one another, the ways
we share power and control, as well as the ways we express emotion and con-
cern for one another. We typically learn about others’ expectations for our
36 G. L. KREPS

communication with them by observing their responses to us. If they respond

positively to the way we communicate, we make a mental note to use the same
communication strategies with them in the future. If they respond negatively
to something we say and do, we decide not to use these communication strate-
gies with them in the future. It is more comfortable for people to communicate
and enforce relational expectations subtly, but if someone we interact with
continues to violate our communication expectations, the reaction can become
more overt. For example, if a healthcare team member does not pick up on the
fact you don’t want to be addressed by your last name and keeps addressing
you that way, you might eventually say to them with some consternation,
“Please don’t call me that anymore; I want to be called by my first name.”
However, by the time you get to this overt level of response (a form of meta-
communication, or communication about the ways we communicate), you are
likely to be pretty frustrated with this dense team member and probably have
not established a very satisfying relationship with them.
The more we are able to meet the relational expectations of others, the more
comfortable they will feel with us, and the more they will want to meet our
relational expectations for them. This urge to match others’ behaviors toward
us is known as the norm of reciprocity, and it can encourage us to respond
favorably to those who meet our relational expectations, as well as respond
negatively to those who violate our relational expectations. The implication
from the norm of reciprocity is that to develop strong, cooperative interper-
sonal relationships in healthcare teams, we need to be sensitive to identifying
the expectations other team members have for us and to meeting those expec-
tations by the ways we interact with them. The more we fulfill others’ relational
expectations for the ways we communicate with them, the more they are likely
to strive to meet our relational expectations, establishing strong reciprocal
implicit contracts that build cooperative relationships. On the other hand, the
more we violate others relational expectations, the more they are likely to vio-
late our expectations for them, weakening implicit contracts and diminishing
relational cooperation.
To further complicate the relational development process, however, we
need to recognize that the expectations that others have for us are likely to
change over time as they evolve, as we grow, and as the situations we share
together evolve. For example, as we get to know each other better, we might
expect to engage in more friendly and personal communication with one
another. Team members may expect those with whom they have worked over
time to back them up on different positions for which they advocate. They may
expect other team members to fill them in on important information to which
they may be privy. They may expect others to do them favors in exchange for
favors they can provide quid pro quo. If a team member fails to recognize and
fulfill these updated expectations, they are likely to disappoint relational part-
ners and reduce the effectiveness of their relationships with these partners. This
suggests that to build and maintain effective interpersonal relationships in
healthcare teams, team members need to continually renegotiate and fulfill new
 2 COMMUNICATION AND EFFECTIVE INTERPROFESSIONAL HEALTHCARE TEAMS 37

implicit contracts. Failure to update implicit contracts will inevitably lead to

relational deterioration. Team leaders can help minimize relational deteriora-
tion by promoting sensitivity and adaptiveness in encouraging team members
to meet one another’s relational expectations.
Relational development and maintenance in healthcare teams is an evolving
process that demands ongoing attention and adaptation. If team members are
attentive to the changing life cycle of interpersonal relations in healthcare
teams, these teams are likely to develop the ability to become increasingly col-
laborative and effective at addressing complex health issues cooperatively.
Groups that establish strong communication norms for cooperation and sup-
port eventually develop a culture of cooperation that is tremendously useful in
building effective interprofessional health teams.

Conclusion
Interprofessional healthcare teams have become an integral part of modern
health care systems. These teams enable interdependent healthcare providers
and consumers to share needed expertise for making complex and important
collaborative healthcare decisions. Effective teams also promote coordination
among different specialists and key stakeholders in delivering the best possible
care. However, effective communication is an essential part of effective health-
care teams and care must be taken to build meaningful, respectful, and coop-
erative relationships among team members. It is important for team members
to perform important functional task and maintenance goals within their teams,
while minimizing the expression of dysfunctional roles. Teams also demand
effective leadership, both formal leadership and emergent leadership. Effective
leaders encourage the sharing of relevant information and productive manage-
ment of conflict. Ultimately, the members of the best teams use their interper-
sonal communication skills to develop cooperative relationships and
collaborative teams.

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 CHAPTER 3

Interprofessional Communication:
A Continuum of Intentions and Practices

Emmanuelle Careau and Stephanie Fox

In the current literature on interprofessional collaboration, communication is

frequently described as one of several competencies that make up the profile of
a good collaborator (e.g., Bainbridge et al. 2010; Suter et al. 2009). It is often
considered as the transmission of the right information between the relevant
professionals, at the right time and using the right means (Eisenberg 2008).
However, interactions and interdependence are at the heart of the consultation
processes, the deliberative exchanges, meaning-making and decision-making
among health professionals that constitute interprofessional work. This means
that communication goes far beyond an individual skill or competency that
needs to be developed. It also means that communication in this field is not
limited to the exchange of information about a patient’s situation, as one might
think at first glance.
In fact, as this chapter will show, communication can be both a facilitator
and a barrier in deploying positive collaborative practices, establishing a healthy
work climate, responding to patients’ needs, and delivering safe, high quality
care and services. For example, when practitioners use highly specialized pro-
fessional jargon, it can limit their ability to make themselves understood by
others, thereby reducing the likelihood that they can solicit a complementary
contribution from colleagues that could be beneficial to the patient. On the

E. Careau (*)
École des sciences de la réadaptation, Faculté de médecine (Rehabilitation
Department of the Faculty of Medicine), Université Laval, Québec, QC, Canada
e-mail: [email protected]
S. Fox
Département de communication (Department of Communication), Université de
Montréal, Montréal, QC, Canada
e-mail: [email protected]

© The Author(s) 2025 41

S. Fox et al. (eds.), Interprofessional Communication in Health and Social
Care, https://doi.org/10.1007/978-3-031-70106-1_3
42 E. CAREAU AND S. FOX

other hand, appropriate communication within the interprofessional team is

often a determining factor in achieving the level of interdependence needed to
adopt innovative solutions or a concerted response to a complex patient
problem.
While the ultimate goal shared by all healthcare professionals involved in
interprofessional collaboration is to provide the best possible care and services
to patients, there is often some confusion about how communication relates to
interprofessional practice. Therefore, in this chapter, we describe how interac-
tions can constitute different types of interprofessional practice and explain
that interprofessional communication dynamics are contingent on collabora-
tors’ intentions. That is, the ways that healthcare professionals communicate
vary according to collaborators’ intentions regarding the collaborative situa-
tion, and these intentions form a continuum of practice (see Fig. 3.1). For
instance, when transmitting diagnostic information while referring a patient to
new provider, communication tends to be unidirectional, whereas building a
multidisciplinary care plan might involve a back-and-forth information
exchange between providers. When providers must address a more complex
situation in an interdisciplinary fashion, they should engage in more dialogic
communication practices, negotiating meaning, discussing and perhaps pre-
senting alternative perspectives before they can arrive at a joint understanding
and a truly consensual decision.

Fig. 3.1 Continuum of Collaborative Practices. Reproduced with permission by the

Réseau de collaboration sur les pratiques interprofessionnelles (RCPI) of Université
Laval and the CIUSSS de la Capitale Nationale
 3 INTERPROFESSIONAL COMMUNICATION: A CONTINUUM OF INTENTIONS… 43

Our goal in this chapter is to explain in greater depth communication’s role

in interprofessional collaboration by providing a guide that applies different
conceptual models of communication (e.g., transmission, transactional, consti-
tutive, see Chap. 1) to various types of interprofessional practice that are rec-
ognizable in clinical contexts. Building on the continuum of collaborative
practices in health and social services developed by the first author and her
colleagues (Careau et al. 2015), the continuum in this chapter offers a useful
conceptual and practical framework for contextualizing interprofessional
dynamics in health and social care. In what follows, we will explain each part of
this continuum, focusing on the different types of interprofessional practice
and the relevant model of communication, offering real-world examples from
clinical care contexts, and identifying the challenges inherent to communica-
tion in that type of clinical situation. We close with an illustrative vignette from
primary care to demonstrate how collaborating professionals must be respon-
sive and adapt their communication and collaborative practice according to the
complexity of patient needs (Callout 3.1).

Callout 3.1 Adjusting Communication and Collaboration to the Situation

Interprofessional collaboration is a response to health and social care
needs. Because needs are defined by the patient or client’s care situation
and can change and evolve, there is not a one-size-fits-all recipe for inter-
professional collaboration. Rather, collaborators must “read” the com-
plexity of the situation and continually adjust their intentions as well as
their communication and collaboration practices accordingly. While it is
often possible to respond to less complex situations by sharing informa-
tion with other professionals, more complex situations require shared
meaning making and action planning, where collaborators must bring
together their disciplinary expertise to make sense of the situation and
figure out how to respond. While all forms of interprofessional commu-
nication and collaboration present opportunities for misunderstandings,
this intensive and dialogic form of interprofessional communication can
be particularly challenging. Therefore, it is essential for health and social
care professionals to learn to recognize the signs of high complexity situ-
ations and to be sensitive to the potential communication pitfalls they
can entail.

Explaining the Continuum

Interprofessional practice varies, so the continuum maps out different types of
collaborative practice, which can range from independent to integrated and
interdependent practice (see Fig. 3.1). On the left-hand side of the continuum
is independent practice, which is not interprofessional because providers prac-
tice autonomously from one another. Moving closer to the middle, we locate
two forms of integrated collaborative practice: parallel practice and
44 E. CAREAU AND S. FOX

consultation or reference practice. Finally, moving to the right, we find two

types of interdependent practice: concerted practice and shared healthcare
practice. What distinguishes these different types of practice are four features
that influence interprofessional collaboration and are described as rows on this
continuum.
First, as the client and family’s biopsychosocial situation becomes more
complex, it is likely that more integrated interprofessional practice will be
appropriate, requiring the input and voices of more than one professional.
Second, as we mentioned at the beginning of the chapter and will explore in
more depth below, the intention of interprofessional collaborators influences
how they communicate, which in turn constitutes the form of interprofessional
practice they adopt in a given situation. This is key to understanding the con-
tinuum, and it requires a keen ability to read the complexity of the clinical situ-
ation, both at the individual and collective levels. Certain benchmarks can help
practitioners determine whether a change in collaborative practice along the
continuum is needed: there is insufficient progress toward a treatment goal
despite the patient or client’s commitment to participating in their care; inter-
professional colleagues only have a partial understanding of the client’s situa-
tion; the presence of different or contradictory messages; additional or
increasingly complex client needs; a patient or client’s unstable physical, psy-
chological, or social health status; a compromised situation where the patient
or client’s integrity or safety is jeopardized; or a state of high vulnerability
(Milot et al. 2016).
Third are interactions. As interprofessional practice becomes more inte-
grated and interdependent, interactions between communicators become more
intense, both in terms of their frequency and the level of engagement in collec-
tive sensemaking (see Chap. 5). Interprofessional interactions can take many
forms, ranging from asynchronous information updates in the patient health
record and referrals to face-to-face meetings needed to collectively make sense
of complex situations.
Fourth is the level of integration of disciplinary knowledge. As interprofes-
sional practice becomes more interdependent, we can think of it as moving
from unidisciplinary to multidisciplinary to interdisciplinary. Unidisciplinary
practice might involve collaboration between practitioner and patient but does
not require the disciplinary knowledge of more than one profession. For exam-
ple, a specialized nurse practitioner assesses a patient and diagnoses community-­
acquired pneumonia, prescribes treatment, gives standard instructions, and
arranges a follow-up visit for reassessment. In contrast, multidisciplinary prac-
tice does require knowledgeable disciplinary input from different professions,
yet these inputs do not meld together, remaining instead like a salad where
each ingredient remains distinct and identifiable. For instance, if a young man
is admitted to a traumatology department following a skiing accident, his
 3 INTERPROFESSIONAL COMMUNICATION: A CONTINUUM OF INTENTIONS… 45

treatment plan might consist of surgical interventions to treat a fracture, fol-

lowed by post-operative nursing follow-up, a pharmacy consultation to adjust
pain medication, and physiotherapy treatments to prepare for rehabilitation.
This is his individualized multidisciplinary plan, a specific salad prepared
according to his needs. If, however, a few months later, this young man’s situ-
ation has become much more complex, entangled, and multifactorial (i.e.,
involving a number of potential dimensions or causes)—for instance, he is liv-
ing with several neurocognitive sequelae in addition to chronic pain and
depressive symptoms, and it is interfering with his work and studies—he will
need his interprofessional team to engage in interdisciplinary practice. This
requires the blending of different disciplinary knowledges to fully comprehend
a complex clinical situation; in this sense, we might use the analogy of a cake,
where many ingredients must be integrated to create something new. In this
instance, the young man’s interprofessional team will collectively re-examine
his situation with him to create a joint action plan in view of the prognosis, that
is, a blended cake adapted to his life plans and the intervention priorities deter-
mined as a team (Callout 3.2).

Callout 3.2 Multifactorial Complexity Requires an Interdisciplinary

Approach to Interprofessional Collaboration
When a patient or client’s care situation is characterized by multifactorial
complexity, it means that care needs are not only high and complex, but
that the underlying problems are likely intertwined. Consequently, to
ensure quality care and patient safety, multiple disciplinary perspectives
are needed to collectively untangle the nuances of the situation to jointly
come up with an appropriate care plan. This blending of disciplinary
knowledges, or interdisciplinarity, is the most intensive form of interpro-
fessional practice, situated on the right-hand side of the continuum pre-
sented in this chapter.

It is important to understand that one form of interprofessional practice is

not superior to the others, and healthcare organizations and teams should not
adopt a one-size-fits-all approach. Rather, collaborative success is contingent
on (a) collaborators’ individual and collective ability to read the clinical com-
plexity of the patient and family’s situation, and (b) on their capacity to swiftly
adopt the appropriate form of interprofessional practice, and by extension
appropriately contact, interact, share information, or even construct meaning
with each other, as the situation requires. A continuum is therefore an excellent
way to describe the dynamic approach to interprofessional practice that is nec-
essary for quality care. We turn now to explaining the different types of inter-
professional practice, beginning with parallel practice and the intent to inform.
46 E. CAREAU AND S. FOX

Informing Parallel Practice

In parallel practice, different professionals provide care to the client separately,
that is, in parallel to one another. When these professionals communicate with
one another about the patient, they likely do so with the simple intent to inform
the other professional of some information they deem important.
The transmission model of communication, which emphasizes communica-
tion as the sending of messages between sender and recipient, is typically suf-
ficient to describe such situations, where the goal is to share information. This
understanding of communication is appropriate in clinical situations where one
practitioner must leave traces of their actions (Fox et al. 2021) or situate their
practice within an ecosystem of practitioners’ interventions, for instance, in the
client’s electronic health record. This is also one-way communication: Other
practitioners can consult this record at a later date, but the “sending” practitio-
ner (i.e., the source of the information) might not know or need to know if the
others have received, or understood, the information, because the intention is
just to leave a trace to inform others. Indeed, in parallel practice, the sender is
not necessarily looking for the input of other professionals. Thus, disciplinary
knowledge is not integrated, and this constitutes a low-intensity form of mul-
tidisciplinarity. Practitioners do not share accountability to one another or for
shared actions. As such, situational interdependence between practitioners is
relatively low.
In such situations, the biopsychosocial needs of the client and family are
usually not complex. For instance, a family physician sees an older patient who
mentions an adjustment to their medication. The physician will go into the
patient’s health record and check what the pharmacist has written, without
needing to discuss with the pharmacist. In this instance, it is the pharmacist
who has left a trace of their intervention (i.e., transmitted information).
In parallel practice, interactions most often occur through asynchronous
communication, that is, communication where the sending and receiving do
not occur at the same time. Asynchronous communication is often mediated
by an information technology, such as an electronic medical record or written
progress notes in the patient’s chart, or even transmitted by the patient him- or
herself, like in the example above. Sometimes, this information transmission
occurs in a synchronous communication situation, such as a team meeting,
where each professional gives a report on their contributions to care and the
meeting leader might acknowledge receipt by simply saying, “Thanks.”
Challenges associated with such one-way transmission of information
include professional jargon that expresses mutually exclusive disciplinary para-
digms (Nadarajah et al. 2021), such as relating raw data from an evaluation or
from tests without translating or interpreting this information into a profes-
sional analysis that is comprehensible to other professionals, or sharing a pro-
fessional opinion using complex words that only some specialists will
understand. While this may not be a problem when the receiving practitioner
 3 INTERPROFESSIONAL COMMUNICATION: A CONTINUUM OF INTENTIONS… 47

has the same disciplinary knowledge as the sender and therefore shares their
frames of reference, this is not always the case on an interprofessional team. In
fact, the practitioner receiving the information might not actually understand
the sender’s message but is not able or is too shy to ask clarifying questions. Or
perhaps worse, the receiving practitioner might think that they understand the
message, without realizing that they and the sender are speaking two different
professional languages (i.e., they encode and decode messages differently but
do not realize, as they interpret messages, that they don’t share meanings).
Additionally, information might be missing, or there might be some other
uncertainty about the situation, which can have more serious consequences in
the case of complex situations. The transmission model is most applicable to
communication situations involving information technology, and this poses its
own challenges, for instance, information systems that are incompatible and
cannot “communicate” (Hyvämäki et al. 2022); this can be the case in interor-
ganizational communication in health care (Auschra 2018). Even in relatively
“low tech” organizations using paper charts, it may be cumbersome to the
point of being prohibitive to sift through the many documents in a chart to
find the one piece of needed information left by another professional—and
even then, their handwriting might be illegible!
Furthermore, time pressures can create blinders, leading practitioners to
adopt this form of communication because they believe they don’t have the
time to have a discussion with the other professional. Similarly, lack of role
awareness might mean that one professional does not necessarily see what
another has to offer, and thus doesn’t engage in dialogue with the other
(Dreher-Hummel et al. 2021). Finally, a practitioner might try to be a “hero”
and do it all on their own, which their professional socialization might have
encouraged.

Exchanging Information in Consultation

and Referral Practice

Moving right on the continuum, we next find consultation and referral prac-
tices, which involve seeking out the expertise and input of another professional.
The intention behind the interaction is to exchange information with at least
one other practitioner in order to explain, add to, or inform one’s own inter-
ventions. For instance, a psychiatrist treating a patient might ask an occupa-
tional therapist (OT) to conduct a functional evaluation in order to inform her
own professional judgment when making a diagnosis and subsequently orient
the psychiatric treatment plan. The OT does the assessment and sends his clini-
cal impression to the psychiatrist, who will incorporate the information into
her own interventions as she sees fit. Or a nurse practitioner might phone the
team pharmacist to ask about the latest blood thinning medication to see if it
would be a good choice for her patient. This can be considered multidisci-
plinary practice.
48 E. CAREAU AND S. FOX

Once again, the transmission model of communication can adequately

encompass most of what is happening in these interprofessional interactions,
provided that we take feedback into account (this means the receiver gives
feedback about their interpretation of the sender’s message, and if needed, the
sender can clarify; see Chap. 1). This is a clinically appropriate form of com-
munication when the client and family’s situation is slightly more complex,
exceeding the capacities of the intervening professional, but not requiring the
two professionals to put their heads together to jointly figure things out.
Examples include requesting a consultation or referring a patient for specialist
care, where a follow-up report is sent to the referring professional to inform
them of treatment or findings. There is two-way interaction between commu-
nicators and a minimal form of interdependence, but the intention of practitio-
ners is not to influence the others’ professional practice, as they don’t share
collective accountability. The intention is rather to adjust one’s own individual
practice or to seek complementary care that will benefit one’s patient. Just as
with parallel practice, asynchronous communication is typical for this form of
collaborative practice, for instance through the use of referral forms.
Asynchronous communication can also take place via the patient, who serves as
the “messenger” or “channel,” giving an account to each practitioner of what
has been done by the other and what is being requested.
Challenges to communication in consultation and referral practice are
largely tied to issues of comprehension, timing, and complexity. For instance,
if the patient serves as the messenger between practitioners, such as a family
physician and a physiotherapist, each practitioner’s decision-making can be
very dependent on the patient’s communication abilities and their healthcare
literacy, such as whether they understand what each practitioner is doing.
Similarly, if two communicating practitioners do not share similar frames of
understanding (and perhaps do not realize their differences), the one who
encodes her professional needs (i.e., what she asks of the other) may be misun-
derstood when the recipient is interpreting the message. Indeed, misunder-
standing the roles of other practitioners becomes evident in requests for
consultation, which can lead to latent conflict (Fox et al. 2021). This might
open the doors to problems stemming from the professional hierarchy (Noyes
2022). For example, imagine a medical prescription for a rehabilitation referral
that specifically identifies the actions and interventions expected in rehabilita-
tion. The way the referral is written leaves no latitude for the rehabilitation
professional to conduct their own assessment and determine according to their
own professional judgment what is best for the patient. This situation, regard-
less of the initial intention, has the potential to crystallize certain biases or to
give the impression that the referring professional does not recognize the reha-
bilitation professional’s role and expertise.
In terms of timing and complexity, if a patient’s situation changes rapidly,
especially if their situation is unstable, it can be difficult for intervening practi-
tioners to track information through consultation and referral practice to mon-
itor and manage the patient’s care. For instance, the care for children with
 3 INTERPROFESSIONAL COMMUNICATION: A CONTINUUM OF INTENTIONS… 49

complex needs often changes quickly. If practitioners rely solely on referral and
consultation practices, the parents and guardians of these children can find
themselves with a sense that the healthcare system is disorganized. This might
occur when practitioners do not recognize the complexity of the situation,
leading them to choose an inadequate form of interprofessional collaboration
and communication.

Exchanging Information in Concerted Practice

Concerted practice involves coordinating the patient’s overall care to ensure
that it is coherent and complementary, rather than disjointed or redundant,
with the same services being requested by multiple professionals. In this sense,
the intention is to plan and fit together—or articulate (Strauss 1988)—differ-
ent disciplinary contributions to achieve a common objective: coordinated
care. This requires an overall understanding of the care planning situation as a
disciplinary puzzle (or salad). Therefore, the intention of each professional is
to fit their disciplinary contribution into the overall efforts, but the nature of
their disciplinary way of working is not modified.
Communication in concerted practice is two-way and moderate in intensity,
meaning that collaborators interact just enough to obtain the information they
need to adjust their own efforts, which can be understood through the trans-
mission model seen in Chap. 1. With this in mind, we can see that the notion
of feedback, which informed systems theory, is essential:1 Each part of the sys-
tem interacts with the others (i.e., transmits or exchanges information) to
mutually adjust their contributions in order to accomplish systemwide objec-
tives (e.g., providing coherent and coordinated care), hence there is an
increased degree of interdependence between practitioners. However, their
individual contributions remain within their respective disciplines. We can con-
sider this to be a situation of high intensity multidisciplinarity: Each collabora-
tor works within the bounds of their own disciplinary knowledge, yet their
collaboration is constituted entirely through their interactions where they share
information that allows each to adjust to the others.
This type of interprofessional practice works best in situations that are rela-
tively predictable. Therefore, concerted practice is clinically appropriate in care
situations that are relatively common and foreseeable. Usually, the interdepen-
dence of the collaborators is already built into the situation, such as hospital
discharge planning that relies on a procedural or disciplinary check list to
achieve the shared objective of safely discharging the patient. For instance,
discharging a hip replacement patient will likely require a sign-off by the ortho-
pedic surgeon, as well as the green light from the attending physiotherapist and
potentially the occupational therapist. This patient’s needs might be complex
but are not multifactorial in the sense that most needs can be met by the

1
For an elegant example of systems theory applied to communication in healthcare organiza-
tions, see Apker (2012).
50 E. CAREAU AND S. FOX

different professions in a sequential fashion, and it is clear at each stage along

the discharge trajectory which professional ought to be involved at that time.
Challenges to concerted practice are primarily related to adequately reading
the care situation. For instance, practitioners must know what information
from their disciplinary perspective they should bring to the table. They also
have to gauge if that information is relevant to others or to the team as a whole,
and to know if it is accurate, up-to-date, and sufficient. Hence, collaborators
must be able to both collectively and individually gauge the clinical situation
on an ongoing basis and remain attentive to red flags that might crop up. This
means collaborators are constantly checking to see if the situation is still pre-
dictable and relatively routine, or whether it has deviated from the norm (Weick
and Sutcliffe 2015).
If the situation has become more complex and unpredictable, or if the per-
son has needs that intersect across several professional or disciplinary scopes of
practices, then collaborators must be able to accurately read the situation and
switch to an interdisciplinary mode of functioning, blending both disciplinary
knowledges and professional ways of doing (D’Amour and Oandasan 2005), as
we describe in the next section. Of course, accurately reading the situation also
requires a general understanding of other collaborators’ professional mental
models and scopes of disciplinary knowledge, another challenge to concerted
practice; it requires many interactions with other professionals to develop. This
can also be complicated by challenges stemming from the professional hierar-
chy in health and social care; it is imperative that higher-status decision makers
allow other professionals to give voice to their concerns (Fox and Comeau-­
Vallée 2020).

Sharing Decisions and Actions Regarding

a Common Objective

This interprofessional practice refers to clinical situations and patient cases that
are complex, evolving, and may be relatively unpredictable. Here, the collabo-
rators or team members are accountable to each other (and probably to their
organization) for working together to arrive at treatment decisions. Hence,
there is a high level of interdependence among collaborators. This interdepen-
dence expresses itself in two ways: first, each professional is committed to con-
tributing to the team through their professional role, and second, professionals
defer to the team’s plan. Disagreements do not derail teamwork, because even
if a collaborator does not agree with a decision, she is still able to understand
the issues and her colleagues’ reasoning, and she is committed to maintaining
solidarity with her team, provided it does not jeopardize patient safety.
The constitutive model of communication best describes this kind of col-
laborative practice because shared understandings, decisions, and actions can
only be collectively constructed (i.e., shared) in and through communication.
Thus, through their interactions, the collaborators create a collective “cake,”
 3 INTERPROFESSIONAL COMMUNICATION: A CONTINUUM OF INTENTIONS… 51

something more than the articulation of their individual professional contribu-

tions. More precisely, the collaborators’ task is to collectively make sense of the
situation and, if possible, come up with an action plan for moving care forward.
This is collective sensemaking (see Chap. 4), and it involves the negotiation of
meaning among interacting collaborators, rather than simply sharing informa-
tion for the purpose of accomplishing one’s own professional objective. This is
a strong form of interdisciplinarity in the sense that professional knowledges
are blended in the processes of sensemaking, creating the collaborative “cake.”
While we must always make sense of situations in our daily lives at work, this
particular kind of collective sensemaking is especially appropriate in complex
and potentially unpredictable situations. Usually in this type of situation, the
patient’s care needs are multiple and interrelated, yet it might be unclear which
need is the most urgent or overarching. Thus, interprofessional collaborators
must engage in collective sensemaking to untangle the pieces of the puzzle.
To return to our previous example, let’s say the hip replacement patient’s
situation becomes more complex with regard to discharge. His medications
might be stable, but there are concerns about his ability to understand which
ones he should take when. Or perhaps the patient is suffering from delirium, or
maybe the occupational therapist has concerns about the multiple staircases in
the patient’s home and his ability to navigate them, or the social worker on the
team is tipped off that there might be abuse concerns at home. This multifacto-
rial complexity would require the team to shift to interdisciplinary, shared
healthcare practice to collectively figure out whether discharge to home is still
the right plan. However, sharing decisions and actions can be hard to accom-
plish because it requires a high level of interdependence and collective knowl-
edge about how to share and negotiate meanings. This shared knowledge and
interdependence can be difficult to put in practice if there are latent or overt
conflicts within the team or if the professionals do not know each other well on
a professional or personal level, perhaps due to high turnover.
Indeed, the challenge at the heart of this interdisciplinarity is embracing the
interdependence needed to achieve true group consensus and integrated clini-
cal conduct. This requires open communication in which each participant has
the ability to articulate their own clinical reasoning and professional thinking
(i.e., paradigm) to understand others’ disciplinary perspectives. One of the
limitations most frequently observed in interdisciplinarity is professionals’ ten-
dency to simply exchange information from their different professional analy-
ses, without engaging in the more complex communication skills of dialogue
and negotiation of meaning. Genuine engagement in collective sensemaking
activity calls for professionals to detach themselves from their role as disciplin-
ary experts and really connect with others in order to understand, explore, and
discuss different perspectives, even when this might entail disagreements. This
in turn requires the development of shared communication competence, that
is, collectively agreeing on the best way that collaborators should communicate
with one another (see Chap. 10 on shared communicative competence).
52 E. CAREAU AND S. FOX

And yet, the way healthcare professionals are trained naturally leads them to
construct a professional identity as experts in their field (see Chap. 4 on inter-
professional education). While this is not problematic in itself, professionals
must be able to transcend this approach and demonstrate humility in their
relationship with others. For example, a physician who is intrinsically convinced
that her clinical judgment offers only part of the overall picture of an older
hospitalized patient will be more inclined to hear and consider others’ opin-
ions. Thus, she will consider the physiotherapist’s opinion on the risk of falls,
the nurse’s opinion on the patient’s condition throughout the day, and the
occupational therapist’s opinion on the home environment before signing a
patient’s discharge, and she will certainly do so “in the name of the care team.”
Relatedly, the interactional context must be psychologically safe (Jones and
Jones 2011) so that everyone can speak up. However, the professional hierar-
chy might inhibit free-flowing interactions in which everyone’s voice and
expertise are respected (see Chap. 8 on professional hierarchy).
Sharing decisions and actions with other collaborators also requires trust, as
each individual assumes professional responsibility for the shared decision. It
also requires relational and emotional communication competencies to develop
the trust necessary for team members to collectively engage in a shared action
for which everyone is accountable (Gregory and Austin 2016; see Chap. 6 on
relational dimensions). This collective engagement of individual accountability
often represents an obstacle to interdisciplinarity, as some professionals may
ultimately disregard team consensus by claiming individual legal responsibility
for the patient. However, in many jurisdictions, legal considerations have
evolved over time with the development of a collaborative approach to care.
For instance, in Canada, a number of jurisprudence cases have shown that the
law recognizes that each professional on the healthcare team is responsible and
accountable for the care they provide (The Canadian Nurses Protective Society
2018). The law also considers the duty to communicate diligently within the
team or even to escalate opinions or concerns to ensure patient safety.
Rather than being an obstacle to interdisciplinarity, these legal consider-
ations should actually encourage interdependent approaches to interprofes-
sional collaboration. If a real consensus is reached through open and transparent
communication (i.e., interactions are not rushed and communicators feel safe
to say what they think needs to be said), this can only enhance the quality and
safety of decisions. On the other hand, returning to the previous example, if
the physician does not understand other colleagues’ concerns about the older
patient’s ability to securely navigate his home environment, this could lead to
an unsafe discharge decision. In this instance, the physiotherapist, nurse, and
occupational therapist might become acutely aware of the dialectical tensions
that stem from having to enact their professional role while making accommo-
dations across professional boundaries (see Chap. 7), which in this case might
involve deference to the physician.
 3 INTERPROFESSIONAL COMMUNICATION: A CONTINUUM OF INTENTIONS… 53

Patient Partnerships Within Interprofessional Teams

While the intentions that influence communication between professionals
should dictate the type of collaborative practice they engage in, these inten-
tions must be informed by a real partnership with the patient and their loved
ones (if they are involved). In order to provide quality patient-centered care,
the patient and their loved ones must be considered as partners of the interpro-
fessional team, because they have expertise about their own situation and
health condition. There is extensive literature on patient-professional commu-
nication (Dean 2016) as well as patient partnerships (Pomey et al. 2015).
Various indicators can illustrate optimal communication and partnership with
the patient in an interprofessional context (Milot et al. 2019; Coly 2022).
These include the patient and their loved ones having the information needed
to be engaged in their care, being able to discuss their preferences and values
with the team, and actively participating in decisions concerning them and
evaluating outcomes following actions taken to meet their needs.

Concluding Thoughts
It is essential to take a critical look at collaboration processes, especially com-
munication, rather than focusing only on collaborative results (Careau et al.
2014). By opening up and examining interprofessional communication, we can
see how it shapes collaborative practice. In this regard, the continuum of prac-
tice described here is useful for identifying what type of practice is actually
deployed in the field, determining whether this type of practice is adapted to
the complexity of the individual’s situation, and whether it corresponds to
what the organization or team wishes to put into practice.
The continuum also tells us that health and social care professionals and
learners must continually monitor the patient’s biopsychosocial situation,
determining whether the intention being pursued (e.g., to inform or to share
decisions and actions) is in keeping with the complexity of the situation. Team
members must use their best judgment here, as there are no established rules
that absolutely determine the need for multidisciplinary or interdisciplinary
intervention. This means paying attention to indicators about changes in the
situation and adapting interprofessional communication and collaborative
practice accordingly, that is, to transition or slide across the continuum as
needed. This also requires taking into account the personal desires, goals, and
values of the patient and their loved ones when making care decisions.
We conclude with a vignette from primary care illustrating the shifting needs
of Mr. Bélanger and how his care team adapts. Throughout the vignette, we
use italics to identify indicators that his care needs may have changed and that
a reassessment of the appropriate interprofessional collaborative practice—and
associated communication practices—may be required to address his needs.
54 E. CAREAU AND S. FOX

Sliding Across the Continuum as Needed: The Case

of Mr. Bélanger2

Mr. Bélanger, 72, lives alone. He has Type-1 diabetes, for which he is insulin-­
dependent. His condition has been stable for years. He is under the care of his
family doctor, who monitors and renews his insulin prescriptions, and he con-
sults his pharmacist as needed. Communication between the pharmacist and
the family doctor is indirect, going through either Mr. Bélanger’s medical
record, his prescription, or through Mr. Bélanger himself, who informs each of
what the other professional has mentioned. This represents parallel practice,
where communication between professionals is low in intensity, unidirectional,
and asynchronous.
With his consent, Mr. Bélanger’s daughter accompanies him to his annual
doctor’s appointment this year. She mentions that her father’s diet has been
deteriorating for some time, and that he tells her he can’t eat any better because
of financial difficulties. This signals the addition of a new patient care need, and
potentially the need to adopt a more collaborative approach to respond to his needs.
The doctor validates the information with Mr. Bélanger, and they discuss the
possibility of a social work referral. Although Mr. Bélanger says he doesn’t need
one, he accepts the referral. With Mr. Bélanger’s agreement, the doctor con-
tacts the nurse in the family medicine clinic who is in charge of his case.
Following this exchange, she agrees to see Mr. Bélanger again to manage his
diabetes. This indicates a shift from parallel practice to consultation-referral
practice: In this two-way communication, information is exchanged between the
doctor and the nurse, and a social work referral is put in place to add in the disci-
plinary perspective of this professional.
Over the course of several weeks, the nurse follows how Mr. Bélanger is
managing his diabetes. The social worker also begins her assessment. Mr.
Bélanger participates well in the assessment but says he doesn’t understand the
reason for the social work intervention, as he is organizing himself well. He
tells her that his wife passed away last year, and that it was she who used to
prepare all the meals. He insists that he can cook himself simple meals and
refuses to talk about his financial situation. He says he loves his daughter deeply,
but that she worries about him for no reason. This could indicate a need for a
shift in the type of collaborative practice, as it is a contradictory message. He men-
tions in passing that he gets dizzy from time to time, but that it’s normal at his
age to not be in great shape.
Considering his diabetes, the social worker suggests referring him to a nutri-
tionist to help him with his diet; Mr. Bélanger says he would like to think about
it. This indicates a new need has been added to his situation. However, he agrees
to let the social worker contact his daughter and talk to the nurse.

2
We are deeply grateful to Nadia Julien and Geneviève Côté at RCPI (Réseau de collaboration
sur les pratiques interprofessionnelles en santé et services sociaux – CIUSSS de la Capitale-Nationale
and Université Laval) for this vignette. It is based on their own experience in providing and teach-
ing interprofessional collaborative care and communication practice.
 3 INTERPROFESSIONAL COMMUNICATION: A CONTINUUM OF INTENTIONS… 55

During the call, his daughter confirms that her father is dizzy and refuses to
talk to her about managing his diabetes. Once again, this contradictory message,
which offers only a partial view of the situation, is another indicator that the col-
laborative approach needs to be reassessed. In light of this new information, the
social worker organizes a conference call between her, the doctor, and the
nurse to discuss the situation and plan further action. Mr. Bélanger doesn’t
wish to be present but he does want to be kept informed of what they decide.
The team agrees that the nurse will give Mr. Bélanger this feedback about the
meeting. This constitutes a shift from consultation/referral practice to concerted
practice: The professionals work together because of the greater complexity of Mr.
Bélanger’s biopsychosocial situation. They exchange information to adjust their
respective disciplinary actions. The intention is to coordinate care and services in
a coherent and complementary way.
Further investigations are carried out by the nurse. She observes that he is
having great difficulty managing his diabetes, leading to increasingly frequent
periods of hypoglycemia. Despite the nurse’s advice, his diabetes continues to
be unbalanced. She also notices an infected sore on one foot, which indicates
heightened health risks. Although Mr. Bélanger has accepted the nutrition ser-
vice, he has missed his appointments twice. His daughter mentioned to the
social worker that she was increasingly worried about his safety at home.
A team meeting is scheduled with Mr. Bélanger, who wishes to be present
with his daughter. During the meeting. Mr. Bélanger mentions that it has been
harder to keep himself organized since the death of his wife, but that he doesn’t
want to worry his daughter. He doesn’t really have any financial problems, but
he’s no longer interested in making meals and finds the daily management of
his blood sugar levels complex. During the discussion and given the complexity
of his needs (which indicate an unstable health status and insufficient progress),
Mr. Bélanger discusses possible options with the team. Together, they agree
that the best solution to meet his needs is to find a living environment offering
various services, such as meals and nursing care, to ensure his safety. By mutual
agreement, they set a common and shared goal to ensure his safety while await-
ing relocation. The collaborators move from consultation practice to highly inter-
dependent, shared healthcare practice: Mr. Bélanger’s situation is complex and
worsening. Instability and unpredictability call for a shared vision in which pro-
fessional knowledges are blended and responsibility is shared. This shared vision is
constituted in and through their communication.

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 CHAPTER 4

Rethinking How Communication Is Taught

as an Interprofessional Competency

Marlène Karam and Isabelle Brault

Introduction
Education in interprofessional (IP) collaboration has taken off in health science
curricula over the past fifteen years. In a global context of aging populations
and chronic diseases with multiple comorbidities, many countries have recog-
nized that no single profession is capable of meeting the complex needs of their
populations. The centrality of interprofessional collaboration in a health and
social care system that aspires to deliver comprehensive care and services, at the
right time, in the right place, and by the right professional, has become self-­
evident. Substantial efforts have thus been made to move from fragmented
health and social services systems to integrated systems where the provision of
care is coherent and continuous between different health professionals, clinical
settings, or lines of care. Indeed, the impact of fragmentation is felt not only in
terms of patient satisfaction and clinical outcomes, but also in terms of the
costs inherent in sub-optimal quality of care, inefficiency of care, and redun-
dancy of clinical and diagnostic examinations.
Collaborative practice is defined as “an interprofessional process of commu-
nication and decision-making that enables the separate and shared knowledge
and skills of healthcare providers to synergistically influence the patient care
provided” (Way et al. 2000). Not surprisingly, communication is identified as
one of the core competencies needed for optimal interprofessional collabora-
tion. A wide range of methods for teaching and learning communication skills
have been developed over the years and in different countries for both

M. Karam (*) • I. Brault

Faculté des sciences infirmières (Faculty of Nursing), Université de Montréal,
Montréal, Québec, Canada
e-mail: [email protected]; [email protected]

© The Author(s) 2025 59

S. Fox et al. (eds.), Interprofessional Communication in Health and Social
Care, https://doi.org/10.1007/978-3-031-70106-1_4
60 M. KARAM AND I. BRAULT

professionals and students in the health sciences. And because it is a collabora-

tive skill, it is often taught as part of a broader interprofessional education
(IPE) program (Callout 4.1).

Callout 4.1 Defining Interprofessional Education

The Canadian Interprofessional Health Collaborative (CIHC) defines
IPE as “the process of preparing people for collaborative practice,” which
in turn is intended to improve patient and client safety and health out-
comes (CIHC 2010, 6). This preparation occurs when “two or more
professions learn with, from, and about each other to improve collabora-
tion and the quality of care” (Goldman et al. 2009, 151).

The purpose of this chapter is threefold: (1) to provide an overview of the

main frameworks that have guided the development of IPE programs, and to
examine the place they attribute to communication; (2) to present the experi-
ence of the Université de Montréal’s interprofessional education curriculum,
outlining the aspects surrounding interprofessional communication; and (3) to
discuss the challenges, issues, and perspectives of developing an IPE curricu-
lum in general and the teaching of interprofessional communication within the
context of IPE in particular. This chapter concludes with an illustration of
interprofessional communication from the perspective of a patient-partner.
Several studies have highlighted the centrality of communication as a com-
ponent of interprofessional collaboration. For instance, in a systematic review
of qualitative studies about collaboration in healthcare contexts (Karam et al.
2018), we compared the conceptual frameworks of interprofessional collabora-
tion (IPC) with those of inter-organizational collaboration (IOC), with a view
to clarifying the specific features and challenges of each of these two forms of
collaboration. We defined IPC as collaboration between professionals belong-
ing to the same organization (e.g., physicians and nurses on a hospital care
unit), and IOC as that occurring between professionals from different organi-
zations (e.g., outpatient family physicians and community pharmacists). Several
components emerged as essential to both forms of collaboration, such as trust,
respect, and knowing each other. These three components are also seen as key
elements in mitigating the power play that might exist between stakeholders at
different hierarchical levels. Other common components included shared
patient-centered objectives, the challenges posed by the characteristics of a
given task, and the impact of the external or macro environment such as gov-
ernment policies, legislation, and available resources. The need to formalize
processes and clarify roles was identified as more important in the IOC context
than in the IPC, where role flexibility is tolerated and even encouraged. In
addition, the internal environment plays a key role in IPC. Finally, one compo-
nent was identified as central to both forms of collaboration: communication.
Indeed, communication emerged as the component that facilitates all the
 4 RETHINKING HOW COMMUNICATION IS TAUGHT AS AN INTERPROFESSIONAL… 61

others (respect, trust, clarification of roles, formalization, etc.). In other words,

communication is at the heart of all collaborative processes.
In another literature review, we looked at care and service coordination
activities by front-line nurses for people with complex needs (Karam et al.
2021). Along with interprofessional collaboration, coordination is a key strat-
egy in facilitating an integrated system of care and services (see Chap. 1). The
Agency for Healthcare Research and Quality, a US federal agency, defines care
coordination as “the deliberate organization of patient care activities between
two or more participants (including the patient) involved in a patient’s care to
facilitate the appropriate delivery of health care services” (McDonald et al.
2007, 5). Based on a review of the coordination activities carried out in the
different types of coordination interventions (case management, care manage-
ment, disease management, patient navigation, integrated care, etc.), we devel-
oped a model of care and service coordination for people with complex needs.
The model highlights four categories of coordination activities carried out by
nurses: activities aimed at the individual and his or her family; those aimed at
the interprofessional team; those that create links and connections between the
individual, their family, and the interprofessional team; and interpersonal and
interprofessional communication and information transfer, a cross-cutting cat-
egory that supports and facilitates the other categories. Indeed, every activity
that nurses undertake with beneficiaries or the intra- and interprofessional team
relies on communication. Communication is particularly relevant for clarifying
roles and responsibilities, establishing shared accountability, and facilitating the
implementation of an interprofessional approach, which again reinforces the
place of communication within interprofessional collaboration.
Despite its proven benefits, interprofessional collaboration remains difficult
to accomplish due to multiple factors at the macro (health system and policy),
meso (organizations), micro (health and social care teams), and individual
(professional) levels. In their systematic review, Mulvale et al. (2016) identified
studies demonstrating an association between these factors and collaborative
processes. They offer a taxonomy of factors that can improve interprofessional
collaboration within care teams. Of the 18 factors identified, 13 are the respon-
sibility of teams and individuals, such as conflict resolution and decision-­making
processes, support from colleagues, feeling part of the team, and, of course,
open communication. These results show that, over and above reforms to care
systems, funding, organizational cultures, and information-sharing systems,
we, as team members and individuals, can improve factors that are within our
reach and enable us to improve our day-to-day collaboration.
Relatedly, another barrier to collaboration that has been studied at length in
the literature is the lack of role clarity within interprofessional teams (see Chap.
6 on the relational dimensions of collaboration). Knowledge of roles and rec-
ognition of the expertise of each team member, and of the added value of this
expertise in optimal, comprehensive patient care, are essential to interprofes-
sional collaboration. Once these roles and expertise have been clarified, it is
easier to negotiate responsibilities and reduce any tensions associated with the
62 M. KARAM AND I. BRAULT

feeling of having to protect one’s own role so as not to be sidelined or replaced

by other professionals. Interprofessional communication plays a vital role in
clarifying roles, and it is thanks to IP communication that professionals can
speak up and define their own contribution to the team and to care.
Communication is also how teams can overcome different viewpoints stem-
ming from divergent professional cultures to reach consensus and coordinate
care and services (Suter et al. 2009). For patients and their families, open,
transparent, and ongoing communication adapted to the patient’s needs and
characteristics is vital to providing safe, high-quality care.
In short, studies that reflect the reality of practice and the professionals’
experiences and perceptions as well as conceptual and theoretical frameworks
that aim to create an ideal towards which professionals should strive emphasize
the centrality of interprofessional communication to collaboration between
team members and with the patient. Hence, there is a clear need to teach
future professionals to communicate appropriately in order to prepare them for
optimal collaborative practice.
Today, studies from different countries seem to indicate that IPE in general
and interprofessional communication training more specifically are being
implemented in the university curricula of health and psychosocial science stu-
dents to varying degrees and through a wide range of teaching and learning
methods. However, despite this diversity of approaches, the common objec-
tives are to develop effective ways for interprofessional teams to work together,
including clarifying and respecting the roles of each team member. To achieve
this goal and create an environment conducive to interprofessional learning,
the majority of IPE programs are designed to be delivered to interprofessional
groups, although some courses include both interprofessional and intra-­
professional elements. Indeed, role clarification implies an understanding of
one’s own role first and foremost, and the ability to describe and communicate
this role to other professionals on the team. And it is primarily to this objective
that the intra-professional elements of IPE programs respond.

Frameworks for Interprofessional Education: What

Competences Are Needed and What Is the Place
of Communication?

This section aims to examine the place of communication in the main frame-
works that have guided the development of interprofessional education and
collaborative practice competencies. We discuss two frameworks that played a
key role in defining and refining interprofessional competencies internationally
and a third, inspired by various other frameworks and work, that has guided
the development of the IPE program at the Université de Montréal in
Quebec, Canada.
The three frameworks presented are as follows:
 4 RETHINKING HOW COMMUNICATION IS TAUGHT AS AN INTERPROFESSIONAL… 63

• The Canadian Interprofessional Competency Framework (CIHC 2010)

• The U.S.-based Interprofessional Education Collaborative (IPEC) Core
Competencies for Interprofessional Collaborative Practice (IPEC 2023)
• The Collaborative Practice and Patient Partnership in Health and Social
Services Competency Framework (DCPP and CIO-UdeM 2016)

The National Interprofessional Competency Framework: Canada

The Canadian Interprofessional Health Collaborative (CIHC) is a consortium
of healthcare organizations, healthcare professionals, decision-makers, profes-
sors, researchers, and students from across Canada that has been acting as a
mobilizing force for interprofessional practice for over a decade (CIHC n.d.).
In 2010, the consortium published the first pan-Canadian interprofessional
collaboration competency framework: the National Interprofessional
Competency Framework (Bainbridge et al. 2010). This framework is designed
for learners and practicing professionals who wish to further develop their
interprofessional collaboration skills, and it identifies six competency domains.
The first four competency domains are distinct or stand-alone: role clarifica-
tion, teamwork, collaborative leadership, and interprofessional conflict resolu-
tion. The importance of each of these domains varies according to considerations
such as the complexity of the situation, the context of practice, and the need
for quality improvement. Two additional domains—interprofessional commu-
nication and care centered on the patient, client, family, and community—are
considered to be transversal, cross-cutting competency domains that support
the other four and are therefore always relevant, regardless of context. In sum,
in this model, interprofessional communication plays an essential role in sup-
porting the other competencies. According to the CIHC framework, IP com-
munication is defined as follows: “Learners/practitioners from different
professions communicate with each other in a collaborative, responsive and
responsible manner” (CIHC 2010, 16). The CIHC framework offers insights
about indicators to be used to evaluate professionals’ competencies through
detailed descriptors of each competency. These indicators are also useful for
determining consistent standards of practice across settings. More specifically,
professionals need to be able to: “establish team-work communication princi-
ples; actively listen to other team members including patients, clients, and fami-
lies; communicate to ensure common understanding of care decisions; develop
trusting relationships with patients, clients, and families and other team mem-
bers; and effectively use information and communication technology to
improve interprofessional patient/client/community-centred care” (CIHC
2010, 16).
The CIHC framework has guided the development of several IPE models.
For example, the University of Saskatchewan (Canada) used the CIHC frame-
work to develop an introductory IPE activity for nursing students, delivered by
different healthcare professionals with the goal of creating an interprofessional
learning environment (Bally et al. 2022). The activity consists of a theoretical
64 M. KARAM AND I. BRAULT

overview of the framework competencies, followed by vignettes or case studies

created by an interprofessional team that are discussed during lectures deliv-
ered by various professionals. Students also have the opportunity to meet and
discuss with students from other professions as part of their clinical courses. A
different pedagogical strategy is adopted to teach and learn each of the frame-
work’s six competencies. In the case of interprofessional communication, the
strategy consists of clarifying, at the start of each class, expectations in relation
to listening, respect, professional interaction, and negotiation (Bally et al. 2022).
Another pedagogical tool based on the CIHC framework is the interprofes-
sional communication course developed at the University of New Brunswick
(Canada) that adopts a team-based learning approach (Doucet et al. 2013).
The course coordinator forms teams of students from different professions at
the start of the course to encourage team heterogeneity. Students learn together
throughout the course, with a view to analyzing a “case” that includes medical,
psycho-social, and ethical aspects. They must jointly propose an action plan
that includes interventions by the different professions relevant to the case.
Inevitably, the students’ evaluation of this tool indicates that they gain greater
awareness of interprofessional roles.
In fact, a strength of the National Interprofessional Competency Framework
is that it offers a common understanding of interprofessional collaboration and
its cross-cutting influences, which are applicable to any context and any care
setting. This reinforces the framework’s relevance internationally, as it assists
educational establishments to develop IPE activities aimed at effective inter-
professional collaboration specific to their respective contexts.
However, one of the criticisms levelled at the framework is that it does not
describe indicators that enable evaluators to know when particular competen-
cies have been mastered or the levels at which professionals are expected to
perform. This oversight paved the way for the development of assessment
models and strategies linked to the framework. Among these measurement
instruments, the Interprofessional Collaborative Competency Attainment
Survey (ICCAS; MacDonald et al. 2010) is the best known. The survey is a
20-item self-assessment questionnaire designed to measure the attainment of
the framework’s six competencies before and after exposure to an IPE activity,
on a Likert scale. In addition to assessing the effectiveness of the activity, this
exercise enables learners to reflect on how the activity impacts their IP collabo-
ration skills. More specifically, achievement of the communication competency
is self-assessed by learners’ ability to

promote effective communication among members of an interprofessional team;

actively listen to interprofessional team members’ ideas and concerns; express
their ideas and concerns without being judgmental; provide constructive feed-
back to interprofessional team members; and express their ideas and concerns in
a clear, concise manner. (Archibald et al. 2014, 3)
 4 RETHINKING HOW COMMUNICATION IS TAUGHT AS AN INTERPROFESSIONAL… 65

The ICCAS has shown good reliability and stability, and has been widely
used in Canada, the USA, Norway, Australia, and Indonesia to assess the
achievement of the framework’s six competencies, including communication,
following various IPE activities. For example, it has been used in simulations
between pharmacy and medical students (Shaikh et al. 2020), in workshops
bringing together healthcare students from 11 different disciplinary programs
(Fleming et al. 2023), and to compare the effectiveness of in-person and virtual
community clinics involving students in nursing, pharmacy, social work, and
nutrition/dietetics (Watts et al. 2022). The French-language version of this
tool is used to evaluate IPE at the Université de Montréal.

The IPEC Core Competencies for Interprofessional Collaborative

Practice: USA
The Interprofessional Education Collaborative (IPEC) is a United States coali-
tion of 21 health professions associations that are involved in the higher educa-
tion of future health professionals. Their framework, the Core Competencies
for Interprofessional Collaborative Practice, was initially launched in 2011,
then updated in 2016 and revised in November 2023. Consistent with the
objective and strategic vision of IPEC, their framework aims at “preparing
learners to engage in lifelong learning and collaboration to improve both per-
son/client care and population health outcomes” (IPEC 2023, 10). Their tar-
get audience is therefore current and future health care professionals. The
framework defines four core competencies to be included in curricula design
and mapping that fall under the domain of IPC: values and ethics for interpro-
fessional practice, roles and responsibilities, interprofessional communication,
and teams and teamwork. For each of these four core competencies, IPEC
designed a set of sub-competencies in order to give more clarity to the objec-
tives of each competency and to help users define the learning objectives of
their program, its content, and the evaluation process.
Communication competency is explained as being able to “communicate in
a responsive, responsible, respectful, and compassionate manner with team
members” (IPEC 2023, 18). Seven sub-competencies are associated with
communication:

1. Communicate one’s roles and responsibilities clearly.

2. Use communication tools, techniques, and technologies to enhance
team function, well-being, and health outcomes.
3. Communicate clearly with authenticity and cultural humility, avoiding
discipline-specific terminology.
4. Promote common understanding of shared goals.
5. Practice active listening that encourages ideas and opinions of other
team members.
6. Use constructive feedback to connect, align, and accomplish team goals.
66 M. KARAM AND I. BRAULT

7. Examine one’s position, power, role, unique experience, expertise, and

culture towards improving communication and managing conflicts.

One criticism that has been levelled at this framework is that its competen-
cies were defined on the basis of an expert consensus process rather than scien-
tific evidence and that, as a result, these competencies may evolve with time
and the availability of new empirical data (Lockeman et al. 2016). On the other
hand, some researchers criticize the framework for offering few theoretical and
practical tools for achieving these goals within educational and clinical health-
care systems (Dow et al. 2013). However, university curricula and continuing
education programs around the world have integrated pedagogical approaches
and content that promote the achievement of these sub-objectives, even if
these programs were not initially guided by the IPEC core competencies. For
example, a survey commissioned by the English National Health Service in
2005—well before the first version of this framework—identified several com-
munication themes included in interprofessional education courses that are
closely aligned with the sub-competencies mentioned above. These include
self-awareness and self-disclosure, written and non-verbal communication, lis-
tening skills, barriers to effective communication, evaluating the effects of skill-
ful communication, engaging clients and relationship building, a client-centered
approach, teamwork, and many others (Priest et al. 2005). That said, the IPEC
core competencies have been widely mobilized to support the design of IPE
activities and the development of IPE programs (Zorek et al. 2022). For exam-
ple, the IPEC framework has guided the development of interprofessional
simulation activities between nurses and social workers (Murphy and
Nimmagadda 2015), and an interprofessional case conference model involving
students from eight different health professions (Davis-Risen et al. 2021).
More recently, it has provided the theoretical basis for the development of a
micro-credentialing framework for interprofessional curriculum development
that weaves learning activities together in a coherent, holistic, and logical way
(Fribance and Susan 2020).
In addition, several instruments have been developed to measure the attain-
ment of IPEC competencies. One such instrument is the IPEC Competency
Self-Assessment survey, a questionnaire initially developed by Dow et al. (2014)
and composed of 42 items, 11 of which aim to self-assess the level of attain-
ment of communication competence on a Likert scale. The questionnaire was
refined in 2016 when Lockeman et al. created a shorter, easier-to-use version
without altering its psychometric properties. Of the final 16 items, only one
assesses the achievement of communication competence as perceived by
respondents. This item is: “Choose effective communication tools and tech-
niques to facilitate discussions and interactions that enhance team function.”
Another assessment tool related to the IPEC framework, the IPEC
Institutional Assessment Instrument, was identified and adopts an institutional
perspective and aims to answer the question: “In higher education for the
health professions, how do institutional leaders use IPEC core competencies to
 4 RETHINKING HOW COMMUNICATION IS TAUGHT AS AN INTERPROFESSIONAL… 67

assess the quality and effectiveness of IPE programs?” (Zorek et al. 2022, 2).
This instrument equips educational institutions to assess their institutional
capacity to effectively implement an IPE program, and consequently to plan
strategies to improve their identified weaknesses. It consists of 20 items grouped
under three factors: institutional infrastructure, institutional commitment, and
the IPEC competency framework. The 10 items under this last factor are not
specific to any one of the framework’s competencies, but rather assess the level
of effort deployed by the institution to achieve these competencies across the
board. The strength of this tool lies in the critical look it takes at the educa-
tional institution’s commitment to effective IPE. It therefore recognizes the
multi-level nature of the factors influencing the results of an IPE program. A
self-assessment questionnaire of this kind has the potential to raise awareness
and give a sense of responsibility to the leaders of educational establishments
and institutions regarding the need for strong leadership that advocates the
adequate investment of human and material resources in their IPE program
(Callout 4.2).

Callout 4.2 Comparing IPE Frameworks

The two frameworks (CIHC, Canada; IPEC, United States) are very
similar and even contain three overlapping domains, namely communica-
tion, role clarification, and team functioning. However, a main difference
may be noted: In the CIHC framework, interprofessional communica-
tion is considered as a supportive domain that will always influence the
other domains and will therefore always be relevant regardless of the
context.

Collaborative Practice and Patient Partnership in Health and Social

Services Competency Framework
The final competency framework presented in this chapter is the Collaborative
Practice and Patient Partnership in Health and Social Services Competency
Framework. This framework was co-constructed with patients and family care-
givers, educators, professionals, managers, and health and social services
researchers, and it integrates the notion of patient care partnership (DCPP and
CIO-UdeM 2016). This competency framework is used in the development of
the interprofessional collaboration and patient care partnership training cur-
riculum at the Université de Montréal (Canada). It targets several types of
users: the public at large, patients and caregivers, health and social services
practitioners and students, health and social services decision-makers and
researchers, teachers, organizational and clinical managers, decision-makers,
and researchers in health and psychosocial sciences education.
The framework describes one core competency, the planning, implement-
ing, and monitoring of healthcare and social services, as well as seven cross-­
cutting competencies: teamwork, health education, clinical ethics, clarity of
68 M. KARAM AND I. BRAULT

roles and responsibilities, conflict prevention and resolution, communication,

and collaborative leadership.
The communication competency is described as:

The patient partner and the practitioners in the team communicate with each
other in a timely manner, effectively, and in a spirit of respect, openness, and col-
laboration. They specify the most appropriate methods of communication accord-
ing to the nature of the information to be shared, the time available, and the
persons involved. They are careful to select and arrange a physical space that will
be conducive to discussions and support confidentiality. They clarify all profes-
sional or technical terminology that could impede the understanding of the infor-
mation being exchanged. They adapt the level of their language to that of the
different people with whom they interact. They are sensitive to the expression of
emotions and respond with tact. The patient partner participates actively in con-
versations about him/herself, including in teaching situations with trainees and
residents. (DCPP and CIO-UdeM 2016, 12)

In this framework, three abilities are related to the communication compe-

tency: (1) promoting a climate of openness and respect, (2) establishing and
maintaining communication, and (3) sharing relevant information clearly, con-
cisely, and safely. In addition, a set of observable behaviours and attitudes are
described in relation to these skills, such as communicating with each other as
equals and using language that is common to everyone, that is understandable,
and that is adapted to the patient.
In order to give the reader a sense of how IPE tools can be put into practice,
in the following section, we describe the Université de Montréal’s interprofes-
sional education (IPE) curriculum, which is based on this third competency
framework, and we offer a glimpse into the perspective of a patient partner in
the IPE curriculum. A key feature of the curriculum is the integration of
patients in all steps of course planning and delivery.

The Université de Montréal’s Interprofessional

Education (IPE) Curriculum
With a view to improving the quality of care and services offered to patients,
IPE activities began in 2008 at the Université de Montréal with a pilot project
(Vanier et al. 2013) involving students from four professions: medicine, phar-
macy, occupational therapy, and nursing. These activities quickly expanded to
include a larger number of professions and to facilitate the implementation of
an accredited training curriculum. By 2010, the curriculum integrated patient
partners into the various activities. This IPE curriculum recognizes that patients
have specific knowledge developed through their experience of living with ill-
ness and mobilized within the care relationship (Karazivan et al. 2015), and it
values their contribution as patient partners to academic training. Now called
 4 RETHINKING HOW COMMUNICATION IS TAUGHT AS AN INTERPROFESSIONAL… 69

“Formation Partenaires1” the training curriculum integrates patient partners

into all stages of the training curriculum, from planning to course manage-
ment; this integration is one of the curriculum’s main features. In this partner-
ship model, patients are recruited according to their ability to mobilize specific
skills (Jackson et al. 2020). Each patient is a person:

(who is) gradually empowered to participate in the decision-making process

regarding his/her care plan and to make free and informed choices; who is
becoming a full-fledged member of the interprofessional team handling his/her
care; whose experiential knowledge and ability to develop care expertise for his/
her medical condition are recognized as evidence; and who influences the inter-
ventions chosen and their prioritization in accordance with his/her life project.
(Vanier et al. 2014, 75–76)

The curriculum includes three mandatory courses on collaborative practice

in partnership with patients, involving students from 13 health and social sci-
ence programs: audiology, occupational therapy, kinesiology, medicine, den-
tistry, nutrition, optometry, speech therapy, pharmacy, physiotherapy,
psychoeducation, nursing, and social work. These compulsory one-credit
courses reach some 1,500 students per course, and almost 4,500 per academic
year. The aim of the curriculum is to train health and social services profession-
als who are: humble; curious about others; flexible; and able to reflect, listen
actively, integrate their partners’ points of view, and dialogue effectively in an
interprofessional context.
Until 2021, the curriculum aimed at achieving the eight competencies of
the Collaborative Practice and Patient Partnership in Health and Social Services
Competency Framework. Vanier et al. (2013) provide an overview of the
teaching activities. These include both inter- and intra-professional elements
and a diversity of pedagogical approaches such as e-learning modules, a col-
laborative logbook, and intra- and interprofessional activities that integrate
patients.
In 2021, the IPE curriculum undertook a major redesign of the Formation
Partenaires courses in order to give priority to the development of three of the
eight competencies of the Collaborative Practice and Patient Partnership in
Health and Social Services Competency Framework (DCPP and CIO-UdeM
2016): (1) health education; (2) communication; and (3) clarity of roles and
responsibilities. The redesign also aimed at reorienting pedagogical activities to
ensure better alignment between the objectives pursued and the activities
delivered.2
As a result, three courses designated as Collaboration en sciences de la santé
(or Collaboration in the Health Sciences) were restructured to enable the
development of these competencies. All courses are taught by a team-teaching

The Formation Partenaires can be translated as “Partner-led Education.”

1

Please note that program modifications are still ongoing as part of the University’s commit-
2

ment to continuous improvement.

70 M. KARAM AND I. BRAULT

“tandem” consisting of a professor or a facilitator and a patient-partner. The

courses follow a common format: (1) an introductory session on each course’s
concepts; (2) online modules about the principal concepts of each course; (3)
intra-professional activities allowing students to reinforce their own profes-
sional identity in partnership with the patient; and (4) an intra-professional
workshop with the patient for the first course and an interprofessional work-
shop with the patient for the second and third courses.
The first-year course explores concepts related to the care partnership with
the patient, focusing on the competency of health education. During this intra-­
professional course, students are introduced to the importance of creating a
solid relationship with patient-partners in their future clinical practice. For this
reason, the workshop focuses on communicating with the patient-partner
through discussions to analyze the patient’s life story and mobilizing the care
partnership concepts. The second-year course includes interprofessional teach-
ing activities and addresses the concepts of interprofessional collaboration in
patient care partnerships and the importance of interprofessional dialogue. The
main skill focuses on communication with students from other programs as well
as with the patient. The workshop, always co-facilitated by a patient-partner,
focuses on interprofessional and patient discussions of clinical situations involv-
ing chronic diseases. Finally, the third-year course aims to integrate the princi-
ples of interprofessional collaboration and patient partnership. Here, the goal
is to develop the competency of clarifying the interprofessional and patient
roles. These concepts are integrated into an interprofessional intervention plan
for a palliative care situation, developed during the workshop. In the following
section, we share the perspective of a patient-partner who has participated in
this IPE program.

Interprofessional Communication: The Perspective

of a Patient Partner

Mr. Leblanc (a pseudonym) is a trained patient-partner who has participated

for four years in the Collaboration en sciences de la santé courses at the Université
de Montréal. Mr. Leblanc is considered a patient expert in living with illness, as
he has been living with his disease for over 20 years. Below, we present excerpts
of our conversation with him about his personal experience with the Formation
Partenaires program. We have summarized his responses to our questions, but
indicate his direct quotes with quotation marks (all excerpts have been trans-
lated from French). His words represent his unique opinion as an expert
patient-partner on interprofessional communication and are thus not necessar-
ily representative of all patient-partners who have taken part in the training.

What do you consider to be the strengths of the course you co-delivered?

 4 RETHINKING HOW COMMUNICATION IS TAUGHT AS AN INTERPROFESSIONAL… 71

The key point is to raise awareness of what a patient is. “A patient is not just
an illness, but a person with an identity, a culture, a history, and a life project.”
It is important to know the patient to better understand all aspects of their situ-
ation, and to grasp all the nuances involved in providing care and treatment.
The patient’s story as told by the patient him- or herself contributes to inter-
professional communication skills and enables students to listen. Sharing helps
students to understand that the patient is not a number, but has an identity, is
a person. “That’s the most beautiful message we can give students.” Secondly,
it’s essential to take time with each patient. Professionals are busy, but taking
time with the patient is crucial: “Listen to the patient well in order to under-
stand what kind of communication they need (…) You have to give the patient
time to express themselves and create a climate of openness and respect towards
them. (…) The professional has to draw the patient out, and therefore must be
attentive to their non-verbal cues to encourage them to express themselves.”
The space for exchange with patients offered in the courses is a lever for devel-
oping interprofessional communication.

What do you think about the importance of communication in interprofes-

sional teams?

The interprofessional team must use language that the patient can under-
stand, and avoid the scientific jargon often used by professionals. From Mr.
Leblanc’s perspective, the benefits of effective communication include greater
team trust, satisfaction, respect, and mutual commitment. When these com-
munication skills are mastered, this demystifies everyone’s roles and humanizes
what is being said. From his perspective, communication is the key to reaching
agreement on the best care for patients. The consequences of ineffective com-
munication with patients are numerous. For instance, patients might start to
shut down because they don’t understand the treatment plan.

In your opinion, is the program achieving its objective of raising students’ awareness
of interprofessional communication?

“I think we’ve achieved our objective.” However, Mr. Leblanc suggested

discussing more real-life clinical situations, such as those experienced by the
patient-partners who take part in the courses.

Challenges and Issues in Delivering IPE

at the Université de Montréal

While the strengths of the Université de Montréal’s curriculum lie in its deploy-
ment across 13 programs and the integration of patient-partners at all stages of
training, this also bring its own set of challenges, such as the diversity of profes-
sional identities and differences in professional cultures. These challenges are
unavoidable when so many professions come to the table, sometimes with
72 M. KARAM AND I. BRAULT

different vocabularies, sometimes with different understandings of the same

concept. Fortunately, such challenges can be mitigated by a shared willingness
to work towards a common goal and through the establishment of a collabora-
tive governance model for decision making. This model draws on complemen-
tary expertise, including that of patient trainers, and insists on the need for
formal exchange with a view to resolving differences. For this reason, an inter-
faculty operating committee was created to offer a space for consultation, rep-
resentation, and dialogue as well as to develop and maintain the curriculum
and ensure the smooth running of the training program despite any differences
in professional cultures. In addition, over the years, the program established
poles of expertise with specific, punctual mandates relating to pedagogy, gov-
ernance, research, and evaluation. These poles of expertise include representa-
tives from the various programs and patient-partners, with a view to making
decisions that are in line with diverse visions and priorities.
The active involvement of patients in training also poses particular chal-
lenges. Professors and facilitators, who are often recruited from clinical settings
to teach, must adapt to and adopt this new teaching model. The aim of recruit-
ing professional facilitators is to build bridges between the academic and clini-
cal worlds and to ensure that approaches centred on patient partnership
continue to be implemented in healthcare organizations. Patient recruitment is
the responsibility of the Université de Montréal’s Bureau du patient partenaire
(BPP, or Patient Partner Office) and its network of partners. Recruiting patient-
partners is also a challenge, as their health issues can sometimes result in absen-
teeism. Over 300 co-leaders are mobilized every year, half of whom are
patient-partners. In addition to recruiting patient-partners, it is essential to
prepare them for this role. The IPE program teaches its patient-partners con-
cepts related to care partnership with patients and relatives, as well as concepts
related to specific courses.
Other challenges relate to the number of university teaching staff required.
In addition to the 300 co-facilitators, nearly 25 professors are involved annu-
ally, and turnover among them requires ongoing efforts to ensure that new
staff understand and transmit the vision associated with each course (Brault
et al. 2016). Moreover, the logistical requirements are complicated, especially
for face-to-face teaching, where many classrooms must be reserved to meet the
needs of the large cohort of students. Reconciling students’ schedules is
another major challenge. Fortunately, these logistical and human resource
challenges can be overcome, thanks to a dedicated resource team of teachers,
patients, and administrative staff who ensure the coordination of activities.
For the Université de Montréal’s IPE program, as elsewhere in the world,
assessing the competencies associated with interprofessional collaboration
remains a challenge. As mentioned earlier in this chapter, the Université de
Montréal uses the French-language version of the ICCAS developed by a
Quebec team and validated by representatives of 19 different professions
(MacDonald et al. 2010). Communication skills are self-assessed through five
questions, and the results consistently show a difference in students’ sense of
 4 RETHINKING HOW COMMUNICATION IS TAUGHT AS AN INTERPROFESSIONAL… 73

these skills before and after participating in interprofessional learning activities.

As is often the case in IPE programs elsewhere in North America and interna-
tionally, assessment of communication competency is often integrated into
assessment of all competencies targeted by an IPE program. In other words,
communication is often one of the dimensions used to assess IP competence.
Despite the challenges of IPE, the benefits for patients, teams, and the
healthcare system alike are well documented in the scientific literature. Reeves
et al.’s (2013) systematic review on this topic included 15 studies that reported
positive outcomes in the following areas: improved healthcare quality goals;
improved collaborative team behaviors; improved patient-centered communi-
cation; increased diabetes screening rates and diabetes clinical outcomes;
improved team behaviors and information sharing for operating room teams;
reduced clinical error rates for emergency department teams; and improved
mental health practitioner skills related to patient care delivery. However, some
studies included in their review showed mixed results, no impact, or significant
differences between participants who received IPE and the control group.
More recently, a systematic review and meta-analysis on the outcomes of
IPE included eight studies from Brazil, New Zealand, USA, Japan, Germany,
Belgium, and Turkey (Saragih et al. 2023). The results showed that only
knowledge related to IP collaboration was positively impacted by health sci-
ence students’ participation in IPE. No significant effect was observed in this
target audience in relation to their readiness to function in an interprofessional
team, their attitude towards IPE learning, or their interprofessional skills
(Saragih et al. 2023). The results of this meta-analysis are thus in contradiction
with others demonstrating significant positive effects in relation to these three
outcomes (Burgess and McGregor 2022; Miselis et al. 2022). In sum, the
effectiveness of IPE (including communication) remains unclear due to the
heterogeneity of studies, target populations, interventions, and contexts, which
make it very difficult to evaluate their overall impact and determine the key
elements of success.
A committee convened by the Institute of Medicine (IOM) in the United
States to determine the best methods for measuring the impact of IPE on
healthcare delivery and outcomes has concluded that “the lack of a well-­
established causal relationship between IPE and health and system outcomes is
due, in part, to the complexity of the environment in which education inter-
ventions are conducted” (IOM 2015, 39). In order to address this particular
challenge, the committee recommended that education and practice need to
be better aligned. The academic, clinical, and political environment in which
IPE activities are designed and conducted should be more conducive to a col-
laborative practice. This entails joint planning for linking IPE to practice and a
better integration of educational reform with health system redesign.
74 M. KARAM AND I. BRAULT

Perspectives on Teaching
Interprofessional Communication
Based on our experience at the Université de Montréal, we have been able to
identify certain key ingredients that contribute to effective implementation and
sustainability of IPE curriculum. These ingredients can be found at differ-
ent levels.
At the level of universities where IPE efforts take place, the allocation of
material and human resources is a must. However, these resources are not
unlimited. Considering the scale of resources typically mobilized as well as the
various challenges faced by the academic community when implementing and
maintaining an effective interprofessional curriculum, it is unrealistic to ask for
more university resources in order to integrate this core competency. Instead,
innovative strategies should be implemented to reinforce existing strengths and
adopt new ways of doing things when necessary. For instance, in order to
strengthen and maintain the extraordinary efforts over the long run of those
who contribute to the time-consuming process of teaching IPE, their efforts
should be recognized and rewarded (e.g., at the Université de Montréal, they
are presented and thanked on the Formation Partenaires website). In addition,
curriculum leaders, operational managers, and trainers can be communication
role models in their respective tasks as well as in their communication with
students. Similarly, but with regard to pedagogical considerations, it is impor-
tant to develop case studies and clinical vignettes that support student learning.
Teaching teams must ensure that such cases and vignettes are authentic and
representative of real practice. Indeed, it is hardly productive to develop
vignettes about professionals who work or communicate very little together in
practice.
At the faculty level, the development of communication competence should
not simply rely on interprofessional courses but should be integrated into other
intra-professional courses as well. For example, in nursing, courses on leader-
ship, conflict management, chronic disease management, clinical practice, and
many other topics offer good opportunities to teach and reflect on interprofes-
sional communication. Each faculty or school should identify these opportuni-
ties and align courses with the IPE curriculum in order to integrate
interprofessional communication in a way that emphasizes certain key messages
and complements others. Furthermore, faculties and schools should identify
and create opportunities and moments for informal exchanges between their
students, with a view to fostering socialization and breaking down barriers
linked to professional identities.
Clinical internships are the ideal opportunity to put into practice the theory
learned during the IPE curriculum. Providing activities in internship settings
that encourage students to work in interprofessional teams in real-life situa-
tions will certainly have a real impact on the development of their communica-
tion skills.
 4 RETHINKING HOW COMMUNICATION IS TAUGHT AS AN INTERPROFESSIONAL… 75

As for clinical settings and workplace learning, professional continuing edu-

cation should consolidate previous academic learning. The development of
learning activities around interprofessional communication could be greatly
enriched by the situations encountered on a daily basis in these environments,
which would once again give them meaning.
And finally, the research community also has a role to play in this quest for
competent communication. Not only is it essential to enrich curricula with up-­
to-­date research findings and evidence, but also to develop validated, easy-to-­
implement, and easy-to-analyze assessment tools to measure communication
competence, which can be used to extract the data needed for continuous
improvement in the quality of interprofessional communication teaching.
In conclusion, effective interprofessional communication improves the qual-
ity of care and patient safety, as well as the satisfaction and well-being of both
professionals and patients. Teaching interprofessional communication to future
professionals helps clarify roles and expertise and it prepares them for effective
teamwork in which clinical and ethical decisions are shared. The challenges of
such teaching are many, but strategies at individual, faculty, and university level
exist and need to be developed or reinforced. Collaboration between the clini-
cal and research communities would help academia in this mission and ensure
the continuity and relevance of the learning provided.

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 PART II

Fundamental Processes and Dynamics of

Interprofessional Communication
 CHAPTER 5

Sensemaking in Interprofessional
Communication

Nina Lunkka, Ville Pietiläinen, Ville Kivivirta,

and Sanna Laulainen

Introduction
To deal with complex patient or client situations, interdependent health and
social care professionals seek to create collective meaning about what is hap-
pening and what they should do next. This requires moments of sensemaking.
Scholars who study sensemaking have identified the process through which
people make decisions (Weick et al. 2005). We suggest that a sensemaking
perspective provides a useful lens for practitioners to understand interprofes-
sional communication. We argue that it is especially useful in the health and
social service sector, which increasingly relies on interprofessional collaboration
practices to provide safe, high-quality, efficient, and effective care and services
to patients and clients (World Health Organization 2010; Fox and Gilbert
2015; Fox and Brummans 2019; Fox et al. 2021).
From a sensemaking perspective, communication is viewed as a social pro-
cess of meaning-making. This means that social reality is created, maintained,
and shaped (i.e., constituted) by the talk and interaction between people (see
Chap. 1). Therefore, we consider communication as occurring among two or

N. Lunkka (*) • V. Kivivirta • S. Laulainen

Department of Health and Social Management, University of Eastern Finland,
Kuopio, Finland
e-mail: [email protected]; [email protected]; [email protected]
V. Pietiläinen
Faculty of Social Sciences, University of Lapland, Rovaniemi, Finland
e-mail: [email protected]

© The Author(s) 2025 83

S. Fox et al. (eds.), Interprofessional Communication in Health and Social
Care, https://doi.org/10.1007/978-3-031-70106-1_5
84 N. LUNKKA ET AL.

more relational parties, where their relationship emerges because of the com-
munication they engage in.
In this chapter, we consider interprofessional communication in situations
that entail a high level of situational complexity and that require shared under-
standing amongst the professionals involved in making shared decisions for the
benefit of the patient or client (i.e., collaborative practice on the right end of
the continuum presented in Chap. 3). Communication in interprofessional
collaboration in such circumstances plays an important role; adaptive interac-
tion skills are usually crucial for effective interprofessional collaboration because
the trajectories of complex patient or client situations cannot be understood or
addressed through the activities of any single professional. Therefore, empha-
sizing the interactional skills of an individual professional, for example, does
not explain how shared understanding of the situation develops, nor where or
how it can fail. A sensemaking perspective enables us to understand how shared
understanding is collectively constituted.
Originally, sensemaking was introduced by organizational theorist Karl
Weick (1995) who conceptualized organizations as dynamic, constantly regen-
erating communicative networks, in contrast to the common view of organiza-
tions as static entities, where the focus is mostly on structure, hierarchy, tasks,
and responsibilities (Langenberg and Wesseling 2016). From a sensemaking
perspective, “organizations” do not exist as stable structures but are in a con-
tinuous process of existing. It is organizational members’ communication that
enables this ongoing organizing (Kreps 2009). Through communication, indi-
viduals and groups make sense of their organizational reality by interpreting
and making meaning of their experiences and constructing their understanding
of the organization and its goals (Cooren et al. 2006). Through such sense-
making, people interpret and give meaning to their collective experiences.
Sensemaking is ultimately an issue of communication through which situa-
tions, organizations, and environments are talked into existence as the basis for
collective action (Weick et al. 2005).
A sensemaking perspective provides a novel and useful way to understand
interprofessional communication and offers a nuanced perspective on the con-
stitutive role of language. It deepens our understanding of how communica-
tion shapes the shared meanings, beliefs, and values that guide decisions,
actions, and behavior within interprofessional collaboration. As such, success-
ful interprofessional sensemaking can help professionals to make sense of
emerging situations. The sensemaking perspective can be used to improve the
quality, impact, and efficiency of interprofessional communication. It can also
assist in identifying communication challenges and opportunities as well as in
informing communication interventions to improve interprofessional commu-
nication in health and social service organizations in general and in interprofes-
sional collaborative practices in particular.
The chapter proceeds as follows. First, we briefly introduce the sensemaking
perspective within the context of interprofessional communication, labeling it
as “interprofessional sensemaking.” Next, we briefly discuss the three central
processes related to ongoing sensemaking, namely enactment, selection, and
 5 SENSEMAKING IN INTERPROFESSIONAL COMMUNICATION 85

retention. We then present the relevance of an interprofessional sensemaking

approach in practice by introducing three ways to support interprofessional
sensemaking. After concluding remarks, we provide an illustrative vignette of
how the issues discussed in the chapter can be understood in practice.

What Is Interprofessional Sensemaking?

High-needs patients and clients greatly benefit from integrated interprofes-
sional practices because they typically need both health and social sector ser-
vices. For example, integrated care planning aims to make sure that high-needs
patients and clients receive comprehensive, coordinated, and effective care.
However, because these care situations are complex, they are sometimes diffi-
cult to make sense of, requiring significant interaction from many parties. The
professionals involved need to identify the problems and challenges of the situ-
ation in order to form a shared understanding that they can address collectively.
Yet, these problems and challenges do not present themselves to professionals
as a given. Instead, the interprofessional team must “construct” them from the
material the situation offers. In other words, to turn information about a com-
plex situation into a problem, professionals need to do a certain kind of work—
they must make sense of it. This sensemaking is a communicative process known
as “problem setting,” through which professionals label problems to which
they then attend and frame the context for action. In this way, professionals try
to understand what is going on, what they think about the situation, and what
they should do (Weick 1995).
Sensemaking involves all the people and practices that are in some way
involved in the development of a given interprofessional care situation. Hence,
as a process, sensemaking takes place not only inside the heads of professionals
(i.e., at an intrapersonal level) and within their interactions (i.e., at an interper-
sonal level) in particular contexts (i.e., at an organizational level), but it can be
considered a systemwide process (Weick et al. 2005). Moreover, sensemaking
is not confined to a single part of a system or organization; it is a holistic pro-
cess that involves all parts of the system in often distributed ways. When sense-
making is distributed, it means that the process of making sense is not confined
to a single individual or a single point in time, but it spreads out across multiple
individuals and over time. This systemwide view emphasizes the importance of
communication to ensuring shared understanding (Callout 5.1).

Callout 5.1 Sensemaking

Sensemaking is a communicative process that documents how profes-
sionals come to understand the complex situations they face in interpro-
fessional collaboration. According to a sensemaking perspective,
professionals are not passive receivers of information, but active creators
of meaning. Drawing upon various cues from the social context and data
obtained from interactions with their colleagues, interprofessional teams
interpret what is going on and then act accordingly.
86 N. LUNKKA ET AL.

Interpretation of abundant and changing information can vary across differ-

ent parts of the organization in ways that are difficult to localize or attribute to
a specific person or group. Hence, interprofessional sensemaking must inte-
grate a variety of information sources, which may include, for example, previ-
ous discussions with professionals not directly involved in interprofessional
collaborative practices, material from a professional training session, or a con-
versation where a patient or client’s relative shares their concerns. For example,
geriatric care for older adults requires collaboration between many professions,
sometimes from many organizations, and communication between the differ-
ent parties involved becomes essential to make sense of the patient’s or client’s
situation.
Hence, communication is crucial in interprofessional sensemaking. That is,
by interacting, professionals try to understand what is going on and to pinpoint
what they think about the situation. In the sensemaking literature, this is
explained by the concept of enactment, which refers to the process of creating
meaning through (inter)action with one’s environment, for instance, by look-
ing for interpretive cues in the patient’s health record. This means that profes-
sionals do not simply react to their environment, but they also interpret and
shape it through their actions, behaviors, and interactions. More specifically,
they enact the meaning of the situation in narrative accounts to share under-
standing of the ongoing circumstances (Weick 1995).
For example, a diabetes nurse may initiate a care plan for a diabetic older
adult with dementia who lives at home with his family and whose foot health
must be carefully monitored. The nurse may then send the care plan to other
professionals, such as the older adult’s primary care physician and home care
worker, thereby proposing a particular interpretation of her client’s situation.
In this way, the diabetes nurse shapes social reality by assigning meanings to the
client’s situation. Yet, the needs of the client are not static but emergent and
changing, which requires repeated sensemaking among the professionals.
Therefore, ongoing, interactive updating of the evolving situation is crucial.
Thus, the professionals involved formulate and exchange their interpretations
about the meanings of the complex situation that they jointly experience.
During the sensemaking process, enactment is followed by selection, which
is the process of choosing among different interpretations or explanations of a
complex situation. Through selection, professionals try to decide which inter-
pretations or explanations are acceptable and relevant to the situation. They try
to find the logic, sense, or reasons for the situation by talking to each other and
sharing their thoughts, feelings, and goals. Such articulation is a social process
whereby professionals attempt to share their understanding of ongoing cir-
cumstances by reducing the complexity of the situation, making it simpler,
ordered, and relevant to the present circumstances. In other words, profession-
als formulate and exchange meanings to arrive at a shared understanding of the
jointly experienced complex situation (Weick 1995; Weick et al. 2005). For
instance, in the case of the diabetic older adult, the care team professionals talk
with one another and recognize that there are multiple challenges, but “select”
 5 SENSEMAKING IN INTERPROFESSIONAL COMMUNICATION 87

as the most pressing problem the need to get the increasingly confused patient
to cooperate with dressing changes.
Retention, the third step in the sensemaking process, involves storing and
remembering the selected meanings for future use. Professionals create inter-
pretive tools or shortcuts such as mental models, stories, rules, or routines that
capture the essence of the meaning they ascribe to a situation. These interpre-
tive tools can then guide their future actions. They can also be shared with and
communicated to others. In this way, professionals do not need to actively
make sense of every single situation they encounter. Retention is important for
maintaining coherence and consistency in the face of complex situations with
multiple potential interpretations. Retention is also a source of learning and
adaptation, as professionals can modify or discard their existing meanings based
on new experiences or feedback (Weick et al. 2005). To return to our example,
perhaps the home care worker remembers from working previously with the
older adult’s family that the granddaughter is the one who is best able to get
the patient to cooperate and submit to examination of his feet, but that she is
only home on Tuesdays. The team then writes this solution in the case notes
and thereby “retains” this solution for next time.
Complex and dynamic care situations therefore require constant communi-
cation between different parties. Such circumstances require professionals to
create, maintain, or alter the meanings of the situation to address what is cur-
rently identified as the problem and to form a shared understanding of what
they should do to solve it and thus improve the situation. The concept of
interprofessional sensemaking describes these processes and provides concep-
tual tools for practitioners to understand how meanings, which serve as the
basis for problem solving, decision making, and actions, are created and shaped
collectively.
In the next section, we provide three recommendations that we think are
relevant for successful interprofessional sensemaking. The processes of enact-
ment, selection, and retention are related to these recommendations in several
ways (Callout 5.2). First, we suggest that when forming a shared understanding

Callout 5.2 Enactment-Selection-Retention

Sensemaking includes processes of enactment, selection, and retention.
Enactment refers to the process by which professionals “create” their
environments through their actions, that is, by searching for and reading
the cues in their environment. This produces the needed information
that collaborators can then make sense of. Selection involves interpreting
the information that has been enacted. This entails the creation of a plau-
sible narrative of the situation using the chosen cues. In retention, orga-
nizational members will tend to retain this narrative explanation of the
situation if it continues to help them make sense of the ongoing situation,
which affects future processes of enactment and selection.
88 N. LUNKKA ET AL.

of the emerging situation, professionals should avoid over-simplification so that

they are able to gain a more complete, nuanced picture of what is happening.
For this to happen, they must make room for the enactment of multiple mean-
ings in their interprofessional interactions, to inform how they frame the situa-
tion. Second, we suggest that trust building is intertwined with successful
interprofessional sensemaking. Trust enables professionals to express diverse
understandings of the situation, rather than homing in too quickly on one
shared understanding, which may be the one that comes from the person at the
top of the professional hierarchy. Finally, we think that it is just as important to
pay careful attention to how the emergent situation unfolds—that is, the situa-
tion as process—as to the care plan itself or the accuracy of decisions. This is
because selected and retained meanings need to be altered or changed as the
situation evolves to correspond to the patient’s or client’s needs.

Enhancing Sensemaking
in Interprofessional Communication

Because the steps in the sensemaking process can seem abstract and compli-
cated, practitioners may not immediately see how they could apply them to
their practice and use them to improve interprofessional communication. To
help in this regard, we make the following three recommendations where we
assess how the basic principles of interprofessional sensemaking can support
successful interprofessional collaboration. We hope that practitioners will be
able to grasp the constitutive nature of interprofessional sensemaking through
these recommendations.

Avoid Simplification
As mentioned above, interprofessional collaboration addressing complex situa-
tions requires professionals with different clinical backgrounds, knowledge,
and expertise to develop a shared understanding of what is going on, what the
problem is, and what should be done about it. Creating shared understanding
necessitates active participation and interaction from all involved. However,
each professional, by virtue of their training, likely has a particular view of the
situation that they apply in their work. As a result, each professional typically
makes sense of the situation differently and therefore they will think and act
using a different logic.
This is a crucial issue to understand when thinking about interprofessional
sensemaking, because diverse views of a complex situation easily create multiple
interpretations (that is, different professionals can enact a situation differently).
Although interprofessional collaboration requires members of the care team to
develop some level of shared understanding so that the various elements of the
care plan are well coordinated, diversity is actually desirable because it allows
different perspectives on complex situations to be brought to the fore.
 5 SENSEMAKING IN INTERPROFESSIONAL COMMUNICATION 89

At the beginning of the sensemaking process, during enactment, diverse

perspectives can contradict each other. Through the selection process, profes-
sionals aim to reduce these multiple, sometimes contradictory, interpretations
to simplify the situation to make sense of it. Yet, in complex situations, profes-
sionals should be reluctant to accept simplifications too quickly (Weick and
Sutcliffe 2001). Professionals should deliberately create a more nuanced and
complete picture of the situation because if they simplify less, they see more.
Likewise, it is important to consider diverse interpretations of the situation and
embrace different opinions in a way that does not dismantle the nuances that
various professionals detect (Weick and Sutcliffe 2001). This is particularly
important in healthcare, where it can be easy to rely on the opinion of a profes-
sional higher up in the hierarchy. For example, in the case of the older, diabetic
adult, it was crucial to consider the opinion of the home care worker who had
knowledge of the family dynamics.
Therefore, it is essential that each professional creates space so that the voice
of other professionals can be heard. Making space is a prerequisite for interpro-
fessional sensemaking to happen. In practice, this means that it is important to
be able to lay one’s own professional role and discipline aside when needed and
become interested in the way other professionals think. Each participant ought
to detach themselves from the perspective of their own profession and draw on
the expertise of others to expand their own understanding. The aim is to bring
different views into contact with each other, so that they can be tested together.
This not only brings new elements to the case at hand, but also new models of
solutions and interventions that take into account the patient or client’s life
circumstances and unique characteristics.
Such collaboration requires that professionals are ready to question their
own perceptions, which further requires confidence and trust. Only then can
collaborators reach a deeper level of understanding of others’ thoughts, goals,
and practices. Hence, to avoid simplification in interprofessional sensemaking,
it is vital that professionals adopt an attitude that supports the emergence of
multiple voices. It is important to recognize and understand one’s own role
not only as a professional transmitting information to other professionals but
also as a part of a collective that produces something new about the complex
situation, through communication.

Build Trust
Interprofessional work entails a high level of interdependence and typically
requires intensive collaboration. In such circumstances, communication is
based on a relationship of trust. Trust means that professionals feel that other
professionals are honest, act in good faith and in line with previously agreed
upon commitments and decisions, and do not act opportunistically (Louis
et al. 2009). Trust allows professionals to dare to test their thoughts and under-
standing without threatening their professional face. In practice, this means
that different professionals are interested in each other’s views, opinions, and
90 N. LUNKKA ET AL.

experiences, and that they want to learn from each other, actively seeking out
multiple perspectives and fostering styles of dialogue that create debate (Jordan
et al. 2009). If there is trust, professionals are more inclined to express their
views, sentiments, and thoughts. Trust establishes a setting in which emerging
issues may be discussed and resolved openly and candidly.
Trust is crucial in interprofessional communication because people are more
likely to divulge relevant and complete information in high-trust situations
(Louis et al. 2009). Trust can establish a sense of safety that in turn supports
communication, critique, and examination of taken-for-granted assumptions
(Louis et al. 2009). Hence, trust makes collective action, such as interprofes-
sional sensemaking, more feasible. However, from a communication-as-­
constitutive perspective, trust is not about the qualities that create
trustworthiness in a given individual, nor is it an isolated, static phenomenon
(Näslund 2016). Instead, interactions constitute the trust-building process:
Trust is not achieved by a solo act of a single professional but is created in
interaction with other professionals (Näslund 2016). Trust can thereafter be
strengthened, weakened, broken, lost, and regained through interaction
(Näslund 2016). Such interaction can be represented using the metaphor of a
dance, which involves continuous movement and mutual adaptation where
each professional matches their steps to the other professional’s steps.
We conclude, then, that shared understanding is not limited to deciphering
the actions of others but emerges from the collective sensemaking process of
interacting professionals. It is thus important to be aware of how you interact,
not only what information you aim to transmit. Through collective sensemak-
ing, meanings are generated and transformed in the interplay among interact-
ing professionals and the interaction process itself (Fuchs and De Jaegher
2009). Trust-building is therefore intertwined with successful interprofessional
sensemaking and related to avoiding simplification. Professionals must have
enough mutual trust to make room for multiple meanings of a situation to be
enacted; only then can they glean more interpretations from the situation and
form a shared understanding in a way that avoids simplification. At the same
time, professionals may feel frustrated, insecure, or even angry when they
believe that other professionals do not understand what they mean, or that
things proceed too slowly or in the “wrong” direction. In such cases, interpro-
fessional collaboration can trigger negative emotional reactions that are likely
to adversely impact trust and the quality of their current and future interactions.
However, even negative emotions can be harnessed for the benefit of collec-
tive sensemaking when interprofessional teams have sufficient space to deal
with emotional issues. In fact, negative emotions may indicate that something
does not quite make sense and should perhaps be explored further (Maitlis
et al. 2013; Lunkka et al. 2017). For example, in a situation where a profes-
sional is hesitant to share their thoughts, it is helpful if other professionals act
in a way that reduces these insecurities and encourage others to speak up. Here,
other professionals need to be mindful of the reactions and responses of the
professional who seems reluctant to voice their thoughts. They need to reflect
 5 SENSEMAKING IN INTERPROFESSIONAL COMMUNICATION 91

on what the hesitant professional is stating (or not stating) and what meanings
they are enacting, thereby making room for or shifting the meanings emerging
within the interaction. All this requires trust and space to work through emo-
tional issues together.

Pay Attention to the Process

Since the situations of high-needs patients or clients are not static but evolve
over time, misunderstandings or even errors in interprofessional care can occur.
Careful care planning and structured documentation are ways of managing
misunderstandings and reducing the likelihood of errors in interprofessional
collaboration. However, relying too strictly on plans may lead professionals to
overlook the emergent nature of a complex situation. While at one point in
time selected interpretations might work and be viewed as “appropriate,” when
situations are emergent and evolving, interpretations typically change, develop,
or shift over time. Therefore, what was the “correct” decision in the past may
become incorrect in the present (Weick et al. 2005).
Hence, over-reliance on a care plan, for example, may lead professionals to
pay insufficient attention to the “nuts and bolts,” small changes occurring dur-
ing the evolving situation that hint that circumstances have likely changed.
Therefore, it is important to pay careful attention to the evolving situation, in
another words, to the ongoing process. We return here to our earlier example
where a care plan was initiated to ensure monitoring the status of foot health
of an elderly diabetic adult. In the plan, the granddaughter was identified as the
person who was able to get the older adult to accept examination of his feet.
Once the care plan was in place, the home care worker noticed that the exami-
nations did not seem to be taking place as intended and there was increasing
concern about potential foot sores. She informed the care team, and they dis-
cussed how to proceed. They decided to consult the wound nurse, who noticed
that his feet required more active, daily care. Although the granddaughter was
selected as the best option to get the older adult to agree to examinations, she
was not the best option for actual wound care. The team was able to alter the
previously selected and retained meaning of the situation to make more
nuanced sense of it. With the help of the granddaughter, the wound nurse was
able to convince the patient that from there onwards, the home care worker
would provide care according to the wound nurse’s instructions.
As the example above showcases, in interprofessional sensemaking, interac-
tion is important because this is how professionals can test their interpretations
of the emergent situation, learn from their experiences, and alter the selected
and retained meanings if necessary. At the same time, this can be difficult
because interprofessional sensemaking sometimes requires professionals to act
outside their professional comfort zone. It requires professionals to pay atten-
tion to how an ongoing situation unfolds and to allow, or even encourage,
alternative interpretations of the situation to emerge. This requires the ability
to revise their own previous beliefs and thoughts and the humility to acknowl-
edge that someone else might know more than they do (Weick et al. 2005).
92 N. LUNKKA ET AL.

Therefore, central to interprofessional sensemaking is that professionals

actively and continuously update each other on what is happening. It becomes
important to “live” with the emergent situation, which requires constant atten-
tiveness to the patient’s or client’s condition and the ability to change the
selected interpretations that are retained either in collective memory or in
patient records, for example. This calls for professionals to communicate their
hunches to other professionals if something does not seem or feel quite right.
Interprofessional sensemaking also relies on the ability to make tacit knowledge
explicit so that it can be communicated to other professionals in a persuasive
manner (Weick et al. 2005).
To foster continuous updates, there should be room for more than one-way
information sharing in interprofessional communication. Structural factors that
support interprofessional sensemaking include a team and organizational cul-
ture that supports seeking and receiving feedback, sharing information, asking
for help, and talking about errors or misunderstandings. The possibility of
reflecting together on the situation and what is happening becomes crucial.
This requires time and space for interprofessional sensemaking that neither the
organization nor the team should perceive as time taken away from “real” work.

Concluding Remarks
Interprofessional sensemaking offers an approach to understanding the consti-
tutive role of communication in interprofessional collaboration. This approach
helps practitioners comprehend that interprofessional sensemaking shapes
shared understandings that guide interprofessional collaboration in practice. It
can likewise help with recognizing the challenges of interprofessional commu-
nication in health and social care. A sensemaking approach is particularly useful
for health and social care professionals who confront complex situations with
diverse information inputs.
In this chapter, we make three recommendations for practitioners that we
think enable successful interprofessional sensemaking: to avoid simplification
while making sense of a complex situation; to enhance trust-building in inter-
professional communication; and to pay careful attention to the process, as the
situation unfolds. Furthermore, we illustrate how the three sensemaking-­
related processes—enactment, selection, and retention—play out in our three
recommendations. We hope that in this way we have been able to explain to
practitioners how interprofessional communication is a collaborative process of
creating shared awareness and understanding out of different individuals’ per-
spectives and varied interests in emergent and complex situations.
As our recommendations demonstrate, interprofessional sensemaking requires
that certain elements be considered. First, professionals need to understand that
their role in interprofessional collaboration involves more than information shar-
ing or formulating clear information to be transmitted to other professionals.
Rather than focusing on what is communicated and how clearly the information
 5 SENSEMAKING IN INTERPROFESSIONAL COMMUNICATION 93

is transmitted, interprofessional sensemaking emphasizes how professionals inter-

act and how they position themselves within the interactional process.
Given the central role that interaction plays in interprofessional communica-
tion with regard to complex situations, professionals need to learn to assess and
reflect on how their colleagues may interpret and react to their tone of voice,
nonverbal gestures, perceived openness, honesty and interpersonal warmth,
and their ways of expressing emotions (e.g., doubts, uncertainty, or surprise).
Colleagues’ ways of being affect the quality of the interactional process and, by
extension, the variety and richness of meanings that guide and underpin inter-
professional collaboration. At the core of this is mutual trust building, which,
in turn, is intertwined with successful interprofessional sensemaking.
In this regard, we can think of interprofessional sensemaking is something
like a jam session, as Weick (1998) described: Jazz musicians listen to one
another to make a jam session work, to shut out distractions, and finally to build
something together. We think this is at the core of interprofessional communi-
cation, which is a flexible and dynamic process that requires trust to occur.
Overall, this means that professionals must take shared responsibility for the care
process from start to finish (even if responsibility for decisions cannot be shared)
because successful collaboration requires shared ownership of the whole process.

Making Sense of Complex Needs

The following is a fictional vignette that illustrates the sensemaking process in
interprofessional networking. A single mother brought her 12-year-old child,
Emma, to their physician’s office. Emma tells the physician that she often loses
her strength and sometimes gets dizzy. She says she does not always really under-
stand what is going on around her. Emma receives referrals for blood tests, among
other things, but there are not sufficient grounds for a diagnosis. The following
week, neighbours find Emma wandering in front of the family’s flat, confused and
wearing only her underpants. They found no signs of intoxication or drug use but
made a child protection report just in case. The municipal social worker has not
identified any signs of neglect, but Emma’s mother says she is so tired that she
does not always have the energy to look after Emma as she would like. She does
not understand what is wrong with Emma. Also, Emma’s teacher has been wor-
ried that she has now passed out several times at school, seems depressed, and has
started to stutter. Emma has been referred from school to a psychologist, but the
psychologist has not identified any clear grounds for a psychological diagnosis.
Emma has not received any special or extended support at school, but the school
has agreed that a special education teacher will “keep an eye on her.” A week later,
Emma was caught after stealing an energy drink from the nearby shop.
The school psychologist convenes a multidisciplinary network meeting to
review Emma’s situation. The team meeting involves the child, her single
mother, a social worker, school psychologist, school nurse, physician, and
speech therapist. The multifactorial complexity of the situation requires the
team to switch into interdisciplinarity and shared practice (see Chap. 3) to
94 N. LUNKKA ET AL.

collectively figure out what to do with the situation. During the meeting,
which can be understood as the enactment phase of their collective sensemak-
ing, each member of the group articulates their own perspective on the situa-
tion, and each professional seeks to attain their own professional objective. The
physician and the psychologist first consider that further investigations in the
hospital could bring clarity to Emma’s situation. The speech therapist suggests
a series of counselling sessions with accompanying speech exercises. The social
worker considers how the mother could possibly be given more support. The
school nurse is worried about Emma’s nutrition and its possible impact on
depression. She also thinks that Emma’s social relationships may have an impact
on the situation. The mother is crying and seems unable to cope. Emma seems
distressed because she has caused so much trouble for others. Overall, partici-
pants of the team meeting are clearly unable to define the problem situation
and do not know how to proceed.
However, the participants manage to avoid over-simplifying the situation by
focusing on a holistic understanding of the child’s perspective. First, the social
worker asks Emma, “Can you imagine a situation a year from now, and things
have got better for you? What would have happened then?” Emma is initially
reluctant to start but then says, “I have slept better. It may have helped that I
don’t feel so dizzy.” At this point, the school nurse asks, “Where did you get the
support to make this good progress?” Emma thinks longer at this point. “The
best support has been that the teacher understood me, and the school has not
demanded so much. When less was demanded from me, I could concentrate
better. My mother has also been more supportive because she has not so much
to do.” At this point, the mother asks Emma, “What worried you most that
year, and what would make you worry less?” To this, Emma replies, “I worried
most about you when you were so tired. I was happy when you got more help
and support from others.” Other experts also ask the girl additional questions.
After listening to the child, the professionals move on to the selection phase
by starting to think about a joint action plan. Their open-ended questions have
laid the groundwork for the trust-building process, as they aim to consider the
child’s experiential understanding of what the problem is, rather than homing
in on any professional’s specific knowledge. More importantly, their open-
ended questions engage the child in the trust-building process. Based on
Emma’s story, the participants begin to think about the school’s role and the
mother’s situation. Regarding school, they note that the rhythm seems too fast
for Emma. There also seem to be too many distractions. At the same time, they
note that Emma is not receiving any special or enhanced support at school. The
psychologist and the physician start to consider possible further investigations
from a slightly different angle, with an emphasis on neuropsychological tests
rather than laboratory tests. At the same time, the social worker recognizes that
a peer network of parents she is guiding could be helpful for the mother. She
also considers the possibility of involving a family worker to provide additional
support. The selection phase concludes with further clarification about the
actions to be undertaken, and the interprofessional collaboration group agrees
 5 SENSEMAKING IN INTERPROFESSIONAL COMMUNICATION 95

to have a follow-up meeting in six months. Emma’s mother also has the option
of calling a group meeting earlier if the situation takes a turn for the worse.
After the meeting, as a result of discussions about how Emma’s education
could be better organized to meet her individual needs, Emma was placed in
special education and given a personalized educational plan. Her mother
attended the network meetings the social worker suggested. In addition, Emma
had access to a couple who acted as family workers once a month.
Six months later, the action plan is evaluated in a follow-up meeting. The
school nurse does not attend this meeting, but the school’s special education
teacher has stepped in to replace her. First, the mother says that her fatigue
improved considerably after talking to other parents in a similar situation,
thanks to peer support. Emma is relieved that her mother has not been so tired.
She also really enjoyed visiting the family worker couple. Emma’s speech
impediment is still present to some extent but neither the child nor her school
considers it to be an important disturbance. However, Emma says that special
education has been quite boring. She says she is now ready for more challenges.
The interprofessional collaboration group now begins to consider a possible
return to regular or extended support education. Sensemaking starts again,
more structured and refined from the starting points as the child and the pro-
fessionals have already learned about the process.

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 CHAPTER 6

Foregrounding the Relational Dimensions

of Interprofessional Collaboration:
A Communication Perspective

Kirstie McAllum, Stephanie Fox, Laura Ginoux,

and Léna Meyer

Introduction
Professional differences and the interdependence required by collaborative care
can make interprofessional relationships challenging. Yet, interprofessional col-
laboration requires the development and maintenance of multiple relation-
ships—with other healthcare providers, supervisors, peers, as well as patients
and their families who need to be considered as part of the team. Poor or dys-
functional relationships can impede collaboration, negatively affect how inter-
professional teams work together, and diminish the quality of patient care.
Negative workplace interactions also increase workers’ stress and the possibility
of burnout, a major problem for healthcare workers (Adriaenssens et al. 2017).
Strong relationships, by contrast, tend to contribute positively to all four goals
of the Quadruple Aim (Bodenheimer and Sinsky 2014), a document that
establishes four overarching goals to guide U.S. health care efforts and reforms:

K. McAllum (*)
Department of Media and Communication, Te Whare Wānanga o Waitaha | the
University of Canterbury, Christchurch, New Zealand
e-mail: [email protected]
S. Fox • L. Ginoux • L. Meyer
Département de communication (Department of Communication), Université de
Montréal, Montréal, QC, Canada
e-mail: [email protected]; [email protected];
[email protected]

© The Author(s) 2025 97

S. Fox et al. (eds.), Interprofessional Communication in Health and Social
Care, https://doi.org/10.1007/978-3-031-70106-1_6
98 K. MCALLUM ET AL.

reducing healthcare costs, developing population health, enhancing patients’

experience, and ensuring collaborators’ wellbeing.
In light of the importance of the quality of relationships for achieving these
outcomes, this chapter explores relational dimensions of collaboration and
their grounding in communication practices. If relationships are “ongoing
entities defined by patterned interaction that occurs over time” (Sias 2014,
375), we can assess the quality of what interprofessional collaboration can
achieve by examining the communication that holds it together. The literature
often identifies two distinct orientations to collaboration: whether collabora-
tors hold a task orientation or a relationship orientation (e.g., Keyton and Beck
2009). By orientation, we mean the focus of energy and attention by collabora-
tors and other stakeholders with regard to interprofessional collaboration. A
task orientation concentrates on how collegial relationships enable collabora-
tive work to get done more efficiently and effectively. A relationship ­orientation
looks at how members of interprofessional teams build and consolidate positive
interpersonal relationships in the context of their collaboration. Institutional
discourses often grant considerably more importance to a task o ­ rientation,
which is not surprising given the imposed need to do more (e.g., provide more
services for an aging population with complex health and social care needs)
with less (e.g., cope with limited public funding or funding that privileges mea-
surable outcomes as well as short-staffing and high staff turnover). However, a
relational orientation is just as important to collaborative success and especially
to occupational wellbeing (Haskins et al. 1998).
In practice, the task (or content) and relational dimensions of communica-
tion are intertwined and present simultaneously (Valo and Mikkola 2020). For
example, imagine a situation where a nurse feels uncomfortable interrupting a
doctor who has come to look at a patient’s chart due to a professional hierarchy
that privileges the doctor’s time and expertise over the nurse’s. The asymmetry
in their interprofessional relationship can impede information-sharing (a task-­
oriented problem that reduces collaborative efficacy) and might indicate a lack
of interpersonal connection (a relationship-oriented issue). Analytically speak-
ing, however, the literature on the relational dimensions of collaboration often
emphasizes one orientation or the other. Moreover, each orientation views
communication differently. A task orientation often draws implicitly or explic-
itly upon the transactional model of communication (see Chap. 1):
Interprofessional team members’ collaboration breaks down or is suboptimal
because their style of workplace communication does not facilitate or under-
mines the development of shared mental models and trust, and thus they can-
not “make” meaning together. In contrast, a relationship orientation more
frequently relies on a constitutive approach to communication. Here, commu-
nication is what creates and shapes interprofessional, role-based, and interper-
sonal relationships.
Hence, we consider both orientations separately in this chapter, which is
divided into three parts. We begin with an overview of theories of workplace
collaboration that adopt a task orientation. These theories assert that by
 6 FOREGROUNDING THE RELATIONAL DIMENSIONS OF INTERPROFESSIONAL… 99

improving interprofessional communication, members of different professional

groups with high levels of task interdependence are able to develop and main-
tain high quality work relationships and work together more effectively. The
second part of the chapter focuses on relational challenges that can undermine
the effectiveness of task-based interprofessional collaboration, namely role
understanding and trust. Finally, in the third part of the chapter, we turn our
attention specifically to a relationship orientation to interprofessional collabo-
ration, discussing how mutually supportive, compassionate communicative
practices can build positive interprofessional relationships (Callout 6.1).

Callout 6.1 Orienting to Collaboration

A task orientation to collaboration sees work relationships as an effec-
tive means to an end to get work done. The intended outcome is work-­
centered: to develop shared goals, to improve decision-making processes,
and to improve the quality of care. Relationships are not based on inter-
personal ties but on work roles. In contrast, a relationship orientation
to collaboration views supportive relationships as a goal in itself: an
ongoing commitment to supporting others that serves as a significant
source of synergy and harmony. The intended outcome is person-­
centered: to improve wellbeing and the quality of work relationships.
These relationships are supported through the interpersonal enactment
of respect, trust, compassion, humility, active listening, and social support.

A Task Orientation to Collaboration: Building Solid

Relationships to Get Work Done
Theories of workplace collaboration that adopt a task orientation focus on
improving role-based work relationships so that collective meaning-making,
interprofessional decision-making, and team-based interventions occur more
smoothly. Integrating the tasks of multiple professionals is especially important
in health and social care contexts where there is a high level of interdependence
and uncertainty, and work processes are subject to time pressures, such as in a
busy emergency department. A good example is Gittell’s (2006) theory of
relational coordination. Gittell describes relational coordination as a way of
communicating that strengthens the ties between people who work together,
improves work processes, and benefits patients, workers, and their employers
(Bolton et al. 2021). Thus, relational coordination involves not only “the man-
agement of interdependence between tasks but also the management of inter-
dependence between the people who perform those tasks” (Gittell 2014, 1). In
other words, interprofessional collaboration is not only about fitting together
the different elements of care, but also about how the people putting the puz-
zle together relate to one another. Importantly, Gittell (2014) insists that these
relationships are not based on interpersonal ties but rather ties between
work roles.
100 K. MCALLUM ET AL.

Specifically, relational coordination theory proposes that frequent, timely,

and accurate communication that is focused on problem-solving generates
shared goals, shared knowledge (or mental models), and mutual respect within
the interprofessional team. The theory also contends that this type of commu-
nication reinforces team members’ ability to develop shared goals, shared
knowledge, and mutual respect. Such communication strengthens professional
relationships and enables effective and efficient task integration. Shared goals
and shared knowledge help workers to step outside their professional silos and
engage in holistic systems thinking, where team members see how their contri-
bution connects and supports the contributions of others and can thus act with
regard for the whole. Mutual respect is what helps fit all the pieces together and
establish collegial relationships even in the presence of barriers like status dif-
ferences. For example, an older immigrant recently diagnosed with Type 2
diabetes after joining his son and daughter-in-law through a family reunifica-
tion program will need input from his family doctor, a dietician, a diabetes
nurse who will teach him to monitor his glucose levels, and a community health
worker who can help him manage his new diet in a way that is culturally appro-
priate for him. By respectfully sharing information and making adjustments
when necessary, these collaborators—including the patient and his family—can
coordinate their efforts and establish an appropriate care plan.
Conversely, Gittell (2014) contends that narrow and profession-specific
goals (e.g., the dietician proposes a meal plan that doesn’t account for the fam-
ily’s cultural norms), exclusive knowledge (e.g., the nurse cannot access the
doctor’s notes), and lack of respect (e.g., the doctor ignores the role played by
the community health worker who comes from a similar cultural context to her
client) leads to infrequent, delayed, and inaccurate communication as well as
poor quality handoffs and a tendency to blame others for errors or omissions.
In the example above, failure to coordinate the team’s expertise and efforts will
likely compromise the man’s ability to manage his blood sugar levels.
An important argument of relational coordination theory is that organiza-
tional supports and interventions that cut across professional groups may
enhance relational coordination. These might include opportunities for inter-
professional education, interprofessional team meetings, electronic medical
records accessible by multiple professional groups, and the promotion of lead-
ers who focus on relational quality. While such initiatives can improve collective
performance, they simultaneously rely on collegial relationships to be effec-
tively implemented. Indeed, initiatives can be thwarted by weak relational
coordination. Gittell and colleagues have since suggested that collegial rela-
tionships and relational coordination can be fostered through communication
interventions by organizational leaders such as coaching and feedback strate-
gies to help establish new ways of relating among colleagues with a history of
working together (Bolton et al. 2021).
One reason why relational coordination theory is useful is that it provides
tools for managers and health and social care professionals to evaluate the qual-
ity of their communication and relationships within their interprofessional
 6 FOREGROUNDING THE RELATIONAL DIMENSIONS OF INTERPROFESSIONAL… 101

workgroup, in particular a quantitative survey developed by Gittell around

seven key questions (e.g., “When there is a problem with the work you do
together, do the people in the groups you work with blame others or work with
you to solve the problem?” and “Do people in these groups respect your role
in the work you do together?”). The survey results provide an overall snapshot
and benchmark measure of the extent of relational collaboration within an
interprofessional team at a given point in time, as well as an indication of an
interprofessional team’s strengths (e.g., a collective focus on solving the prob-
lem at hand rather than blaming individual team members for gaps or over-
sights in care) and areas that need more work (e.g., a lack of awareness of
others’ work roles). Improving relational coordination seems to have positive
effects for workers as well as patients and organizations: House et al.’s (2022)
scoping review found a positive link between relational coordination practices
and job satisfaction, engagement at work, and reciprocal learning among
healthcare professionals, as well as less burnout and lower turnover rates.
Nonetheless, relational coordination theory has several limitations. First of
all, the theory appears to be most applicable to teams and collaborators who
have a history of working together. It presumes that this collaborative history
gives collaborators the opportunity and time for recurring interactions through
which the meaning of their relationships and trust can be built. While allocat-
ing time and resources is often identified as key to establishing effective inter-
professional collaboration (Morgan et al. 2015), in many instances,
interprofessional collaborators have zero history working together. Yet these
collaborators still have to establish some kind of relationship even as they focus
on accomplishing tasks. However, an organizational culture that supports
interprofessional collaboration can foster this kind of zero-history collabora-
tion by ensuring that professional roles are well understood by all. A second
limitation is that relational coordination theory seems to assume that more
frequent interactions mean more trust and respect among collaborators.
However, more familiarity can sometimes decrease rather than increase respect.
Indeed, having a history of conflict with a colleague is an important predictor
of future conflict. A third limitation is that the theory seems to put all three
outcomes—shared knowledge, shared goals, and mutual respect—on the same
level. Yet, expressing mutual respect is a key facilitator for building shared
knowledge and establishing shared goals. Finally, the theory’s task orientation
can be seen to instrumentalize work relationships, whereas the Quadruple Aim
suggests that wellbeing in collaborative relationships ought to be a goal in itself.
Critiques aside, relational collaboration theory acknowledges that it is chal-
lenging for collaborators to build shared goals, shared knowledge, and mutual
respect, especially in interprofessional contexts where team members do not
necessarily know each other well before they need to collaborate. The follow-
ing section outlines two challenges frequently identified in the interprofessional
literature that all interprofessional collaborators face, irrespective of the length
of their relational history: role awareness and lack of trust.
102 K. MCALLUM ET AL.

Relational Challenges that Threaten Task Orientation:

Role Awareness and Trust in Interprofessional Teams

Role Awareness
Role awareness refers to collaborators’ awareness and comprehension of other
professionals’ scopes of practice and their team or professional roles in provid-
ing patient care (Suter et al. 2009). Sometimes referred to as role clarity, it is
considered a key interprofessional competency (Canadian Interprofessional
Health Collaborative (CIHC) 2010). However, lack of role awareness can lead
to conflict in interprofessional relationships and diminish the quality of patient
care. Complicating matters is the fact that formal professional role demarca-
tions can sometimes be blurred. Role blurring occurs when members of an
interprofessional team have overlapping mandates or complementary profes-
sional expertise, which can lead to disciplinary crossover: Several professional
groups could claim responsibility for the same or similar tasks. For instance,
paramedics must document a patient’s history and symptoms on route to the
hospital, and emergency department nurses must also ask the patient identical
questions on arrival. Similarly, in some jurisdictions, family physicians, nurse
practitioners, and pharmacists can all prescribe smoking cessation aids, vac-
cines, or medication to treat shingles in primary care. Role blurring can be seen
both as beneficial for efficiency of and access to care but also as relationally
straining, especially if some professions perceive it as encroachment on their
scope of practice (Macnaughton et al. 2013).
Lack of role awareness is another challenge to relationships in interprofes-
sional collaboration. It occurs when interprofessional collaborators misinter-
pret or do not know the scope and content of others’ jobs or fail to see what
role others could play in care. For instance, Fox et al. (2021) noted that physi-
cians in family medicine clinics sometimes conflated the roles of social work
and psychology when referring patients for mental health or community ser-
vices. This led to irritation and unwillingness to collaborate among some of the
professionals whose roles were misunderstood. Indeed, role blurring and lack
of role awareness become problematic when interprofessional collaborators
think that members of other professional groups encroach on or do not respect
their role. For instance, paramedics may feel slighted and react angrily when
their documentation is ignored, as though their observations, insights, and
expertise are worthless for staff in the Emergency Department. Similarly, family
physicians may find it challenging to integrate nurse practitioners in their prac-
tices, especially when institutional guidance about their professional role over-
laps is unclear or conflicts with time pressures (Fox et al. 2023). Such ambiguity
about respective responsibilities can have negative consequences not just for
patients (e.g., service duplication or gaps), but also for organizations, such as
when some professionals’ expertise is under-utilized or when it leads to team
 6 FOREGROUNDING THE RELATIONAL DIMENSIONS OF INTERPROFESSIONAL… 103

conflicts and tension (Ly et al. 2018). Differing role interpretations can gener-
ate conflict about how tasks should be accomplished, as well as about relative
status, potentially leading interprofessional colleagues to push back against the
current authority structure and distribution of roles and responsibilities.
To avoid these issues, role clarification is essential (CIHC 2010). This entails
professionals explaining their own role and learning the roles of others through-
out the care trajectory. An important component of role clarification for teams
and collaborators is collectively finding the necessary equilibrium between
interdependence and autonomy (Suter et al. 2009; Macnaughton et al. 2013).
Interdependence entails establishing mutual agreement about moments where
expertise overlaps, whereas autonomy requires each group to recognize and
respect others’ profession-specific strengths.
What is also essential to developing role awareness are the time and rela-
tional expertise needed to become familiar with what is important for other
professional groups, such as their goals, resources, and expertise. Relational
expertise requires recognizing “what engrosses others, taking their standpoint
and mutually aligning motives so that engagement continues” (Edwards 2012,
25). For instance, a care coordinator on a surgical ward needing to discharge a
patient with complex post-surgical needs must be attuned to a variety of pro-
fessional and organizational concerns, such as the charge nurse’s need to ensure
beds are available for upcoming surgery patients and the social worker’s frus-
tration when home care services are not available in the patient’s area. The
solution might be to find temporary care in the community to free up the
surgical unit bed but still keep the patient safe. However, it takes role under-
standing, awareness of others’ preoccupations, and communication for the
team to arrive at this solution.
It also important to acknowledge the difference between a professional role
and a team role. A professional role is typically institutionally negotiated and
regulated, delineating a profession’s scope of practice. A team role has to do
with one’s status and responsibility on the team, such as leading meetings even
if one doesn’t occupy a formal leadership role, such as ward manager. Team
roles are often negotiated through interactions over time, but they also inter-
twine with professional roles, especially in what has been called “plug-and-play
teaming” (Faraj and Xiao 2006), where a professional steps into a team to
perform a particular professional role, for instance, a substitute anesthesiologist
joins a surgical team for a week. While the anesthesiologist likely knows their
professional role well, they may feel less comfortable in their team role in the
operating room at this particular hospital. Those who do not have to work with
the same group of professionals on a regular basis may feel less motivated to
invest effort, time, and energy negotiating their team role.
Ultimately, however, delineating roles and understanding other team mem-
bers’ concerns and reasons for acting is not enough. It requires trust, an issue
to which we now turn.
104 K. MCALLUM ET AL.

Trust
Positive collaborative interactions and relationships can develop when team
members trust each other, and vice versa. Trust is obviously a necessary compo-
nent of the therapeutic relationship between healthcare provider and patient
(Gilson 2006), but when it comes to trust among team members, it is more
difficult to pinpoint its conceptual contours and empirical manifestations. While
definitions of trust vary widely, some commonalities can be identified. First,
trust involves some kind of evaluation of another, especially that the other will
perform an expected action or behavior competently. Second, trust is relational;
it is “a voluntary response to a set of expectations about how the person trusted
will behave in relation to you in the future” and that they “will have concern for
your interests” (Gilson 2006, 360). Third, it involves vulnerability and risk due
to uncertainty about “the motives, intentions, and prospective actions of oth-
ers” (Kramer 1999, 571) on whom one depends. Interprofessional trust is often
thought to lead to more efficient communication, because collaborators can use
a “shorthand” based on shared ideology and mental models and can thus trans-
mit information more easily and quickly (Varpio and Regehr 2013).
Kramer’s (1999) typology of types of trust describes how trust—and par-
ticularly professional trust—develops. History-based trust, which is based on
cumulative interactions over time, is only possible for interprofessional teams
who work together on a longer-term basis. Moreover, this slowly building type
of trust is more likely if colleagues are predictable, reliable, and consistent in
their behavior (Lewicki and Wiethoff 2006). For instance, a nurse at the
Emergency Department who notices over the course of several months that the
paramedics on certain shifts fill in the patient report forms thoroughly may
start reading the form first before asking patients questions.
History-based trust, which we have just described, resembles rule-based
trust: A person may be deemed trustworthy when they consistently adhere to
formal and informal rules, or social norms, that represent shared understanding
about appropriate behavior (Kramer 1999). Mutual trust is easier to accom-
plish if everyone abides by the organizational or team rules. However, rule-­
based trust can be problematic when it reinforces rather than transforms
sub-optimal, even dysfunctional structures and relationships. Our ED nurse,
for example, may choose to trust those paramedics who defer to her authority
(e.g., “Hello Janet, we’re leaving the patient in your capable hands now”) and
sideline those who dare to identify symptoms or services that they think she
needs to attend to (e.g., “Hello Janet, this patient really needs to be referred to
someone who can help him with his mental health”).
Role-based trust stems from a person’s organizational or professional role
and others’ positive perceptions that the person who fills this role is knowl-
edgeable, responsible, and able to do their job (e.g., a physician may trust
another physician’s diagnosis but call into question the report written by the
nurse practitioner in her clinic). Pullon’s (2008, 134) analysis of interprofes-
sional nurse—doctor relationships suggested that when role-based trust exists,
 6 FOREGROUNDING THE RELATIONAL DIMENSIONS OF INTERPROFESSIONAL… 105

“people can develop and share values and ideas, (…) they more fully under-
stand each other’s intentions, such that they can ‘act for each other,’ often
without the need for specific instruction.” While history-based and rule-­based
trust can be earned by demonstrating competence, role-based trust builds
upon a belief that untested others will perform at the expected level, such as in
plug-and-play teaming. Role-based trust requires role clarity because role-
based trust is difficult if not impossible when lack of role understanding impedes
professionals from comprehending and respecting others’ roles (Callout 6.2).

Callout 6.2 Interprofessional Trust

Trust is essential to interprofessional collaboration, and communication
is the foundation of trust. Trust is relational, involving a mutual evalua-
tion between collaborators that the other is trustworthy. It also entails
risk and vulnerability, as one’s evaluation can be mistaken. We outline
three types of trust. History-based trust is based on previous experience
working with collaborators; a positive history of prior collaboration is the
basis for deciding that one can continue to rely on them. Rule-based
trust is founded on mutual respect for shared rules, such as trusting that
other professionals will adhere to patient safety rules or will follow docu-
mentation procedures. This kind of trust is fostered by a shared team or
organizational culture, where collaborators value such adherence to the
rules. Role-based trust stems from belief that other collaborators are
competent in their roles; this requires understanding and appreciating
what interprofessional collaborators bring to shared health and social
care. These three types of trust are enhanced when collaborators trust
that they can speak up when needed in their interactions with other col-
laborators, what is sometimes called psychological safety.

While trust in interprofessional relationships can facilitate interprofessional

communication, trust can also counterintuitively become “a perilous pitfall
because it erodes the checks and balances supporting patient safety” (Varpio
and Regehr 2013, 703). Research from aviation safety tells us that communica-
tion shortcuts based on trust can lead to incomplete information being con-
veyed without collaborators being aware. For instance, if collaborating
specialists trust one another too much, they might not ask necessary confirm-
ing questions when receiving a referral from the other, thereby potentially
jeopardizing patient safety. To counterbalance the tendency to uncritically trust
one’s colleagues, standardized communication protocols, such as checklists,
may help to avoid potentially dangerous communication shortcuts; however,
care must be taken that their use does not perpetuate asymmetrical power rela-
tionships or generate local level resistance (Kitto 2010).
On the other hand, trust is required to encourage the expression of contrary
opinions, which can be vital to patient safety and quality care. This is more
106 K. MCALLUM ET AL.

likely if collaborators accept that conflict—when managed productively—is

part of normal, healthy team functioning. This means normalizing the expres-
sion of conflicting viewpoints, so team members can voice differences more
easily. This in turn requires psychological safety (Edmondson 1999).
Psychological safety exists when the team’s interpersonal communication cli-
mate has developed in a way that allows its members to take interactional risks,
such as questioning a decision, bringing new information to the table, suggest-
ing an improvement, or asking the team to consider another approach. Team
members will voice concerns and ask questions when the benefits of speaking
up outweigh the risks for the speaker. Empirical studies show that a team’s
climate must be free from ridicule and be a space where colleagues give others
the benefit of the doubt if its members are to participate collaboratively in
decision-making and take actions that provide for their wellbeing (Edmondson
1999). To foster wellbeing, teams and organizations must also attend to a rela-
tionship orientation to collaboration, which we turn to next.

A Relationship Orientation to Collaboration: Fostering

Supportive Interprofessional Relationships
Many healthcare contexts are resource-thin these days, a fact that leads to myr-
iad challenges for collaborating healthcare professionals, such as moral distress,
burnout, compassion fatigue, and decreased job satisfaction (Fox et al. 2024)
as well as for organizations, such as absenteeism, turnover, and the need to hire
“travelers” or temporary professional staff (Adriaenssens et al. 2017).
Supportive relationships at work can buffer work stressors and improve indi-
vidual and collective wellbeing and resilience (Aburn et al. 2020). Support
manifests in different ways, including informational, social, and emotional sup-
port. Importantly, supportive relationships emerge through and are fostered by
supportive communication practices at the interpersonal level, in team interac-
tions, and at the organizational level (McAllum et al. 2023; Fox et al. 2024).
In this section, we adopt a relational orientation to specifically explore the
communicative practices that foster supportive interprofessional (and interper-
sonal) relationships. While these practices likely also enhance team effective-
ness, this relational orientation implies that tending to the quality of
collaborative relationships and collective wellbeing has intrinsic value, regard-
less of how well tasks are accomplished. In other words, relationships are seen
not only as a facilitator for task effectiveness, but as a way of fostering wellbeing
at work.

Communicating Compassion and Social Support

The concept of team care has been defined as “the compassionate and rela-
tional dimensions of collaboration in healthcare contexts that contribute to
healthcare worker well-being and ability to provide compassionate care to
patients” (Fox et al. 2023, 961). In interpersonal team interactions, team care
 6 FOREGROUNDING THE RELATIONAL DIMENSIONS OF INTERPROFESSIONAL… 107

is enacted by specific communication practices. These include sharing difficult

experiences and challenges with teammates; supporting others by showing
respect, noticing others’ needs, showing empathy, and letting others know they
matter and are valued; and leading with compassion, which entails being avail-
able, checking in with others, and making time to discuss relational issues. This
set of communicative practices has some overlap with Croker et al.’s (2016)
RESPECT (Reflexive Endeavours in Supportive Practice for Engaged Centred-­
on-­people Teamwork) model, which calls for questioning, providing informa-
tion, responding, clarifying, attentive listening, and empathizing with others.
In both cases, speaking and listening have a supportive, person-centered aim
rather than a strictly task-oriented goal (Mikkola 2020). That is, socially sup-
portive communication and team care aim to build and sustain interprofes-
sional relationships, and not only to get work done. In such a context, team
members are not “individual performers who identify primarily with their dis-
ciplines [professions] and secondarily (and impassionately) with their current
institutional home [e.g., clinic, hospital]” (Haskins et al. 1998, 34). Instead,
they recognize that commitment to relationship-centered collaboration is what
makes their work possible—and excellent.
Importantly, both RESPECT (Croker et al. 2016) and team care (McAllum
et al. 2023) are relational. That is, rather than being the responsibility of any
one individual, they require input from all parties involved. For Croker, Higgs,
and Trede, supportive teamwork necessitates engagement from and mutual
recognition of both the self and other. Such active engagement and dialogue
with others require that team members develop the three “Rs” needed for col-
laborating: reflexivity, reciprocity, and responsiveness. Reflexivity implies both
self-knowledge and self-respect. Reciprocity and responsiveness are directed
toward others: Questioning one’s willingness to be open and inclusive is a pre-
cursor to developing empathic connections and engaging in humble inquiry
(Bolton et al. 2021).
McAllum et al. (2023) consider the relational dimensions of team care some-
what differently. They contend that team care emerges when dyads, groups,
teams, or even entire organizational units collectively cultivate compassion and
caring interactions, especially when team members are faced with suffering or
stress. Yet, they note that, similarly to a self-regulating thermostat, team care has
upper limits: Coworkers may deliberately decide not to “notice” suffering when
relational issues have been hashed over too often or for too long and when they
require support that will exhaust the team’s relational resources.
Haskins et al. (1998) affirm that when organizations provide resources (see
below) for working together that enable teams to transcend a focus on com-
pleting specific tasks or projects or fulfilling a predetermined set of responsibili-
ties, they facilitate the development of a “mysterious ‘alchemy’ [that] creates
true colleagues fueled by investments of spirit and heart, thus producing energy
and excitement” (35). In addition to providing requisite resources, healthcare
establishments need to foster an organizational culture where connections
between people and commitment to one another are key values.
108 K. MCALLUM ET AL.

Organizational Resources that Facilitate and Promote

Relational Collaboration
The relational dimensions of collaboration do not depend solely on the types of
relationships that interprofessional colleagues co-construct but are anchored in
an organizational context. Organizations can hinder or help relational develop-
ment and maintenance depending on how space, time, people, and organiza-
tional policies are deployed. One key organizational resource is the built
environment, which can be designed to increase interprofessional visibility and
accessibility. While empirical research has shown that physical proximity of inter-
professional collaborators can offer occasions for frequent interaction that can
improve team effectiveness (Pullon et al. 2016), having a shared, “backstage”
space for team members to interact can offer the privacy to share feelings and
communicate support. Providing time to interact and understand others’ goals,
knowledge, and concerns is also vital (Edwards 2012). Although Gittell’s rela-
tional coordination theory specifically mentions the importance of shared
spaces, shared information systems, and shared meetings and huddles, we argue
that a relationship orientation to collaboration must embrace tools and pro-
cesses not only to facilitate task-based collaboration but must also incorporate
practices such as debriefing and Schwartz rounds, where collaborators can dis-
cuss the emotional dimensions of work. Because interprofessional teams often
suffer when their collective efforts are unsuccessful (e.g., members of a pediatric
oncology team will keenly feel the death of a patient they are unable to save),
post-event analysis can enable team members to strengthen their professional
and personal relationships. For example, Minguet and Blavier’s (2018) study of
interprofessional teams in a Belgian neonatal intensive care unit described how,
two weeks after a child’s death, “team members collectively made sense of how
they had worked together, articulated their emotional reactions, and reflected
on the quality of their work practices, as the suffering associated with death was
as much a professional crisis as a personal one” (McAllum et al. 2023, 4).
Evidently, for these team practices to foster stronger interprofessional ties
and worker wellbeing, the organizational culture must allow its members to
express vulnerability. This requires the mindful cultivation of psychological
safety for collaborators of all stripes. This is especially challenging in healthcare
contexts that have an established medical hierarchy. Both those with high (e.g.,
the head of an outpatient clinic) and low levels (e.g., a student nurse doing his
practicum in the clinic) of hierarchical power may find it challenging to let
down their guard. Organizational leaders play a key role in authorizing and
normalizing emotional expression and the sharing of personal concerns (Fox
et al. 2024).
For compassionate relational patterns to become embedded within collab-
orative practices at the organization level, person-centered communicative
practices and organizational support for collaboration are necessary. Haskins
et al. (1998) concur, insisting that person-centered attributes in interpersonal
 6 FOREGROUNDING THE RELATIONAL DIMENSIONS OF INTERPROFESSIONAL… 109

communication at work must interact with organization-level elements like

resource allocation and decision-making and reward systems that are congru-
ent with relationship building and learning. In their study, a “caring attitude”
included genuine concern for colleagues’ development and wellbeing as well as
care for the quality of the work they performed. Hence, caring for colleagues
did not mean that team members would not hold others accountable for meet-
ing expected standards of excellence. Caring relationships and interpersonal
trust enhanced professionals’ creative energy whereby they reflected on fail-
ures, set goals for improvement, and innovated. It is clear, then, that interpro-
fessional collaboration improves both relational quality and task-based
effectiveness. It is not just an “extra,” nice-to-have aspect of clinical work, but
a key contributor to fulfilling the Quadruple Aim: reducing healthcare costs,
developing population health, enhancing patients’ experience, and ensuring
collaborators’ wellbeing.
We close this chapter with a fictional vignette drawn from our empirical
research on collaboration during the Covid-19 pandemic in residential care
facilities for older adults. In the vignette, we see that relational coordination
was jeopardized, and efforts to maintain a coherent task orientation broke
down. Roles became blurred and trust was imperiled. Various practices of com-
municating compassion helped the care teams to make it through this devastat-
ing time.

Collaborating Through a Crisis—and Coming Out

the Other Side Stronger

Caring for older adults who had lost much of their independence had never
been easy. Most staff at Davies Residential Care Home—nurse managers, reg-
istered nurses, limited practice nurses, personal care attendants, social workers,
physiotherapists, dieticians, and recreation specialists—described their work as
a calling. However, when the Covid-19 pandemic hit in March 2020, the stress
of working as part of the interprofessional team at this facility became unbear-
able. Residents’ loved ones couldn’t visit or provide extra care as they usually
did, increasing the physical and emotional workload for the personal care
attendants. What’s more, the workplace was characterized by fear and uncer-
tainty. Infection control directives from the government’s public health agency
were inconsistent and confusing, leaving facility managers like Jill, a nurse man-
ager, to come up with ad-hoc strategies for isolating infected residents and
keeping staff members safe.
Despite their valiant efforts, Jill and her team were underequipped (there
was a nation-wide shortage of personal protective equipment) and felt ill-
informed. In the first months of the pandemic, scientists, policymakers, and
frontline essential workers did not know that the coronavirus spread through
airborne microdroplets, and many residents died due to insufficient separation
110 K. MCALLUM ET AL.

from those who were already infected. Staff got sick or were too scared to come
to work, leaving team members who remained with unmanageable workloads
and feelings of distress, intense anxiety, and fear. At one point, so many Davies
staff members were off work sick or confined because a close contact had Covid
that there were only 3 people per floor to take care of 70 residents!
Things got so bad that the government called in the military for two weeks
to help deal with a surge in infections in long-term aged care facilities and to
provide logistical and medical support. Yet, this collaboration was filled with
friction, because the facility and military chains of command were not always
well coordinated. The military did set up systems to treat residents who caught
Covid and protect non-infected residents, but only a small number of military
paramedics were authorized to help the personal care attendants carry out basic
care for the residents.
Once the army created a Covid “hot zone” to isolate infected residents,
some of the nurses, limited practice nurses, and personal care attendants volun-
teered to work in it. The government initially provided money to put these
staff members up in hotels to protect their families. If they caught Covid, they
continued to receive their wages. The rules changed after a few months, and
when workers tested positive for Covid at work, they were sent home and had
to use up their sick leave if they wanted to be paid. Many of those working in
the hot zone stopped trusting anything that the managers, who were transmit-
ting governmental directives, were telling them.
Because personal care attendants got sick more often than other profes-
sional groups due to their close personal contact with the residents, while
feeding, washing, and changing them, the government invited members of
the public to take up a paid care attendant role in order to make sure that
care was not compromised. These “volunteers,” who had worked in service
sector occupations like hospitality, which had been shut down by the pan-
demic, had little idea of how to care for dependent older adults in an envi-
ronment where rules and processes changed sometimes daily. Personal care
attendants who had been working with the residents for over a decade felt
frustrated that the newbies didn’t ask for direction or admit that they felt
lost and uncertain. Some volunteers even avoided the experienced personal
care attendants.
All of this put tremendous strain on relational coordination. New and expe-
rienced personal care attendants did not have shared knowledge, shared goals,
or mutual respect: Old hands accused some of the “volunteers” for being at
Davies Residential Care Home to receive a paycheck, instead of having a voca-
tion to care for older adults. Across the interprofessional team, trust was threat-
ened because, in many instances, collaborators had zero history working
together. What’s more, role-based trust was difficult, because professional and
team roles were no longer clearly demarcated: Understaffing was such a prob-
lem that Jill had to ask everyone to pitch in with whatever needed to be done
 6 FOREGROUNDING THE RELATIONAL DIMENSIONS OF INTERPROFESSIONAL… 111

to provide basic care to residents, so the nurses, recreation staff, social workers,
and dieticians worked alongside the personal care attendants to feed and wash
residents. Even so, resources were stretched so thin that it was not always clear
who was ultimately responsible for what, nor which tasks ought to take priority.
To many, it seemed the rules kept changing, so collaborators couldn’t rely on
rule-based trust either.
Determined to provide a beacon in the storm, Jill and the other managers
decided to hold team briefings once or twice a shift to share the latest informa-
tion they had received from the public health authorities, communicating as
clearly as they could what the situation and goals were for that day. This helped
the staff to trust that their managers were doing the best they could and to
know at least minimally who should collaborate on which tasks.
Jill also noticed that many team members were hiding their suffering, wait-
ing to cry in the bathroom or once they were at home, because no one at work
seemed to be able to handle anybody else’s distress. When she asked the social
worker and one of the nurse managers about it, they explained that the team
had so much to do that there was no time to stop and talk about how they were
feeling. Others, they said, believed that, because the “higher-ups” never asked
them how they were doing, they did not care. Consequently, tempers frayed,
while other people shut their emotions down: The team care thermostat had
reached its upper limit. What felt worst was the lack of socially supportive inter-
actions; staff couldn’t even eat lunch together because of physical distancing
requirements. Jill felt helpless as she watched her staff’s morale deteriorate, and
although she repeatedly asked her network administrators for more help, it
seemed her requests fell on deaf ears, as though her organization had set her
adrift while expecting miracles. She knew her team needed more and better
supportive communication.
Therefore, she started taking a minute or two during each team debriefing
to ask—and really listen to—how people were feeling and what they needed
that day. They asked to be given the chance to share what they loved about
each resident who passed away and to be able to communicate with the resi-
dent’s family members. She told everyone that, if they needed to vent their
frustrations, her door was always open. Many team members appreciated hav-
ing the chance to be heard. But, when Jill’s boss suggested that they form a
committee to nominate the “hero of the week,” someone who made the team’s
culture a bit more caring, employees were cynical.
Now that the pandemic is over, Jill’s team has stuck with these new support-
ive communication practices. They also plan potlucks every month to socialize
and unwind. Some personal care attendants are wistful, remembering the role
blurring that took place during the pandemic, because they felt that “higher
status” professionals finally appreciated and understood what they contributed.
Yet, for everyone, it was a relief to know who should be doing what. Trust has
improved, thanks in part to stronger relationships between collaborators.
112 K. MCALLUM ET AL.

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 CHAPTER 7

Dialectical Tensions in Interprofessional

Relationships: Understanding Relational
Dialectics Theory in Health and Social Care
Teams

Leena Mikkola, Maija Peltola, and Julie Apker

Introduction
Interprofessional (IP) relationships materialize in interpersonal communication.
Accordingly, understanding interprofessional collaboration and teamwork
requires unpacking the dynamics of interpersonal communication. It is particu-
larly important to understand the tensions that appear in team communication;
tensions do not necessarily stem from interpersonal conflict or the actions of spe-
cific team members. Rather, tensions, a natural part of social interaction, emerge
from contradictions in communication (see Baxter and Montgomery 1996;
Putnam et al. 2016). Tensions and the contradictions behind them can be recog-
nized and identified and, most importantly, balanced by using certain communi-
cation strategies. Understanding these dynamics may enhance team communication
and increase positive team outcomes, such as cohesion, trust, and performance.
In this chapter, we examine relational contradictions and tensions in interpro-
fessional teamwork through the lens of relational dialectics theory (RDT), which

L. Mikkola (*) • M. Peltola

Faculty of Information Technology and Communication Sciences, Tampere
University, Tampere, Finland
e-mail: [email protected]; [email protected]
J. Apker
School of Communication, Western Michigan State University, Kalamazoo, MI, USA
e-mail: [email protected]

© The Author(s) 2025 115

S. Fox et al. (eds.), Interprofessional Communication in Health and Social
Care, https://doi.org/10.1007/978-3-031-70106-1_7
116 L. MIKKOLA ET AL.

suggests that interpersonal relationships are inherently dialectical (Baxter and

Montgomery 1996; Baxter 2011). RDT is a discourse-centered, dialogic theory
(Baxter et al. 2021) that is aligned with the constitutive approach of communi-
cation (Putnam et al. 2016). We first define interpersonal relationships before
introducing the principles of RDT. We then review earlier research on relational
dialectics in the context of interprofessional teams and collaboration, exploring
what we currently know about relational dialectics and tension management
strategies in interprofessional teams. Next, we focus on patients from the per-
spective of RDT to consider what kind of tensions may emerge when patients
participate in team communication. Finally, we draw some conclusions and con-
sider the implications of research on RDT that focuses on interprofessional teams.

Interpersonal Communication and Relationships

The term interpersonal refers to a personal level of communication where com-
municators can identify each other (i.e., communicators recognize with whom
they are communicating, see Bateson 1983). This recognition can be solely
role-based, when the other is identified, for instance, as “a psychologist” or “a
nurse” or “a patient.” This kind of identification is grounded in cultural and
societal information, which creates expectations about the representatives of a
certain profession or a certain role. However, in teamwork, members usually
have some personal knowledge of other team members. Accordingly, in team
communication, cultural and societal expectations combine with personal
information, and both these elements shape how team members will interact.
Interpersonal communication is a complex, reciprocal, contextual, and situ-
ational social process in which shared meanings are created by exchanging mes-
sages (Burleson 2010). As they create shared meanings, communicators strive
to achieve task-oriented, relational, and identity goals at the same time (Valo
and Mikkola 2020). Through communication, we get collective tasks done,
maintain relationships, and negotiate identities. Indeed, in the context of work
and team communication, relational and identity-related meanings are never
put aside. For instance, in a meeting to talk about a patient’s care plan (a task-­
oriented goal), team members also express and interpret their attitudes towards
others (relational goals), and, through their interactions, they interpret and
display their own professional identity, which is continuously present in team
encounters (identity goals). This explains why interpersonal communication
requires sensitivity and effort to sustain relational communication, through
which relationships are constructed and maintained.
According to the constitutive approach (see Chap. 1), communication has
the power to create relationships. This means that interpersonal relationships—
both team members’ relationships and patient-professional relationships—
emerge in interpersonal communication. Hence, our relationships are not
containers in which communication takes place but quite the opposite; it is
through communication practices that our interpersonal relationships are cre-
ated (Baxter 2011). Once constituted, an interpersonal relationship is a mutual,
dynamic system among the parties (e.g., Bateson 1983) that needs to be
 7 DIALECTICAL TENSIONS IN INTERPROFESSIONAL RELATIONSHIPS… 117

maintained and constantly renegotiated in interactions. Each interaction cre-

ates relational meanings. Through mutual relational meaning making, every
interpersonal relationship becomes unique (Callout 7.1).

Callout 7.1 Relational Communication

Relational communication refers to how communicators express their
mutual relationship and how they relate to each other. Thus, relational
communication is the process by which a mutual relationship is sustained
through constant relational meaning making. Relational communication
can be verbal, when parties express verbally their mutual liking, respect,
or trust for one another. However, nonverbal communication often plays
a major role when communicators express and interpret each other’s rela-
tional messages. In particular, dominance is a relational factor that may
be expressed nonverbally.

However, professional, institutional, and organizational cultures and prac-

tices influence the meanings that are given to a relationship. For instance, a
nurse who believes that a patient’s treatment needs to be adjusted may frame
his opinion as a suggestion when speaking with the attending physician instead
of making a direct request. Using a suggestion rather than a request manifests
the nurse’s deference to the physician’s position in professional hierarchy. The
nurse’s deference in this case will shape future interactions and expectations
within this specific nurse-physician relationship. Over time, the choices made in
interpersonal interactions can also modify interprofessional practices and orga-
nizational cultures (Callout 7.2).

Callout 7.2 Interpersonal Relationships

An interpersonal relationship is a social system of (at least) two communi-
cators that is characterized by frequent and established ways of commu-
nicating, continuity, and engagement (see Sias 2008). Meanings about
the other and the nature of the mutual relationship are constructed in
communication. In interpersonal relationships, reciprocal affect creates
social and emotional connection, and mutually shared information makes
a relationship unique. Relationships are dynamic as the parties negotiate
the meanings they give to their relationship over time. In healthcare con-
texts, both interprofessional relationships and patient-professional rela-
tionships are interpersonal relationships.

As the prefix “inter” (i.e., “located between” or “among”) implies, the indi-
viduals involved in interpersonal relationships are always separate but con-
nected through communication. This connection between different parties
who remain distinct makes all our relationships dialectical, which means that
opposite tendencies appear simultaneously. In interprofessional contexts, the
core dialectic of connection and autonomy emerges when parties collaborate
118 L. MIKKOLA ET AL.

across professional boundaries while also striving to maintain their own profes-
sional autonomy; by its very nature, interprofessional collaboration generates
these contradictory aspirations. These contradictions are often experienced as
interprofessional tensions during interpersonal encounters. In contrast to pri-
vate-life relationships, in health care, the asymmetry or imbalance of power
relationships (Freidson 1970; Ruben 2016) may also amplify tensions in both
interprofessional relationships and patient-provider relationships.

Principles of Relational Dialectics Theory

The starting point of healthcare teamwork is the idea that team members bring
diverse forms of expertise to their team and create shared understanding from
equal positions. However, team members cannot avoid encountering organiza-
tional hierarchy, which is often a significant source of difficulties in teamwork. The
contradiction between equality and hierarchy is an example of the simultaneous
presence of opposite poles (i.e., equality where power is shared versus hierarchy
where power is unequally divided), which is the primary premise of RDT (Baxter
and Montgomery 1996; Baxter 2011). These opposite poles are a manifestation
of contradictory discourses, in this case, the discourses of equality and hierarchy.
A discourse is an internally coherent system of meanings or system of thought,
which becomes visible in social interactions and language-in-use in a particular
sociohistorical context (Baxter 2011; Alvesson and Kärreman 2000). As dis-
course has the capacity to create and maintain meanings, it both manifests and
produces social realities. Accordingly, the appearance of the discourse of hierar-
chy in health and social care makes hierarchical structures and hierarchical rela-
tionships visible, but simultaneously, it brings the hierarchy to life. For instance,
when a physician chairs a team meeting, this role not only reveals the physi-
cian’s authority and position in the team, but it creates and confirms physi-
cians’ senior position in the healthcare hierarchy. At the same time, the discourse
of team equality manifests meanings of complementary expertise and recogni-
tion of others’ equally important professional knowledge. It makes a certain
equality between the representatives of different professions in teamwork visi-
ble. Such discourses, then, form the basis of our understanding of the dialecti-
cal social reality present in the health and social care workplace (Callout 7.3).

Callout 7.3 Discourse

A discourse is an internally coherent system of meanings or system of
thought, which becomes visible in social interactions in specific cultural
and sociohistorical contexts. As discourse has the capacity to create and
maintain meanings, it both manifests and produces social realities.
As multiple social realities are possible at the same time, so are discourses,
and they can compete or even struggle. Persistent societal and cultural dis-
courses are called Discourses, with a “big-D” (e.g., Alvesson and Kärreman
2000). These Discourses are the context for more local discourses with a
“small-d.” For example, small-d discourses about workplace hierarchy draw
on societal big-D Discourses about the professions and professionalism.
 7 DIALECTICAL TENSIONS IN INTERPROFESSIONAL RELATIONSHIPS… 119

When we consider the discourse of hierarchy and the discourse of equality,

it is obvious that these discourses compete with each other. Yet, according to
RDT, the two discourses are, at the same time, interdependent: To understand
the meaning of hierarchy requires understanding the meaning of equality
(Baxter 2011; see also Putnam et al. 2016). Relational dialectics theorists
express the idea that competing discourses are opposite poles of the same whole
or two sides of the same coin by using the term dialectical contradiction
(see Baxter 2011). Dialectical contradictions are called also relational contra-
dictions because the meanings given to a relationship are created in the inter-
play of contradictions (Baxter 2011). Hence, the primary location of dialectical
contradictions is the relationship (Callout 7.4).

Callout 7.4 Dialectical Contradictions

Dialectical contradiction refers to a situation where competing discourses
are opposite poles of the same whole. These poles are separate from but
also dependent on each other. The term dialectics means that there is a
constant interplay between the opposing poles. For example, autonomy
and dependence form a dialectical contradiction that appears in commu-
nication when healthcare professionals strive for independent action,
while communicating their willingness to collaborate. Contradictions
cannot and do need not to be resolved. Communicators can, however,
try to balance the contradictions using different communication
strategies.

The concept of dialectics refers to the dynamic interplay between opposite

poles. As we highlighted above, the poles cannot be separated, and they should
not be understood as negative or positive. Therefore, there is no need nor is it
even possible to “resolve” the contradiction (Baxter and Montgomery 1996).
Over time, either of the two poles may dominate in interactions. Depending on
the issue or the case discussed by the team, there may be a stronger pull towards
either equality or hierarchy. For example, when planning an orthopedic
patient’s rehabilitation needs, both the physician’s and the physiotherapist’s
knowledge and professional qualifications are required. However, relational
dialectics emerge when professional hierarchy challenges professional equality.
Challenges can occur because of working practices or legal requirements (e.g.,
the physician is the one who signs the form despite the fact that the team was
able to fill it out because of the physiotherapist’s expertise) or because of the
team’s interactions (e.g., team members express status differences in their
interactions). Moreover, in different team or organizational cultures, some dis-
courses may be more powerful than the others. For example, in specialized
hospital care, the discourse of hierarchy may be more dominant than in outpa-
tient primary healthcare centers because, in hospital contexts, the roles and
tasks of physicians and other personnel are more formally defined based on
120 L. MIKKOLA ET AL.

professional scopes of practice. Furthermore, the professional status of special-

ists may strengthen the hierarchies in hospitals. However, a skillful team can
adapt their interactions to balance the contradictions and maintain relational
balance.
Because competing discourses and their dialectics emerge in various cultural
and social contexts, they can be specific to a certain context or relationship.
However, Baxter (1988) identified three basic contradictions—the “Big 3”
(Baxter et al. 2021)—that seem to appear in every relationship. First, the inte-
gration–separation contradiction refers to the interplay between autonomy and
integration; pursuing independence is always limited by the demands of inte-
gration. In interprofessional (IP) teams, this means that while team members
strive to maintain their professional autonomy (e.g., insisting on their right to
make autonomous decisions based on their own professional knowledge), in
most of their tasks, they need to collaborate with representatives of other pro-
fessions, which can impinge on their professional freedom. The second basic
contradiction, stability–change, is grounded in the simultaneous push for con-
sistency and the urge for novelty. In IP teams, there is a requisite to trust that
others will follow standard professional practices but that they will also develop
new ideas, change ways of doing things, and improve role behaviors to better
fulfill patients’ needs. The third basic contradiction is the dialectic of expres-
sion–non-expression, which is the interplay between disclosing personal infor-
mation and protecting one’s privacy. In IP teams, this may emerge when a
patient shares private information with a team member, who then faces the
dilemma between honoring the patient’s request for privacy and wanting to
share the patient’s disclosure with other team members.
The examples above show how relational contradictions are at the core of
interpersonal relationships. Thus, it is natural that interpersonal encounters are
challenging and sometimes even uncomfortable; relational contradictions raise
relational tensions in interaction. Tensions are “push and pulls” among choices -
also in interpersonal encounters - , which may create stress, anxiety, discomfort,
and frustration (Putnam et al. 2016). However, instead of trying to avoid or
forget the tensions and dialectics behind them, team communication requires
strategies for balancing the contradictions (Baxter and Montgomery 1996).
To find a sustainable way to develop communication and balance the ten-
sions, it is important to recognize the tensions and analyze how they coexist
with others. Furthermore, various strategies can be used to manage the ten-
sions in team interactions. For instance, collaborators may try to neutralize
tensions by ignoring the extremes and “mediating” between the poles (Baxter
and Montgomery 1996). Neutralizing occurs, for example, when team mem-
bers avoid referring to the rights or professional privileges of a certain team
member in interprofessional team, but rather try to make status differences
fade away. Another strategy is when they strive to separate the poles by empha-
sizing each pole at different times or according to the type of task being carried
out (Baxter and Montgomery 1996). For instance, a team may decide that the
 7 DIALECTICAL TENSIONS IN INTERPROFESSIONAL RELATIONSHIPS… 121

job of taking and writing up the notes during interprofessional meetings should
rotate among all the members (thereby privileging equality), but simultane-
ously expect that the physician leads the discussion of patient cases, thus
emphasizing a medical perspective and the physician’s leading role (swinging
toward hierarchy). Reframing is another strategy for managing tensions where
collaborators reinterpret the tension in a way that enables “both-and” interpre-
tations of the tensions (Putnam et al. 2016). This may be done, for example,
by revealing and emphasizing the potential benefits of both poles for quality
care. In sum, to foster healthy team communication, becoming aware of and
accepting the contradictory nature of interpersonal relationships in interprofes-
sional communication is an important starting point.

Relational Dialectic Tensions in Interprofessional

Care Teams
The most common relational dialectic found in the interprofessional care
research literature pertains to healthcare professionals’ desire to work autono-
mously, according to their occupational scope of practice, while recognizing
the need for and benefits of team connectedness. The pervasiveness of this
dialectic is due in part to asymmetrical, hierarchical organizational structures
(Freidson 1970): physicians often act as team leaders, and they have the great-
est professional autonomy and medical expertise as well as the main legal
responsibility for the team’s actions. However, the larger healthcare culture
encourages egalitarian, interprofessional collaboration. Extant research shows
that the complexity of the autonomy-connection dialectic prompts varied
forms of communication management techniques from team members, which
we explore next.

Experiencing the Autonomy–Connection Dialectic

The autonomy pole involves team members taking initiative, displaying com-
petence based on their education or expertise, and performing role-related
tasks independently of others. The connection pole manifests through team
member interdependence such as providing physical assistance, seeking and
giving expert feedback, and showing respect for and valuing other team mem-
bers’ contributions. This dialectic has been called different names; some schol-
ars use the original RDT terms of autonomy-connection (Jameson 2004)
whereas others use modified phrasing such as autonomy–interdependence
(Martin et al. 2008), leadership–support (Jones et al. 2019) and independence–
collaboration (Gilstrap and White 2015).
Findings across studies indicate that status differences inherent to IP teams
contribute to the autonomy–connection tension. IP teams ideally value all
member roles equally, but team activities occur within a traditional profes-
sional hierarchy that assigns status based on positional authority, clinical
122 L. MIKKOLA ET AL.

expertise, and legal and ethical responsibility for patient care (Denvir and
Brewer 2015; Omilion-Hodges and Swords 2017). In separate studies of
nurse–physician teams, Martin et al. (2008) and Jameson (2004) found a
contradiction between a desire by both parties for nurses to practice indepen-
dently and the constraints of hierarchical team structure in which nurses
report to physicians rather than share patient care responsibility. This tension
contributes to misunderstandings, frustration, and conflict in nurse-physician
work relationships.
Research about IP teams that are larger and more complex than nurse–
physician teams also reveal the influence of physician status differences on the
autonomy–connection dialectic. For instance, Denvir and Brewer’s (2015)
study of medication recommendations in pharmacy student–physician com-
munication shows that students encountered a relational dilemma between
deferring to physician expertise and authority (a move that preserves team
connection and recognizes the student's subordinate status) and asserting
their autonomous, professional competence. Other studies specifically high-
light how status differences related to physicians’ legal and ethical responsibil-
ity can influence the autonomy-connection dialectic. For example, a
leadership-­support dialectic was found in team medical error disclosures (Jones
et al. 2019). The leadership pole is present when physicians assert their status
as leaders by taking full responsibility for the team’s error and directing
patient–team conversations. The support pole is present when physicians and
other team members reduce status differences by taking shared responsibility
for the medical error. In another example, Gilstrap and White (2015) found
that status differences contributed to an independence-collaboration dialectic
in IP teams consisting of hospice nurses and non-hospice providers. Their
study revealed that hospice nurses recognized their connectedness to non-
hospice physicians and pharmacists—due in part to these clinicians’ status and
ability to prescribe medications—while simultaneously desiring autonomy
when handling patients’ comfort care. Nurses managed the tension with non-
hospice physicians and pharmacists through different persuasive techniques.
For example, nurses not only clearly identified patient problems but took the
extra step to communicate solutions based on their clinical expertise.
Furthermore, nurses persuaded non-­hospice physicians and pharmacists by
preemptively identifying and overcoming any concerns they might have had
about patient pain management.
The autonomy–connection dialectic is the most pervasive in the research
literature, but scholars have identified other relational tensions too, such as
transparency–protectionism (Jones et al. 2019) and uniqueness–predictability
(Martin et al. 2008). In addition, in a study specific to palliative IP teams,
Omilion-Hodges and Swords (2017) identified two tensions of living–dying
and practicing–advocating that reflect philosophical differences between pallia-
tive and biomedical or curative care approaches. Taken together, this research
demonstrates that multiple relational contradictions exist in IP teams.
 7 DIALECTICAL TENSIONS IN INTERPROFESSIONAL RELATIONSHIPS… 123

Managing the Autonomy–Connection Dialectic

Healthcare professionals manage the autonomy-connection tension in IP inter-
actions through a repertoire of communication techniques. Studies by Gilstrap
and White (2015) and Martin et al. (2008) show how nurses rise above their
need for professional autonomy while still preserving necessary and beneficial
teamwork. In both studies, nurses used the technique of reframing the tension
by proactively communicating shared patient care concerns and solutions while
at the same time making sure to gain input and agreement from team members.
The underlying autonomy–connection tension remained but nurses transcended
it by showing self-sufficiency without threatening requisite collaboration.
The technique of balance is also used to manage the autonomy-connection
dialectic. Balance refers to communication that solves problems through com-
promise (Jameson 2004), somewhat meeting all parties’ needs for indepen-
dence and teamwork. For example, Jameson identifies several face-saving
strategies used by IP team members in times of conflict that preserved team
member autonomy while, at the same time, upholding team affiliation.
Techniques included emphasizing respect for professional scope of practice,
stressing team solidarity for patient care, and seeking/giving clinical knowl-
edge to increase collaborative learning. Relatedly, a form of balance called stra-
tegic deference is another strategy employed to manage the autonomy–connection
dialectic. Denvir and Brewer (2015) found that when pharmacy students gave
advice about medications to physicians, they intentionally used tactics like
“consulting” physicians about their recommendations and directly conveying
physicians’ final decision-making authority. Students’ communication balanced
the need to assert the value of their professional opinion with a desire to recog-
nize physicians’ medical expertise and maintain positive team relationships.

Role Dialectics
IP teams comprise unique qualities specific to team roles. First, roles are always
in transition: The professionals who make up the team change depending on
shifting care requirements (e.g., patient health status, treatment plan). Second,
when performing their roles, team members are typically accountable to each
other rather than to one consistent, formally appointed leader. Third, team
members’ role expectations of others vary, creating role tensions that require
ongoing negotiation. These role complexities are perhaps most visible in IP
hospital teams, a context in which multiple specializations and care providers
frequently come in and out of patient care: Team members provide care at dif-
ferent times and locations, and often communicate with one another
asynchronously.
The role complexities in IP hospital teams prompted Apker et al. (2005) to
integrate concepts from role theory and relational dialectics theory into a new
124 L. MIKKOLA ET AL.

framework identified as role dialectics. Role dialectics center on “the ongoing

interplay of contradictions that produce, shape, and maintain behaviors associ-
ated with a particular role” and explore how “role tensions are negotiated com-
municatively within the varied relationships which comprise social units” (97).
For example, Apker, Propp, and Zabava and Ford found that nurses experience
a superior–equal dialectic in which the power of their professional status con-
tradicts the team’s democratic ideals. Nurses must supervise other nurses and
lower-status team members (superior pole) while simultaneously minimizing
hierarchical differences to ensure an egalitarian, respectful team dynamic (equal
pole). Nurses manage this tension through recalibration, a form of reframing
that transcends “the role expectations of superiority or equality in order to
promote team harmony; however, the underlying contradiction remains”
(105). For instance, nurses soften the hierarchy through courtesies (e.g., ask-
ing versus telling subordinates to perform tasks) and praise. This technique
enables them to remain in charge while at the same time showing care and
support to enhance team cohesion.
Lindholm (2018) added to role dialectics research by exploring the tensions
experienced and managed by hospice chaplains as they fulfilled their spiritual
care roles alongside the physical care roles performed by other team members.
Similar to the autonomy–connection dialectic found in other interprofessional
RDT research, Lindholm discovered that chaplains encountered an
independence-­teamwork role tension. For instance, chaplains desired pastoral
privilege with patients independently from the team, which contradicted team
members’ expectations that chaplains would share confidential patient infor-
mation in order to provide good patient care. Chaplains managed this tension
through selective communication (e.g., favoring patients’ privacy over team
members’ information needs) and segmentation (e.g., keeping most informa-
tion private but making exceptions).
In summary, the autonomy–connectedness dialectic figures prominently in
the interprofessional team research literature on relational dialectics, a pattern
that shows team members experiencing a tension between an inherently asym-
metrical team structure with the traditional professional hierarchy and a health-
care culture that values interprofessional collaboration and egalitarianism.
Scholarship also shows that this complex dialectic prompts varied communica-
tion management techniques among team members. Studies based on role
dialectics research have been limited to date, but the framework appears to
have promise for future inquiry about interprofessional relationships and
patients’ participation in the interprofessional team, an issue that we will dis-
cuss next from the perspective of relational dialectics.

Patients as Participants in an Interprofessional Team

The dialectical nature of interprofessional communication has been studied
almost entirely by asking what kind of tensions professionals feel and can iden-
tify. However, dialectics will also play out in interprofessional communication
 7 DIALECTICAL TENSIONS IN INTERPROFESSIONAL RELATIONSHIPS… 125

between health and social care professionals and patients. The patient’s role as
a participant in interprofessional teams has become increasingly prominent in
discussions about shared decision making and care quality (IPEC 2016; Sigmon
et al. 2022). These discussions about patient participation align with a patient-­
centered care orientation, where mutual respect and integration of the patient’s
needs, wishes, and expectations are seen to form the basis of joint interaction
and care (e.g., Michie et al. 2003; Street 2017). Research has focused on, for
instance, factors that facilitate and impede patients’ participation in interprofes-
sional collaboration (e.g., Didier et al. 2020; Kurniasih et al. 2023; Van Dongen
et al. 2017). These factors include expressing mutual respect and trust, clarify-
ing why certain professionals are on the team, reporting the patient’s health
status to the others, and by explaining what kind of issues need to be discussed
(Sigmon et al. 2022). However, despite growing interest in a patient-centered
orientation, there are still large knowledge gaps about patients’ perspective
regarding IP team care. Thus, we claim that there is an assumption that the
patient’s role is limited to being an informant in team discussions. The ques-
tion remains how patients can be full members of the IP team and how dialecti-
cal contradictions emerge and might be balanced in IP team communication.
With regard to the patient’s role, researchers’ attention typically focuses on
two things. First, the patient’s knowledge is different from professionals’
knowledge. The patient has a particular form of experiential knowledge of their
own health situation, which is a unique and valuable everyday expertise that
professionals need to take into account when planning appropriate care (e.g.,
McGill et al. 2016). Thus, the patient’s knowledge completes the team’s
expertise, and the IP team needs to integrate the two. Second, asymmetry is a
crucial feature in the patient–professional relationship. Due to relational asym-
metry and different kinds of knowledge and responsibilities, patients do not
have the opportunity to receive and interpret information in the same way as
professionals do (Ruben 2016). This asymmetry emphasizes role dialectics
(Apker et al. 2005) in the patient–professional relationship or in the patient–
team relationship, and the tension between professional knowledge and expe-
riential knowledge may intertwine in a complex way with relational tensions in
the patient–provider relationship.
Given the paucity of research on RDT from the patient’s perspective, we can
utilize Baxter’s (1988) notion of the basic contradictions found in personal
relationships, as it is likely that the same contradictions of autonomy–connec-
tion, stability–change, and expression–non-expression will also appear in
patient–professional and patient–team relationships. For example, in the con-
text of hospital treatment, it is quite typical that professionals make a prelimi-
nary treatment plan before they meet the patient. Such a starting point is likely
to emphasize the imbalance of the autonomy–connection contradiction by
amplifying professionals’ autonomy with respect to the patient’s dependence.
This limits the possibility of the patient influencing meaning-making and
decision-­making about their own care. The IP team’s decision to create a pre-
liminary treatment plan before meeting the patient may reinforce the patient’s
126 L. MIKKOLA ET AL.

traditional role as a more passive participant in patient–professional communi-

cation and reduces the team’s ability to reenvisage the stability–change dialectic
by creating new, individual ways of having inclusive discussions. As for the
expression–non-expression contradiction, it is expected that a patient is mainly
an informant in their case and gives all the information that is asked of them,
while professionals control the content, the course of the conversation, and the
amount of shared information. For instance, professionals’ previous discussions
may not be shared with the patient.
In the case of chronically ill patients, some professionals will have had an
opportunity to form a relationship with the patient before the entire interpro-
fessional team meets them. Questions arise about how such an individualized
patient–professional relationship and the issues discussed in it are integrated
into the interprofessional collaboration and whether one relationship is consid-
ered more important than another by the interprofessional team.
Interprofessional discussions might also make individual professional–patient
relationships vulnerable to changes, as information and treatment recommen-
dations may come up in the joint discussion in a different form from the views
expressed in earlier one-to-one patient–provider discussions. In this kind of
situation, the contradictions of both expression–non-expression and stability–
change may emerge and produce tensions.
In interprofessional teams, all of the “Big 3” contradictions appear, but in
the patient–professional relationship, specific contradictions may also emerge.
In their interview study, Peltola and Isotalus (2019) examined what dialectical
tensions patients with Type 2 diabetes experience in interpersonal encounters
with nurses and physicians. They identified three dialectics: (1) guidance–con-
trol; (2) personalization–standardization; and (3) having the right to care–
deserving care. Their findings showed that dialectical tensions of
professional–patient relationships are closely related to the patient’s health situ-
ation; in particular the dialectic of having the right to care–deserving care
emerged from the stigmatized nature of Type 2 diabetes. This dialectic caused
turbulence in how the patient–professional relationship was defined, specifi-
cally whether the relationship was seen as either every patient’s right, irrespec-
tive of what patient had or had not done, or as something to be deserved
individually by taking good care of oneself. The findings suggest that dialectical
tensions in patient–professional relationships are related to contextual factors
but also to fundamental questions regarding the purpose of the patient–profes-
sional relationship and the rights and responsibilities of each party in their
interactions.
In sum, with regard to the patient’s participation, it is of vital importance to
be aware of relational contradictions in every situation of collaboration and to
pay attention to the tensions that they may produce. These tensions can be
managed when participants are aware of them. The better participants succeed
in making the issues they discuss in individual relationships visible during IP
team conversations, the better the entire team can integrate different forms of
information and utilize this as a basis for joint decision-making.
 7 DIALECTICAL TENSIONS IN INTERPROFESSIONAL RELATIONSHIPS… 127

To enhance collaboration and the patient’s genuine participation, it is also

crucial to openly discuss role expectations and the intentions behind discus-
sions when the patient is present: What is the purpose of the discussion? Is it an
information session or an opportunity to map out alternatives? What discus-
sions have taken place in advance and what does the patient, who is at the
center of the team, hope for from the discussion?

Maria’s Visit to the Neurological Clinic

Maria is a 25-year-old university student, who has been suffering from life-­
limiting neurological symptoms for several months. She hopes to complete her
Master of Arts degree soon, but her studies have seriously suffered due to her
health condition. After her initial examinations in specialized medical care,
doctors recommended epilepsy medication as a treatment, but Maria’s symp-
toms continued. After more detailed examinations, the symptoms were not
considered to be dangerous, and the team of neurologists decided to discon-
tinue the medication. They also recommended that no further examinations be
done. However, Maria continued to experience considerable difficulty manag-
ing her symptoms, and she requested a new visit to the same medical care unit
for a new assessment.
On arrival at the clinic, Maria first saw a nurse who was new to her. When
discussing Maria’s situation, the nurse wrote down Maria’s concerns and stated
that it was truly necessary to reassess Maria’s care needs. Maria felt that com-
munication with the nurse was easy and relieved her worries, which suggests
that, together, Maria and the nurse succeeded in balancing the dialectic of
certainty–uncertainty: Even though talking with a new person produced uncer-
tainty, the conversation followed Maria’s story and brought certainty to their
interaction in the form of safety. In addition, both the autonomy–dependence
and hierarchy–equality contradictions were present in Maria’s interaction with
the nurse. The communicators were dependent on each other’s knowledge,
but they made space for each other in the conversation, and Maria was allowed
to define the situation from her own point of view, which embodied autonomy.
While Maria’s experiential knowledge was valued by the nurse’s decision-­
making, which emphasizes equality in the relationship, the nurse still drew her
own professional conclusions in order to manage Maria’s care, embodying
hierarchy.
After the conversation, the nurse directed Maria back to the waiting room
and delivered the written information to the physician. After the physician had
familiarized herself with the nurse’s notes, Maria was called to the physician’s
room. The nurse was also in the room. The physician, who was unfamiliar to
Maria, started the conversation by asking Maria how she felt. Maria explained
the current situation briefly, mostly repeating the information she had already
given to the nurse. The physician then continued by reading aloud the previous
test results in Maria’s record and by saying that she saw no reason for further
clarifications or assessment. Maria was surprised by the physician’s rapid
128 L. MIKKOLA ET AL.

conclusion and disagreed with her. Maria reiterated that she was worried about
the symptoms and about not being examined further, and she then started to
cry. At this point, Maria looked for support from the nurse and was even more
confused as the nurse did not seem to be participating in the conversation at
all—even though the nurse presumably disagreed with the physician. Finally,
the physician proposed a solution: If Maria’s symptoms changed significantly,
her examinations could be continued in the same treatment unit. Since Maria
felt that there was no other option, she accepted the physician’s proposal in
order to maintain the possibility of asking for a new series of medical examina-
tions in the future.
During Maria’s interaction with the physician, many tensions emerged, as
several contradictions were imbalanced. The discussion was totally under the
physician’s control, and Maria was entirely dependent on the physician’s under-
standing of her situation. The physician’s professional autonomy combined
with Maria’s dependence on the physician’s decision-making power meant that
the physician had wide autonomy in this case, while Maria had little or none.
Although the physician had to ground her decision on the nurse’s notes and
Maria’s earlier patient records, Maria felt that the meaning of her own experi-
ential knowledge was invalidated, and that the physician’s knowledge was con-
firmed as “good, objective information that could be depended on.”
A similar dynamic played out in the nurse–physician relationship, where the
autonomy–dependence and hierarchy–equality contradictions manifested as
tensions. The nurse presumably noticed Maria’s confusion but given that the
physician was directing the conversation with Maria, it is likely that the nurse
could not find any strategy to influence the course of the discussion or reduce
the tensions that were building. The nurse’s silence increased the imbalance in
the autonomy–dependence contradiction in the patient–physician relationship,
which manifested as a palpable sense of tension during the conversation.
Because of the entrenched physician-centered discourses in the clinic, the phy-
sician, who also noticed the uncomfortable atmosphere during the consulta-
tion, did not have any strategies to balance the tensions. Unfortunately, as
hierarchical communication practices were well established in the clinic, the
team’s ability to create new strategies that could change the stable protocol
guiding patient–physician–nurse interactions and to redress the unbalanced
uncertainty–certainty dialectic was minimal.
What would have been helpful in this case? If the care providers had devel-
oped a shared understanding of the discourses that steer their interactions in
the clinic and of the contradictions these discourses create, they could have
been more aware of and prepared for the tensions that emerged. They would
then have been able to create strategies for those situations when patients were
present. In Maria’s situation, the tension could have been managed if the nurse
had opened the conversation with the surgeon and Maria by telling the sur-
geon what she and Maria had previously discussed. This would not have
involved taking sides but would have made it possible for everyone’s voice to
be taken into account from the beginning of the discussion.
 7 DIALECTICAL TENSIONS IN INTERPROFESSIONAL RELATIONSHIPS… 129

Conclusions and Implications

In this chapter, we described the dialectical nature of interpersonal relation-
ships that shape communication in interprofessional teams. On the basis of our
literature review, we offer three main conclusions. First, we conclude that the
contradictions of hierarchy–equality and autonomy–connectedness are particu-
larly prominent during health care collaboration and modify healthcare team
communication. We claim that the autonomy–connectedness and hierarchy–
equality dialectics are intertwined, and that, for instance, emphasizing the pro-
fessional hierarchy usually strengthens physicians’ autonomy. To find strategies
to manage these core dialectics, future research should focus on the interplay
between the two.
As we have shown, it would be overly simplistic to think that, in interprofes-
sional teamwork, all hierarchy should be avoided (see Chap. 8) or that team
members should give up their autonomy as much as they can. Through the lens
of relational dialectics theory, this is not desirable nor possible. Therefore, we
claim that the first step and the only way towards good quality interprofessional
team communication is to accept the dialectical nature of interpersonal and
interprofessional relationships and to become aware of the tensions that dialec-
tics may produce. Contradictions are inevitable, but we can shape how tensions
are interpreted and make space for managing them in team communication.
Strategies for managing tensions center on team members’ asserting their pro-
fessional expertise and doing so while also recognizing the team hierarchy and
maintaining positive team relationships. When it comes to the hierarchy–equal-
ity tension, the strategy of segmenting seems to provide a way to consider what
kind of tasks require more hierarchical interactions (e.g., emergency care) and
which tasks demand a more egalitarian approach (e.g., developing team care).
Moreover, by reframing the hierarchy and equality within an interprofessional
relationship, it is possible for example to limit the hierarchy to moments of
medical decision-making while emphasizing relational equality.
The second conclusion refers to the competing discourses present in health-
care contexts. For example, both discourses of hierarchy and equality are mani-
festations of societal and cultural discourses, while healthcare discourses are still
dominated by the professional hierarchy. As there are possibilities for different
interpretations of discourse, one way of managing the tensions is to change the
weight attributed to each discourse or to create new meanings. For example,
for a long time in health care, the professional hierarchy has been seen as “a
natural way” of organizing care or as a structure that enables more autonomy
for some and forces others to limit their actions. Becoming aware of how we
talk about hierarchy changes the meanings we give it, and, thus, provides a way
to change. Hierarchy can be productively aligned with tasks and situational
decision making without requiring relational hierarchy; in other words, it does
not require the reenactment of hierarchy in interpersonal interactions. Because
every organization’s culture is manifested and reproduced in discourses differ-
ently, the negotiation of what meanings are produced by discourses and, relat-
edly, how contradictions and tensions are managed, must be worked out in
130 L. MIKKOLA ET AL.

every organization. Similarly, tensions appear in different ways in different

organizations. There are no solutions—or meanings—that fit every context.
The third conclusion focuses on the patient’s role in interprofessional team
communication. Although the patient has been identified as an important part
of an interprofessional team, less attention has been paid to understanding how
dialectical tensions are managed in these team situations. In addition, we need
more research about the relational and role dialectics in interprofessional teams
from the patient’s perspective in order to achieve the core purpose and vision
of interprofessional team practice. Patients’ understanding of participating in
interprofessional teamwork needs to be more fully defined.

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 CHAPTER 8

Negotiating Power Relationships

in Interprofessional Health Care Groups

Allison L. Noyes

Healthcare organizations are typically structured around a professional status

hierarchy with physicians at the top and nurses and other clinical staff filling out
the middle and bottom. While the concept of a professional hierarchy is simple,
the underlying relationships and processes that create and maintain this hierar-
chy are quite complex. Interprofessional power relationships serve as the foun-
dation for the professional hierarchy, and these relationships are negotiated
through interpersonal communication. Clinicians operate largely through
group or organizational work routines, which shape how different health pro-
fessionals act. However, some clinicians are less constrained by routines than
others; they have more freedom to determine their own actions outside of typi-
cal routines (Giddens 1984, 15) and may also be able to shape the range of
actions others can take by managing meaning or interpretations of a particular
situation (Foucault 1982, 222). From this perspective, a clinician’s “power” is
negotiated relative to others through interaction, so it is often shaped by inter-
professional communication.
Healthcare teams face an intriguing communication challenge related to
the hierarchical structure of power relationships among the health profes-
sions. Research from a variety of different fields indicates that collaborative
process and outcomes improve when power relationships are more balanced
and less hierarchical. For instance, a study on community health alliances
found that the most successful alliances “embraced a norm of equality
among members” (Alexander et al. 2010, 651). Experimental research has

A. L. Noyes (*)
Department of Communication Studies, Loyola Marymount University,
Los Angeles, CA, USA
e-mail: [email protected]

© The Author(s) 2025 133

S. Fox et al. (eds.), Interprofessional Communication in Health and Social
Care, https://doi.org/10.1007/978-3-031-70106-1_8
134 A. L. NOYES

similarly found that mixed-status groups were less likely to reference impor-
tant information in their discussion and made worse decisions than equal-
status groups (Hollingshead 1996). Research in healthcare organizations
specifically has found that a hierarchical culture negatively impacts patient
safety climate and that greater power imbalance is linked to more medical
errors (Hartmann et al. 2009, 328; Sutcliffe et al. 2004, 193). This body of
work seems to suggest that balancing power relationships should be crucial
for successful interprofessional collaboration in providing patient care.
However, many scholars of interprofessional communication agree that
hierarchy is deeply embedded in healthcare organizations and that balancing
power among health professionals is an unrealistic ideal (Fox and Comeau-
Vallée 2020, 572).
Researchers have made the case that the professional hierarchy in health
and social care organizations is constructed and maintained through com-
munication, but much of this communication has become deeply routin-
ized, leading to the institutionalization of hierarchical power relationships
(Fox and Comeau-­Vallée 2020; Noyes 2022). The “balancing” of these
entrenched power relationships would therefore involve the dismantling
and reshaping of even the most basic patient care routines, which would be
nearly impossible. It could also be counterproductive. While hierarchy pres-
ents a challenge for collaborative care, it also improves clarity and efficiency
at crucial points in the patient care process—like decision-making. Many
studies have found that regardless of the collaborative processes used by dif-
ferent interprofessional groups, there is widespread agreement among health
professionals that physicians are responsible for making final decisions in the
patient care process, and this physician responsibility is legally mandated in
many countries as well (Beringer et al. 2006, 331; Lingard et al. 2012,
1764; Noyes 2022, 73). There is also evidence that efforts to transition to
more collaborative models of care can actually exacerbate hierarchical differ-
ences among professions and create more interprofessional conflict as those
at the top of the hierarchy who feel threatened by other professionals reas-
sert their dominance (Freidson 1974, 155; Janss et al. 2012, 844; McMurray
2011, 812–13).
It seems that hierarchical power relationships are unproductive and detri-
mental to collaborative care and at the same time are an institutionalized given
that cannot be effectively disentangled from basic patient care routines. Perhaps
instead of trying to resolve the tension between these seemingly incompatible
truths, we need to reframe how we think about professional hierarchy—from a
monolithic absolute to a flexible and negotiable social order that can serve
multiple purposes at different points in the patient care process. In the next
section, I discuss the relationship between hierarchy and communication and
explain why it’s important to clinical practice. Then I propose a communicative
framework of interprofessional hierarchy negotiation that can help us to
 8 NEGOTIATING POWER RELATIONSHIPS IN INTERPROFESSIONAL HEALTH… 135

understand how interprofessional care groups can negotiate hierarchical power

relationships in ways that improve collaboration without increasing conflict.
Finally, I end with a short case study that highlights two contrasting ways that
care groups might negotiate power relationships and some of the potential
implications of each approach.

Communication and Interprofessional Hierarchy

Impact of Hierarchical Power Relationships
The communication-related challenges resulting from a steep power hierarchy
in organizations are well-documented. First, hierarchy can negatively impact
the amount and quality of communication in an organization. Research con-
ducted in a teaching hospital documented a challenge faced by medical resi-
dents who feel they cannot ask too many questions of their attending because
it may make them look incompetent. The residents also felt they should not
speak up in situations where they might offend their superiors—whether this
involved bothering them in the middle of the night or speaking up when they
had a different perspective on the best course of treatment for a patient
(Sutcliffe et al. 2004, 188).
Hierarchy can also impact attitudes toward interprofessional collabora-
tion, which in turn affects communication. Many studies have documented
the differing values ascribed to collaboration by different professions—
often resulting from education and assimilation into different professional
cultures. Because physicians occupy the position at the top of the power
hierarchy, they have more freedom to work independently than nurses or
other allied health professionals. As a result, they may value collaboration
less than other professionals and feel that their participation in interprofes-
sional collaboration is optional (Filizli and Önler 2020, 3; Beales et al.
2011, 6). This can result in a one-way flow of communication from doctors
to others (i.e., doctors giving orders) with limited knowledge or informa-
tion shared in the other direction (Frimpong et al. 2017, 3). Hierarchy
generally has a negative impact on communication and collaboration and as
a result can shape other outcomes—like team effectiveness, patient safety,
care quality, productivity, and employee satisfaction (Appelbaum et al.
2020, 23; Stocker et al. 2016, 54; Frimpong et al. 2017, 3; Lackie and
Tomblin Murphy 2020, 5). While research focused on the impact of hier-
archy typically relies on the transmission model of communication, another
way to think about the relationship between hierarchy and interprofessional
practice is to consider the role interprofessional communication plays—as a
transactional or constitutive process—in actually shaping power relation-
ships (see Chap. 1) (Callouts 8.1 and 8.2).
136 A. L. NOYES

Callout 8.1 Power Relationships

Power relationships refer to the relationships of influence between
health and social care professionals, and between these professionals and
resources, that are negotiated through everyday communication and
interaction. For example, every day when Dr. Johnson arrives on the unit
to check on his patients, he walks down the hall saying hello to all the
staff nurses: “Hi, Mark! Hello, Shayla. Good morning, Kristine!
The nurses all smile and say, “Hi, Dr. Johnson!” Dr. Johnson never
explicitly asked the nurses to call him “Doctor,” but the nurses know that
it’s a sign of respect to use this honorific, and it’s just what has always
been done, so they fell into the habit of calling him Dr. Johnson, and Dr.
Johnson never invited them to use his first name, so they continue to call
him “Doctor.” While this exchange may seem insignificant, even this
simple routine plays a role in shaping the relationships of power between
Dr. Johnson and the nurses. The regular reminder that Dr. Johnson is a
physician every time they speak to him serves as a little indicator to the
nurses of his extensive training, knowledge, and expertise, and of the dif-
ferential between his biomedical knowledge and theirs. The structuring
of power relationships through this exchange will have an impact on
other interactions between the nurses and Dr. Johnson—and even
between the nurses and other physicians. Although health professionals
always have the capacity to negotiate their power relative to others, much
of the communication and interaction between different health profes-
sionals follows institutionalized routines, like this morning greeting
between Dr. Johnson and the nurses on the unit, which creates some
stability around how power is typically deployed (or not) by people from
one profession in their interactions with members of other professions.

Callout 8.2 Hierarchy

Hierarchy is the (seemingly) enduring structure of power relationships
that’s created through routinized interactions between different profes-
sionals. For example, Dr. Johnson greets all the staff nurses on his unit by
their first names when he arrives each morning, but the staff nurses
respond by calling him “Dr. Johnson.” This morning greeting with the
use of Dr. Johnson’s honorific is one of hundreds of routine interactions
that these nurses may have with Dr. Johnson. Many of these routine
interactions will reinforce Dr. Johnson’s power, and even though some
interactions will likely challenge Dr. Johnson’s power, the enduring
power differential between Dr. Johnson and the nurses is likely to feel
clear and somewhat stable.
 8 NEGOTIATING POWER RELATIONSHIPS IN INTERPROFESSIONAL HEALTH… 137

Power Relationships, Communication, and Interprofessional Practice

One process that shapes interprofessional hierarchy is the communication of
professional boundaries that distinguish one health profession from another.
An ethnographic study showed how attending surgeons assumed the personas
of expert lead actor and facilitator/director in the operating room to establish
their power relative to others. They also assumed the more informal persona of
observer/audience, which relaxed boundaries and allowed other members of
the surgical team to cross them on occasion. Boundary crossing took the form
of calling attending surgeons out or contesting their interpretation as well as
other team members “stepping in” for each other in fluid ways rather than rely-
ing on surgeons to direct them. Yet, interestingly, attendings’ control of the
relaxing and firming of professional boundaries was itself a demonstration of
power because the conditions that enabled boundary crossing by other profes-
sionals were almost entirely determined by the persona attendings chose to
display (Brommelsiek et al. 2020, 6). Higher status health professionals may
also be less likely to participate actively in interprofessional education (IPE)
initiatives, which one study suggests could be a strategy for maintaining the
boundary between their profession and others (Baker et al. 2011, 102).
Interprofessionalism could be inherently threatening to physicians’ power
because it limits their ability to work autonomously whereas nurses’, thera-
pists’, and other professionals’ active participation in IPE initiatives provides a
way to challenge physicians’ dominance and to protect and define the boundar-
ies of their work relative to others. The negotiation of professional boundaries
may feel more challenging but also more important as new roles professionalize
with increasing levels of education, expertise, and skill. For example, nurse
practitioners (NPs) in some places now have the legal authority to indepen-
dently carry out clinical tasks that were previously only the responsibility of
physicians, so physicians may communicate professional boundaries as a way to
maintain their status. Primary care physicians in one study were happy to men-
tor new NPs, but they were less comfortable creating opportunities for them
to use their skills and knowledge for tasks that overlapped with those of physi-
cians, like diagnosing patients (McMurray 2011, 810) (Callout 8.3).

Callout 8.3 Status

Status refers to lasting perceptions of a health professional’s position in
the hierarchy resulting from how power relationships are structured
through routine interaction. Most physicians have a higher status while
staff nurses typically have a lower status than physicians. However, staff
nurses may have a higher status relative to another professional—like a
nursing assistant—so their perceived status may fall somewhere in the
middle of the hierarchy.
138 A. L. NOYES

Institutionalized processes also give higher-status health professionals more

control over the deployment of symbolic communication resources—like
knowledge, time, and physical space. For example, doctors often determine
which space is used and how it’s occupied during interprofessional meetings or
rounds. Table rounds can reinforce imbalanced power relationships based on
where different people sit and how this affects participation. Lower status indi-
viduals are more likely to be located on the periphery or at the opposite end of
the table from higher status individuals, and this impacts nonverbal participa-
tion cues like eye contact as well as degree of inclusion in the discussion (Noyes
2022, 78; Nugus et al. 2019, 108). Institutionalized patterns of movement
also reinforce professional power differences with lower status professions
working in “more visible and immoveable spaces” (e.g., nurses constrained to
their patient care units and nursing stations) while higher status professions
enjoy more “flexibility of movement” (Barbour et al. 2016).
Physicians’ institutionally sanctioned role as leaders specifically during inter-
professional meetings like rounds can also reinforce professional boundaries
and hierarchy. Even when rounds are explicitly designed to be interprofes-
sional, physicians often take the lead. Their biomedical perspective for discuss-
ing patient care can make the contributions of other professionals inherently
less relevant to the discussion (Paradis et al. 2016, 744). Medical residents are
socialized through these ritualized encounters where they learn that their med-
ical expertise gives them permission to “control topics of conversation with
subordinate groups” and that they can accomplish this by relying on the dis-
course of scientific medicine—especially when other professionals raise contex-
tual or non-medical concerns (Apker and Eggly 2004, 425). Physicians may
also structure participation in a way that unintentionally maintains their social
control of meetings—like using a pattern of interaction in which all exchanges
are between doctors and other professionals or by using the spotlight effect
where other professionals are addressed by physicians in a way that opens them
up to public examination (Manor-Binyamini 2020, 3–4).
In sum, communication as a transactional process of information sharing is
often negatively impacted by hierarchy in health and social care organizations,
but communication as a constitutive process is also the means through which
power relationships are negotiated by all health professionals. Research that
recognizes the negotiability of power relationships views professional hierarchy
as socially constructed (Fox and Comeau-Vallée 2020, 569; Noyes 2022,
67–68). If the professional hierarchy is a communicative construction, the key
to improving collaboration and reducing conflict in health care organizations
may lie in how interprofessional groups communicatively negotiate these rela-
tionships to strike just the right balance of power at different points in the col-
laborative process. In the next section, I propose a communicative framework
of interprofessional hierarchy negotiation that offers some insight into how
healthcare teams can navigate power relationships in a way that improves inter-
professional collaboration without increasing conflict.
 8 NEGOTIATING POWER RELATIONSHIPS IN INTERPROFESSIONAL HEALTH… 139

Communicative Framework of Interprofessional

Hierarchy Negotiation

A Flexible Social Order

The professional hierarchy in health and social care organizations appears to be
a stable social structure, but its stability comes from patterns of communication
and interaction that have become institutionalized through repetition over
time and across space. So hierarchy is both a complex, ongoing communicative
accomplishment (Apker et al. 2005, 112) and at the same time a deeply embed-
ded set of social rules that constrains clinicians’ interactions. Health profession-
als “use” the social rules and structures that constitute hierarchy to guide their
interactions with others while simultaneously recreating these rules and struc-
tures by their very use of them (Giddens 1984, 19). Power, then, is constantly
under negotiation since even simple interactions that reconstitute the standard
hierarchy without a power struggle still involve a basic assertion of power by a
higher status professional and an acceptance or acknowledgement of that asser-
tion of power by others—or a lower status professional deferring to a higher
status professional. Power, from this perspective, is not something a health
professional “has” but rather something a health professional “uses” in contex-
tualized interactions with others. Physicians have extensive knowledge about
disease and treatment that they acquire through their rigorous education. But
simply having this knowledge does not make doctors inherently powerful; it’s
their communication of this knowledge in a contextualized interaction with
another health professional that allows them to claim power. Assertions of
power also involve the deployment of social and material resources through
communication (Giddens 1984, 33). For example, when a physician orders a
particular medication for a hospital patient, she uses her knowledge to com-
municate her control over a material resource (i.e., the medication itself) and a
social resource (i.e., the nurse who is ordered to administer the medication to
the patient). Much of the interprofessional interaction in hospitals follows pre-
scribed routines, which gives hierarchy stability, but people can also break from
these routines, and then power must be negotiated interactively. And health
professionals do break from these routines regularly—even in very small ways
to claim power for themselves and to challenge others’ power.
Interprofessional power struggles can emerge anytime that power is negoti-
ated interactively, but problematic team conflict seems to become a regular
problem primarily in two extreme situations: (1) healthcare teams whose rou-
tines consistently recreate extreme power imbalance so that those with less
power constantly have to struggle and fight to challenge those with more
power, or (2) teams that try to “balance” power relationships, which can make
higher status professionals feel threatened so that they aggressively reassert
their power. For example, if hospital administrators try to give nurses a more
active role in interdisciplinary rounds by having charge nurses lead these
rounds, physicians may challenge the charge nurse’s authority by not attending
140 A. L. NOYES

rounds or by challenging their biomedical knowledge during rounds. They

may even begin to reassert their power in other ways with other members of
the team (e.g., insisting that all staff nurses use the honorific “Dr.” when speak-
ing to them) in order to protect their status as the most powerful members of
the group. Health and social care teams may inadvertently develop routines
that create one of these two extreme situations if they have a simplistic view of
“the hierarchy” as a stable social structure that exists outside of interprofes-
sional interaction. From this perspective, power relationships are either bal-
anced or imbalanced. If teams embrace the status quo, they will lean toward
the extreme power imbalance that is historically institutionalized in health and
social care organizations. But if they recognize that hierarchy can have a nega-
tive impact on collaboration and other important outcomes, they may lean
toward extreme power balance, and then attempts to eliminate hierarchy could
create more group conflict. But by rethinking our understanding of hierar-
chy—from a stable social structure that impacts communication to a flexible
social order that is negotiated through communication—it may be possible to
create a third option that avoids the conflict-causing pitfalls of either extreme
hierarchy or extreme power balance. If health and social care teams develop
communication routines that enable individuals to move seamlessly between
hierarchy-relaxing communication and hierarchy-affirming communication,
then it may be possible to strike just the right balance of power to improve col-
laboration without increasing conflict (Noyes 2022, 85; Fox and Comeau-­
Vallée 2020, 586).

Negotiating Power Relationships for Collaborative Team Care

Drawing from research on interorganizational collaboration, as well as research
on interprofessional health and social care groups, we can conceptualize inter-
professional collaboration as a complex interactional process in collaborative
care with more hierarchical or more balanced power relationships serving dif-
ferent parts of the process in different ways. In problem-solving interactions,
hierarchy-challenging communication that reduces power differences among
professionals may help to improve collaborative participation and information
sharing (Gray 1985, 924–26), whereas in final decision-making or implemen-
tation interactions, hierarchy-reinforcing communication that improves effi-
ciency and reduces the threat of encroachment felt by those at the top of the
hierarchy may help interprofessional teams to avoid unnecessary conflict (Noyes
2022, 84; Janss et al. 2012, 844).

 roblem and Direction Setting

P
In the literature on interorganizational collaboration, problem-setting interac-
tions involve determining the shared issue that concerns collaborators and who
needs to work together to address it. Direction-setting interactions involve the
different collaborators providing their input and seeking a common under-
standing and solution (Gray 1985, 917). These phases of the collaborative
 8 NEGOTIATING POWER RELATIONSHIPS IN INTERPROFESSIONAL HEALTH… 141

process are better served when power is dispersed among the collaborators.
Although the intra organizational collaborative process among health and
social care professionals may not have such clear phases, the idea that the
problem-­solving part of the collaborative process will benefit from relaxing the
hierarchy is supported by research, as explained above. Through a variety of
different mechanisms, hierarchy can limit participation in group problem-­
solving, which suppresses collective intelligence (the outcome of combining
the knowledge and skills of all group members that often results in the best and
most creative solutions), negatively impacts care quality, and generates stress
and conflict, especially for lower status professionals (Woolley et al. 2010, 688;
Stocker et al. 2016, 55; Moreland and Apker 2016, 817). Relaxing the hierar-
chy for group problem-solving could improve participation, team effectiveness,
and ultimately the quality of collaborative care.

Decision-making and Implementation

The later phases of the interorganizational collaboration process involve
decision-­making and implementation. This part of the process is less about
information sharing and collective intelligence and more about action, so
power can be more concentrated among the relevant collaborators who will be
responsible for the final decision and implementing the plan without negatively
impacting the outcome (Gray 1985, 929–30). In health and social care teams,
it may be difficult to distinguish between problem-solving and decision-­making
in practice as these processes run together, but we can distinguish them con-
ceptually in a way that is helpful for understanding the subtle shifts in power
balance that may improve collaborative care. When collaborators are discussing
possible options and sharing information and professional perspectives, they
are engaging in a kind of problem-solving, but when this shifts to making a
final determination about a course of action, they move into decision-making.
Teams may even go back and forth between problem-solving and decision-­
making, but if the hierarchy is relaxed enough to allow all members of the team
to participate in problem-solving, then research has found that most health
professionals accept a firmer hierarchy during decision-making and implemen-
tation (Noyes 2022, 73; Fox and Comeau-Vallée 2020, 586).
A clear hierarchy in decision-making and implementation could also be use-
ful for clarity and efficiency and for avoiding some of the conflict that can
emerge when higher status professionals feel constantly challenged (Janss et al.
2012, 844; McMurray 2011, 812–13; Freidson 1974, 155). To be clear, this
does not mean that other health and social care professionals should always
avoid disagreeing with physicians’ decisions. Instead, this approach suggests
that as a general practice, some parts of the collaborative process may benefit
more from relaxing hierarchy while other parts may benefit from reinforcing
hierarchy. Interestingly, if health teams can develop routines for flexibly navi-
gating this relaxing and reaffirming of the hierarchy, then the outcome might
be a team dynamic characterized by the trust and psychological safety that are
142 A. L. NOYES

necessary for allied professionals to feel comfortable disagreeing with a physi-

cian’s decision when it really matters.

 he Practice of Negotiating Hierarchy for Collaborative Care

T
Thinking about the different parts of the collaborative care process helps us to
understand conceptually how health and social care professionals can negotiate
power relationships to improve collaboration, but it may not help us to really
grasp what this communicative negotiation of power looks like in practice.
Relaxing the hierarchy often looks like subtle (or not so subtle) challenges from
lower status professionals and a purposeful ceding of power from higher status
professionals. Reaffirming the hierarchy involves lower status professionals
deferring to higher status professionals and those with higher status claiming
their power relative to others.
Research on hierarchy and interprofessional communication provides exam-
ples of these communication patterns. One study examined how “leadership is
shared (or not) as a result of how the professional hierarchy gets negotiated in
interactions” (Fox and Comeau-Vallée 2020, 570). They found that enacting
hierarchy involved physicians claiming power—like using condescending lan-
guage, cutting others out of discussions, assigning tasks, granting permission
to speak, and challenging others’ interpretations—and other professionals
deferring to them—like accommodating physician outbursts, remaining silent,
using honorifics, and accepting tasks. Resisting hierarchy involved physicians
sharing power—like using inclusive pronouns or humor, pausing and asking for
contributions, and recognizing others as important contributors—and other
professionals challenging physicians’ power and claiming power for them-
selves—by using first names, expressing strong emotions, interrupting, jump-
ing in to contribute, challenging others’ interpretations, and assigning tasks.
Another study provided examples of how all members of interprofessional
teams reinforce or challenge hierarchy through their interactions and estab-
lished processes. When team members communicate that doctors make the
decisions, that doctors are the most vital members of the care group, or that
doctors have the most knowledge and expertise, they reinforce hierarchy within
their team. However, when they communicate a shared purpose, that all group
members have valuable perspectives, or that established group processes are
important, they challenge hierarchy (Noyes 2022). Often these guiding prin-
ciples are communicated not just verbally and nonverbally but also symbolically
through actions—like when physicians in one group decided to stop a patient’s
physical therapy during rounds without a physical therapist present, which
reinforced the idea that doctors make the decisions or when another group put
staff nurses in charge of the patient report during rounds, reinforcing the idea
that established group processes are important.
In both studies, hierarchy was constantly under negotiation from one inter-
action to the next with all professionals communicating in ways that both rein-
forced and challenged hierarchy. But care teams also established communication
routines that shaped a particular balance of power, and if these routines
 8 NEGOTIATING POWER RELATIONSHIPS IN INTERPROFESSIONAL HEALTH… 143

encouraged only hierarchy-reinforcing communication and very little hierarchy-­

challenging communication, collaboration suffered. However, if these routines
were able to strike the right balance between hierarchy-reinforcing communi-
cation and hierarchy-challenging communication, collaboration improved.
More research is necessary to clearly understand the mechanisms through
which this balance of hierarchy-challenging and hierarchy-reinforcing commu-
nication impacts collaboration and other group outcomes, but there’s some
evidence that relaxing the hierarchy improves psychological safety, which is a
feeling of freedom with no negative consequences for sharing one’s perspective
(Edmondson 1999, 350). One study found that hierarchy on health teams
negatively impacted team effectiveness, but only through the moderators of
psychological safety and team cohesion (Appelbaum et al. 2020, 23). Viewing
hierarchy as a fluid social order helps us to see how interprofessional teams can
navigate power relationships through communication in a way that creates
more psychological safety for lower status professionals without threatening
the position of higher status professionals.
One crucial factor impacting this process of negotiating hierarchy to improve
collaboration is the active participation of higher status professionals, especially
physicians. Lower status professionals can relax hierarchical power relationships
by claiming power in interactions with those who typically have a higher status,
and this process can include challenging their higher status colleagues. These
claims to power are an important part of striking the right balance of power to
improve collaborative problem-solving. However, these claims and challenges
by lower status professionals alone will not make a meaningful difference in
relaxing the hierarchy without physicians actively working to share some of
their power. Physicians’ power is so deeply embedded in the communicative
routines that maintain the institution of health care that challenges to the tra-
ditional hierarchy by other professionals alone likely will not be successful in
striking a balance of power that improves collaboration. Physicians have to
learn how to cede some of their power to other professionals “if they are to
leave space for the others to participate fully in the interprofessional collabora-
tion and provide their needed professional expertise” (Fox and Comeau-Vallée
2020, 586). Ultimately, each health team will have to develop communication
routines that strike the right balance of power for their group and the work that
they do together.

Two Tales of Communicating Hierarchy

The Oncology Team’s Hierarchy Affirming Communication

Morning rounds are about to begin for the oncology team. Dr. Z, an attending
oncologist, enters the physician work room and takes her seat at the head of the
table (power is claimed and hierarchy is reaffirmed by sitting in this position of
authority and by holding rounds in a room that “belongs” to physicians). The resi-
dents currently rotating through oncology sit just to the left and right of Dr.
144 A. L. NOYES

Z. The table is not big enough to accommodate the whole team, so the other
allied health professionals (pharmacist, charge nurse, occupational therapist,
and social worker) scramble to find seats at the other end of the table. A nurse
practitioner and nurse care coordinator sit on the ledge behind the physicians
(hierarchy is reaffirmed as physicians claim power by sitting together at one end of
the table, and other health professionals acknowledge physician power by accepting
their place at the other end of the table or on the ledge behind the table or even
standing when there is no room to sit). Dr. Z begins rounds by identifying the
patient (patient A) she would like to discuss first and then requests that the
resident assigned to this patient provide the patient report (hierarchy is reaf-
firmed by Dr. Z claiming the power to choose the order in which patients are dis-
cussed and by requesting information from the resident). The resident provides
the patient report. The social worker looks like she has something relevant to
add, and she tries to make eye contact with the resident, but he is only looking
at Dr. Z, and Dr. Z is only looking at the resident, so the social worker does not
get a chance to share (hierarchy is reaffirmed by physicians’ failure to acknowl-
edge social worker and social worker not speaking up). The resident provides her
care plan for the patient. Everyone else remains silent (hierarchy is reaffirmed
by everyone else remaining silent as the resident provides her care plan). Dr. Z
seems to agree with the resident’s care plan but asks the charge nurse a ques-
tion about patient A’s status (hierarchy is reaffirmed by this request for informa-
tion). The charge nurse does not have the answer but believes the staff nurse
would know; however, the oncology physicians had decided it was too ineffi-
cient to wait for staff nurses to join them in the physician work room one-by-­
one for rounds as they discussed each patient, so there are no staff nurses
present (hierarchy is reaffirmed by physicians’ decision to exclude an important
member of the team from rounds). The charge nurse makes a note to ask the
staff nurse this question about patient A after rounds. Just as the team is about
to move on to the next patient, the social worker finally interrupts and begins
to share the pertinent information she wanted to share about patient A earlier
(hierarchy is challenged by social worker’s interruption), but Dr. Z cuts her off
and tells her there might be time to discuss psychosocial issues at the end of
rounds (hierarchy is reaffirmed when Dr. Z cuts the social worker off and ques-
tions the relevance of her expertise). At that moment, the door opens and another
attending physician, Dr. Y, walks in with two fellows (hierarchy is reaffirmed by
the interruption). He has a question about patient A, and as he walks in, the
charge nurse gets up and gestures to her chair: “Dr. Y, would you like to sit?”
Dr. Y sits in her chair, and she stands behind him for the duration of his discus-
sion with the team (hierarchy is reaffirmed by charge nurse using honorific, “Dr.”
and giving up her chair). The rest of the conversation is mostly a discussion
between Dr. Y and Dr. Z though they occasionally ask for information from the
resident assigned to patient A’s case (hierarchy is reaffirmed by cutting others out
of the discussion). At the end of the discussion, Dr. Z asks if anyone else has
anything to share (they don’t), assigns tasks to the rest of the team, and reminds
the charge nurse to request that information from the staff nurse (hierarchy is
 8 NEGOTIATING POWER RELATIONSHIPS IN INTERPROFESSIONAL HEALTH… 145

simultaneously challenged when Dr. Z invites others to speak and reaffirmed when
she assumes responsibility for task assignments).

The Critical Care Team’s Hierarchy Balancing Communication

Morning rounds are about to begin for the critical care team. Dr. X, an attend-
ing critical care physician, gathers the team in a circle outside patient B’s room.
A social worker joins at the last minute, and everyone takes a step back so
there’s room for him in the circle (power is ceded by physicians and hierarchy is
relaxed since physicians have the power to determine the process and location for
rounds, and walking rounds on the unit are less hierarchy-reinforcing than table
rounds). Everyone looks to the staff nurse currently caring for patient B, and
she starts rounds with the patient report (power is ceded by physicians and hier-
archy is relaxed since often residents do patient report, but having staff nurses do
it gives them an active role in rounds and makes it easier for them to join the
conversation). When she finishes, the resident assigned to patient B begins to
share her evaluation of the patient’s status and care plan for the patient (power
is claimed by resident determining the care plan and hierarchy is reaffirmed). She
pauses to ask the staff nurse about the patient’s current level of pain, to ask the
social worker about the patient’s ongoing symptoms of depression, and to ask
the pharmacist her opinion about the best option between two similar medica-
tions (power is ceded by resident recognizing others’ knowledge and expertise).
After the resident finishes providing her care plan, Dr. X looks to the rest of the
team and asks what others think about the plan (hierarchy is simultaneously
reaffirmed and relaxed as the attending claims power by demonstrating her role
as leader while also ceding power by requesting feedback). A nurse practitioner
(NP) responds to Dr. X: “Christina, I think it’s a good plan, but I know patient
B well, and he hasn’t been sleeping lately” (hierarchy is relaxed when the NP
claims power by using the attending’s first name). Dr. X asks the NP if they
should also prescribe a sleeping pill (hierarchy is relaxed by the attending ceding
power as she requests the NP’s input). The social worker interrupts to add that
this patient has struggled with a dependence on sleeping pills in the past but
defers to the physicians’ judgement on whether sleeping pills are still the best
option for the patient to get some rest (hierarchy is simultaneously relaxed and
then reaffirmed as the social worker claims power by interrupting Dr. X but then
acknowledges Dr. X’s power by deferring to her judgement). Neither Dr. X nor
the resident were aware of this. The occupational therapist (OT) jumps in to
suggests that he could work with the patient on relaxation activities that could
naturally help with sleep (hierarchy is relaxed as the OT claims power by provid-
ing his perspective without waiting for an invitation to speak). Dr. X agrees, and
the occupational therapist asks the resident to put in an order for OT for the
patient. The resident reiterates the final care plan for the patient (hierarchy is
reaffirmed) and then looks to Dr. X for approval (hierarchy is again reaffirmed
by this deference to the attending). Dr. X agrees with most of the plan but makes
one small change and uses the change as a teaching opportunity with the
146 A. L. NOYES

residents (she claims power and reaffirms hierarchy by making the change and
demonstrating her knowledge through teaching.). Dr. X then reiterates the final
care plan and assigns tasks to team members (hierarchy is reaffirmed when she
assumes responsibility for confirming task assignments).

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 CHAPTER 9

Building Blocks and Weaving Threads:

An Intercultural Communication Framework
for the Study of Professional Identity
Construction in Interprofessional Collaboration
in Health Care

Malgorzata Lahti and Karoliina Karppinen

Introduction
The organization of work in today’s health and social care system increasingly
relies on interprofessional collaboration. Such collaboration brings together
people with diverse knowledge bases and roles to jointly manage complex
treatment processes. This arrangement might entail a great deal of identity
work as it creates the need for people to establish their positions as experts in
relation to one another. What we know from the research literature (e.g.,
Baxter and Brumfitt 2008) is that successful interprofessional collaboration
does not consist in simply creating a shared space for the expression of tradi-
tionally understood professional identities. Research on interprofessional

M. Lahti (*)
Department of Language and Communication Studies, University of Jyväskylä,
Jyväskylä, Finland
e-mail: [email protected]
K. Karppinen
Faculty of Information Technology and Comunication Sciences, Tampere University,
Tampere, Finland
e-mail: [email protected]

© The Author(s) 2025 149

S. Fox et al. (eds.), Interprofessional Communication in Health and Social
Care, https://doi.org/10.1007/978-3-031-70106-1_9
150 M. LAHTI AND K. KARPPINEN

healthcare teams (e.g., Faraj and Xiao 2006; Fox et al. 2021) suggests that,
depending on the situation at hand, team members might indeed approach one
another as having some fixed and distinctive professional expertise and respon-
sibilities. Nonetheless, they may also treat professional boundaries as fluid as
they recognize overlaps in expertise and determine mutual responsibilities and
objectives. In this chapter, we draw on the constitutive view of communication
(see Chap. 1) and see professional identities as social constructs produced and
negotiated in communication. We propose that realizing the full potential of
interprofessional collaboration requires a careful balancing act where team
members navigate between fixed and fluid notions of professional identity. Far
from being an individual accomplishment, this navigation is something that
people achieve together in a coordinated manner in interaction. We therefore
invite you to consider interprofessional collaboration as a jointly coordinated
meaning making process in which team members oscillate between fixed and
fluid constructs of professional identities to provide the best quality of care.
To shed more light on the process in question, we will present a framework
developed from concepts in the field of intercultural communication. The per-
spective of intercultural communication is particularly useful here as it is gener-
ally concerned with how people manage their identities in interaction. It offers
us the notions of essentialist and non-essentialist constructions of identities
(e.g., Holliday 2011; see also Dervin 2011) through which we can address the
fixity and fluidity of professional identities discussed above. Essentialism refers
to an approach where social categories, such as professions, are treated as natu-
rally associated with sets of factual characteristics. These characteristics are
taken to define people who claim to belong—or whom we see as belonging—
to a specific social category. Essentialism focuses on professional differences
as fixed and objective facts that manifest themselves in communication. By way
of example, nurses and physicians might be seen as fundamentally different
from one another in terms of expertise and responsibilities, ways of orienting
to others at work, or the language they speak, which may result in misunder-
standings and conflicts. The essentialist view of professional identities sees
interprofessional collaboration as predictable: We can determine beforehand
who is responsible for knowing and doing what. This view of collaboration may
be relevant in some cases. However, complex situations might require that
responsibilities are negotiated rather than taken for granted.
According to the non-essentialist standpoint, on the other hand, profes-
sional identities are fluid and ever evolving. They do not exist outside of social
interaction but are “talked into being” as team members communicate with
one another. These professional identities are relational and context-specific;
they unfold as team members jointly establish their professional characteristics,
rights, and obligations in relation to one another in specific communication
situations. As example of this would be an implicitly negotiated practice of
using first names by non-physicians to refer to and address physicians. By agree-
ing on using first names, team members dismiss hierarchical status differences
and foreground partnership and equality. The non-essentialist perspective
allows collaborators to identify overlaps and revise the boundaries of
 9 BUILDING BLOCKS AND WEAVING THREADS: AN INTERCULTURAL… 151

professional expertise, learn from each other, and build shared interpretations
of the treatment process.
Essentialism and non-essentialism are associated with larger meta-­theoretical
perspectives in intercultural communication, with non-essentialism developed as
a critical response to the more established essentialist view of social categories
and identities. However, the two perspectives are not incompatible, and they
co-exist in everyday communication. When you pay attention to how people
communicate about social categories in interaction, you will notice that both
essentialist and non-essentialist notions of identity are used, depending on what
the situation requires. As we pointed out earlier, successful interprofessional
practice may, indeed, require that professionals orient to one another in both
essentialist and non-essentialist ways. In this chapter, we will present the theo-
retical framework of small culture formation on the go (e.g., Holliday and
Amadasi 2020; Amadasi and Holliday 2017), which specifically investigates how
a small group of people negotiate essentialist and non-essentialist identity con-
structs in their everyday interactions through deploying what the authors refer
to as block and thread narratives. A possible shortcoming of this framework is
that it might favor non-essentialist identity constructs over essentialist ones. We
therefore expand the existing framework with the concept of simplexity (e.g.,
Dervin and Gross 2016), which presumes that simple essentialist and complex
non-essentialist views of identity are not only equally important but also support
and enhance each other. We argue that in successful interprofessional collabora-
tion, professionals form their small culture by oscillating between blocking and
threading narratives in a coordinated manner to meet the goal of providing the
best quality of care to the patient. We illustrate the value of our theoretical
framework with the discussion of a vignette developed from the dataset of audio-
recordings of weekly meetings of an interprofessional team comprised of nurses,
physiotherapists, and ward clerks involved in specialty care in a Finnish hospital.

Essentialist and Non-essentialist Approaches

to Communicating Professional Identities

As we have already explained, notions of professional identities as fixed and

fluid can be addressed in more depth by connecting them to the concepts of
essentialism and non-essentialism. Essentialism and non-essentialism are associ-
ated with larger meta-theoretical perspectives in intercultural communication
(Holliday 2011). They stand for philosophical standpoints that researchers
have taken when examining the characteristics of different social categories and
their relationship to people’s identities. In this section, we will present the two
standpoints in more detail, paying particular attention to how they understand
communication.
Essentialism refers to treating social categories (such as nation, ethnicity,
gender, or profession) as independent entities existing “out there” as stable
systems of cognitive and communicative traits (see, e.g., Holliday et al. 2021).
Such systems of traits are taken to “naturally” form the essence of the identities
152 M. LAHTI AND K. KARPPINEN

of the people seen as category members (Holliday et al. 2021; Piller 2012). For
example, people belonging to the category “social worker” may be seen as
essentially different in terms of expertise, worldview, or communication style
from those who belong to the category “nutritionist.” In this line of thinking,
communication is approached as transmission of information (see Chap. 1) as
it is seen as a channel for people to express their inner, stable, and intact profes-
sional identities. In other words, different professional identities are believed to
surface in how members of different professional groups communicate. In the
context of interprofessional collaboration, essentialist thinking about profes-
sional identities encourages practitioners to orient to one another using a priori
assumptions. An example of this would be the notion that we can prepare
ourselves for—and thus avoid misunderstandings and conflicts in—interactions
with different specialty physicians by learning about the characteristics of these
different categories.
The essentialist approach to social categories has dominated both research
and popular discourses on workplace diversity. A recent review of literature
looking into issues of diversity in the context of interprofessional healthcare
teamwork (Mikkola and Lahti, forthcoming) has, indeed, identified a reliance
on the essentialist orientation among researchers. Most studies have examined
collaboration as hindered by the diversity of national, ethnic, and linguistic
backgrounds among interprofessional team members. For example, Egede-­
Nissen et al. (2019) interviewed nurses and care assistants with a migrant back-
ground working in elder care in Norway. They explain their research
participants’ reported challenges in becoming socialized into their team as
stemming from their non-Norwegian cultural background. Difficulties brought
about by differences in professional identities have also been addressed in the
literature. For instance, Kirschbaum et al. (2015) see different medical cultures
as shaping and explaining physicians’ incompatible orientations towards com-
munication and teamwork. These authors developed and tested a communica-
tion training to help operating room physicians in obstetric care
(anesthesiologists, general surgeons, and obstetrician–gynecologists) lean away
from their discipline-specific communication styles, thus improving collabora-
tive team communication.
The essentialist standpoint in social research has been criticized for offering
simplistic and stereotypical explanations of social interaction that overempha-
size selected differences while ignoring the social, historical, institutional, orga-
nizational, and political context of human interaction, as well as the socially
constructed and fluid character of identities (e.g., Piller 2012). Overreliance on
stereotypes might limit interprofessional interactions to a narrow set of sce-
narios that do not necessarily enable collaborators to benefit from or make the
most of professional synergy. For instance, the potential for learning from one
another or creating novel solutions together might be restricted if team mem-
bers hold on to static descriptions of professional categories, including hierar-
chies that give more weight to the contributions made by those who occupy
more senior and higher status positions. For instance, while exclaiming “What
 9 BUILDING BLOCKS AND WEAVING THREADS: AN INTERCULTURAL… 153

a classic surgeon!” might easily explain a colleague’s irritating behaviour, the

comment masks the team’s shared responsibility for negotiating respectful and
appropriate interaction practices for collaboration.
However, in a fast-paced environment where human lives are at stake, there
is an important place for routines, presuppositions, and a clear division of roles
and responsibilities. In other words, the notion of professional identities as
fixed and predictable might be a vital ingredient in interprofessional collabora-
tion. We will return to this matter later in the chapter. For the time being, let
us return to the domain of social research where several concepts and frame-
works have been developed to provide alternative—non-essentialist—explana-
tions of the connections between social categories and identities.
These theoretical tools are based on the constitutive view of communication
as a dynamic and mutual process of negotiating meanings through which we
orient to the social world (e.g., Braithwaite et al. 2022). As the argument goes,
social categories such as nationality, ethnicity, gender, or profession are not
natural or neutral entities that are external to communication; they are imag-
ined communities (Anderson 2006). In other words, collectives such as profes-
sional groups have so many members that one could never meet or even hear
about all the other members of the group. Therefore, providing an objective
description of the characteristics that members of this group presumably have
in common is impossible. It is more fitting to say that we imagine ourselves,
and are imagined by others, as members of specific groups and we negotiate
meanings attached to specific group memberships (Piller 2012). Treating pro-
fessional categories as imagined and not “real” does not discount their impor-
tance. Shared understandings about professional categories play a key role in
how we experience ourselves, how we act, how we are viewed, and what we
aspire to as professionals.
Rather than an entity that we carry inside us, professional identity is
approached as an ever-evolving process that takes place between and among
people as they jointly construct and negotiate meanings about who they are as
experts in relation to one another. This process may be affected by broader
social, institutional, or organizational contexts and beliefs. By way of example,
specialist physicians with low proficiency in the working language of their
healthcare organization might need to put extra effort into establishing their
professional credibility, which would be taken for granted in a different linguis-
tic setting. Similarly, gendered and heteronormative ideals in healthcare work
might create extra labor for men in nursing, who, irrespective of their sexuality,
might find themselves caught in a paradoxical struggle to distance themselves
from the stereotype of the effeminate nurse, while also countering the notion
that men are incapable of providing intimate care in an asexual way (Cottingham
et al. 2016). From the non-essentialist standpoint, professional identities are
fluid and complex and they emerge at the intersections of different group
memberships and personal trajectories that might be relevant at any given
moment. To continue with the example of nursing identity, besides gender or
sexuality, one’s professional identity as a nurse might be affected by one’s
154 M. LAHTI AND K. KARPPINEN

earlier lengthy career in IT, experiences of caring for an elderly parent, or mem-
bership in an amateur ice-hockey team. In this sense, our professional identities
are always unique and diverse in diverse ways (Dervin 2017).
Professional differences may be talked into—and out of—existence in a vari-
ety of ways and with a variety of consequences. While differences might become
relevant, the non-essentialist perspective acknowledges that people are also
concerned with constructing togetherness, negotiating similarity, and nurtur-
ing supportive interpersonal connections (Amadasi and Holliday 2017).
Interprofessional collaboration offers multiple opportunities for establishing
interconnectedness as it brings people together around a joint endeavour, cre-
ating the need for identifying overlaps in expertise, negotiating shared practices
and goals, as well as opening the space for relational development and mutual
learning (Callout 9.1).

Callout 9.1 Differences between Essentialist and Non-essentialist Notions

of Professional Identity
The concepts of essentialism and non-essentialism are useful for address-
ing professional identities as fixed and fluid. Essentialism and non-­
essentialism refer to broad philosophical viewpoints about social categories
and people’s identities. The essentialist view sees social categories as
objective entities that exist outside of interaction and that define the
essence of the people belonging to the category. Professional identities
are treated as stable, singular, and mutually exclusive with other profes-
sional identities. They are taken to surface in how members of different
professional groups communicate. Essentialist constructions of profes-
sional identities are inevitably limited. They reduce our ideas about one
another to stereotypical qualities, thus curbing mutual learning and cre-
ativity, and upholding traditional power dynamics. In healthcare collabo-
ration, they may, nevertheless, be useful in constructing clear divisions of
roles and responsibilities. Non-essentialist notions of identity have been
developed as a response to essentialism. Non-essentialism sees profes-
sional identity as a communication process where people jointly construct
and negotiate meanings about who they are as experts in relation to one
another. Professional identities are thus fluid and complex social con-
structs that do not exist outside of communication but unfold differently
across communication situations. They are informed by our personal tra-
jectories and memberships in other social categories, as well as by social,
organizational, and institutional contexts. The non-essentialist viewpoint
treats professional differences as dynamic and complex. At the same time,
it highlights mutual learning, building common ground, and construct-
ing interpersonal connections.
 9 BUILDING BLOCKS AND WEAVING THREADS: AN INTERCULTURAL… 155

Interprofessional Healthcare Collaboration as a Site

for Building Blocks and Weaving Threads

Essentialism and non-essentialism are associated with separate meta-theoretical

perspectives in intercultural communication, with the non-essentialist perspec-
tive developed as a response to the challenges associated with essentialism. The
essentialist standpoint in research has come under criticism for perpetuating ste-
reotypes about groups of people that often support unequal power relations in
interactions across different social contexts. While this approach might be prob-
lematic as an overarching and singular viewpoint for researching the social world,
there have recently been calls for research to integrate different and perhaps even
incongruent fixed and fluid explanations about identities (Dervin 2023).
When we shift the focus onto what people are doing in their everyday lives,
occasionally drawing on stereotypes seems normal. Studies into identity work
in mundane interactions have shown that people may, indeed, juggle fixed and
fluid ideas about identity to accomplish specific social actions when communi-
cating with one another (e.g., Stokoe and Attenborough 2015). For example,
a group of ward clerks might discuss among themselves how they sometimes
handle work considered to fall within the professional jurisdiction of physi-
cians. While clerks are primarily responsible for administrative matters, their
specialized healthcare expertise enables them to monitor patients’ treatment
plans and correct any mistakes that physicians may have left unnoticed. Through
this kind of talk, the ward clerks shift the boundaries of traditional professional
identities, thus challenging the established division into less prestigious admin-
istrative work and more prestigious clinical work. This allows them to create a
more favorable ward clerk identity for themselves. Conversely, in an organiza-
tional meeting where representatives of different occupational groups working
at the specific hospital are present, ward clerk representatives might draw on
the notion of fixed professional education and expertise to counter the attempts
by the management to add additional responsibilities to the clerks’ existing
workload, which they already struggle to manage. Declaring that some respon-
sibilities are beyond one’s professional jurisdiction may be a strategic essential-
ist act designed to protect the group’s rights.
Let us now take a closer look at the framework of small culture formation on
the go (e.g., Amadasi and Holliday 2017; Holliday and Amadasi 2020), which
sheds light on how people involved in interprofessional collaboration develop
a shared meaning system for moving between essentialist and non-essentialist
professional identity constructs. The concept of small culture is concerned with
what happens at the level of interaction when two or a few persons get together.
It is therefore significantly different from the popular understanding of culture
as meanings and practices assumed to be common to a large collective—or, as
we explained earlier—an imagined community (such as “national culture” or
“professional culture”). Small culture refers to “the rules and identities neces-
sary for being with people and getting on with things” (Holliday 2016, 3) that
are constructed when a small group of people interact with one another. In
156 M. LAHTI AND K. KARPPINEN

interprofessional settings, the necessary rules can refer to the collaborative

practices that are created and negotiated in interprofessional teams, whereas
the needed identities can be considered as the professional positions and the
expectations attached to those professions. These expectations relate to, for
instance, the presumed expertise, characteristics, rights, and obligations of dif-
ferent occupations. “On the go” refers to the dynamic nature of how people
engage in small culture formation—people are coming, going, and passing by,
and they might accept, reject, remake, or challenge the norms and social con-
ventions created (Amadasi and Holliday 2017, 244; Holliday and Amadasi
2020, 9). In other words, the formation of a small culture does not require a
stable team with specific members and clear boundaries. The process of nego-
tiating relationships, identities, and shared rules for engagement is put in
motion whenever people get together. This view applies particularly well to the
context of healthcare where shift work and plug-and-play teaming are common.
The concept of small culture formation on the go approaches small groups
of professionals involved in collaboration as continuously creating and recreat-
ing culture in their interactions. Cultural realities are thus treated as built at the
level of interpersonal interaction around individuals’ personal circumstances
(such as family, peers, education, profession). These realities are taken to be
produced in and referred to through block narratives and thread narratives.
Narratives refer here to “how people construct the events they observe and
their meanings in relation to the temporal and spatial dimension of other
events” (Amadasi and Holliday 2017, 259). Focusing on narratives means
examining how people draw connections (such as cause-effect relationships)
between different events, and how different identities come to be positioned as
part of the emerging plot. Block narratives are built on essentialist identity
constructs that highlight fixed differences. In other words, block narratives are
based on presumptions that people behave and communicate in a certain way
because they “belong” in a certain social category, such as “nurses” or “doc-
tors.” Blocks also emphasize differences between these categories. Blocking
can be detected, for example, when professionals refer to different stereotypical
characteristics and presumed duties of other professionals. According to the
small culture framework, these blocks can, and should be, overcome through
pulling on non-essentialist threads, that is, by constructing narratives that iden-
tify similarities, nurture connections, acknowledge social injustices, and resist
commonplace beliefs that normalize power inequalities (Amadasi and Holliday
2017; Holliday and Amadasi 2020). Thread narratives create common ground
and concentrate on what we have in common. For example, patient-centered
stories can be seen as a form of intercultural threading as they focus the atten-
tion to healthcare workers’ joint goals of helping patients.
The framework of small culture formation on the go has been developed for
the needs of intercultural education to understand how we can overcome ste-
reotyping and build meaningful interpersonal relationships with people whom
we consider as different from us. The main argument of this chapter, however,
is that in the context of interprofessional collaboration in health care, both
block and thread narratives are needed to make the most of distinct
 9 BUILDING BLOCKS AND WEAVING THREADS: AN INTERCULTURAL… 157

professional expertise and responsibilities, as well as mutual learning and inter-

connectedness. Indeed, research into interprofessional collaboration in authen-
tic teams, that is, teams that have a shared working history and orient to a
shared future together, suggests that effective interprofessionality does not
entail a dismissal of traditional occupational responsibilities and expertise. By
way of illustration, Fox et al. (2021) conducted shadowing observations and
interviews with clinicians and support staff in two primary care clinics. They
noted that the research participants engaged in a variety of interprofessional
collaborative practices that required different degrees of interdependence.
However, these practices appeared to be rich in nuance and complexity. Even
the more independent practices that highlighted individual professional exper-
tise, such as consultation or referral, were not disconnected from the ideals of
patient-­centeredness, multivocality, and shared decision making. Instead, they
contained elements of interdependence as they laid the groundwork for build-
ing shared understanding. An illustrative example of this was when team mem-
bers employed their professional expertise to support one another in better
understanding complex patient cases. When viewed from the perspective of
block and thread narratives, this suggests that blocks (distinct professional
expertise) might be necessary for threading (e.g. patient-centeredness) to occur.
Faraj and Xiao’s (2006) ethnographic work on the coordination of expertise
in a trauma center showcases the need for both essentialist blocks and intercul-
tural threads in small culture formation to achieve what the authors refer to as
“partial improvisation.” The authors argue that in a hectic and unpredictable
working environment with no tolerance for errors, there is a need for both
formal coordination and hierarchical decision making to make sure that respon-
sibilities are clearly divided and decision processes run smoothly, as well as a
need for flexibility in structures to enable improvisation and emergent decision
making. Rather than always aspiring towards anti-essentialism, interprofession-
ality involves manoeuvring between the essentialist blocks of disciplinary roles
and expertise and the non-essentialist threads as represented in democratizing
the sharing of knowledge and authority, recognizing overlaps in expertise, and
constructing new knowledge together.
Therefore, the framework of small culture formation on the go needs some
tweaking to be workable in the context of interprofessional collaboration in
health care. We revise the small culture framework by adding the concept of
simplexity, which was originally developed in philosophy, biology, and neurosci-
ences (Dervin and Gross 2016). The neologism “simplexity” was coined by
combining “simplicity” and “complexity” to describe the evolutionary proper-
ties of living organisms. Berthoz points out that the developing brain has had to
find solutions based on simplifying principles to “process complex situations very
rapidly, elegantly, and efficiently, taking past experience into account and antici-
pating the future” (2012, 1). Simplexity has been introduced in intercultural
communication research (e.g., Dervin 2017; Dervin and Gross 2016) to capture
how, in social interaction, we can never fully embrace the complexity of the social
world but, rather, move back and forth between simple (fixed, essentialist, block-
ing) and complex (fluid, non-essentialist, threading) ideas about others.
158 M. LAHTI AND K. KARPPINEN

As such, the process of simplexifying is not simple as it does not reduce the
complexity of reality and the other (Berthoz 2012). Simplexifying entails
changing perspectives and framing challenges in novel and unexpected ways; it
requires the ability to “refuse, inhibit, choose, connect, and imagine” (Berthoz
2012, 2). When viewed from this vantage point, weaving threads is not consid-
ered as the better end of the spectrum. Blocking and threading are both neces-
sary as they support, enhance, and feed into each other, enabling effective and
creative collaboration. In the process of simplexifying, members of an interpro-
fessional team balance traditional essentialist professional boundaries that cat-
egorize healthcare workers hierarchically with jointly constructing narratives
that democratize their knowledge sharing and decision making. During this
ongoing process, collaborating communicators constantly move between block
and thread narratives as they position and reposition themselves and others
depending on what happens in interaction (Holliday and Amadasi 2020, 11).
Berthoz (2012) further suggests that the simplifying of solutions arises from
and enables intersubjectivity, or the ability to grasp and comprehend the inten-
tions of others. We can see how this idea connects to the formation of small cul-
ture as an ongoing communication process where representatives of different
administrative and healthcare professions are jointly figuring out shared rules of
engagement. These shared rules for engagement both develop through and make
it possible for the team to coordinate their blocking and threading practices. The
achievement of this coordination requires a strong mutual foundation of shared
understandings about when we use blocks and when we use threads (Callout 9.2).

Callout 9.2 Formation of Small Culture on the Go in Interprofessional

Collaboration
Small culture formation on the go happens when a small group of people
create, maintain, challenge, and recreate joint rules, identities, and rela-
tionships for being together and accomplishing shared tasks in their daily
interactions. Such small culture formation occurs in all kinds of social
groups, such as families, leisure groups, and work teams. “On the go”
implies that we are taking part in small culture formation all the time in
our interactions, whether we are permanent or drop-in members of a
group. It also refers to the dynamic nature of culture: It is constantly “on
the move” as people continuously enforce, contest, or reshape culture
when they interact. In the context of interprofessional collaboration in
health and social care, professionals jointly form their small culture by
drawing on narratives that emphasize either professional similarities
or differences. These narratives are called thread narratives and block nar-
ratives. With threads, we concentrate on what we have in common.
Blocks conversely highlight differences and create juxtapositions. These
two types of narrative are not mutually exclusive, but they support and
enhance each other. Team members form their culture by oscillating
between blocking and threading in a coordinated manner, combining
simple and complex ideas about others (in other words, simplexifying)
for enhanced efficiency and creativity.
 9 BUILDING BLOCKS AND WEAVING THREADS: AN INTERCULTURAL… 159

“Why Couldn’t They Simply Ask Patients about Their

Discharge Preferences?”
This chapter’s main argument is that successful interprofessional collaboration
can be viewed as a process where professionals jointly move between blocking
and threading narratives of professional identities in a manner that supports
them in accomplishing their collaborative tasks. Let us now illustrate the use-
fulness of our framework by applying it to an example of an episode in a meet-
ing of an interprofessional healthcare team. This narrativized example is based
on the audio-recordings of 5 weekly meetings of nurses, physiotherapists, and
ward clerks who worked together in an outpatient orthopedic clinic in a large
Finnish hospital.1 The meetings were attended by 7 to 9 participants. The team
can be regarded as an authentic, naturally occurring team. At the time the data
was collected, they had a history of working together and they oriented towards
a shared future. The team meetings on which our example is based represent
what can be called the clinical backstage (Ellingson 2003) in that they take
place outside of—and are designed to support—clinical interactions involving
patients. Neither patients nor physicians are present in the meetings, which
enables certain talk about these two groups. In the meetings, the participants
organize their joint work by reporting on and coordinating their activities,
sharing views on joint practices, and planning future actions. The meetings
start with one of the team members going over the agenda but unfold in a fairly
unstructured fashion as the participants engage in spontaneous discussion.
In one of the meetings, the group discusses post-operative patient discharge
procedures. One of the nurses shares feeling uneasy whenever young and oth-
erwise healthy patients ask her why they cannot be sent home on the day of the
surgery. Obviously, it is the physician who oversees the treatment process and
who decides on the specific discharge option for the patient. Sadly, physicians
do not provide the reasons behind this decision in the patient’s electronic med-
ical record. The nurse, who can only read the decision in the documentation,
is very uncomfortable about not being able to explain to patients why they
have been disqualified for an early discharge.
Other meeting participants sympathize with the nurse. In an animated man-
ner, they start jointly criticizing the physicians for omitting to write the justifi-
cation in the medical record, thus placing the already overburdened nurses in a
difficult position and creating extra detective work for them. It often feels that
the physicians fail to consider just how busy nurses are, and what a big favor it
would be for the others if they would simply document their decisions more
transparently! The meeting participants agree that, at the end of the day, early
release criteria are not clear-cut. Patients could be sent home early if they are

1
The data was collected in a research project InterProfInterAct (2019–2024), led by principal
investigator Leena Mikkola.
160 M. LAHTI AND K. KARPPINEN

young and otherwise in healthy. Then again, having someone at home who will
look after you also plays a role. In fact, even older patients could be sent home
right after the surgery if they have family members available to take care
of them.
One of the participants then raises a related worry: With the early discharge
option being a new practice at their hospital, he sometimes suspects that the
physicians are not even aware of this option. He can think of one specific physi-
cian (everyone else in the meeting seems to know whom he is talking about)
who is probably unaware—or he does not care or would rather not take the
responsibility. This physician tends to confine his patients to a night on the
ward even if they would clearly qualify for an early release. The meeting partici-
pants start wondering why physicians could not simply ask patients about their
discharge preferences. Some of them clearly want to go home early, and being
able to do so could support their healing process.
Let us now reflect on how the meeting participants build blocks and weave
threads as they jointly negotiate identities, relationships, and rules for shared
engagement in the above example. Several intertwined and mutually sup-
portive threading and blocking narratives can be identified as the meeting
participants reconstruct the treatment process and reflect on how the process
could be improved to cut the unnecessary work for the representatives of
some of the professional groups and, most importantly, to better meet
patients’ needs. By recreating the steps of the treatment process leading up
to and following the surgery in which representatives of different profes-
sional groups are involved (pre-operative consultation with a physician, pre-
operative meeting with a nurse, post-surgery discharge as authorized by the
physician, post-surgery recovery of the patient), the meeting participants
construct a threading narrative where different team members are connected
as a relay team.
However, this threading narrative would not be possible without a block-
ing move as all the different parties involved in the process, including the
patient, are categorized as having some distinctive rights, obligations, exper-
tise, and authority. Besides forming the basis for the construction of profes-
sional interdependence, this blocking narrative can be regarded as an important
means for managing and critically reflecting on the functioning of the collab-
orative machinery. By establishing what belongs and what does not belong to
different colleagues’ responsibilities, the participants in the meeting are able
to justify their frustration with the physicians. Be it out of ignorance, arro-
gance, or in order to shirk responsibility, the physicians are accused of partially
failing to fulfil their duties, thus creating disturbances down the line in the
treatment process. Furthermore, this blocking narrative enables the partici-
pants to downgrade physicians’ professional expertise and moral integrity,
thus challenging the hierarchical relations among different professional
groups. This act of opening up high status identities for scrutiny can be
regarded as threading.
 9 BUILDING BLOCKS AND WEAVING THREADS: AN INTERCULTURAL… 161

Patients are brought into the discussion through both blocking and thread-
ing narratives. As we noted above, the blocking narrative—where different par-
ties are defined as playing their distinctive role in the treatment process—enables
positioning patients as team members, which can be considered as threading as
it shifts the focus onto the joint goals of all those involved in the process. More
specific categories of patient types (such as “young and generally healthy,”
“older,” “qualifying for an early discharge”) are necessary for managing the
workflow and smoothly handling numerous patient cases. However, the meet-
ing participants are also able to leave this blocking narrative aside and engage
in threading through constructions of patients as persons in their own right
with whom they empathize; people who do not neatly fit into the aforemen-
tioned categories, and who are not objects. When the participants suggest that
physicians should ask patients about their discharge preferences, they construct
patients as playing an active role in the treatment process through doing the
work of healing and contributing their expert knowledge on their care prefer-
ences and the support they might need after the surgery. Our example demon-
strates how the meeting participants combine block and thread narratives in
intricate ways. These jointly managed moves can be seen as the formation of a
small culture. Blocking demarcates the boundaries between different profes-
sional categories and is utilized here to express criticism about the representa-
tives of the professional group not present in the meeting. However, blocking
also contributes to improving work fluency by clarifying everyone’s roles and
responsibilities. Threading can be identified in the narratives that describe all
the team members as working towards a shared goal, as well as in narratives
that democratize healthcare collaboration. Threading narratives construct the
patient as an active agent and team member. Most importantly, blocking and
threading are interconnected—they feed into and enhance each other.

Conclusions
In this chapter, we proposed that successful interprofessional collaboration
does not simply entail expanding the pool of traditionally conceived profes-
sional identities and learning to communicate with representatives of different
professional groups. Interprofessional collaboration creates the conditions for
rethinking professional identities altogether as team members identify overlaps
in expertise, revise professional boundaries, define their shared objectives, and
develop a sense of mutual accountability. This does not mean that there is no
place for traditionally understood professional identities. Successful interpro-
fessional teams display the ability to move between essentialist and non-­
essentialist identities in a coordinated manner depending on the task at hand.
In this chapter, we introduced the framework of small culture formation on the
go to explain how people negotiate identities, relationships, and rules for
shared engagement through building essentialist blocks and weaving
162 M. LAHTI AND K. KARPPINEN

non-­essentialist threads. Working with the concept of simplexity, we argued

that both blocks and threads may be mutually dependent and equally valuable
in interprofessional healthcare collaboration. By analyzing a vignette developed
from observations of the recorded meetings of an authentic healthcare team,
we demonstrated how traditional essentialist identities may be necessary for
venturing into the creative process of renegotiating the meanings we attach to
ourselves and others as experts. This process of building blocks and weaving
threads creates and is created by developing a shared understanding of the dif-
ferent ways in which it is acceptable to work together as a team to accomplish
joint tasks. In closing, we propose that this shared understanding can be sup-
ported by being mindful about team communication. Such mindfulness entails
the ability to monitor one’s team interactions, and to identify and reflect on the
situations where essentialist and non-essentialist professional identity con-
structs are used. The next time you are interacting with your colleagues, try
paying attention to the following issues: Who introduces a blocking or a
threading narrative and for what purpose? How do the others respond? When
and how do the blocking and threading narratives work to support construc-
tive, efficient, and high-quality health and social care work?

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 CHAPTER 10

Shared Communication Competence: Moving

Beyond the Individual in Interprofessional
Communication

Tessa Horila

Introduction
Communication is recognized as one of the core competencies of interprofes-
sional teamwork (IPEC 2023), and an overall key competence area in all work-
ing life (Horila 2020). The importance of communicating competently in health
professions is highlighted, for example, because good communication is seen as
key in preventing adverse events (e.g., Hüner et al. 2023), errors, and mistakes
in patient care—and in reverse, errors are often attributed to communication
failures between professionals or professionals and patients (e.g., Spitzberg
2013). Communication competence is mostly viewed as something that can be
taught, developed, and evaluated. Indeed, a vast amount of literature exists per-
taining to the education and training in communication competencies, especially
skills, in organizational contexts, and specifically in interprofessional teamwork.
This chapter proposes a novel conceptualization of shared communication
competence, which offers new insight into how communicative practices in IP
teamwork are collectively understood and developed. This conceptualization
adopts a constitutive perspective of communication. Thus, social reality—includ-
ing meanings and practices related to communicating competently—is seen as
created and interpreted in communication. While a lot of attention has been
devoted to identifying and developing communication competencies in working
life and specifically in interprofessional settings, the focus has primarily been on

T. Horila (*)
Faculty of Information Technology and Communication Sciences, Tampereen
yliopisto (Tampere University), Tampere, Finland
e-mail: [email protected]

© The Author(s) 2025 165

S. Fox et al. (eds.), Interprofessional Communication in Health and Social
Care, https://doi.org/10.1007/978-3-031-70106-1_10
166 T. HORILA

recognizing, measuring, and improving individual communication skills. In

viewing communication competence as something that is shared, this chapter
does not focus on such individual skills. Instead, the focus is on teams as a whole,
and how, over time and through continuous interaction and reflection, they can
build a shared understanding and practice of competent communication.
In line with this perspective, the chapter views communication competence
in IP teams in a way that accounts for the demands and complexities of inter-
professional work, as well as the multilevel dynamics of small group communi-
cation that affect all teamwork. To date, such a conceptualization of
communication competence has been missing, leaving a gap in our under-
standing of competent and incompetent communication in IP teams at the
collective level. Such an understanding will benefit both researchers and those
tasked with developing competence in IP teams. At the same time, outside the
field of communication, theorization of and research on collective IP team
phenomena and competencies has garnered interest. These advancements will
also be referenced in the conceptualization of shared communication compe-
tence presented in this chapter.1

Communication Competence in Teamwork

and Interprofessional Collaboration

Communication competence is commonly defined as the knowledge, motiva-

tion, and skills that enable individuals to communicate effectively and appro-
priately in different communicative contexts and relationships. This definition,
introduced by Spitzberg and Cupach (1984), continues to be prevalent in
research and education, especially in the context of health communication
(e.g., Carmack and Harville 2020). It is commonly accepted that the ability to
communicate competently is a combination of domains that are behavioral
(e.g., skills), affective (e.g., motivation, emotions) and cognitive (e.g., knowl-
edge resources and metacognitive skills). Two criteria for competent commu-
nication—effectiveness and appropriateness—are most often referenced.
Effectiveness is understood as communication that meets communicators’
goals when they interact. Appropriateness refers to communication that is seen
as acceptable according to societal, cultural, or relational norms (Callout 10.1).

Callout 10.1 Communicative Competence

Communication competence: Most commonly defined as the knowl-
edge, motivation, and skills that enable an individual person to commu-
nicate effectively and appropriately in communication situations,
according to the context and the relationships in which they
communicate.

1
This chapter is partly based on a theoretical and conceptual article regarding shared communi-
cation competence in teamwork, published in Finnish by Horila and Valo (2016).
 10 SHARED COMMUNICATION COMPETENCE: MOVING… 167

Thus, when communication is both effective and appropriate, it most likely

meets various other criteria, such as clarity or satisfaction (Spitzberg 2013).2
Researchers widely agree that communication competence is something that
can be developed, and that competence inevitably changes in many ways
throughout the lifespan. This can occur both informally through experience
and feedback from communicative partners, and formally, such as through sys-
tematic interventions, training sessions, and programs.
The importance of communication competence is recognized in all profes-
sional contexts, including healthcare communication. The model consisting of
knowledge, motivation, and skills is widely used in research on competent
communication in healthcare (see Spitzberg 2013) and has been applied to
numerous communicative situations, tasks, and relationships, including doc-
tors’ competence in communicating affection to patients (e.g., Hesse and
Rauscher 2019) and analysis of the role of communication competence in
nursing curricula (Carmack and Harville 2020).
Interprofessional teams are task-oriented small groups. In small groups
research, a key area of interest has been identifying the communication skills
that members need in order for the group to reach its task-oriented goals.
Traditionally, group communication research has largely focused on decision
making and problem solving, which are among the key tasks of work groups
and teams. Similarly, competence research in small group communication has
focused on the central relational, task, and procedural skills of group decision
making, such as climate building (relational), inference drawing and arguing
(task), and planning (procedural) (see Gouran 2003; Shockley-Zalabak 2015),
mirroring the established view of group communication as consisting of task
and relational communication. The theoretical underpinnings of such research
lie largely in functionalist theories of group communication, which aim to
identify key functions of, and barriers to, effective decision-making (Gouran
and Hirokawa 1996).
Other notable streams of group communication competence research
include examining competence relevant to specific team roles, such as leaders,
or competence in specific types of professional teams (Shockley-Zalabak 2015).
The latter approach resembles the “communication in the disciplines” perspec-
tive (Dannels 2001), in which communication competence is approached as a
situated profession-specific skill that should be identified, taught, and assessed
according to the demands of a specific professional context. Examples include
the importance of interviewing skills and relationship building for dietitians
(Vrchota 2011), skills needed in history-taking, such as providing structure
and asking questions, for medical students (Koponen et al. 2014), and active
and empathetic listening especially as a nonverbal skill, for nurses (Carmack
and Harville 2020).

2
Other relevant criteria, such as ethics and fidelity, have also been suggested; however, they are
often seen as being incorporated into the two overarching criteria of effectiveness and appropriate-
ness (see Graves 2021).
168 T. HORILA

In interprofessional teams, the need for communication competence natu-

rally relates to the very nature of interprofessional work. The Interprofessional
Education Collaborative (IPEC) first published a report in 2011 outlining the
core competencies for interprofessional collaboration that should guide the
education of future health professionals. Their intent was to move beyond
profession-­specific competencies in healthcare curricula and focus on educa-
tion that engages students from various disciplines to learn with and from each
other, and to better prepare them for working as members of interprofessional
teams. The report highlights four key competence domains: values and ethics
for interprofessional practice; roles and responsibilities; interprofessional com-
munication; and teams and teamwork. The communication domain is further
divided into 8 competency areas, which highlight responsive and responsible
communication with patients, families, communities, and other professionals,
specifically: (1) choosing effective communication tools and technologies; (2)
using understandable, jargon-free communication with patients, families, and
team members; (3) expressing opinions and knowledge clearly and respectfully
whilst ensuring common understanding; (4) listening actively; (5) giving
timely, sensitive, and instructive feedback, and receiving feedback respectfully;
(6) using respectful language in difficult situations and conflicts; (7) recogniz-
ing culture, power, expertise, etc., and their effect on team communication;
and (8) communicating the importance of teamwork. Similar competencies are
often highlighted in overviews of interprofessional communication (e.g., Kreps
2016) and empirical research. Recent empirical research of competence in IP
team communication has examined, for example, competence in decision-­
making between patients and team members (Warzyniec et al. 2019), profes-
sionals’ (Donesky et al. 2020) and students’ (e.g., Ragucci et al. 2016)
confidence in communicating competently in IP teams as well as the effects of
communication skills training on team outcomes (Hüner et al. 2023).

What We Currently Know and Don’t Know About IP

Communication Competence

Focus on Situational Skills

The focus of communication competence research in interprofessional teams
has thus far largely focused on identifying, categorizing, evaluating, and
improving relevant team communication skills. An overarching question has
been: What are the communication skills needed in specific situations, roles, or
team compositions? A common research agenda involves measuring or other-
wise assessing the effects of members’ communication skill levels on the team’s
functioning and outcomes; commonly studied situations include handoffs and
communication of medical errors (e.g., Baalmann et al. 2023). Study settings
also frequently include single educational interventions and their self-perceived
effects on communication skills (Hüner et al. 2023); these are often
 10 SHARED COMMUNICATION COMPETENCE: MOVING… 169

zero-history student team members’ skills in simulated situations (e.g., Ragucci

et al. 2016).
This focus on single skills and training efforts is understandable from the
perspective of IPE: It is important to identify key skills and investigate how
education and training affects the competence of current or future IP team
members. However, what is missing thus far with such a situational, skill-­
oriented focus is knowledge on the continual change and improvement of
interprofessional teams in actual clinical practice and their communication
competence, especially over long periods of time. Competence levels of indi-
viduals are not static, but rather can change and fluctuate over time (Jablin and
Sias 2001) and, in interprofessional teams, as tasks and challenges change, so
do competence needs. In essence, a member of an interprofessional team might
communicate competently in a given situation—such as during a handoff—but
at another time, perhaps due to a change in resources, team membership, or
organizational setting, communicate less competently in another handoff
situation.
A situational focus also largely ignores team relationships, how they influ-
ence competence, and what sort of competence is needed to maintain them.
For example, interprofessional teams of students assembled for research pur-
poses have neither a history nor an anticipated future and will not form mean-
ingful relational ties. Conversely, teams operating together in working life do
form such ties, yet studies focusing on skills in specific situations often ignore
these team formation processes and their implications for competent commu-
nication. These gaps in understanding have been noted in research on IP health
teams (e.g. Links 2014), and the question is prevalent more broadly in all team
communication competence research. Shockley-Zalabak (2015) noted that
more must be known about how relationships, ongoing communication pro-
cesses, and group phenomena such as the permeability of group boundaries
affect group communication competence over time. There is still need for fur-
ther empirical research of the interpersonal communication competencies that
are continuously needed, developed, and maintained in interprofessional teams,
regardless of task or situation, as well as how the history and anticipated future
of teams and team relationships affect communication competence.

Focus on Individuals: How Competently Do Individual Team

Members Communicate?
As noted earlier in the chapter, communication competence is most commonly
defined and studied as an individually located competence based on the moti-
vation, skill, and knowledge of communicators, which are seen as their capital.
A team, then, becomes the context where one’s individual competence is “pre-
sented,” that is, members’ competence precedes team interaction. Competence
is thus regarded as an input from team members that affects team processes and
outcomes (Shockley-Zalabak 2015). A similar individual emphasis can be
found in the IP literature and research: in IP education, this perspective on
170 T. HORILA

communication skills has even been characterized as psychological (Carmack

and Harville 2020), which overlooks the very communication processes needed
to build interpersonal skills. Likewise, empirical studies often focus on indi-
viduals and their self-reported communication skills or attitudes (e.g., Donesky
et al. 2020)
While it might be intuitively appealing to see competence as an individual
quality, this view is an oversimplification. Indeed, the locus of competence has
been called a “yet to be seriously resolved” question (Spitzberg and Changnon
2009, 44). No individual can, in essence, be competent alone. This does not
negate the fact that individual skills, knowledge, and motivation are key to
forming a communicatively competent team. However, communication com-
petence is inherently relational and intersubjective (see Wiemann et al. 1997):
Competence is always relative to other peoples’ (relationally constructed) per-
spectives, evaluations, values, and so forth (Spitzberg 2013). Thus, compe-
tence can only exist in a relational context in which it is both displayed, but also
evaluated and relationally negotiated. What then should be the unit of analysis,
when trying to understand the formation of communication competence: a
communicating individual, their communicative partner, the relationship in
which standards of competence are negotiated, or the entire team?
Given this important question, there are calls for more multilevel and sys-
temic perspectives on group communication competence (Jablin and Sias
2001; Shockley-Zalabak 2015). Groups and teams form their own norms, ritu-
als, structures, and shared symbolic realities in their everyday communication,
and these will likely influence meanings of communication competence (Jablin
and Sias 2001). When focusing on what happens in groups, it is important to
stay mindful of such communicative phenomena that are specific to groups.
Even such seemingly everyday communication processes in groups such as sto-
rytelling, anecdotes, and so called “inside jokes” might entail implicit meanings
of what a team considers competent communication in, for example, decision
making (Horila 2021). However, studies considering such team-level mean-
ings of competent communication are very few.
In summary, we know a lot regarding the communication skills needed in
team communication in general, and specifically in IP situations and tasks, and
how to teach these skills to individuals. However, specifically in interprofes-
sional teams, it would be beneficial to look into what communication compe-
tence as a team level quality might entail and how such a team-level
communication competence is jointly produced, managed, enacted, and
evaluated.

Emergent Phenomena: Teams That Know, Feel, and Operate Together

as Systems
While communication competence research has been focused on individuals,
an interest in multilevel, systemic, and emergent team phenomena has grown,
especially since 2000. A basic assumption behind such research is that, as teams
 10 SHARED COMMUNICATION COMPETENCE: MOVING… 171

work together over time, knowledge, skills, and attitudes that are more than or
different from the sum of their parts can (and often do) emerge.
Numerous affective, cognitive, and behavioral team phenomena have been
studied as constructed and located at both the individual and the team level.
For example, cognition and knowledge management, emotions, efficacy beliefs,
and creativity have been shown to manifest at the group level as something dif-
ferent than individual members’ knowledge or attitudes separately or com-
bined (for a summary of research, see Fulmer and Ostroff 2015). Such emergent
phenomena and the ways in which they affect team coordination, productivity,
and efficiency have recently been of interest to IP team researchers as well. For
example, IP teams that construct shared mental models, that is, a shared under-
standing of their resources, tasks, and relationships, have been shown to experi-
ence more cohesion and openness of communication, as well as alignment on
the patient situation in, for instance, discharge situations (Manges et al. 2020).
When studying phenomena such as shared mental models or other forms of
team cognition, the interest is not on what members know individually, but
rather, what kind of knowledge structures teams produce and maintain as
systems.
A key team phenomenon that has been theorized and studied especially in
healthcare teams is collective team competence. The notion of collective com-
petence has emerged due to criticism of the individual-based competency lit-
erature on healthcare teams. Lingard (e.g., 2016), in particular, challenges the
idea that professional competence in healthcare teams results from individual
capabilities, and argues that the individualist tradition in medicine should give
way to a focus on the collectiveness of competence. When defined collectively,
competence is distributed, dynamic, strongly contextual, and nonreducible to
individual team members. Instead of listing and teaching individual competen-
cies, it is thought that effective and optimal care is based on the interprofes-
sional team’s collective efforts and collaboration in tasks such as decision-making.
In essence, the shift of perspective from individual to collective competence
underscores that a team can be competent, even if some individual members
are incompetent and vice versa. Rather than seeing competence as individual
and static (in that it can be attained and then utilized in any team), team com-
petence is seen as fluctuating, complex, and negotiable.
Definitions and models of collective competence usually touch upon issues
of competent communication, such as in McLaney et al.’s (2022) model of six
core team-based competencies and associated team behaviors for interprofes-
sional teams. These competencies include communication, interprofessional
conflict resolution, shared decision making, reflection, role clarification, and
interprofessional values and ethics. However, in such competence models,
communication is usually mentioned as merely one competence area among
others—and might often be reduced to information sharing—or it is implicitly
present but not explicitly defined in several competency areas. This is a prob-
lem, because a transmission-based view of communication as information shar-
ing can limit our understanding of the complexity of communication processes
172 T. HORILA

and how they relate to the various aspects of negotiating and enacting IP team-
work. A similar issue pertains to models that aim to explain collaborative prac-
tices in organizations: Communication, often found at multiple levels of
abstraction and seen as both a process and an outcome, is not explicitly defined
(Keyton et al. 2008). What is needed, then, is a definition of communication
competence that acknowledges the systemic and team level nature of compe-
tence and that treats communication as the essence, rather than as one compo-
nent, of teamwork. While a significant amount of theorization and empirical
findings exist regarding the collective, systemic, and emergent properties of
various team phenomena, to date, communication competence in teamwork
and specifically in interprofessional teams has not been approached from this
perspective. Therefore, a consideration of shared communication competence
on IP teams is proposed next.

Shared Communication Competence

in Interprofessional Teams

Clearly, a definition of shared communication competence (SCC) in interpro-

fessional teams is needed, and I offer one here based on Horila and Valo
(2016). This definition builds on four elements: (1) the constitutive nature of
all communication; (2) the nature of interprofessional collaboration, which
requires the coordination and negotiation of expertise, knowledge, and roles;
(3) the gaps in our knowledge regarding communication competence in inter-
professional teams; and (4) knowledge about emergent and collective phenom-
ena in teams. Shared communication competence is thus defined as a
communication competence that is (a) emergent, jointly produced, and negoti-
ated, and (b) temporally changing in that it develops or changes over time and
over repeated team interaction (Callout 10.2).

Callout 10.2 Shared Communication Competence

Shared communication competence: team-level communication com-
petence that is produced, maintained, and evaluated in everyday com-
munication processes, and that is subject to change over time. A team
that has developed shared communication competence is “on the same
page” about what effective and appropriate communication means and it
demonstrates this shared understanding in its communicative practices.

Shared Communication Competence Is Emergent, Jointly Produced,

and Negotiated
The emergence of SCC refers to communication competence in teams at both
the individual and team levels: Individual members have separate communica-
tion competencies, but a team’s communication competence is something that
emerges in—rather than precedes—teamwork. This shared competence
 10 SHARED COMMUNICATION COMPETENCE: MOVING… 173

emerges at the team level through members’ continuous interaction, meaning-­

making processes, and everyday work. Therefore, emergent team phenomena
and collective competencies are not reducible to their individual parts, in this
case, members’ competencies (e.g., Fulmer and Ostroff 2015; Lingard 2016).
Similarly, a team’s communication competence might be more than or differ-
ent from the sum of its parts. For example, interprofessional Team A might
very smoothly share and take on emergent leadership roles in their meeting
interaction, increasing the effectiveness of their communication. A team mem-
ber or an outside observer might evaluate this team as competent in such lead-
ership communication. However, when members of Team A attempt to claim
or negotiate emergent leadership as they do in Team A when participating in
Team B, they might run into role conflicts if members of Team B view this
communicative behavior as inappropriate or ineffective, and therefore incom-
petent. Thus, the effectiveness and appropriateness of leadership communica-
tion is a feature of that specific team, rather than of its individual members.
The second aspect of the definition of shared communication competence
specifies that team-level communication competence is jointly produced and
negotiated. Team-level shared communication competence must be continu-
ously negotiated in team communication processes, whether teams deliberately
do so or not. Members must negotiate meanings of competent communication
and align these meanings between three levels at play in their team communi-
cation processes: the individual, the profession, and the group.

 he Individual Level
T
The team communication skills, motivation, and knowledge often assessed at
the individual level might include members’ listening skills, their personal
motivation towards group communication, and their metacognitive knowl-
edge regarding their own competence levels. Team members develop these
individual competence areas during their experiences of group and team
communication.

 he Professional Level in Interprofessional Interactions

T
In interprofessional teams, each member’s understanding of competent com-
munication is likely influenced by their professional background. These mean-
ings must constantly be negotiated in team interactions, where they may clash
with other members’ professional meanings. For example, team members may
have differing expectations as to which member of the team should take on a
leadership role in a complex decision-making situation, as well as how that
leadership role should be enacted in interaction. Another aspect at play is the
professional culture in which each team member has been socialized because it
may affect the ideas each member has about what constitutes “good” or “effec-
tive” communication. These ideas depend on the discipline- or profession-­
specific communication skills that were explicitly or implicitly highlighted in
their education and other socializing experiences. Also, team members may
have expectations regarding each other’s professional communication, and for,
174 T. HORILA

example, the ways in which a “competent” doctor, nurse, or occupational ther-

apist communicates. For instance, a primary care team’s social worker might
have the most holistic understanding of a client’s situation and therefore feel
they are best placed to lead team decision making. Perhaps they communicate
by narratively explaining the client’s history and goals. However, to the family
physician, this may seem less competent because it “takes too long” and fur-
thermore, the physician might feel that she is expected to take the lead as she
is the one who will have to sign off any paperwork.

 he Group Level
T
In between the individual and professional level is the group level, which is
essentially where teams negotiate the shared meanings and practices of com-
municative competence. Indeed, the group level represents the meso-level of
communication, in which individual, relational, and organizational meanings
are “revealed and acted upon” (Keyton et al. 2008, 402). Regarding, for exam-
ple, the cognitive domain of competence, at the group level, the emphasis
shifts from what individuals know about communicating competently to how
interprofessional team members produce a shared understanding of what com-
petent communication means and looks like in their specific team. Individuals
who would be regarded by others as competent in a given interprofessional
team might in another team setting need to engage in significant meaning-­
making to align understandings of competent communication. In essence, the
group level is where, for instance, profession-based stereotypes should be over-
come to negotiate a team-specific meaning and practice of competent commu-
nication that also suits the individual preferences and strengths of team
members. To return to our previous example, the social worker and the family
physician would have to negotiate a way of sharing information and making
decisions that is both holistic and time-efficient, perhaps by combining a writ-
ten patient referral with a brief face-to-face conversation to contextualize
information.
A shared understanding of competent communication might be produced
both explicitly—for example by negotiating appropriate meeting procedures
and agreeing on use of communication technologies—or implicitly, by con-
tinuous feedback processes in the team, such as team members’ reactions to
specific types of humor. This ongoing feedback and explicit meaning-making
can gradually build a shared understanding of what kind of communication is
regarded as both effective and appropriate in a given team. Of course, not all
teams will form such shared understandings of communication competence or
will form only partially shared meanings. For some teams, especially those
working together only briefly, this might not be a problem, if, for example, the
individual members possess sufficient general communication skills that aid in
reaching team goals. However, especially over time, teams that fail to negoti-
ate, implicitly or explicitly, shared meanings and practices of competent
 10 SHARED COMMUNICATION COMPETENCE: MOVING… 175

communication, might run into conflicts over work processes. While occasional
conflicts can even be fruitful for generating shared meanings, recurring conflict
will likely be disruptive.

Shared Communication Competence Changes Over Time

Interprofessional teams, especially those working together for longer periods of
time, must continuously renegotiate, develop, and revise their shared commu-
nication competence. First of all, the tasks and challenges that teams face
change over time. For example, well-functioning team decision making is not
reached by learning sufficient skills once and for all and then employing them
time after time; decisions themselves are complex and ongoing, and needs,
resources, and schedules may constantly change. Second, team members work-
ing together over longer periods of time (such as months or even years) will, to
some degree, get to know each other. This can be both an asset and a challenge
to team communication: Horila and Siitonen (2020) found that as members of
long-term teams learn about each other and their communication styles and
preferences, they might learn to be more flexible and understanding in team
communication. However, they also found that the passing of time can also
cause rigidity and “historical baggage” for team communication, which can
make it difficult to change and renew accustomed ways of communicating or
give up outdated assumptions about each other’s communication, roles, or
expectations.
Interprofessional team-based care requires teams to develop “a collective
identity and shared responsibility” (IPEC 2023). Shared communication com-
petence as a perspective and practice supports this goal of collectiveness. SCC
refers to both metacommunicative competence—forming and aligning team-­
specific meanings of competent communication—as well as explicit communi-
cative behaviors in teams—creating effective and appropriate communication
strategies as a team. In sum, teams as collectives are called upon to develop
communication competencies that suit each specific team given its context,
tasks, and relationships. In this sense, SCC does not aim to produce a general-
izable model or lists of interprofessional team communication competencies
but rather to direct attention to the negotiation processes of competence in
teamwork.

Practical Ideas
At the heart of developing shared communication competence in interprofes-
sional teams, and encouraging SCC in interprofessional education, is joint
reflection on communication competence at all the aforementioned levels: the
individual, the profession, and the group. At the individual level, this manifests
as reflection concerning each member’s communication style, as well as their
176 T. HORILA

strengths and targets for improvement. At the professional level, this reflection
might focus on, for example, tacit and explicit profession-specific ideals of good
or effective communication and how applicable they are for interprofessional
collaboration. At the group level, the individual and the professional are com-
bined, as teams discuss and align joint meanings for competent communica-
tion. Members of interprofessional teams might even have very differing
meanings concerning what a team is. For example, doctors have been found to
conceptualize teamwork in various ways: Some highlight teams as a collection
of clear roles and responsibilities, while others view teams as a group with a
jointly negotiated goal. These different conceptualizations themselves may
have impactful consequences on how they work in teams (Rydenfält et al. 2019).
Reflective questions to be discussed by teams include:

• Individual level: What kind of communicators do we view ourselves and

each other to be? What is each member’s communicator self-image? What
are the communicative strengths of each team member?
• Professional level: What kind of profession-specific communication ideals
do we identify with? What is seen as competent communication in each
member’s profession? Are specific skills highlighted? How do profession-­
specific cultures influence our ideas about effective and appropriate com-
munication and about how typical team roles should be claimed or
assigned?
• Group level: What kind of effective and appropriate communicative prac-
tices do we already have? What are we good at as a team? In what ways do
our meanings for competent communication differ? How could individ-
ual and profession-specific differences be utilized in our team? Do we
identify profession-specific ways of speaking that could hinder the effec-
tiveness and appropriateness of our communication in this team?

In addition to reflecting on communication competence at multiple levels,

teams should also stay mindful of any need for change and development in
their competence. This could mean, for example, being critical of doing things
“the good old way.” Just because something, such as a specific way of giving
feedback, has worked in a previous team (individual experience), it may not be
best suited for the current team’s needs. Similarly, a profession-specific way of
communicating might not work in an interprofessional team setting. Finally,
teams themselves should stay mindful with regard to changes in their circum-
stances that require once again figuring out the best ways of communicating as
a team, for instance, if the tasks, resources, or organizational structure have
changed, then teams would also benefit from realigning their ideas about good
communication.
In closing, the idea behind SCC is to provide teams with tools for building
a shared understanding and practice of competent communication, not to sug-
gest a normative framework for competent team communication skills.
Essentially, a team that is “on the same page” about what constitutes good or
 10 SHARED COMMUNICATION COMPETENCE: MOVING… 177

high-quality communication (or poor, ineffective communication) is also more

likely to communicate accordingly and find communicative strategies to
enhance the quality and outcomes of that team’s communication. Conversely,
if members do not know where their ideals and expectations differ, they are
more prone to making inaccurate assumptions and evaluation regarding each
other’s communicative behavior.

Developing the Use of Questions as Part of Shared

Communication Competence on an IP Team
This section contains a vignette that illustrates shared communication
competence:3 An interprofessional orthopedic team in an outpatient clinic has
gathered for their weekly meeting. This team comprises several professionals
including nurses, physiotherapists, and ward secretaries, and the team has an
appointed leader. The team’s weekly meetings offer an opportunity to discuss
shared practices, ongoing and future actions, organizational changes, and
events. The meeting structure is rather loose, with an agenda presented by the
team leader, but with a lot of free-flowing discussion where all members spon-
taneously take the floor.
At today’s meeting, the team is discussing, among other things, new instruc-
tions concerning day surgeries for knee operations and their first upcoming
surgery under the new protocol. There is confusion within the team regarding
some of the instructions and whether the written material that the team has
access to is up to date. To clarify these issues, the team discusses the structure
of the new protocol in general and, more specifically, the instructions it con-
tains on changing surgical dressings after the surgery. Observe, in the following
small excerpt, the use of questions by Tina (the team leader), Kathy (ward
secretary), Peter (nurse) and Nina (nurse).
First Tina, as the team leader, asks a question, attempting to make sure she
understands how a dressing change is done according to the new protocol.
Nina states that she has never seen it done, which leads Tina to ask if anyone
else has. Tom now replies, sharing some insights on the type of dressing
being used.

Tina: Alright, the dressing change, with a knee patient, isn’t it so that they have
some sort of, I haven’t even seen it, they have a different kind of dressing
in use at the ward, don’t they…?
Nina: Something to replace the (previous) dressing… I don’t know, I haven’t
seen it.
Tina: Has anyone seen it?
Tom: I’ve seen it, it’s like this, how should I put it, self-adhesive, and then there’s
these marks.

3
This vignette is based on data that was collected in a research project InterProfInterAct
(2019–2024), led by pricipal investigator Leena Mikkola.
178 T. HORILA

Tina again asks a question, describing the dressing, and checking if she
understands correctly. Tom confirms this and adds more detail. Now, Nina
comments that they should have Sandra (physiotherapist) demonstrate the
procedure, with Tom adding that he hasn’t performed the change in a year.
Tina continues to ask for more information about the dressing, this time about
the padding, and Tom shares his knowledge.

Tina: Is it the kind that reaches from here, from the toes to somewhere in
the groin?
Tom: Yes, it goes from the ankle up I guess, the dressing and
Nina: This is exactly why Sandra (physiotherapist) should demonstrate this
Tom: It’s been like almost a year since I’ve last done these
Tina: And underneath is probably some kind of surgical dressing?
Tom: There’s padding underneath and all kinds of things over the wound. It’s a
bit like, it hasn’t really been defined, what to put there. It’s whatever the
nurse finds and grabs from their closet. There’s a lot of variation.
Tina: Uh-huh, and then they’re undone?

At this point in the discussion, Kathy (secretary) participates, also with a

question, that entails a suggestion that the team go over the instructions
together. She then raises another question related to a post-op injection. To
this, Peter (nurse) replies with a question and a statement, openly vocalizing his
uncertainty about the procedure.

Kathy: Should we just go over these (instructions)? I’m thinking, how does the
injection work, don’t they get one after the surgery?
Peter: How does it (work)? I’m like, I’m completely lost now…

After Peter’s question, Tina suggests what should be done according to the
protocol, again in the form of a question, with Tom agreeing, and Nina asking
a question to clarify Tina’s suggestion. After this, the team continues the dis-
cussion, agreeing on a plan about how to go over the material and ensure a
shared understanding of the protocol.

Tina: Well, should you then, make a call on the first day, if they (the patient) were
to come here, then you’d guide them, take the pain meds with you? This is
in the template as well
Tom: Yup, that’s also on our list
Nina: Are you saying they’ve all stayed until the next morning until now?
Tina: We haven’t had any, this is our first day surgery knee, there’s been no knees
Nina: Okay, I understand

In this example, you can see how team members repeatedly ask and answer
questions. They do this throughout their meetings, in both informal and for-
mal discussions when they engage in problem-solving, decision-making, and
idea generating. They use questions to ask for each other’s opinion or expert
 10 SHARED COMMUNICATION COMPETENCE: MOVING… 179

insight, to vocalize uncertainty and need for help, to ask for clarification or
assurance, or to ensure a shared understanding concerning a given topic. They
often also make suggestions and guide the discussion in the form of questions,
as both Tina and Kathy did in the excerpt.
Questions and their use in team communication has been of interest to
communication scholars. In institutional settings, they are often studied to
understand how they afford differential speaking rights and contribute to an
emergence of asymmetry (Aritz et al. 2017). However, it has also been sug-
gested that ample questioning might be especially beneficial for interprofes-
sional healthcare teams as a strategic device to manage boundaries and tensions
in a diplomatic and polite manner (Arber 2008). Questions have been shown
to be a strategy especially used by nurses (Kurhila et al. 2020), in order to indi-
rectly, and diplomatically, make suggestions or challenge decisions. The ortho-
pedic team’s members seem to be doing exactly this—sharing information and
making suggestions in the form of questions. Furthermore, asking questions
can be a way to give the right to speak (i.e., conversational floor time) to all
members—perhaps even flattening hierarchies during team interactions. The
team has been working together for some time, and it may be that they have
created, over time, this shared technique of ensuring the effectiveness and
appropriateness of their communication.
Yet, while this style might be very effective and appropriate for this team, it
might not be transferrable as such to other team contexts (e.g., in emergency
medicine). Perhaps no individual team member would be individually skilled in
asking such questions or would ask them in other teams. Such behavior, in
another team, might not be viewed as appropriate and effective, but rather as
repetitive or a sign of hesitation. Shared communication competence, as has
been discussed in this chapter, manifests as aligned team-specific meanings and
practices of competent communication. This interprofessional team self-­
identifies as well-functioning, and this might well be in part due to their ample
use of questions, which is a jointly constructed practice in their
communication.

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 PART III

Interprofessional Communication in
Specific Contexts and Practices
 CHAPTER 11

Case Management as a Structural Condition

for Effective Interprofessional Communication

Yves Couturier, Stephanie Fox, Paul Wankah,

and Julie Martin

Introduction
The notions of interdisciplinarity and interprofessional collaboration have pro-
gressively gained prominence and established a good level of conceptual matu-
rity as a result of decades of scientific work. Researchers have a better
understanding of the main elements of interprofessional collaboration, the key
ingredients for successful interdisciplinarity, and the overall effects of these col-
laborative models. Specifically, there is converging consensus that communica-
tion is both a key element of good interprofessional collaboration as well as one

Y. Couturier (*)
Département de travail social (Department of Social Work), Université de Sherbrooke,
Sherbrooke, QC, Canada
e-mail: [email protected]
S. Fox
Département de communication (Department of Communication), Université de
Montréal, Montréal, QC, Canada
e-mail: [email protected]
P. Wankah
Faculty of Dental Medicine and Oral Health Sciences, McGill University,
Montréal, QC, Canada
e-mail: [email protected]
J. Martin
Département des sciences de la santé communautaire (Department of Community
Health Sciences), Université de Sherbrooke, Sherbrooke, QC, Canada
e-mail: [email protected]

© The Author(s) 2025 185

S. Fox et al. (eds.), Interprofessional Communication in Health and Social
Care, https://doi.org/10.1007/978-3-031-70106-1_11
186 Y. COUTURIER ET AL.

of the positive effects of interprofessional collaboration. Building on these

insights, the debate has now shifted to the development and implementation of
concrete innovations that embody the core principles of interprofessional col-
laboration. In the health and social care field, these innovations encompass care
philosophies, such as approaches that enable aging in place; organizational ser-
vice models such as integrated care; and interprofessional ways of working such
as case management. In this chapter, case management will be presented as an
interprofessional communication support in the coordination of care, espe-
cially for complex care needs.
The chapter begins with a brief working definition of case management
before detailing its historical roots. Next, we contextualize the need for case
management to enhance continuity in contemporary health and social service
delivery systems. We explain the place of case management in new models of
service integration, putting particular emphasis on how case management pro-
motes various kinds of continuity in care. We then explain the essential com-
munication support role that case management provides in service integration
before considering communication challenges specific to case management.
We then explore the story of Benoît, an older adult who has lost functional
autonomy but whose complex care needs have not been met. This vignette
illustrates the pivotal role that case management could have played in his case.
We close the chapter with a critical discussion of the vignette’s significance in
light of what case management can offer interprofessional care and
communication.

Defining Case Management

Broadly speaking, case management can be understood as an interprofessional
component of service integration. Case management’s aim is to facilitate com-
prehensive and coordinated care, and it is particularly appropriate in clinical
situations where a service user has complex needs and requires an integrated
response to those needs. When many professionals or organizations are involved
in providing care, case management facilitates the continuity of the service
user’s care.
The notion of “case” in case management is not reductive and therefore
does not refer to a single clinical category, such as a pathology or a social prob-
lem based on a categorization (such as diabetes care), which can be convenient
for administrators but constraining for the user. Rather, the notion of case calls
for a holistic view of the service user as a person. This holistic view considers
the synergies that unite all the biopsychosocial dimensions that clinically char-
acterize the concrete needs of a person in their environment, at a given moment
in their life. Because of the complex and dynamic nature of case-situations, the
social response to identified needs is necessarily multiple, requiring the simul-
taneous mobilization of several types of clinical and professional resources.
These resources may even be competing to take responsibility for a user’s care
(or to transfer it elsewhere), such as the tension that is sometimes common
 11 CASE MANAGEMENT AS A STRUCTURAL CONDITION FOR EFFECTIVE… 187

between primary and specialist care. In the name of clinical efficiency, it there-
fore becomes necessary to dedicate a professional to manage these interdepen-
dencies and reduce interprofessional, inter-organizational, and inter-sectoral
inconsistencies. This dedicated professional is often called a case manager.
All people whose functional autonomy is diminished due to disability,
chronic illness, or a mental or cognitive health problem can benefit from the
work of a case manager. The case manager will support and advocate for them
as long as their loss of autonomy requires, considering all their needs as a
whole, regardless of the organization(s) whose services will be mobilized to
meet them. This response therefore requires coordination among the various
actors from different professional and organizational backgrounds. Such coor-
dination demands a sustained effort on the communication front.
Clearly, then, the case manager is a professional dedicated to intra-­
organizational, inter-organizational, and inter-sectoral service coordination.
He or she assesses needs and plans and coordinates services based on formal
communication strategies aimed at all actors involved in the clinical situation.
In this way, the case manager can serve as a key player in interprofessional care.
The case manager role can be performed by various professionals, such as social
workers, nurses, or occupational therapists. Case management has been
described as the human and communicative component of service integration
arrangements (Mullahy 2014; Hébert et al. 2010). While, today, case manage-
ment is increasingly seen as essential to ensuring the continuity of health and
social care, this was not always the case (Callout 11.1).

Callout 11.1 Case Management

Case management is an essential component to the integration of inter-
professional health and social care services. The case manager is a dedi-
cated professional who consults with service users (i.e., patients or clients)
and their families to help them navigate the network of services, ensuring
their voices are heard and preferences considered when intervention
plans are created. Sometimes referred to as care coordinators, liaison offi-
cers, navigators, or patient advocates, their main duties include assessing
user needs and planning and coordinating their care, especially for service
users whose needs are complex and multifactorial. The case manager sup-
ports and advocates for service users in the coordination of their care,
regardless of the organizations whose services are needed. This coordina-
tion work means that the case manager must accomplish a variety of com-
munication goals, including ensuring the necessary exchange of clinical
and other information between relevant actors in the care network, man-
aging and maintaining relationships, and facilitating interprofessional and
interorganizational collaboration. Their work is seen as essential to ensur-
ing informational, management, and relational continuity. The case man-
ager can thus be understood as an important hub in the interprofessional
collaborative network of care.
188 Y. COUTURIER ET AL.

A Brief History of Case Management

Case management has a rich history, originating in social work in the United
States in the mid-nineteenth century (Rose and Moore 1995). It came back into
vogue in the 1950s and 1970s in response to the needs of repatriated veterans of
the Second World War and the Vietnam War, who suffered from chronic, multi-
dimensional biopsychosocial problems (Tahan 1998). In other words, these vet-
erans had complex needs and required intensive services from orthopedics,
physiotherapy, psychology, and vocational rehabilitation, for instance. However,
it was not enough to offer quality services in a sequential fashion and on a short-
term basis, such as in specialized hospitals. Indeed, the consequences of the vet-
erans’ multiple traumas were to last for decades: alcoholism, drug addiction,
poverty, homelessness, and so forth. The complexity of their needs was such that
the coordination of services appeared essential to the quality of their care (Upman
2003). For example, the film Forest Gump shows the effects of the multidimen-
sional trauma of the Vietnam War on Lieutenant Dan (played by Gary Sinise).
Having gone to war as a healthy national hero, he returns home in his early twen-
ties with post-traumatic shock, both legs amputated, unemployed, and sur-
rounded by young women now inspired by Bob Dylan, who no longer see him
as a hero, but at best as a victim of war, and at worst as someone who was on the
wrong side. Lieutenant Dan’s case was too complex to be treated by any one
profession or discipline; he required a concerted and coordinated approach to
address his multifactorial needs, which is what case management provided.
Speaking more broadly, in the 1970s, as part of a major deinstitutionaliza-
tion movement in the United States, case management underwent another
wave of development (Kersbergen 1996). The same phenomenon was observed
with the shift to ambulatory care in mental health (Fleury 2002), and later with
the shift to home care for older people losing their functional autonomy
(Hébert et al. 2010). All of these developments implied that health and social
care was no longer “housed” in any one organization, but rather dispersed
across the service network, with an increased focus on home interventions and
a cross-sectoral approach to care. However, when care needs are complex,
there is the strong chance of fragmented and discontinuous care, which can
lead to disastrous results, as we will see in Benoît’s vignette. This is precisely
what case management aims to address in today’s health and social care systems.

Case Management to Enhance Continuity

in Contemporary Health and Social Care Systems

Industrialized countries are experiencing significant demographic and epide-

miological shifts in their populations, meaning that people are no longer dying
from the same causes as in the past, especially in high-income countries, where
chronic disease has surpassed trauma and infection as cause of death. This has
led to an increasing proportion of community-dwelling older adults living with
multiple chronic diseases and loss of functional autonomy (Hébert et al. 2010).
This double transition calls for a paradigm shift in the organization of health
 11 CASE MANAGEMENT AS A STRUCTURAL CONDITION FOR EFFECTIVE… 189

and social care systems to address the growing number of older adults living
with complex health and social needs. Specifically, countries must shift from
traditional hospital-centric models that focus on acute care towards innovative
client-centered models that focus on delivering a comprehensive continuum of
services for chronic conditions (Couturier and Belzile 2016). For example,
community-dwelling older adults with loss of functional autonomy need com-
prehensive approaches from various clinically interdependent actors working in
public, private, and community organizations. The interventions of these
actors are based on a wide variety of operating modes and priorities. This diver-
sity has driven the design and implementation of models of organizing health
and social care services that aim to heighten the connectivity and coordination
of professional practices across organizational boundaries, that is, to enhance
integrated health and social services.
Service integration is a way of organizing services that aims to rigorously
coordinate all the resources required for a comprehensive response to complex
client or patient needs, whatever the origin of these resources (e.g., public,
private, family, or non-governmental organization). It brings together resources
that are traditionally, functionally, politically, and financially autonomous.
Therefore, service integration must facilitate information transmission, inter-
vention coordination, and managerial collaboration within and among these
resources (Kodner 2006). Communication between resources is in fact what
allows for service integration, linking nodes in the care network to achieve the
clinical or organizational goals shared by these clinically interdependent play-
ers. This networking requires mediators—that is, case managers—who can
both tailor communication to each situation and standardize it through medi-
ated support mechanisms, such as common clinical tools, shared information
systems, and the like. Again, while service integration requires both technical
devices and human strategies, it is case management that is the most human
component of integrated care (Callout 11.2).

Callout 11.2 Continuities of Care

Continuity of care refers to the quality of health and social care services
over time. It implies the delivery of care and services in a timely and
coherent fashion, ensuring that the appropriate professionals and organi-
zations are involved when needed in the service user’s care trajectory to
meet clinical goals that have been established with the service user. Three
types of continuity are especially important to ensuring quality care over
time: informational continuity, or the timely and logical exchange of
information between the appropriate actors; continuity of approach, or
the coherence of interventions across different professionals and organi-
zations with regard to the clinical goals agreed upon with the service
user; and relational continuity, or a relationship over time between a ser-
vice user and a privileged intervener, such as the case manager who knows
the service user and their clinical history, situation, and preferences. Case
management is intended to enhance continuity of care.
190 Y. COUTURIER ET AL.

The expected outcome of an integrated system is the improved continuity of

services, which can be observed in coherent care paths—this means the appro-
priate professional and the appropriate organization are involved at the right
time in the service user’s care trajectory, according to established clinical
goals—from the point of view of service users, professionals, and organizations
alike. Reid et al. (2002) identified three dimensions of continuity: informa-
tional, management (or approach), and relational. Informational continuity
is characterized by the effective flow of the right information to the right per-
son at the right time and place. This information flow includes clinical informa-
tion (e.g., level of loss of autonomy), administrative information (e.g., access
to care criteria), contextual information (e.g., housing situation), and so forth.
Ideally, it is supported by shared clinical-administrative tools. Clearly, the trans-
mission model of communication (see Chap. 1) best describes what is needed
to maintain informational continuity.
Continuity of approach, also called management continuity, is character-
ized by coherence across the various interventions with respect to the princi-
pal clinical goal that has been agreed upon with the user, for instance, staying
at home despite the loss of autonomy. The case manager is the professional
dedicated to monitoring the coherence of the various professional actions
and ensuring that they meet the needs of the user. This role requires a form
of interprofessional communication whose reach is systemwide. In other
words, the case manager acts as a central communication “hub” of sorts in
order to coordinate with the different actors and organizations involved,
thereby ensuring that everyone shares an understanding of and adjusts their
efforts to the current clinical goal. Hence, not only is this communication
systemwide in character, but it also involves sensegiving (Gioia and Chittipeddi
1991; see Chap. 5 on sensemaking), which refers to providing contextual
frames of reference (i.e., interpretive cues for meaning construction) to col-
laborators so they understand how to interpret the clinical situation with
regard to the established goal (see Chap. 1’s description of the transactional
model of communication).
Relational continuity is characterized by a meaningful link for the service
user with a privileged intervener who can coordinate services over time and
space according to the user’s needs and preferences. This is the role that a case
manager can play. Here, the case manager deploys more relational communica-
tion strategies (see transactional model of communication in Chap. 1; see also
Chap. 6). To foster relational continuity with and for the service user, they
need to know the user well, and convey his or her messages to all the profes-
sional players involved in the clinical situation. In this sense, the case manager
also acts as an advocate within the health and social care system for service
users, especially when they are not present to speak for themselves.
Understandably, these three dimensions of continuity of services call for
substantial communication between users and their families, as well as with all
the professionals involved, regardless of their organizational affiliation. This
systemwide communication also concerns the articulation of efforts (Strauss
 11 CASE MANAGEMENT AS A STRUCTURAL CONDITION FOR EFFECTIVE… 191

1988, 1993) between clinicians and organizational managers, whose decisions

may condition how the intervention plan, which the case manager will have
agreed upon with the user, is carried out. Such articulation or coordination of
efforts necessitates the mutual adjustment mentioned earlier. Various informa-
tion tools and procedures are needed to support the communication efforts of
the case manager, including standardized clinical assessment and service plan-
ning tools, which offer guidelines for how to interpret, evaluate, and create
care plans for frequently encountered clinical situations, as well as recognized
intervention procedures, which indicate how to carry out different parts of the
care plan. While powerful, these tools and procedures only become fully effec-
tive when they are used by the professionals who will employ their full adaptive
capacity for each clinical situation, that is, by professionals who know how to
tailor these tools to the particular service user. To this end, the case manager
again acts as a hub, an advocate, and an interpreter (or “sensegiver”) for inter-
professional communication, helping to make the integration of services hap-
pen in an appropriate and patient-centered manner. The case manager is a thus
a trans-disciplinary professional whose primary mission is to embody the inte-
gration of services at the clinical level, using these strategies and communicat-
ing in a way that is both standardized and adapted to the particularities of every
clinical situation.

Case Management as A Systemwide Communication

Support Strategy
As mentioned above, because case management typically involves multiple
players across the health and social care network, it can be considered system-
wide communication. Consequently, it is often more structured and formal
than the spontaneous forms of interprofessional communication that might
evolve, for example, in a tight-knit interprofessional team working in the same
clinic. Indeed, it modifies the usual forms of professional communication by
reinforcing their structured nature, but without making them automatic or
mechanical. In fact, case management communication must be based on a
common language that is at least partly shared by all actors involved. Case
management communication takes place first and foremost via computerized
clinical tools that produce a comprehensive assessment of needs, which is then
transformed by the case manager into a formal and collective action plan, called
an “individualized and integrated care plan.” The language employed by these
tools is not discipline-specific, but rather is a common trans-clinical-­
administrative language shared by many health and social services profession-
als. Although not very complex, it nevertheless enables the various players
involved to access and understand the common goal of the intervention plan
(e.g., home care or referral of the older adult to long-term care). Each profes-
sional player will manage his or her own disciplinary intervention as he or she
sees fit but takes into account these clinical and patient-centered aims. Similarly,
case management can render interprofessional communication more formal by
192 Y. COUTURIER ET AL.

structuring how and when communication should take place in particular

moments, such as the periodic reassessment of needs. Systemwide and more
formalized communication of this kind is necessary to avoid breakdowns in
service continuity.
The case manager’s communication also goes beyond real-time communica-
tion between two individuals. This is because the temporality of the case man-
ager’s communication is not that of the single intervention in a given moment,
but that of the episode of care, which can last for years for an older adult with
a loss of functional autonomy, or even a lifetime for a person born with a sig-
nificant disability. What’s more, case management communication is not disci-
plinary but dictated by the clinical situation and the service user’s needs. For
instance, for Lieutenant Dan, the case management communication was neces-
sarily intersectoral, linking health, psychology, social services, employment
reintegration, and housing, among others.
Without case management, all these players must still communicate, but will
most often do so in an uncoordinated way, individually and independent of one
another, on an ad hoc basis, which can jeopardize the three types of continuity
of care and services discussed above. Therefore, we can see that case manage-
ment communication is unique not only in duration and spatiality, as we have
just described, but also in terms of accountability. It is the case manager’s duty
to ensure that communication spans the network of necessary actors and is
based on the temporality and spatiality of the clinical situation.
Although supported by clinical and informational tools, communication in
case management remains radically relational, for three fundamental reasons.
Firstly, the case manager is not a giver of orders, but a pivotal player aimed at
improving the coordination of legally independent but clinically interdepen-
dent players. He or she influences, guides, suggests, accompanies, convinces,
manages conflicts, and facilitates interprofessional peace. Communication must
therefore be relational and strategic. Consequently, it cannot be reduced to the
technical dimensions of instrument-mediated communication. Secondly, the
communication competency necessary in case management—such as the skills
needed for facilitating interorganizational meetings—must be mindfully devel-
oped and deployed. Finally, case management draws its legitimacy from in-­
depth knowledge of the clinical situation, and therefore of the user. Drawing
on this in-depth knowledge of the user, the case manager must bring the user’s
voice to bear in all areas of the coalition of inter-sectoral players working
directly or indirectly on the clinical situation. Given the relational complexity
and the difficulty of systemwide coordination, case management communica-
tion can be rife with challenges, which we discuss next.

Communication Challenges in Case Management

A main communication challenge to case management is determining the type
of interprofessional collaboration and subsequent communicative practice that
are required by ongoing changes to the user’s care situation. Sometimes, this
 11 CASE MANAGEMENT AS A STRUCTURAL CONDITION FOR EFFECTIVE… 193

communication only requires the exchange of information to structure and

legitimize an intervention plan and facilitate a mutual adjustment between the
various actors involved in the service user’s situation, and the transmission
model of communication best describes such efforts (see Chap. 1). For exam-
ple, a service user being discharged from the hospital might require a short
time in a lower level of care, such as an assisted living or rehabilitation center,
before going home. In this instance, case management would involve the
exchange of medical and administrative information between the hospital and
the center so they can mutually adjust to this new development while taking
into consideration the user’s preferences. Other times, the communication
involved in case management coordination is continuous and constitutes col-
lective sensemaking (see Chap. 5), especially when the service user’s situation
becomes more complex or evolves rapidly such that it becomes unclear what is
going on, what the service user’s care needs are, or what the priorities ought to
be. This is particularly the case for older adults who, due to a significant loss of
autonomy, face life-threatening risks associated with remaining at home, yet
still wish to remain in their own homes. In such situations, the case manager
must also be able to step in and convene a meeting involving the appropriate
actors to untangle the complexity and make collective action plans. Therefore,
the case manager must be flexible and savvy enough to accurately assess the
complexity of the service user’s evolving care needs, fluidly moving along the
continuum of interprofessional collaboration as needed (see Chap. 3).
The case manager’s work can also be constrained by the fact that he or she
is not the one who gives the orders. All clinical partners collaborating with a
case manager remain fully autonomous and accountable for their actions. In
this context, the case manager must continually convince each of them to relin-
quish a part of their professional autonomy in favor of better-coordinated col-
lective action. What’s more, collaborative culture is never achieved once and
for all. New professionals are hired every day, and the organizations that make
up the health and social services system are constantly changing. So, the case
manager’s communication work is never-ending. As a promoter of the com-
mon good in a fragmented and constantly changing world, the case manager
must develop communication skills typical of interprofessional leadership. This
leadership is based on assertive communication, which is both flexible and
assertive. On the other side of the case manager’s job are typical clinical com-
munication challenges, involving communicating with users whose literacy is
sometimes uncertain, or whose communicative capacity is limited by physical,
psychological, cognitive, or social difficulties. Finally, the most fundamental
communicative challenge in case management concerns the translation of the
user’s words into a clinical-administrative discourse useful to all parties involved
in the clinical situation. The communicative skills required to meet these chal-
lenges are considerable but are not generally the subject of specific training.
In light of these challenges, it is clear that case management is not always
easy. However, its absence can be catastrophic for service users and their fami-
lies. We turn now to Benoît’s evolving story to illustrate the importance of case
management, and what can happen when it is not well implemented.
194 Y. COUTURIER ET AL.

Benoît Falls Through the Cracks of the Care System

Without Case Management
At the age of 88, Benoît has been living with a neurocognitive disorder for
several years. He is frequently disoriented by nocturnal hallucinations, most
likely associated with Lewy body dementia. Despite the presence of a multitude
of clinical symptoms typical of this dementia, this diagnosis has not been explic-
itly established or disclosed to the family. In practice, such lack of disclosure
hampers the implementation of a plan that could set in motion interventions to
maintain Benoît’s autonomy and leads to major disorganization in his clinical
situation. Since his family doctor retired a few years ago, he has been followed
by emergency physicians, visiting medical residents, and nurses, indicating a
break in relational continuity and continuity of approach. Although well-­
intentioned, none of these professionals has been stable in Benoît’s life, and
therefore none can draw on a deep understanding of how his functional decline
has evolved to provide a comprehensive portrait. Each of them communicates
with some of his care and service providers, but always about one subject at a
time, and with one person at a time. Fortunately, his wife, who is supportive,
loving, dynamic, and competent, has compensated for his loss of functional
autonomy, albeit at the cost of many exhausting efforts for her. Married to her
for 35 years, Benoît has two sons from a previous marriage who live with their
wives outside the region and are therefore absent from his daily life.
First hospitalization. At the end of November 2016, Benoît’s situation
deteriorated. Following a fall in blood pressure, he was hospitalized. Despite
several indicators of frailty prior to this hospitalization (including multiple pre-
vious hospitalizations, episodes of delirium, and heart surgery over the past
two years), he had not received home care services, notably because the health-
care establishment felt that the caregiver (his wife), despite being 82 years old,
was effectively compensating for his loss of functional autonomy. For this rea-
son, no multidimensional assessment of his situation was ever carried out in his
home. And, because his clinical situation is now unstable, such an assessment
will not be completed, which means he won’t be eligible for increased home
care services.
Second hospitalization. After returning home without services, the situa-
tion deteriorated even further, and on the evening of December 24, his wife
had no choice but to call an ambulance to take him to the local hospital emer-
gency department. Benoît was suffering from severe anxiety generated by hal-
lucinations, in addition to unusual aggressive behavior. Hospitalization then
provoked (or revealed) delirium and various other health problems, such as a
pulmonary infection.
Transfer to another hospital. Benoit’s wife visited him every day, which
seemed to have a calming effect on both of them. But the moment came when
everything went downhill quickly. With the maximum length of stay at the
local hospital nearly exceeded, and his clinical problems unresolved, he was
transferred to a regional hospital with an available bed, but it was 50 km from
their home. Nevertheless, his wife still found the strength to visit him every day.
 11 CASE MANAGEMENT AS A STRUCTURAL CONDITION FOR EFFECTIVE… 195

Yet another temporary transfer. A few days later and without any formal
assessment, a referral to temporary accommodation was envisaged, pending
permanent accommodation because a return home no longer seemed possible.
Professionals (at the regional hospital 50 km away from their home) assured his
wife that this temporary relocation would respect her choices, and that the
hospital would not plan Benoît’s discharge until a suitable place was found, so
she was relieved. Indeed, the hospital staff verbally promised her that he would
spend the weekend in the same room at the regional hospital. However, that
same evening, she was called by another social worker and asked to make the
transfer herself on Saturday morning to a housing resource found by the
regional hospital, at the patient’s expense.
All of these changes meant that, since December 24, Benoît had been trans-
ferred twice from hospitals for non-clinical reasons. Moving such a fragile per-
son again and again does not make sense clinically. The regional hospital doctor
involved in Benoît’s case resisted these moves, but administrative reasoning is
often driven by concerns (like freeing up beds) that differ from clinical and
common-sense reasoning. The change of hospital meant that some social
workers had to withdraw from his case, but they didn’t realize that his continu-
ity of care was in jeopardy, because they had fulfilled their professional and
organizational duties and did not see the “big picture.” Faced with this incom-
prehensible proliferation of caregivers, Benoît’s wife put together a list of
names of professionals whose respective functions became blurred in her mind.
Who should she refer to first? The hospital social worker or the home service
social worker?
Insensitivity leads to lack of trust. On her first visit to this temporary
accommodation, the wife was required to wear a gown, mask, and protective
gloves. When she asked why she was required to do so, the social workers
invoked “professional secrecy” to avoid giving any reason. When she insisted
on her rights, the professional brutally interrupted the discussion. The same
applied to any questions she had concerning the care plan, since no staff mem-
ber seemed authorized to talk to her (which was not in fact true). Benoît’s wife
really didn’t trust the staff here. At the end of the stay, she noticed that Benoît
was covered in bruises, even though no one had informed her of anything such
as a fall occurring. He was also wearing clothes that didn’t belong to him, his
own clothes having mysteriously disappeared.
No answers to be found. One of their daughters-in-law sought answers
about Benoit’s clinical status. She knew that temporary accommodation is nor-
mally a measure that provides for a return to home, even though returning
home had been deemed impossible in this case. After providing (false) reassur-
ance, the home services’ social worker referred the daughter-in-law to her col-
league at the hospital to clarify Benoît’s housing status. The hospital social
worker confirmed that no assessment of his needs had been carried out due to
the clinical instability of Benoît’s situation, even though this is required by law
prior to hospital discharge. Instead, the hospital social worker explained that
the decision made in Benoît’s case by the hospital and home support
196 Y. COUTURIER ET AL.

management to free up the bed was “exceptional.” Furthermore, he said that,

in order to proceed with the referral to temporary accommodation, a summary
assessment had been produced as a matter of urgency.
He also defended the home services social worker, claiming she was unaware
of the decision, as the information could not have been transmitted to her by
another social worker on a Friday afternoon (despite existing computerized
clinical tools to avoid such breaks in informational continuity). No one seemed
able to explain who the referring professional was now and when the assess-
ment would be completed to allow Benoît’s definitive referral to long-term
care accommodation. In the days following his temporary stay, Benoît was
referred to palliative care, but no comfort care was provided. Instead, he was
transferred back to the regional hospital, where he died in a bed in the internal
medicine department on February 13, 2017.
Disjointed communication. Over the 12 weeks in this care episode, several
professionals had called Benoît’s home and spoken with his wife, but it seemed
they were rarely the same ones. They would state their first names but, more
often than not, their professional or organizational status remained vague: “It’s
the hospital,” or “It’s the social worker,” leaving his wife perplexed about
which of the four or five professionals whose names she had written down she
was speaking with. No one gave her any reminders or documentation about
the clinical or intervention plan, and she never knew who her main contact was;
consent to care was always post hoc. She tried to make up for this lack of com-
munication by seeking information from the hospital nurses’ station, but the
information she received verbally was fragmented, partial, and inconsistent
with what she was told over the phone. Nobody checked her understanding or
provided memory aids. No family meetings were called. Furthermore, she was
cut out of decision-making: Despite their clear marital status and her legal des-
ignation as Benoît’s sole legal representative in case of incapacity, one of
Benoît’s distant children unilaterally changed care instructions, without his
wife being informed. This lack of recognition of her efforts as a caregiver
caused her great suffering. Yet, all the professionals felt that their individual
communication practices were more than satisfactory.

Critically Evaluating How Benoît’s Case Was Managed

Unfortunately, Benoît’s case is not exceptional or extreme, but rather can be
considered somewhat typical, especially for older adults with loss of functional
autonomy who do not die suddenly. While no intervention would have pre-
vented Benoît from eventually dying (after all, death is natural), his complex
yet commonplace clinical situation was unnecessarily made much more difficult
by a communication “fog” that prevented the individual actors from seeing the
big picture and assessing what was globally needed. Indeed, it is likely that each
of the professionals felt that they had been well-meaning and had sufficiently
individually communicated what they deemed useful.
 11 CASE MANAGEMENT AS A STRUCTURAL CONDITION FOR EFFECTIVE… 197

However, this vignette shows that personal conviction is not enough; it

must be backed up by a system that structures clinical communication between
a large number of players who, in every case, likely have different organiza-
tional and clinical statuses and cultures. A quality approach would have con-
sisted in appointing a case manager for Benoît upstream of his first
hospitalization, in fact, from the moment his loss of autonomy set in. This case
manager would have thus been a resource person available to Benoît’s wife and
children and their spouses and would have planned the stages of care to avoid
successive relocations. The case manager would have also ensured consistency
over time in the actions of the various players involved in the clinical situation
and reminded them of Benoît’s and his family’s preferences, such as finding
care closer to their home. An overall assessment of Benoît’s needs would have
been made. From this assessment would have emerged a plan for services that
were predictable and adapted to the needs of Benoît and his loved ones.
This in turn means that communication would have been far more orga-
nized across the care system rather than being strictly bilateral between the
various stakeholders. Most importantly, it would have enabled clinicians and
Benoît’s wife to gain an overall vision of Benoît’s needs. Finally, more explicit
and systemwide communication would have facilitated more informed consent
to care.

Conclusion
As case management demonstrates, interprofessional communication is not
just about sharing common language and maintaining relations. It requires
structural support through the implementation of a new occupational group,
case managers, to predictably facilitate the various forms of interprofessional
and interorganizational communication for people with complex needs. Case
management is a trans-professional model that requires case managers to be
skilled and competent in accomplishing several communication goals: instru-
mental information exchange, strategic planning, and relational maintenance
in order to facilitate extended and effective interprofessional collaboration.

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 CHAPTER 12

Improving Family-Centered Care through

High-Reliability Interprofessional Collaboration
in the NICU

Cassidy S. Doucet and Joshua B. Barbour

Introduction
Healthcare has become increasingly collaborative, and the shift towards team-­
based care has been especially important in the neonatal intensive care unit
(NICU). Prematurity, which the Centers for Disease Control and Prevention
(CDC) defines as birth before 37 weeks’ gestation, is the leading cause of death
in newborns and can cause severe disabilities such as developmental delays, prob-
lems with hearing and vision, and chronic health problems (Institute of Medicine
2007; Baron et al. 2012). Babies born prematurely are typically required to stay
in the NICU without a certain estimate of how long they will need to be admit-
ted. Intensive care is notoriously difficult because of the sheer number of critical
decisions and actions required of providers. Making errors in the ICU can have
dangerous consequences (Donchin et al. 2003). Premature infants can experience
significant changes in health day-to-day and hour-to-­hour, and, coupled with the
unfamiliar environment of the NICU, parents often experience stress, anxiety, and
uncertainty (Charchuk and Simpson 2005). The intensive care required makes
team-based care more challenging and at the same time more necessary.

C. S. Doucet (*)
Department of Communication Studies, The University of Texas at Austin,
Austin, TX, USA
e-mail: [email protected]
J. B. Barbour
Department of Communication, University of Illinois Urbana-Champaign,
Urbana, IL, USA
e-mail: [email protected]

© The Author(s) 2025 199

S. Fox et al. (eds.), Interprofessional Communication in Health and Social
Care, https://doi.org/10.1007/978-3-031-70106-1_12
200 C. S. DOUCET AND J. B. BARBOUR

NICUs as High-Reliability Organizations

The NICU context demands difficult, complex, high-reliability, interprofes-
sional communication. High-reliability organizing prioritizes the prevention of
errors and safe operations as much as, or more than, efficiency and productivity
(Weick and Sutcliffe 2015; Harrison et al. 2020). The communication involved
requires speaking out about problems regardless of status, rank, or domain
(Jahn and Black 2017), the difficulties of which are well-known in medicine
(Carmack and Harville 2020; Watson et al. 2016). Nurses, physicians, occupa-
tional therapists, physical therapists, feeding specialists, and lactation consul-
tants all bring differing frames and scripts for problem-solving, anchored to
their training, experiences, and institutionalized professional practice. The
NICU requires constant, detailed record keeping, including logging feedings,
medications, diaper weights, and so forth that burden already fragile handoffs,
making them more frequent and more difficult (Apker et al. 2016).
The kind of high-reliability organizing called for in the NICU depends on
dynamic learning through vigilance and reflection, what scholarship has called
“mindful” organizing (Weick and Sutcliffe 2015; Myers and McPhee 2006). A
key challenge for practitioners is translating the ideal of “mindful” organizing
into specific communication practices that they can monitor, train, and enact.
Practices that encourage reliability include asking questions that prompt the
necessary reflexivity and situational awareness (Barbour and Gill 2017), sharing
concerns among team members despite power differences (Jahn and Black
2017), and discussing past problems in ways that foster learning and adapta-
tion (Dunn et al. 2016; Williams and Ishak 2017). In care teams, interpersonal
and interprofessional relationships further complicate the communication
needed (Carmack and Harville 2020; Fox et al. 2023).

Communication, Sensemaking, and Sensegiving

A key communication principle of reliable organizing is getting the right mes-
sage to the right person at the same time. Put another way, the transmission
model of communication, defined in Chap. 1, is an important, if incomplete,
view of communication for reliable organizing. At the same time, the constitu-
tive process, also defined in Chap. 1, identifies who the right people are, when
the right time is, and how the right message should be framed. Sensemaking is
a constitutive communication process (Barbour and Gill 2017). Sensemaking
occurs as organizational members attribute meaning to events and behaviors as
they emerge; through the processes of interpretation and communication, peo-
ple “[talk] events and organizations into existence” (Weick et al. 2005, 413).
Sensemaking as a concept is important in the NICU because, before teams of
providers and parents can make decisions, they must make sense of how new-
borns are doing, predict what will happen next, and decide how to intervene.
(For more on sensemaking, see Chap. 5).
 12 IMPROVING FAMILY-CENTERED CARE THROUGH HIGH-RELIABILITY… 201

Just as sensemaking is a vital element of high-reliability organizations

(HROs), so is sensegiving. Sensegiving is a communicative process in which
one individual helps another make sense of an equivocal situation (Gioia and
Chittipeddi 1991). “HROs take deliberate steps to create more complete and
nuanced pictures” (Weick and Sutcliffe 2015, 8). Not only do HROs need to
be able to make sense of the situation in the midst of uncertainty, but they also
need to create processes to operate in these ambiguous situations. In the con-
text of the NICU, where parents play an important role as collaborators in
these interprofessional teams, sensegiving is key. NICUs, as HROs, need to
make sense of these high-risk situations, and they also need to assist parents in
making sense of what is happening. When parents are able to make sense in the
NICU, they can better contribute to the care of their child. We see sensegiving
as an essential but often unstated need in interprofessional and NICU-focused
interventions, which we discuss later in the chapter (Callout 12.1).

Callout 12.1 High-Reliability Organizations

High-reliability organizations (HROs) are more concerned with avoid-
ing errors than with being more efficient or profitable. Unlike most for-­
profit firms, HROs try to avoid failure because the consequences are
especially dire. Classic examples of HROs include nuclear power plants
(Barbour and Gill 2017), aircraft carriers (Weick and Roberts 1993), fire-
fighting (Jahn and Black 2017; Williams and Ishak 2017), and healthcare
organizations and NICUs in particular (Vogus and Sutcliffe 2007;
Harrison et al. 2020). For example, Weick et al. (2005) drew on multiple
examples from pediatric nursing to describe the sort of disciplined sense-
making that goes into high-reliability organizing. Drawing on the work
of Benner (1994), they argued that sensemaking is about crafting order
in chaos. They wrote of a nurse who noticed an infant’s condition had
changed for the worse and intervened:

The nurse’s sensemaking does not begin de novo, but like all organizing
occurs amidst a stream of potential antecedents and consequences.
Presumably within the 24-hour period surrounding the critical noticing,
the nurse slept, awoke, prepared for work, observed and tended to other
babies, completed paperwork and charts, drank coffee, spoke with doctors
and fellow nurses, stared at an elevator door as she moved between hospital
floors, and performed a variety of formal and impromptu observations.
(Weick et al. 2005, 411)

In the NICU, high-reliability organizing requires focusing on the poten-

tial for catastrophic change and avoiding errors—a preoccupation with
failure. Viewing the NICU as an HRO would emphasize the need to
grapple with the complexity that this caregiving involves, avoiding

(continued)
202 C. S. DOUCET AND J. B. BARBOUR

Callout 12.1 (continued)

simplification. That organizing must focus on resilience and processes to
mitigate and minimize the effects of errors. Ideally, high-reliability orga-
nizing prioritizes the expertise of team members rather than their status,
which can be difficult, especially in hierarchical healthcare environments.
Harrison et al. (2020) highlighted handoff protocols, checklists, and pre-
operative interprofessional team briefings as “three types of designed
communicative interventions to reduce medical errors and improve
patient safety” (290–291). These communication interventions attempt
to ensure team members engage in sensegiving and cultivate the sense-
making that produces high-reliability organizing.

Focus on Family-Centered Care

The NICU context also involves greater engagement with the family. Prior
research has found that patient-centered and family-centered communication
with healthcare providers has positive health benefits for patients and their
families (Craig et al. 2015; Street et al. 2009). Family-centered care (FCC) is
“the planning, delivery, and evaluation of health care that is grounded in mutu-
ally beneficial partnerships among health care providers, patients, and families”
(Institute for Patient- and Family-Centered Care 2023, 1). Four fundamental
principles should guide FCC: (a) maintaining family dignity and respect, (b)
information exchange, (c) family participation in care, and (d) collaboration
between the family and medical team (Ramezani et al. 2014; Griffin, 2006).
Implementing FCC in NICUs can lead to decreased parental stress, increased
self-esteem (specifically for mothers), and a sense of control for the parents,
and it has benefits for infants: shorter hospitalization, more effective pain relief,
better sleep, greater success at breastfeeding, and positive impacts on behavior
and learning in the long-term (Craig et al. 2015; Ramezani et al. 2014).
Healthcare organizations benefit from FCC as well by reduced therapy
expenses, increased interprofessional cooperation, greater professional satisfac-
tion, and increased knowledge about care (Callout 12.2).

Callout 12.2 Family-Centered Care

The gold standard for communication in the NICU, family-centered care
(FCC) emphasizes the need to care for not only the patient but also for
the family caregivers. In FCC, healthcare professionals strive to minimize
stress for the parents in the NICU. Parents experience extreme stress,
anxiety, and even post-traumatic stress disorder (PTSD) following the
birth of a premature child who requires time in the NICU. FCC is an
intervention based on theoretical and empirical evidence that encourages

(continued)
 12 IMPROVING FAMILY-CENTERED CARE THROUGH HIGH-RELIABILITY… 203

Callout 12.2 (continued)

person-centered communication with parents and involves parents in
decisions regarding their child’s healthcare (Weis et al. 2013). Hospitals
now implement FCC training for healthcare professionals including
workshops, evaluations, and even certifications. FCC is not contextually
limited to the NICU. FCC is also a widely accepted practice in pediatrics.
Five guiding principles of FCC are: (1) information sharing, (2) respect
for differences, (3) collaboration, (4) negotiation, and (5) care in the
context of family and community (Kuo et al. 2012). This intervention
considers a more holistic view of a child’s health care and acknowledges
the important role that families play in providing care for a patient.

Communication Challenges in the NICU

NICUs are sites of high-reliability interprofessional communication inter-
twined with family communication. The varied professions and families bring
different beliefs and mental models for what effective communication should
involve. That is, communication in the NICU must not only navigate the com-
plexities of intensive care for newborns and interprofessional dynamics associ-
ated with the multiple, overlapping institutions present but also family norms
and legal and regulatory frameworks that define family (Rauscher et al. 2017;
Campbell-Salome and Barbour 2022). Put another way, NICU communica-
tion is challenging because it involves multiple, overlapping institutionalized
ideas about what is effective and what action should be undertaken. The ideas
are institutionalized in the norms, standards, and training of implicated profes-
sions; hospitals’ policies, procedures, and regulatory requirements; and legal
and cultural definitions of family and caregiving. Although all offer different
conceptions of what the goals of NICU communication should be and what it
means to do it well, the ideas transcend any one NICU, but nonetheless frame
and influence the communication that takes place.
In this section, we review how communication interventions in the NICU
take into account the institutional, organizational, and familial dynamics that
make high-reliability interprofessional collaboration more challenging. Then,
we review insights from healthcare communication interventions guided by
two questions: (1) What NICU-specific communication interventions exist?
(2) How do they address the difficulties of communication in the NICU?
Lastly, we will conclude with a vignette that illustrates how these interven-
tions may be implemented in practice in ways that integrate concern for more
effective communication in the NICU among different professions and
families.
204 C. S. DOUCET AND J. B. BARBOUR

Challenges to Interprofessional Communication in NICUs

Three facets of the NICU contribute to distinctive challenges for interprofes-
sional communication. First, the NICU involves multiple professions working
together. The NICU is interdisciplinary. Due to the unique nature of the
healthcare needs of the premature infant, several highly specialized healthcare
professionals work in tandem to access and care for the infant’s medical needs.
For example, a premature infant may require a primary nurse assigned to their
general care including overseeing feedings, hygiene, and vital signs, such as
oxygen levels and heartbeat. However, since these infants require round-the-­
clock care, the nurses take shifts to monitor the baby. So, an infant may be
cared for by a team of 4–6 rotating nurses throughout the week. The infant
may also be visited by a neonatologist, a doctor who specializes in the care of a
premature baby and oversees the infant’s overall progress and diagnosis. The
doctor may prescribe treatments, medicine, and other medical interventions
that the nurses then carry out. Additionally, the infant may require visits from
occupational therapists to ensure they are learning how to eat properly, physical
therapists who make sure the infant’s motor skills are developing, and cardiolo-
gists who monitor the function of the infant’s heart. This is just a small sample
of the healthcare team involved in the infant’s care. Depending on the health
of the infant, that team could include upwards of 10–15 healthcare providers.
Second, the NICU involves distinctive challenges due to how it is orga-
nized. The complex healthcare team of providers faces a host of issues includ-
ing conflicting schedules and differences in training and experience, which in
turn create organizational challenges such as the synchronization of health
monitoring and communication with the parents. Healthcare teams in the
NICU seldom get to meet in person to discuss the overall health of the infant,
due to the challenges of scheduling a meeting that would accommodate the
schedules of so many team members. Instead, these teams rely on written
reports that are saved in a universal patient chart. This creates room for mis-
communication and ambiguity about the meanings of certain notes. It also
means that various professionals are communicating with parents at different
points of the day, and sometimes this leads to conflicting information.
Additionally, because each member of the healthcare team is so highly special-
ized, there often is no consistency in training. So, while nurses might receive
standardized training in how to communicate with parents, neonatologists may
not, creating an uneven range of communication skills. This leads us to con-
sider the challenges of communicating with families.
Third, the NICU also involves distinctive challenges due to the difficulties
that parents experience such as uncertainty, the constraints associated with the
NICU environment, and communication with staff (Ichijima et al. 2011).
Uncertainty can be connected to a lack of information provided to parents by
healthcare workers. The unfamiliar environment of the NICU imposes many
restrictions on parents, such as limiting access to their child and preventing
potential support providers from visiting. Parents reported communication
 12 IMPROVING FAMILY-CENTERED CARE THROUGH HIGH-RELIABILITY… 205

with staff as stressful due to frequent changes in nursing staff, conflicting infor-
mation or advice from staff members, and dismissive attitudes or comments
from nurses who had busy workloads. To address some of these challenges, we
present and evaluate current communication interventions in the NICU.

Communication Interventions in the NICU

Although several communication interventions in the NICU exist, few specifi-
cally address the delicate question of family-centered team communication.
Interventions that do take families into account fall into two broad categories:
(1) those involving parents as collaborators in the interprofessional care of the
child and (2) those addressing the training and education of healthcare workers
in the NICU. Most fall into the first category, focusing on fostering a healthy
bond between parent and child, providing support and sensemaking resources
for parents, or encouraging effective patient-provider relationships. These
interventions seldom consider how interprofessional relationships may enhance
or limit their effectiveness. On the other hand, interventions aimed specifically
at interprofessional relationships or communication tend not to deal with the
NICU specifically; however, the most widely adopted interprofessional inter-
ventions have been tested in the NICU context. We describe some of these
interventions next.

Focus on Involving Family

The majority of interventions specific to the NICU focus on involving parents
to promote the health of the child. One example is the mother-infant transac-
tion program (MITP, Milgrom et al. 2013). This NICU-specific intervention
involves training parents how to recognize a premature infant’s cues to mini-
mize stress both in the NICU and at home. Parents are encouraged to inter-
vene (e.g., pick up, touch, and talk to the baby) to comfort the baby when
stressed. This intervention is similar to family nurture (Welch et al. 2013),
which encourages parents to comfort the infant through calming practices such
as scent cloths, touch, skin-to-skin, eye contact, and vocal reassurances. In
these interventions, parents take on an active role as care providers.

Focus on Training Healthcare Teams

Buljac-Samardzic et al.’s (2020) review of team training interventions identi-
fied four types: (1) training interventions such as TeamSTEPPS (team strate-
gies and tools to enhance performance and patient safety), (2) tools such as the
SBAR protocol for patient handoffs (situation, background, assessment, and
recommendation), (3) organizational interventions aimed at improving team-­
based healthcare in particular settings, and (4) programs that combine ele-
ments of the others. Sawyer et al. (2013) tested TeamSTEPPS in neonatal
intensive care. The intervention aimed to foster nurses’ ability to detect and
206 C. S. DOUCET AND J. B. BARBOUR

challenge errors such as incorrect medication dosages and ineffective chest

compressions during care. The intervention improved perceptions of team-
work skills and increased the odds that nurses would challenge incorrect medi-
cation doses. When Brodsky et al. (2013) tested the TeamSTEPPS in neonatal
intensive care, their results were similar. Their study also documented improve-
ments in job satisfaction and fulfillment.
The TeamSTEPPS intervention stands out for its holistic approach to inter-
professional communication and attempts to address the difficulties of team-­
based, collaborative care through training focused on team structures,
communication, and so forth. Other interventions focus on more specific strat-
egies such as structuring communication processes like rounds to emphasize
the need for communication across professional boundaries (Genet et al.
2015). Bender et al. (2014) tested a simulation intervention’s effects on
improving procedural skills (e.g., intubations and resuscitations) and team
behaviors, demonstrating that repeated, deliberate practice could improve the
procedural skills and teamwork needed for treating critically ill neonates.
Debriefing videos of recent resuscitations may have similar benefits (Nadler
et al. 2011). TeamSTEPPS and the simulation and debriefing interventions
create space for deliberation about communication itself. That meta-­
communication can help participants understand how their interaction is doing
more than just conveying information (see Chap. 10 on shared communication
competence). These interventions are focused on getting the right information
to the right person at the right time, but they also make space for understand-
ing the dynamics around status differences and the different occupational
models for problem-solving that can make this kind of healthcare work more
communicatively challenging. However, all of the interprofessional interven-
tions applied in the neonatal context tend to overlook the family as a distinc-
tively important factor in interprofessional communication.

Focus on Both Families and Healthcare Teams

The family adjustment and adaptation response (FAAR) intervention stands
out among the other interventions because it integrates a concern for interpro-
fessional dynamics and the distinct needs of the NICU (Starks et al. 2016).
This intervention involves training an interprofessional team of nurses, social
workers, chaplains, and a child life specialist to provide communication and
support to family caregivers. This intervention was initially implemented in a
pediatric setting that resembles a NICU context in which the parents of the
hospitalized child are considered essential team members in the child’s care. In
the FAAR intervention, the care team sits down with the parents to understand
their values, understanding of their child’s condition, and support and infor-
mation needs. The care team then documents the notes from this assessment
using a standardized template and checks in with the parents, multiple times a
week. The team’s role is to facilitate communication between healthcare pro-
viders and the parents, convene “care conferences” with the healthcare
 12 IMPROVING FAMILY-CENTERED CARE THROUGH HIGH-RELIABILITY… 207

providers and the parents, and provide informational and emotional support to
the parents during this difficult time. Informational support entails providing
information or advice whereas emotional support is an expression of concern
or empathy (Cutrona and Suhr 1992). Having a dedicated team like this could
resolve many of the problematic interprofessional issues that exist in the NICU
including miscommunication amongst healthcare team members and lack of
involvement of family members in decision-making. Most importantly, the
FAAR intervention team acts as sensegivers and provides parents with space to
make sense of their experiences. In doing so, the intervention may overcome a
challenge that many NICU healthcare providers face: not having the band-
width to facilitate sensemaking due to their demanding job responsibilities.

Summary
NICUs are sites of high-reliability organizing. In these HROs, team members
must be able to make sense of the situation and act quickly under pressure. In
the NICU, parents act as collaborators in these interdisciplinary healthcare
teams and play a vital role in the care of the infant. Therefore, it is essential that
healthcare professionals act as sensegivers to help parents make sense of the
NICU environment so that they can participate in their child’s care. Reviewing
interventions related to interprofessional teamwork in the NICU, interven-
tions tend to be geared towards educating the parents to be more involved in
the care of their infant or focused on just the healthcare professionals—few
combined elements of both. Only the FAAR intervention empowered an inter-
professional team to facilitate communication between the parents and health-
care professionals while also offering support to the parents who had to make
decisions regarding their child’s healthcare. To illustrate these concepts, we
conclude with a vignette of one parent’s NICU experience, weaving these con-
cepts throughout the story.

A NICU Story
I lay on the exam table in the early labor ward, and the nurse said, “You’re
going to have a baby today.” It was 4 a.m. and six weeks away from my due
date. My husband and I were in a state of shock and disbelief. During each of
my prenatal doctor visits, we were told that the baby was healthy and growing.
I had no predispositions to being at risk for a premature birth. Having not
prepared for this outcome, we had so many questions. We were told a neona-
tologist would come to talk to us about what to expect. Hours later, when he
finally arrived, he quickly went over some general information about the
NICU. He was interrupted midway due to an incoming emergency delivery.
He ran out and we were left to wonder about what life would look like with a
child in the NICU. Would she be healthy? How long would she have to stay?
Was she at risk for chronic health issues? When the moment arrived to deliver
our daughter, the room filled up with about a dozen providers: Providers
208 C. S. DOUCET AND J. B. BARBOUR

assigned to help with delivery hovered around me. Another small group of
doctors and nurses stood by with an incubator to take our daughter to
the NICU.
Five pounds and seven ounces. That’s how much my daughter weighed—a
“big” baby they said. When you are expecting a seven-pound baby, five pounds
doesn’t seem like a “big” baby. In fact, she looked like the smallest baby I had
ever seen. They let me hold her and after a quick photo, they placed her in the
incubator and wheeled her out of the room and up to the NICU. I had to wait
four hours before I could see my baby again.
A nurse pushed me in a wheelchair up to the NICU. It was the early hours
of the morning, and I hadn’t slept in 36 hours. When you enter the NICU, you
have to scrub your hands for three minutes. The digital countdown clock on
the wall above the wash basins is activated when you turn on the water. After
that, you are required to sign in at the front desk. You are only buzzed through
the heavy metal doors after showing your hospital band as identification. The
moment you enter the NICU, the environment changes. There are rows of
incubators with dozens of wires coming out of them, hooked up to multiple
glowing monitors. The incubators are covered by fleece blankets in various
prints and patterns. The fluorescent overhead lights are dimmed way down. It’s
quiet. The layout is open, with no real walls: Each baby station is separated by
a linen curtain. Most of the curtains are pulled back and only used when par-
ents are there and want some privacy. I scanned each station, searching for a
sign of my child. Finally, I found her in station 24. There was a laminated paper
with her name, the name of her nurse, a contact phone number, and my daugh-
ter’s goals. On that day, her goals were listed as “feed and grow.” I remember
thinking that was a strange phrase, more appropriate for a houseplant than a
baby. We later learned that this meant she had no immediate health concerns.
Her small, fragile body just needed more time to develop. We also learned that
these goals were fluid and could change by the day.
Premature infants often go through what healthcare professionals call a
“honeymoon phase.” Right after birth, infants appear to be healthy. Usually,
after the first 24–48 hours, problems begin. In our daughter’s case, she devel-
oped trouble maintaining her blood sugar levels. She also developed jaundice
and had difficulties eating. She needed a feeding tube. For parents, the NICU
is a lot like falling down a rabbit hole into Wonderland. Nothing quite makes
sense. On Day 1, you are told that your baby is healthy and just needs some
time to grow. On Day 3, you arrive and there is a feeding tube going down
your baby’s nose. Each day we arrived at the NICU, we were met with some
health update, usually linked to a negative event that occurred during the
night. By Day 5, we went from thinking our daughter would be home in a
matter of days to being told she could be there for a month or more. The hard-
est part about the NICU is the conflicting information.
While visiting the NICU, we met countless doctors, nurses, and specialists,
but never at the same time. We would have one primary nurse assigned to our
 12 IMPROVING FAMILY-CENTERED CARE THROUGH HIGH-RELIABILITY… 209

baby during the day and then a night nurse would take over around 7 p.m.
These nurses also did shift work so we would rotate through 2–3 sets of day
and night nurses. We didn’t always know who we would see again. We had our
favorite nurses and our not-so-favorite nurses. The nurse assigned to a baby
was the primary contact for the baby’s parents. They were the ones who had
the most knowledge of our child’s care. Then we met neonatologists, who
would pop in very infrequently, and speak with us for approximately two min-
utes before moving on to the next family. Once, we were sitting in our daugh-
ter’s station and a small group of four doctors were going through what
appeared to be rounds. They spoke only to the other doctors in the group and
rattled off a bunch of medical terminology. No one acknowledged that we, the
parents, were even present, let alone stopped and gave us an update. Then
there were the specialists: occupational therapists, physical therapists, lactation
consultants, and speech therapists. They came on specific days during specific
timeframes. If you wanted to speak with them directly, you had to be there
when they rounded on your child, but due to emergencies, you could be left
waiting for hours. On Day 3, a professional we hadn’t met before came around
to check in with our nurse. She looked surprised when I spoke to her directly.
I asked about the most pressing question on our minds: When could we expect
to bring our baby home? She told us to expect to be here until our due date
which was still six weeks away. I was taken aback. Until then, no one had given
us such a long estimation. I felt crushed by the weight of her answer.
On Day 6, I broke down. The uncertainty of the future got to me. I just
needed answers. No one seemed to be able or willing to give them to me.
Every answer I received was qualified with “Every baby is different.” That day,
one of our favorite nurses was on duty. She was a favorite because she had an
upbeat and cheery personality. She seemed to understand what we were going
through, and we just connected. While she stopped by to do her hourly check-
­in, I couldn’t help myself and begged her to give me some indication of my
daughter’s timeline. I assured her I understood she wouldn’t be giving me a
guarantee. There are no guarantees in the NICU. I imagine that the last thing
you want to do as a healthcare professional is give false hope. I watched as her
eyes softened and I saw the pity in them. She quietly told me that if things kept
progressing the way they were, it would probably only be another week. When
we arrived the next day, we were met by yet another healthcare professional we
hadn’t seen before, a nurse practitioner. After a brief update on our daughter’s
health, she casually mentioned that our daughter would be discharged the
next day.
It’s been two years since our stay in the NICU. I often reflect on our time
there, and I can still feel those emotions: anxiety caused by the uncertainty of
our daughter’s outlook; feeling overwhelmed by the need to learn the NICU’s
“language”; and fear that the monitor hooked up to my daughter might sound
and indicate a drop in her vitals. Despite these emotions, I am also grateful to
the doctors and nurses who cared for not only my daughter but also for me.
210 C. S. DOUCET AND J. B. BARBOUR

Illustrating Key Concepts

Several issues of family and interprofessional communication from the chapter
are present in this story of a NICU experience. First, there were several key
moments when the healthcare team failed to communicate with the parents,
starting as early as their first interrupted consultation with the neonatologist.
Second, the healthcare team operates using a transmission model of communi-
cation, rather than a constitutive approach. For them, it was an information
allocation problem, not a meaning-making problem. The healthcare workers
were concerned with sending the parents information, rather than helping the
parents make sense of their experience. Third, interprofessional miscommuni-
cation created conflicting information for the parents. Fourth, the parents
lacked a significant role in their child’s healthcare decisions, specifically when
the healthcare team excluded them from the conversation during rounds.
The FAAR intervention focuses specifically on making this sort of NICU
team, including the parents, more successful. As described above, this interven-
tion starts with a care conference where the healthcare professionals can meet
to understand the family’s values, to ensure the care plan maintains respect and
dignity for the family. The FAAR Intervention also promotes regular check-ins
with the family and minimizes conflicting messages because the communica-
tion among the interprofessional care team is synchronized and integrated.
Finally, a significant part of the uncertainty and anxiety these parents experi-
enced might have been minimized had a care team been appointed to address
parents’ questions—if the care team had emphasized their sensegiving role.
Stories like this one are common among NICU parents. Interventions that
integrate a concern for family and interprofessional communication are more
likely to support the high-reliability organizing the NICU requires.

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 CHAPTER 13

Interprofessional Teamwork in Oncology:

Patient-Centered Perspectives and Survivorship
Care Planning

Laura E. Miller

Introduction
In 2007, the Institute of Medicine asserted that all cancer patients should
receive a tailored survivorship care plan. Due to its complexity, cancer care and
survivorship planning are often challenging. Owing to insufficient interprofes-
sional collaboration, cancer care and survivorship planning are also often poorly
coordinated, as patients must navigate care from a diverse range of providers,
including a nutritionist, a genetic counselor (e.g., a healthcare provider who
identifies hereditary risks in patients through the study of genetics), a psycholo-
gist, a social worker, a financial counselor, a surgeon, and a radiologist, just to
name a few (Wu and El-Rayes 2018). To add to this complexity, the transition
from cancer treatment to survivorship may involve different clinicians, which
can impact established interpersonal dynamics within the patient-centered can-
cer care team.
From the patient’s perspective, interprofessional collaboration in survivorship
care planning is crucial. Ideally, a patient’s survivorship care plan would not only
serve as a specified plan to the survivor (e.g., patient-centered care, see Callout
13.1), but it could also be passed to other clinicians to communicate what has
been done in the past and what needs to be done in the future. The care plan
can facilitate communication and information sharing among interprofessional
care providers, which in turn, may improve patients’ survivorship experiences.

L. E. Miller (*)
School of Communication Studies, University of Tennessee, Knoxville,
Knoxville, TN, USA
e-mail: [email protected]

© The Author(s) 2025 215

S. Fox et al. (eds.), Interprofessional Communication in Health and Social
Care, https://doi.org/10.1007/978-3-031-70106-1_13
216 L. E. MILLER

Since the early 2000s, there has been growing consensus that teamwork
training is a salient aspect of effective healthcare teams (Chollette et al. 2022).
Based on this, the American Society of Clinical Oncology (2006) identified
teamwork (i.e., interprofessional cancer care teamwork) as a critical component
of oncological care throughout the illness trajectory. However, survivorship
care planning is demanding, and its inclusion of multiple different healthcare
providers creates multiple communicative challenges. First, interprofessional
care providers may no longer contribute to the cancer survivor’s care as they
did during the period of oncology care. Second, survivorship care planning
requires coordination of activities across a dispersed network of specialists (see
Chap. 1; Reeves et al. 2018).
This chapter utilizes a patient-centered perspective to discuss how well-­
planned interprofessional care may be adopted throughout cancer survivorship
to bolster coping and health outcomes for patients and their families. The
chapter argues that a variety of dyads (e.g., patient/healthcare provider and
healthcare provider/healthcare provider) and teams must communicate in a
variety of contexts (e.g., throughout cancer treatment and throughout cancer
survivorship) to enhance the quality of care. These encounters require clear,
effective, and unambiguous communication, which underscores the salience of
the transmission model of communication (see Chap. 1). However, the trans-
actional model is also relevant: To provide patient-centered interprofessional
collaboration and care throughout the cancer trajectory, providers must be
aware of patients’ perspectives and experiences of cancer survivorship, includ-
ing how these are shaped by broader contextual influences.
The chapter proceeds as follows. First, it presents an overview of cancer sur-
vivorship, followed by an explanation of how patients experience uncertainty
across the cancer care trajectory, especially during survivorship after active
treatment has ended. Third, it describes survivorship care planning, along with
its attendant challenges. Fourth, it discusses the critical role of interprofessional
collaboration in survivorship care planning, including the need for interprofes-
sional education regarding cancer care after treatment has ended. Finally, an
illustrative vignette demonstrates the importance of survivorship care planning
and interprofessional communication, concluding with implications for practice.

Callout 13.1 Patient-Centered Care

Patient-centered care focuses on the patient and each specific patient’s
individual healthcare needs. One goal of patient-centered care is to
empower patients to actively participate in their own healthcare. A sec-
ond, and related, goal of patient-centered care is to facilitate good com-
munication skills between healthcare providers and patients to address
needs effectively (see Rathert et al. 2013 for a review). One aspect of
communication in patient-centered care is to empower patients to express
their healthcare preferences, values, and ultimately, their voice in patient-­
provider encounters.
 13 INTERPROFESSIONAL TEAMWORK IN ONCOLOGY: PATIENT-CENTERED… 217

Overview of Cancer Survivorship

Cancer survivorship is often broadly defined as surviving after cancer, while
cancer survivorship care describes one’s experience across the cancer contin-
uum, in other words, living with cancer, living through cancer treatments, and
living beyond cancer. According to the Office of Cancer Survivorship at the
National Cancer Institute (2023) in the United States, a person is considered
a cancer survivor at diagnosis and thereafter across the lifespan. Cancer survi-
vorship care planning acknowledges that the experience of cancer is not over at
the completion of treatment. Instead, cancer care requires long-term attention
and symptom-related maintenance throughout survivorship. The Institute of
Medicine (2007) notes that cancer often presents unique patient trajectories
and that the experience of cancer differs from patient to patient and necessi-
tates an interprofessional team of providers.
Thankfully, cancer prognoses have begun to improve, yet it remains among
one of the leading causes of death worldwide. Cancer diagnoses introduce
diverse challenges throughout survivorship, many of which do not end imme-
diately after the completion of treatment. Physical challenges relating to
ambiguous symptoms, treatment complications, unwanted side effects, and
impaired abilities may persist throughout survivorship. In addition, psychoso-
cial issues such as changes to valued identities, sexual functioning, finances, and
uncertainty may prove challenging for cancer patients and their families. Recent
statistics indicate that cancer-related deaths in the United States have declined
thanks to advanced treatments and early detection efforts (American Cancer
Society 2023). Positive prognoses, however, mean coping with survivorship
stressors and collaborating with a range of healthcare providers over extended
periods of time. For the aforementioned reasons, understanding cancer survi-
vorship and its associated patient-centered care planning has become increas-
ingly important for cancer survivors, their families, and their interprofessional
healthcare providers, in a new situation that is full of uncertainties.

Uncertainty Across the Cancer Trajectory

One of the main challenges that patients face post-treatment is uncertainty. It
is important for interprofessional care providers to understand this often-­
difficult patient experience. Uncertainty is recognized as an ongoing source of
stress in healthcare contexts and among patients coping with illness (Babrow
et al. 1998). For example, a myriad of illness features may produce uncertainty,
including treatment regimens, diagnoses and prognoses, ambiguous symp-
toms, daily functioning, and recovery (Mishel 1988). Uncertainty is also preva-
lent throughout the cancer experience and may be related to negative health
outcomes, such as anxiety, stress, and maladaptive coping. According to
Brashers’ (2001) uncertainty management theory, “uncertainty exists when
details of situations are ambiguous, complex, unpredictable, or probabilistic;
when information is unavailable or inconsistent, or when people feel insecure
218 L. E. MILLER

about their own state of knowledge or the state of knowledge in general”

(478). Uncertainty management theory challenges the assumption that uncer-
tainty always produces anxiety, asserting that uncertainty experiences vary from
person to person and that people can learn strategies to manage their uncer-
tainty in satisfactory ways. Brashers (2001) argued that:

Although people quite often do want to reduce complexity and ambiguity in their
lives, perhaps as a prerequisite to decision making, planning, or predicting the
behavior of others, there are other times when uncertainty allows people to main-
tain hope and optimism or when tasks can be performed despite, or because of,
uncertainty. (478)

Thus, according to the theory, uncertainty can be negative, but is not uni-
formly appraised negatively. For example, maintaining uncertainty can preserve
a patient’s psychological well-being if certainty about a prognosis is likely to
produce distress. Through this lens, uncertainty can be appraised as an oppor-
tunity facilitating the survival and management of ambiguous circumstances.
Research suggests that the transition from active treatment to long-term
cancer survival is uncertain (Miller 2012) and some individuals experience an
“inability to understand feeling depressed when recovering is a ‘good’ thing”
(Muzzin et al. 1994, 1205). Specifically, the indefinite uncertainty regarding
recurrence is continuous and can be triggered by ambiguous symptoms. When
unexplained symptoms are experienced, survivors’ levels of uncertainty may be
heightened compared to how they felt during treatment and diagnosis (Nelson
1996). Gaining a better understanding of cancer survivors’ experiences is
needed for both patients and healthcare professionals, as smoothly transition-
ing toward survivorship is challenging for many individuals. As Dow
(1990) argued:

Survivors have expressed ambivalence over the end of treatment because they
invested a greater proportion of time and energy in fighting the disease. However,
once treatment was over, the next round of fears of recurrence, concern over re-­
entry into work and family life, and adjustment to disabilities were a new set of
hurdles to endure. Getting well does not mean getting back to normal, because
lives can be radically changed by cancer. Return to normalcy does not mean a
return to the same place, but re-entry into a different place after treat-
ment. (512–513)

As this quote illustrates, the promotion of healthy survivorship is critical, and

more research on this point in the cancer trajectory is needed.
A great deal of research has applied the concept of uncertainty to cancer
care, arguing that uncertainty is prevalent at various points along the cancer
continuum, including during transitions in care (Mishel 1988). For example,
previous research has demonstrated that uncertainty in patients with cancer
relates to emotional distress, fear, lower quality of life, and diminished physical
and psychological outcomes (Mishel et al. 2009). Uncertainty (and its related
 13 INTERPROFESSIONAL TEAMWORK IN ONCOLOGY: PATIENT-CENTERED… 219

outcomes) may be particularly heightened during the transition from active

treatment to long-term survivorship, as this marks a point along the continuum
in which the healthcare team (and contact with the healthcare team) shifts.
From the survivor’s perspective, they may find themselves moving from a
familiar, dedicated interprofessional oncology care team who were co-located
in the same healthcare center to a seemingly disjointed constellation of care
providers—an interprofessional network—that feels difficult to navigate.
Indeed, cancer survivors in Miller’s (2012) study reported myriad sources of
uncertainty throughout long-term survival, many of which related to commu-
nication (or lack thereof) with their healthcare providers. In this study, cancer
survivors and their partners reported many different sources of uncertainty,
including (but not limited to) diagnoses, recurrence, identity shifts, finances,
and relational changes (434). For example, one cancer survivor in Miller’s
(2012) study described the continuous uncertainty relating to her cancer
recurring:

But then, it’s always thinking, “Is it going to come back? Could it come back?”...
And I don’t think you’ll ever be sure whether or not it’s going to come back.
They [healthcare team] always tell you five years. Your chances are the same as
anybody else. I’m waiting to get to that five-year mark. Once I get to that five-­
year mark, I may be a little more at ease. But I’m still always – I think I’ll still
always wonder … I don’t know that that thought will ever go away. (436)

An additional participant in Miller’s (2012) study described the uncertainty

that ensued after interacting with her healthcare provider:

My doctor basically kinda said that there’s really no way for us to know what that
is right now. You just kind of have to let the treatment take its course and come
back in six months, and we’ll rescan you and we’ll check it to see what’s going on.
I guess that made me really uneasy. I felt like there’s still something there. (436)

As these quotes illustrate, one commonly cited stressor for survivors is the
indefinite uncertainty regarding disease recurrence across the lifespan. The
chronic uncertainty can arise due to ambiguous symptoms that survivors may
fear are a sign of recurrence. Survivors have also described heightened levels of
uncertainty stemming from their interactions with clinicians. For example, as
disease-related check-ups approach, uncertainty and distress may increase. In
addition, some survivors (and families) noted increased uncertainty when con-
tact with their clinicians decreased. Dow (1990) describes this interactional
uncertainty: “As treatment ends, we have a tendency to withdraw professional
support at a time when individuals actually require it most” (512). Depending
on the survivorship care plan, survivors may only occasionally meet with their
clinicians and this lack of communicative support proves distressing for many
survivors. For the interprofessional network across the cancer care and survi-
vorship trajectory, it is important to be mindful of the potential for patients to
220 L. E. MILLER

experience heightened uncertainty at these transitions and to communicate

with their patients accordingly. One colon cancer survivor in Miller’s (2014)
study described this uncertainty and his desire for more frequent follow-up
appointments to “ease his mind”:

I’ve got to think about it in another six or seven months, having another colonos-
copy or devising a reason to have it for our own peace of mind. Like I said, we’re
going to try to get in there, even though he said I wouldn’t have to have one for
three years. We’re going to try to get back in there and have one just for our own
reassurance. (238)

This quote highlights the lengths that patients will go to manage their uncer-
tainty throughout survivorship. In order to provide compassionate and thor-
ough care across the cancer trajectory, healthcare providers need to be aware
that this uncertainty exists, and they must understand the nature of the uncer-
tainty their patients encounter. Only then it is possible to find appropriate com-
munication strategies for survivorship care planning that can support
uncertainty management in long-term survivorship.

Survivorship Care Planning

As the transition from cancer care to survivorship care is a huge and uncertain
step for the patient, planning survivorship care means creating a plan to sup-
port patients in this transition and for the rest of their lives. In their seminal
report on care planning entitled, “From Cancer Patient to Cancer Survivor:
Lost in Transition,” the U.S. Institute of Medicine (2006) proposed four
important components of long-term survival: (1) cancer prevention, (2) moni-
toring for long-term side effects, (3) care for disease-related challenges, and (4)
communication, coordination, and teamwork among the patient’s entire
healthcare team. The survivorship care plan, thus, should take into account all
of these components, which requires functional interprofessional communica-
tion and information sharing among professionals from different specialization
areas and professions (Callout 13.2).

Callout 13.2 Survivorship Care Plan

A survivorship care plan organizes information about recommended fol-
low-­up care. This includes how often patients should have check-ups, the
types of tests patients will need, and the potential long-term effects of the
cancer treatments. It also provides suggestions for healthy living
(American Cancer Society 2023). The American Cancer Society (www.
cancer.org), for example, provides informational and emotional support
resources to cancer patients, survivors, and their families worldwide.
 13 INTERPROFESSIONAL TEAMWORK IN ONCOLOGY: PATIENT-CENTERED… 221

Effective survivorship care planning includes summaries of the patient’s past

treatments and prospective needs. Written by oncologists and other healthcare
providers, the care plan communicates what transpired during cancer treat-
ment and outlines recommendations for future care (Institute of Medicine
2007). Ideally, it would be similar to a patient’s hospital discharge summary,
which details care given during the stay and provides recommendations for
how healthcare providers can best treat the patient in the future. The survivor-
ship care plan would then be communicated to the patient and to the patient’s
interprofessional care team.
When survivorship care planning is effectively implemented, it offers many
benefits. One benefit is that it provides survivors and their families with the
physical, emotional, informational, and instructional support they need
throughout long-term survival. Survivorship care planning can also enhance
communication between patients and their interprofessional networks of
healthcare providers. As such, the survivorship care plan can facilitate the com-
munication, distribution, and summary of past medical conditions (e.g., what
occurred during the cancer diagnostic and treatment phases).
Ideally, a survivorship care plan would not only serve the patient but could
also help the interprofessional survivorship care providers to better integrate
their care efforts. For example, the care plan could be shared among a patient’s
interprofessional “constellation” of care providers to communicate and share
information about past medical treatments and future plans. Thus, the care
plan facilitates clarity of communication among an interprofessional team of
clinicians, which in turn, may improve patients’ (and their families’) survivor-
ship experiences. If such clarity of communication is not achieved, patients may
experience heightened uncertainty due to the ambiguity of their healthcare
conversations. To further illustrate the salience of a survivorship care plan, one
survivor in Miller’s (2014) study described the lack of communicative coordi-
nation among her care team:

The emotional rollercoaster comes after treatment is over. I wanted to talk to my

doctor and nurses about how I was feeling, but all of a sudden, you don’t see
them for six months at a time. One guy told me that I would need to go talk to
someone else because he didn’t want to deal with my emotions. He said, “My job
was to get the cancer out of your body. So my job is done. You will have to talk
to someone else about that.” I felt lost and abandoned. (239)

This cancer survivor described a sense of abandonment by her interprofes-

sional healthcare team, giving a drastic example of the discontinuity of care.
The risk of fragmentation and discontinuity is significant during the transition
from active cancer care to survivorship care because patients often see an array
of healthcare providers in various physical locations. Haggerty et al. (2003)
defined continuity of care as care over time that is experienced by patients as
connected and coherent. In the context of cancer survivorship, this could
include the perception that one’s healthcare team knows what happened
222 L. E. MILLER

during active treatment and also knows the future care plan. Haggerty et al.
(2003) present three types of continuity, including informational continuity
(e.g., information about a patient’s medical condition that links one provider
with another), management continuity (e.g., shared management plans pro-
vide a roadmap for patient care), and relational continuity (e.g., establishing
consistent, ongoing relationships with multiple caregivers over time). Each of
these aspects of continuity are highly relevant to a patient’s transition from
active cancer treatment to long-term survival. For example, a patient needs a
survivorship care plan (management continuity), with information document-
ing past medical conditions and received treatments (informational continuity)
and will need this plan to bridge both past care providers and those involved in
future care (relational continuity). All three types of continuity contribute to
improved care throughout cancer survivorship. Thus, continuity of care creates
a framework for setting goals for the interprofessional teamwork in cancer care
that needs to be taken account in survivorship care planning (Callout 13.3).

Callout 13.3 Continuity of Care

Continuity of care refers to patients’ experience that care is connected and
coherent over time (Haggerty et al. 2003). In the context of cancer sur-
vivorship, it includes the perception that one’s healthcare team knows
what happened during active treatment and also knows the future care
plan. Three types of continuity can be recognized: informational conti-
nuity, management continuity, and relational continuity. Each of these
aspects of continuity are highly relevant to a patient’s transition from
active cancer treatment to long-term survival.

Accordingly, to improve survivors’ experiences, the survivorship care plan

should strive for:

Setting out who is to be responsible for what aspects of survivorship care and who
is to take responsibility for implementing the plan [as this] can lead to efficiencies
in health care delivery and potential cost savings. Survivorship care plans also
represent a standardized way of communicating to all involved in the patient’s
care about what went on and essential next steps. (Institute of Medicine 2007, 16)

The survivorship care plan lays the groundwork for future medical treat-
ments, and it helps to promote informational continuity among the members
of the interprofessional healthcare team. In addition, the care plan may relieve
some of the anxieties and sense of abandonment that many survivors face by
providing them with a detailed, personalized plan for their future care.
Taking together the aforementioned advantages, in 2006, the Institute of
Medicine recommended that all cancer patients receive a survivorship care plan
 13 INTERPROFESSIONAL TEAMWORK IN ONCOLOGY: PATIENT-CENTERED… 223

detailing “a summary of their treatments, follow-up care plan, and information

on potential late effects, self-care, and resources” (Nápoles et al. 2019, 2).
Moreover, the Institute of Medicine (2007) declared that psychosocial care
should be included in a patient’s survivorship care plan. Counseling, support
groups, and mental health resources should be outlined and communicated to
patients. As one cancer survivor mentioned, “Posttreatment is really important
for your peace of mind, if nothing else. I was terribly fearful. I woke up in the
middle of the night. I felt like I was just dropped” (Institute of Medicine 2007,
33). As such, a detailed survivorship care plan communicated by healthcare
providers to patients that includes future recommendations for physical and
psychosocial care may ease patients’ minds, confirm the sense of continuity, and
reduce uncertainty throughout cancer survivorship.

Challenges of Survivorship Care Planning

Along with the numerous benefits to survivorship care planning are various
barriers to implementation. The first challenge to survivorship care planning
relates to the unique risks and needs of each cancer survivor. Cancer is a very
complex disease and each and every patient requires personalized attention; in
other words, survivorship care planning is a “one size does not fit all” (Klemp
2015, 67) process. Instead, effective survivorship plans should provide patients
with individualized plans, recommendations, and medical advice. Klemp
(2015) also outlines various aspects of the patient experience that may influ-
ence survivorship care planning efforts, including age at diagnosis (i.e., pediat-
ric or adult), tumor type or stage (i.e., high or low risk of recurrence), disease
specifics (i.e., breast, prostate, lung cancers, etc.), and rural or urban environ-
ments. Such aspects can create burdensome challenges for healthcare providers
who attempt to create personalized care plans that acknowledge the varied
complexities of a cancer diagnosis.
Second, there are challenges relating to provider reimbursement and
resources that can create roadblocks to effective survivorship care. Healthcare
providers maintain very busy schedules, and the time and energy it takes to
construct an effective (and feasible) care plan for each patient may prevent it
from occurring. The level of detail required to complete a thoughtful care plan
can be impractical amid already overburdened clinical practices. Moreover, cli-
nicians are not always reimbursed for completing care plans, thus making them
potentially infeasible. Indeed, oncology clinicians in McKinlay et al.’s (2019)
study described large amounts of preparation time and unpaid hours as barriers
to implementation.
224 L. E. MILLER

Developing Survivorship Care Planning

in Interprofessional Teams

One of the most important factors in survivorship care planning is interprofes-

sional communication and teamworking. Chollette et al. (2022) argue that “a
cancer diagnosis requires a well-coordinated, team-of-teams to provide patients
with access to life saving innovations along the continuum of care” (622); such
teams will inevitably need interprofessional training to jointly foster a collab-
orative learning environment. These authors go on to mention that cancer
patients who experience poor interprofessional collaboration experience greater
uncertainty and less satisfaction with their experience. In health care, a “team
of teams” approach necessitates that every team member–from the oncologist
to the psychologist–needs to have a shared goal of providing patient-centered
care to every patient. To achieve that goal, they need to have sufficient inter-
professional communication skills. This becomes particularly relevant in cancer
survivorship, as survivors are already managing prolonged uncertainty.
Considering interprofessional education, the majority of interprofessional
education work in oncology has been done in the context of active patient care
(e.g., during treatment), leaving a significant gap in cancer survivorship (e.g.,
after treatment has been completed; see San Martin-Rodriguez et al. 2008).
Therefore, offering clinicians interprofessional education during this pivotal
point in the cancer trajectory is crucial, particularly in light of the Institute of
Medicine’s call for survivorship care plans for all patients. Cancer care is com-
plex, and as these authors note, many factors contribute to the growing com-
plexity of delivering well-coordinated care. For example, varied treatment
options, rising incidences of long-term cancer survivors, the introduction of
telehealth, and increased healthcare costs all influence a cancer care team’s abil-
ity to deliver quality care. Moreover, due to the unique nature of cancer survi-
vorship involving interprofessional team members, cancer care necessitates
coordination across multiteam systems, as mentioned earlier. To illustrate,
throughout the survivorship trajectory, a patient’s surgical team must commu-
nicate with their primary care team. The radiology team must communicate
with the oncology team; the pharmacology team must communicate with the
nutrition team. The communication that occurs among these different team
members requires attention and thoughtful coordination, hence, interprofes-
sional education and communication training is highly important in this
context.
In their narrative synthesis of interprofessional teamwork competencies,
Chollette et al. (2022) identified research examining teamwork competencies
pertaining to multiteam systems (MTSs). These authors define MTSs as “two
or more teams that work interdependently to collectively accomplish tasks and
goals related to patient care” (617). Across their review of 107 articles, the
authors found that the most common competencies in interprofessional educa-
tion training programs were communication, role clarity, leadership, situation
monitoring, and patient-family centeredness, with communication being the
 13 INTERPROFESSIONAL TEAMWORK IN ONCOLOGY: PATIENT-CENTERED… 225

most common competency across all reviewed studies. They also found that
most of the interprofessional education training curriculums were developed
for practicing clinicians, followed by nursing students and medical students.
General patient care was the most common healthcare context to include an
interprofessional education training program, followed by pediatrics/obstet-
rics/labor and delivery, trauma, and emergency care.
Specifically relating to cancer care, Chollette et al. (2022) reviewed four
oncology-specific studies. Two of these studies developed and evaluated inter-
professional training programs in cancer care. First, Bunnell et al.’s (2013)
study evaluated a multiteam training program for providers in a breast cancer
clinic. The authors’ results demonstrated “statistically significant increases in
patient satisfaction with care coordination and staff and provider perceptions of
efficiency, safety, and respectful behavior among team members” (621).
Additional results from interviews with clinicians highlighted challenges relat-
ing to asynchronous communication, coordination, and collaboration both
within the clinic team and in collaborating with other team members outside
of the clinic (Bunnell et al. 2013). Second, James et al. (2016) evaluated an
interprofessional team training program that utilized simulated scenarios to
bolster teamwork and communication skills among teams of oncology nurses
and fellows. Program participants reported improved skills in their interprofes-
sional competency, which included competency domains such as team com-
munication and team orientation. None of these studies specifically focused on
cancer survivorship and future work will need to focus on interprofessional care
coordination after cancer treatments have ended.
In summary, cancer survivorship marks a transition period in the cancer
trajectory. Specifically, as patients move from active treatment to long-term
survival, their interprofessional care team(s) may change, as some aspects of
their care may be completed, while others may just be beginning. All these
changes implicate informational, management, and continuity of care chal-
lenges. For example, when a patient is first diagnosed with cancer, it is common
for them to meet with their primary care physician, in addition to a surgical
team, an oncology team, or a radiology team depending on the specific diag-
nosis. The patient may work closely with one or more of these teams as they
complete their treatment regimen(s). Once treatments have been successfully
completed, communication with these teams may lesson, and the patient may
have more contact with healthcare providers designed to facilitate their long-­
term survival, including pharmacists, physical therapists, psychologists, and/or
geneticists. Thus, the transition from active treatment to cancer survivorship is
one in which interprofessional communication and training is paramount, as it
marks a significant point along the cancer continuum when the care team
changes and, therefore, continuity of care is at stake. Moreover, to provide
effective care throughout long-term survival, it is imperative that the patient’s
treatment team engage in interprofessional communication with the survivor-
ship team (Institute of Medicine 2007). The following vignette illustrates many
of these points.
226 L. E. MILLER

Julia’s Transition to Long-Term Cancer Survivor

Julia is a 36-year-old patient who has just transitioned from active treatment to
long-term cancer survivorship. This vignette describes her communication
with the interprofessional team and how that team changes after treatment has
been completed. It demonstrates the numerous challenges and uncertainties
Julia faces based on the interprofessional coordination of the healthcare team.
Julia has recently completed treatment for breast cancer. Her treatment reg-
imen included having a double mastectomy and 23 rounds of chemotherapy.
After completing these treatments, she was put on tamoxifen, a medication
used to reduce the risk of cancer recurrence. In addition to her primary care
physician, her oncologist, her surgeon, and radiologist, she interacted with a
fertility specialist to discuss her family planning options because the chemo-
therapy treatments diminished her ability to conceive. Moreover, she started
seeing a cancer geneticist to learn more about her inherited cancer risk.
Throughout her active treatment journey, she communicated with this inter-
professional team of clinicians through regular face-to-face appointments with
each specialist individually (e.g., she had an appointment with her oncologist,
then an appointment with her surgeon, etc.). After her double mastectomy and
chemotherapy had been completed, her oncology team declared that her mark-
ers were clear, meaning that her cancer was essentially gone. On her last day in
the oncology clinic, her team celebrated her completion of treatment, and she
was able to “ring the bell,” a tradition that marks the passage from active treat-
ment to long-term survival. Her team, which included clinicians from many
different units in the hospital, clapped and cheered for her as she walked out
the clinic doors for (hopefully) the last time. She knew she should be thrilled
and thankful for surviving her treatments and reaching this point, so why did
she feel such a strong sense of anxiety about what to do next?
The day after her bell ringing ceremony at the cancer clinic, she called her
fertility specialist to schedule an appointment. She was particularly nervous
about this appointment because she had always dreamed of having kids, but
she knew that her chemotherapy might have impacted those dreams. She
arrived at the appointment nervous, but ready to tackle this next challenge.
The specialist asked her some questions relating to the specifics of her breast
cancer diagnosis and the specific type of chemotherapy she had received. Julia
was able to answer some of the questions, but then said, “My oncologist was
supposed to send all of my records to you so you would have all of that infor-
mation on file. Did you receive them?” The specialist took a moment to look
at Julia’s electronic medical record, then said, “It doesn’t look like we have. I
will request them again and when they arrive, I will have our office call you to
schedule your next appointment.” Feeling defeated and frustrated, Julia left
the specialist’s office with more questions than she had answers.
While waiting to hear back from the fertility specialist, Julia decided to tackle
the next item on her health-related to-do list, which was to address the numb-
ness she had been feeling in her arms and shoulders that started after her
 13 INTERPROFESSIONAL TEAMWORK IN ONCOLOGY: PATIENT-CENTERED… 227

surgery. She was concerned about this because she worked as an administrative
assistant at a local real estate company and much of her work involved typing,
an activity that had become increasingly difficult due to this side effect. She
called her primary care physician to schedule an appointment and during that
appointment, her physician indicated that her symptoms could be indicative of
lymphedema, a condition that causes numbness around the lymph nodes. He
also mentioned, however, that the pain and swelling she had been experiencing
could also be indicative of a cancer recurrence. Therefore, the doctor recom-
mended that she reach out to her oncologist for further investigation.
She, again, left the appointment feeling lost and uncertain about her next
steps and about her future health. Would she be able to conceive and when
would she find out answers? Moreover, what was causing her pain and numb-
ness? Had her cancer already started to come back so soon after the bell ringing
ceremony? As she unlocked her car and sat down in the driver’s seat, she said
out loud, “So much for being done with treatment. I thought that was sup-
posed to be the hardest part,” as tears started to form in her eyes.
Julia’s experience highlighted the complexity and coordination required of
an interprofessional healthcare network in the context of cancer care survivor-
ship. Her network needed to communicate with each other in order to provide
her with the best, most effective post-treatment care. In addition, her interac-
tions with her care providers lacked informational continuity and heightened
her uncertainty, which in turn, impacted her psychosocial well-being and
adjustment to survivorship. In what ways could a survivorship care plan have
improved her experience? Furthermore, how could interprofessional commu-
nication facilitate smoother coordination between her interprofessional health-
care network?

Conclusion
As the Institute of Medicine (2007) describes, a goal of the survivorship care
plan is to “achieve meaningful improvement in cancer care delivery and the
patient experience” (164). This improvement to cancer care could come in
many forms, including ensuring that patients feel cared for, first of all in their
clinical care. For example, Julia’s oncologist needed to ensure that her medical
records were effectively sent to her other team members (here, her fertility
specialist). In addition, a survivorship care plan can also improve patients’ psy-
chological care. For example, a care plan could make sure survivors receive
necessary information relating to counseling and mental health services, social
support groups, and uncertainty management strategies.
Taken together, cancer patients, survivors, and their families experience
many challenges throughout cancer survivorship. As described throughout this
chapter, physical and psychosocial hardships continue long after cancer is out
of the body and persistent challenges hinder individuals’ transition to long-­
term survival. Evidence suggests that interactions with one’s interprofessional
healthcare providers may change or decrease across the cancer trajectory; this
228 L. E. MILLER

lack of continuity can create added uncertainty, frustration, and confusion for
many people. Survivorship care planning is a way clinicians can offer informa-
tional continuity, follow-up plans, and psychosocial resources for patients
throughout long-term cancer survival. Despite barriers to implementation,
survivorship care planning represents the acknowledgement of cancer as a
“chronic condition that requires long-term monitoring for its aftereffects and
sequalae” (Institute of Medicine 2007, 5). As the number of cancer survivors
continues to rise, the implementation of survivorship care planning has never
been more timely. To foster such care, interprofessional education and training
becomes paramount. As interprofessional communication is the core process of
interprofessional collaboration, interprofessional education initiatives should
consider how communication will be taken account. In the future, clinicians
and interprofessional teams will want to continue prioritizing health-related
transitions (e.g., such as moving from active treatment to long-term survival)
to facilitate coping with cancer’s lingering effects.

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 CHAPTER 14

The Interprofessional Team as an Emergent

Structure of Participation: A Case Study
on Primary Care Visits of Unaccompanied
Foreign Minors

Letizia Caronia and Federica Ranzani

Introduction
In the last twenty years or so, clinical practice has increasingly adopted a dis-
tributed expertise model. This model is based on the idea that the knowledge
that makes a difference in the delivery of safe and effective care must be spread
among different experts: professionals as well as laypersons such as patients and
their natural caregivers. Two main and not surprisingly converging ideologies
lie beneath this distributed expertise turn: patient (and family) centered care
(Mead and Bower 2000) and the interprofessional collaboration approach
(hereafter IPC).1 The former underlines the patient’s expertise about her ill-
ness and her agency (see Callout 14.1) in how to deal with it and treatment
prescriptions. The latter underlines the need to create an osmotic relationship
among the different territories of professional knowledge at stake in patient

1
For a brief history of these two ideologies and a review of the works they inspired, see A. Fox
and Reeves (2015).

L. Caronia (*) • F. Ranzani

Dipartimento di Scienze Dell’Educazione (Department of Education Studies),
Università di Bologna, Bologna, Italy
e-mail: [email protected]; [email protected]

© The Author(s) 2025 231

S. Fox et al. (eds.), Interprofessional Communication in Health and Social
Care, https://doi.org/10.1007/978-3-031-70106-1_14
232 L. CARONIA AND F. RANZANI

care, and advocates for a flat hierarchy of and “respect for disciplinary contribu-
tions of all professionals” (Herbert 2005, 2; on the ideal of “clinical democ-
racy,” see S. Fox et al. 2021). As A. Fox and Reeves (2015) point out, the
“focus on enhancing interprofessional collaboration acknowledges the unique
expertise of various health and social care professions, while encouraging them
to work together to coordinate care, streamline service and optimize treat-
ment” (113, our emphasis).
Despite its ideological implications and hidden economic rationales, such as
freeing up highly expensive medical time by diverting some practices to nurses’
less costly time or displacing legal responsibility on the “empowered patient”
(on the unstated but underlying reasons of such a turn, see A. Fox and Reeves
2015), IPC is increasingly reported as the golden standard of health care.
Scientific as well as gray literature converges in adopting an “ought to be” per-
spective on IPC: Formal models of how IPC should unfold and practical guide-
lines are more and more common (see among others Interprofessional
Education Collaborative Expert Panel 2011; Kreps 2016), and relatively recent
work has even defined and validated a gold standard on how IPC should be
operationalized in clinical settings to promote effective collaboration (see
Careau et al. 2014).
Despite this growing body of normative literature on IPC, there still is a
relative lack of knowledge of how it is actually accomplished (or not) in the
course of interaction as the outcome of observable communicative practices,
especially within primary care (but see Fox et al. 2021). Due to clinical com-
plexity often requiring different specialties and a pre-existing tradition of team-
work, the domains primarily concerned with IPC issues and affected by IPC
informed policies have been hospital care (Reeves and Lewin 2004), specialist
visits (e.g., cancer care, James et al. 2016), community care (Xyrichis and
Lowton 2008), long-term treatments for chronic diseases (Barr et al. 2017),
rehabilitation (Careau et al. 2014), and palliative care (Blacker and Deveau
2010). In fact, only relatively recently has primary care shown interest in
IPC. Traditionally, in primary care, “many patient concerns [...] can be resolved
or treated by a visit to a single health professional” (Fox et al. 2021, 125), but
because of the growing complexity of primary care and increasing number of
chronic conditions, the contribution of other professions has become increas-
ingly relevant and often inescapable.
Among the factors that make “ordinary” primary care more complicated,
linguistic obstacles and the patient’s vulnerable condition can hinder achieving
the main institutional goals of a medical visit: gathering information for diag-
nosing, ensuring understanding of diagnoses and treatment recommendations,
and gaining compliance by leveraging the patient’s agency and active involve-
ment in the visit. Following a recent line of inquiry on how IPC in primary care
communicatively unfolds and a “strong call for qualitative and observational
methods to take communication out of its black box in the IPC literature”
(Fox et al. 2021, 126), this chapter identifies interprofessional attunement (see
Callout 14.2) as one form of interacting in interprofessionally managed care. It
 14 THE INTERPROFESSIONAL TEAM AS AN EMERGENT STRUCTURE… 233

draws on data from a single case study concerning a socially and linguistically
complex case: the primary care visits of unaccompanied foreign minors (here-
after, UFMs) who don’t master the language of the visit. The visits are charac-
terized by a triadic format of participation: the UFM patient is accompanied by
a professional educator who is institutionally in charge of the UFMs’ everyday
care and assists them during any health care encounter as well as other ordinary
and institutional tasks. Professional educators are not cultural and linguistic
mediators and nor do they have any competence in UFMs’ first language. Their
professional expertise is in social care and consists of socio-anthropological and
psycho-pedagogical applied knowledge. As we will illustrate, the co-presence
of the physician and educator creates a form of participation where their respec-
tive and different domains of expertise, institutional mandates, goals, commu-
nicative models, and practices balance each other. The synergy made possible
by mobilizing different professional agendas and communicative resources
(e.g., closed- and open-ended questions, gaze direction, gestures) allows prac-
titioners to reach an outcome that would probably not be attained without
engaging in this (possibly unintentional) form of interprofessional
collaboration.
Although primary care visits of asylum seekers and refugees are not repre-
sentative of ordinary primary care work, they nevertheless constitute a particu-
larly useful case that illustrates (1) the relevance of interprofessionality when
dealing with socially and linguistically complex cases, and (2) how IPC can be
accomplished one interaction at a time through various communicative
resources—ways of speaking and other communicative modalities, such as ges-
tures, body orientations, gaze, and even the use of objects—that are part of the
everyday communicative repertoire of the participants. As we will illustrate, it
is precisely by resorting to identifiable communicative resources and distribut-
ing the burden of communicating with linguistically (locally) impaired patients
that professionals manage to overcome the typical dilemma of these encoun-
ters: maximizing information understanding versus following a patient-­
centered approach.

Interprofessional Care: A Team-Based or

a Team-Emerging Practice?

For the most part, the IPC literature considers “teams” or otherwise institu-
tionally expected forms of interprofessional communication, collaboration,
coordination, and cooperation in normative terms (e.g., Careau et al. 2014;
WHO 2010): application-oriented studies, guidelines, and protocols provide
definitions or even prescriptive models of how communication, collaboration,
and cooperation among healthcare professionals should unfold. Notwithstanding
the practical value of such a normative approach (as well as its ideological
underpinning), it still fails to account for how interprofessional communication
and collaboration unfolds “informally,” that is, outside an official and
234 L. CARONIA AND F. RANZANI

constraining framework (e.g., “teamwork”) that establishes a priori who has to

and how to collaborate, coordinate, and cooperate with whom and for what
clinical purpose. Adopting a constitutive model of communication and brack-
eting any normative approach on how IPC should unfold, in this chapter we
make a case for IPC as a team-emerging communicative practice, that is, a way
of interacting that makes the co-present professionals work and act as a “team.”
Indeed, we propose that the “interprofessional team” should not be consid-
ered as a preexisting participative structure institutionally set up and norma-
tively encouraged so that “different health care professionals [can work]
together to help consumers address their health problems” (Kreps 2016, 1).
Instead, we define the interprofessional team as a way of working that is locally
accomplished one interaction at a time by participants.
From this standpoint, “interprofessional team-based care” (Interprofessional
Education Collaborative Expert Panel 2011, 2) is not necessarily a purposely
designed and training-based form of care “delivered by intentionally created
usually relatively small work groups in health care who are recognized by oth-
ers as well as by themselves as having a collective identity and shared responsi-
bility for a patient” (ibid). Rather, we claim it is an emergent property of
interaction where participants display, manage, and coordinate their differ-
ent—and often hierarchically organized—expertise and institutional mandates.
Locally accomplished and endogenously crafted “interprofessional collabora-
tive practices” (WHO 2010) are therefore conceived of as potentially produc-
ing local forms of “interprofessional team-based care.” Here, we describe a set
of coordinated communicative moves that we call “interprofessional
attunement.”
The adoption of a constitutive model of communication to analyze com-
munication as it actually unfolds in real-life conversations does not necessarily
mirror the participants’ analytical understanding of communication. On the
contrary, it can be the researcher’s theoretical perspective on how communica-
tion unfolds, a kind of second-order construct they use to make sense of what
they observe in the field. The professionals “under scrutiny” have their own—
more or less noticeable and acknowledged—“model of communication,”
depending on their professional culture, pre-service and in-service training, as
well as experience. In our case study, the doctor and the educator are oriented
to a “transmission model of communication” (the doctor) and a “transactional
model of communication” (the professional educator). This orientation is vis-
ible in the different communicative practices they deploy: while the doctor
seems more oriented to pursuing and ascertaining correspondence between
encoded and decoded messages (e.g., by engaging in multimodal communica-
tion, translating specialized lexicon into everyday more accessible terms, see
Caronia et al. 2020, 2022a, b), the educator engages more often in scaffolding
the patient’s meaning-making process, for instance, by reformulating the doc-
tor’s questions to adjust them to the patient’s comprehension.
As the case study demonstrates, building interprofessional team-emergent
care also amounts to bridging and intersecting models of communication that
 14 THE INTERPROFESSIONAL TEAM AS AN EMERGENT STRUCTURE… 235

can be, and often are, very different both in their theoretical assumptions and
in their practical consequences. By mapping the different communicative mod-
els and relative practices within a highly specific primary care setting, this chap-
ter contributes to defining the repertoire of communicative forms through
which IPC is—and therefore can be—accomplished in vivo. Indeed, in this
study we follow a bottom-up approach well suited for delivering ecologically
valid, practice-relevant findings, that is, results whose implications for policies
and practices are rooted in, and therefore sensitive to, the constraints and pos-
sibilities of the IPC actually taking place within interprofessionally managed
primary care visits.
In a nutshell, we contend and empirically illustrate that the necessary and
sufficient conditions to provide “interprofessional team-based care” are few:
the professionals’ co-presence and the deployment of communicative resources
oriented to collaborating in a way that manages the dialectical tension between
connection and professional autonomy (see Chap. 7).

Triadic Interactions in Healthcare Settings

The interest in analyzing how healthcare interactions involving multiple parties
(other than the physician and the patient) unfold in actual medical consulta-
tions has increased in recent years. The bulk of the research explores cases
involving the participation of patients’ “companions,” that is, “people who
support patients and attend health-care appointments with them” (Pino and
Land 2022, 396). Among these observational studies of social interactions,
pediatric care receives particular attention as the presence of parents (or other
adult caregivers) is mandatory in the case of children who are minors (e.g.,
Aronsson and Rindstedt 2011; Stivers 2007). Similarly, companions’ presence
is expected in particularly sensitive settings such as end-of-life care (Pino and
Land 2022), medical visits of patients with communicative or cognitive impair-
ments (Garcia 2012; Muntigl et al. 2014), or oncology (Fatigante et al. 2021).
As these studies illustrate, the delicacy of the contexts mentioned above makes
the participation of the accompanying party particularly challenging. If, on the
one hand, the patient-centered ideology informing healthcare services pushes
for patient autonomy and the related right to “speak for themselves” (there-
fore, the companion’s intervention on the patient’s behalf is not institutionally
desirable), on the other hand, fragile patients may not be able or willing to do
so (therefore, the companion’s intervention may be essential for attaining the
visit’s objectives at the expense of the patient-centered mandate; for similar
considerations, see the next section). In this regard, research based on interac-
tion analysis of observed patient consultations shows that intervening on the
patient’s behalf (e.g., by answering questions clearly addressed to the patient)
does not constitute per se a “bad” practice that unavoidably undermines the
principle of patient autonomy. Rather, companions intervene in a “carefully
calibrated manner” (Antaki and Chinn 2019, 2029) that is (a) the result of a
local adjustment to the specific interactional circumstances (e.g., the
236 L. CARONIA AND F. RANZANI

companion’s intervention is prompted by the patient’s or the professional’s

gaze or question or occurs when the patient does not answer a question asked
by the health care professional, see Pino and Land 2022) and (b) contingent
on the phase-specific goal of the visit (e.g., the companion revises the informa-
tion provided by the patient in the problem presentation phase while concur-
rently preserving the patient’s rights as the owner of the illness story, see
Fatigante et al. 2021).

Callout 14.1 Agency

Notwithstanding the differences among the various definitions of agency,
they all share a core meaning: agency refers to the capacity of an indi-
vidual to act and make a difference in the social world. Many scholars add
two other constitutive components: being in control over one’s own
action and having a choice (Duranti 2004; Giddens 1984). Strictly related
to the notion of agency is that of autonomy. In a nutshell, autonomy
generally refers to the extent to which individuals have the capacity and
self-determination to make decisions without external influence or coer-
cion. Despite some semantic overlap, the notions of agency and auton-
omy do not coincide. While agency emphasizes the ability to have an
impact and make choices through the exercise of personal will, autonomy
pertains to independence and freedom from external control. Agency and
autonomy are considered fundamental ethical principles in the domain of
health care as they uphold individuals’ right and ability to make informed
decisions about their health.

While healthcare interactions where the third participant is another health-

care professional have received less attention in social interaction literature, one
case has been quite investigated: triadic interactions between the healthcare
provider, the non-native patient, and the interpreter (e.g., Baraldi and Gavioli
2012) who attends the visit “with the sole communicative function of making
understanding possible” (Gavioli and Baraldi 2011, 206). Research in this
domain reveals that interpreters’ contribution to the unfolding of the visit can-
not be reduced merely to the accurate linguistic translation of others’ talk on a
turn-by-turn basis. Rather, interpreters play an active role by coordinating who
speaks when and about what (Baraldi and Gavioli 2012), selecting what medi-
cal information has to be translated or not (Davidson 2000), or by expanding
the rendition of the doctors’ questions (Baraldi and Ceccoli Forthcoming).
Compared to the other kinds of triadic medical visits tackled above, triadic
encounters with UFMs and their accompanying educators are potentially char-
acterized by different layers of complexity and, therefore, they can be challeng-
ing in quite specific ways to the professionals involved in taking care of these
patients. We discuss this in the next section.
 14 THE INTERPROFESSIONAL TEAM AS AN EMERGENT STRUCTURE… 237

A New Challenge for Primary Care: The Case of UFMs

Unaccompanied foreign minors (UFMs) are underaged children or adoles-
cents who arrive in a country without their parents or other legally responsible
adults. Internationally, UFMs are considered vulnerable persons who deserve
care and support by the hosting society. Typically, they are hosted in residential
structures where different professionals take care of them. In Italy, where this
data was collected, professional educators are in charge of UFMs’ everyday
well-being. Their expertise is grounded in psycho-pedagogical and socio-­
anthropological knowledge, and they are institutionally expected to support
UFMs in the accomplishment of their educational, administrative, and health-
care tasks. Their pedagogical mandate consists in promoting UFMs’ active par-
ticipation and autonomy as much as possible. The presence of an educator is
normatively required during primary care visits. The accompanying educator is
expected to ensure the effective exchange of biomedical information (and
therefore sometimes they speak for the UFM), and, concurrently, to maximize
the UFMs’ active participation in the visit by making them speak for them-
selves. The promotion of patients’ agency also constitutes a cornerstone of the
professional mandate of the co-present physician: while securing information
understanding throughout the visit constitutes a primary goal, they are institu-
tionally encouraged to foster patients’ involvement in the visit as emphasized
by the patient-centered approach. However, pursuing UFMs’ participation can
be quite a challenging task in this kind of visit since they are characterized by
multiple asymmetries. In addition to the epistemic asymmetry ordinarily at
stake in any medical encounter (Pilnick and Dingwall 2011; see Callout 14.3),
the linguistic asymmetry can be particularly evident in these visits as the patients
typically have low competence in the language of the visit and neither the phy-
sician nor the professional educators know the patients’ first language (and no
interpreter is present). The interaction can also be characterized by a social
asymmetry since UFM patients often experience a fragile socio-psychological
condition due to, alongside other factors, their migratory paths and post-­
traumatic status. Lastly, an interprofessional asymmetry may be operating:
despite the pressure for a flat hierarchy in interprofessional collaboration, par-
ticipants in the medical visit still orient to the primacy of the physician’s bio-
medical knowledge over the educator’s socio-pedagogical knowledge (on
interprofessional power hierarchies, see Chap. 8 and A. Fox and Reeves 2015).
Given this system of intertwined asymmetries, the goals of maximizing patient
autonomy on the one hand and concurrently ensuring reciprocal understand-
ing and information gathering on the other may become incompatible in these
visits. In fact, the more the professionals prioritize biomedical information
gathering and understanding, the more they have to exclude the UFM as the
primary addressee (i.e., the person to whom talk is addressed); conversely, the
more they prioritize the UFM patients’ agency by directly addressing them, the
more they risk missing the full comprehension of their medical history and
overall health condition.
238 L. CARONIA AND F. RANZANI

How do the two care professionals manage this incompatible agenda? As we

will show, it is precisely (a) the educator’s specific institutional mandate and
relevant expert knowledge, (b) her way of cooperating without intruding in
the medical territory of knowledge, and (c) the doctor’s orientation to such
displayed non-medical expertise, which allows participants to overcome the
“maximizing understanding versus allocating agency” dilemma of this kind
of visit.

No Cure Without Care: Exploring Interprofessionality

in the Making

In the next section, we show (1) how interprofessionality is accomplished “in

the making” through observable communicative resources that are mobilized
throughout the different phases of the UFMs’ medical visits and (2) how these
resources allow practitioners to collectively overcome the tension between
ensuring understanding and allocating agency. We draw on a corpus of three
videorecorded primary care visits of unaccompanied foreign minors (UFMs)
collected in an Italian general practice public clinic.2 In line with the constitu-
tive model of communication, we use theoretical and analytical constructs
from conversation analysis (CA)3 (Sidnell and Stivers 2012) to analyze the
excerpts presented in the following section. The video recordings have been
transcribed using CA conventions and enriched with notations for gaze, ges-
tures, body movements, and orientations when ostensibly relevant for
participants.

2
Each visit involved a general practitioner, a UFM patient, and an educator. The UFMs partici-
pating in the study were aged between 16 and 18 and had low competence in the language of the
visit (i.e., Italian). Participants’ consent was obtained according to the Italian and European laws
regulating the handling of personal and sensitive data (GDPR).
3
Conversation analysis (CA) is an observational, micro-analytic approach to the study of real-life
audio and/or video recorded “naturally occurring” interactions, that is, not elicited by the
researcher. It is based on the transcription and close analysis of the tiniest details of participants’
communicative resources, including language, bodily conduct, and the use of material artifacts.
The transcription conventions include not only the transposition of the content of talk (what is
said) but most importantly the different modalities of talk production (how it is said), including
participants’ multimodal conduct (gaze directions, body posture, movements, and gestures),
vocalizations (e.g., laughter) and other interactional features such as the length of silences, overlap-
ping talk, or intonational contours. The advantage of adopting CA to analyze healthcare interac-
tion is that it enables (a) the identification of observable communicative strategies that can foster
(or hinder) patient participation in the visit, (b) the investigation of the association between
observed communicative behaviors and specific outcomes (e.g., patient satisfaction, compliance),
and (c) the identification of visible communicative patterns that healthcare providers can reflec-
tively analyze in training programs and adopt with more awareness when interacting with patients.
 14 THE INTERPROFESSIONAL TEAM AS AN EMERGENT STRUCTURE… 239

Dealing With the “Maximizing Understanding Versus

Allocating Agency” Dilemma: An Interprofessionally
Achieved Goal
The following excerpt is drawn from the problem-presentation phase of the
visit, where patients are typically treated as the epistemic authority having
access to the relevant knowledge (e.g., symptoms, medical history). We show
how, through an interprofessionally accomplished interactive sequence that we
call a “pivot sequence” (see Caronia et al. 2020, 2022a), the professional edu-
cator and the physician cope with the “maximizing understanding versus allo-
cating agency” tension by constituting the UFM patient as a ratified participant,
that is, a participant in the conversation who is clearly addressed by the speaker
and who is expected to take on the speaker role.
What follows is an example of the “pivot sequence,” which is composed of
three interactional moves: (1) the physician’s “oscillatingly addressed ques-
tion,” that is, a question characterized by the simultaneous or in-quick-­
succession use of different and/or inconsistent resources for next speaker
selection, (2) the “pivot move” by the educator, that is, a multimodal contribu-
tion through which the educator constructs the UFM as the physician’s
responder, and (3) the participants’ (re)orientation to the UFM as the physi-
cian’s responder (Fig. 14.1).

Example 14.1 Malik4 (03.14–03.18)

D = Physician; E = Educator; P = Patient (Malik, 18 years old)

In line 1, D asks for the reasons for the visit by means of a yes/no question,
which displays the physician’s orientation to the patient’s low competence in
the language of the visit. Indeed, properly answering this type of question
requires less linguistic competence than required by open-ended questions. P
is also selected through another feature of turn design: lexical choice. The use
of the second person singular form of the verb (“are you,” line 1) and the lexi-
cal item “problem” (the Italian problema is a very common term, part of the
basic lexicon) concur with question format in constructing P as D’s addressee
despite P’s low linguistic competence.
However, D concurrently looks at the documents held by E (line 2, see
Fig. 14.2) and then directly at E (line 3, Fig. 14.3). In this way, E is also
selected as the physician’s addressee. Note that D’s gaze direction toward E at
the end of the turn is considered to further stress who is the selected next
speaker. Through this oscillatingly addressed question, D treats both E and P
as addressees of his question, while prioritizing the educator as the respondent.

4
For privacy reasons, all names have been fictionalized and likenesses blurred.
240 L. CARONIA AND F. RANZANI

Fig. 14.1 Excerpt 1: Problem-presentation phase

Fig. 14.2 D looks at the documents held by E

Yet, E withholds answering D’s question and, after making brief eye contact
with him (line 4, Fig. 14.3), he visibly turns his head toward P (line 5,
Fig. 14.4). In doing so, E makes a “pivot move”: he (re)directs the physician’s
question to P, selecting him as the next speaker. In the following turn, D aligns
with E’s multimodal construction of P as the responder: D looks at P too, thus
unambiguously constituting him as the next speaker (line 6, Fig. 14.5). Then,
P positively answers D’s yes/no question (“yes,” line 7) and provides the rea-
son for his visit (“my eye itches,” line 7).
By cooperatively constituting P as the ratified respondent, D and E observ-
ably act as a team: they synergically mobilize micro-communicative resources
 14 THE INTERPROFESSIONAL TEAM AS AN EMERGENT STRUCTURE… 241

Fig. 14.3 D looks at E, E looks at D

Fig. 14.4 E visibly turns toward P

that reorient the participants toward the attribution of agency to P while ensur-
ing the effective exchange of relevant information. In other words, both pro-
fessionals step back from exclusively pursuing their respective primary
institutional goals; rather, they interactionally attune to the other profession-
al’s stance.
242 L. CARONIA AND F. RANZANI

Fig. 14.5 D stops looking at E and looks at P

The next example shows how the “maximizing understanding versus allo-
cating agency” dilemma is dealt with during the treatment-recommendation
phase, where the physician’s epistemic authority typically prevails. We show
that in this phase, both care professionals seem more oriented to ensuring the
full comprehension of information by momentarily treating the patient as an
unratified participant, that is, a participant who, despite being present and
despite being the subject of the talk, is treated as a mere bystander (Fig. 14.6).

Example 14.2: Malik (6.46–7.15)

D = Physician; E = Educator; P = Patient

We join the conversation when D proffers the treatment recommendation,

that is, using eye drops twice a day. From line 1 to line 3, D clearly addresses P
by using the second person singular (“I am giving you,” line 1) and the gaze
direction (line 3, Fig. 14.7). This means D addresses P as the ratified interlocu-
tor. Yet, D continues describing the treatment procedure by shifting addressiv-
ity: he looks only at the educator (lines 4, 7, 9, 10, see Fig. 14.8; alternatively,
he looks at the computer, lines 6 and 7), refers to the co-present patient in the
third person singular (“he puts an ophthalmic ointment,” line 7, “he drop a bit
of ointment,” line 10), and uses technical jargon (“ophthalmic ointment,” line
7). In so doing, D seems more oriented to prioritizing that treatment informa-
tion is clearly understood by E. Importantly, note that E aligns with him being
selected as the sole addressee of D’s talk by repeating part of the procedure
(line 5), looking at D (line 5), and by displaying his understanding (line 11).
 14 THE INTERPROFESSIONAL TEAM AS AN EMERGENT STRUCTURE… 243

Fig. 14.6 Excerpt 2: Treatment/Recommendation phase

Fig. 14.7 D looks at P

244 L. CARONIA AND F. RANZANI

Fig. 14.8 D looks at E

Fig. 14.9 D looks at E

Contrary to Example 14.1, here E does not (re)direct D’s talk toward P, thereby
momentarily constituting P as an unratified participant. In this way, D and E
observably cooperate to ensure that relevant information is successfully
exchanged even if this means locally excluding the patient from the ongoing
talk and, therefore, not interactionally acknowledging his agency (Fig. 14.9).
In the next section, we discuss the possible reasons why, and outline the
communicative resources whereby the two care professionals differently but
 14 THE INTERPROFESSIONAL TEAM AS AN EMERGENT STRUCTURE… 245

cooperatively work to navigate the “maximizing understanding versus enhanc-

ing agency” dilemma throughout the different phases of the visit.

Discussion: Interprofessional Attunement as a Way

of Working Together

As the examples illustrate, the two professionals work differently but coopera-
tively to navigate the “maximizing understanding versus enhancing agency”
dilemma throughout the different phases of the visit. While the doctor appears
to be more (yet by no means exclusively) oriented to maximizing efficacy in the
information exchange, the educator appears to be oriented to enhancing the
patient’s agency whenever this goal does not compromise understanding. Far
from causing struggles in interaction, these different orientations (arguably
related to the professionals’ different institutional mandates and professional
knowledges) produce an observable dialectical tension between connection
and professional autonomy, which amounts to producing a balance among the
different stances at stake: neither pursues only his primary goal and both take
into account and are responsive to the other professional’s stance. We call this
way of working together interprofessional attunement.

Callout 14.2 Interprofessional Attunement

We define “interprofessional attunement” as a way of interacting whereby
different professionals cooperatively work together by taking into account
and being responsive to the specialized expertise and institutional agenda
of the other co-present professional. Rather than exclusively pursuing
their primary professional goal, interprofessional attunement entails the
work of interactional monitoring and synchronization to the other prac-
titioner’s specific professional mandate. We consider this work of ongo-
ing reciprocal adjustment to each other’s professional culture as a local,
interactive accomplishment, that is, something that the professionals do
in the interaction through a set of synergically mobilized communicative
resources (e.g., lexical choice, gaze direction, gestures). This interaction-
ally accomplished work of “interprofessional attunement” allows the par-
ticipants to act as a team.

Example 14.1 perfectly illustrates how, even where a hierarchy of profes-

sional expertise is at stake, professionals orient to each other’s expert stance and
therefore succeed in balancing the incompatible goals at stake when taking care
of linguistically (locally) impaired patients: “allocating agency” versus “maxi-
mizing understanding.” The educator who, in this setting, is in the inferior
epistemic position, can reorient the structure of participation (see the pivot
move, Example 14.1, line 5) thanks to his professional competence. Yet the
doctor is also open to pursuing the “allocating agency” pole of the dilemma
246 L. CARONIA AND F. RANZANI

(see the oscillating addressivity move, Example 14.1, line 1), and displays his
alignment5 with the educator’s newly established structure of participation (see
Example 14.1, line 6).
We consider these moves as communicative practices available to partici-
pants that can be exploited in similar circumstances. The communicative
resources used to accomplish these practices are various. Consider first the
“oscillating addressivity” practice. Lexical choice (e.g., the use of personal pro-
nouns), gaze direction, and body movements are mobilized by the doctor to
open up the field of addressivity and include both of the other interlocutors:
the patient who is the “epistemic authority” on his symptoms, clinical history,
and reasons for the visit, and the co-present educator, who has the linguistic
means to efficiently transfer that knowledge. While prioritizing the educator as
respondent—and therefore displaying his orientation to efficiency in informa-
tion gathering—the doctor still appears sensitive to the “patient agency” pole.
Consider now the “pivot move” practice: by skillfully exploiting the fissure of
the doctor’s oscillating addressivity, the educator withdraws his role of respon-
dent and passes it to the patient. Here too the resources are multimodal.
Although the example reports only bodily resources (see Example 14.1, line
5), linguistic resources are also at stake, such as formulating the doctor’s ques-
tion as if it were straightforwardly directed to the patient, translating words
from technical jargon to everyday language, or clarifying potentially ambigu-
ous terms (see Caronia et al. 2020, 2022b).
However, and as Example 14.2 illustrates, a kind of interprofessional coor-
dination is also at stake when the doctor does not address the patient as the
ratified interlocutor at all. As we have seen, the educator aligns with the struc-
ture of participation projected by the doctor, that is, he accepts and supports
the activity of momentarily excluding the patient from the interaction and
accepts being the sole ratified addressee of the physician’s talk. Concurrently,
the educator downgrades his professional mandate of enhancing the UFM’s
agency. In this case, the dilemma is cooperatively resolved by locally prioritiz-
ing full understanding over orienting to the patient-centered framework. Why?
Can we consider this common case as a kind of interprofessional collaboration
or is it a specimen of the typical subordination of low-ranked professional
knowledge (e.g., education) and related priorities to high-ranked expertise
(e.g., biomedical knowledge) and agenda? To answer this question, it is worth
noticing that these apparently contradictory stances by the educator are not
fortuitous; rather, they appear to be consistent with the phase-specific relevance
of the patient’s epistemic status, and the degree of linguistic competence neces-
sary to actively participate within each phase.

5
By alignment, we mean that a participant displays their acceptance of the communicative role
projected and/or the activity undertaken by their interlocutor. For instance, in this case, the doctor
shows he accepts addressing the patient as his primary addressee, which is the structure of partici-
pation the educator oriented to immediately before.
 14 THE INTERPROFESSIONAL TEAM AS AN EMERGENT STRUCTURE… 247

Callout 14.3 Epistemic Status

The notion of “epistemic status” refers to what information is known,
how it is known, and the persons’ rights and responsibilities to know it
(Heritage 2012a, b). For example, physicians are socially entitled to pos-
sess biomedical expert knowledge and are expected to manage this kind
of knowledge better than the patient. They are the “epistemic authority”
on this territory of knowledge. The notion of “epistemic authority” refers
to who, in an interaction, is entitled, socially expected to be, and interac-
tively recognized as the one who knows best within a defined territory of
knowledge. However, participants position themselves toward their epis-
temic status, aligning or not to what is socially expected: they can claim
more or less knowledge than expected, reject the epistemic status pro-
jected in the course of interaction, or claim to possess a kind of knowl-
edge they are not entitled to possess. For example, patients may adopt a
stance that claims a greater knowledge regarding their diagnosis than
their layperson’s epistemic status would indicate. The notion of “epis-
temic stance” refers to the moment-by-moment expression of relative
knowledge. Related to the notion of epistemic status and authority is the
notion of “epistemic asymmetry.” It refers to the unequal distribution of
relevant knowledge between doctors and patients, where patients’ first-­
hand, experiential knowledge is ordinarily inspected and assessed by the
doctor who holds biomedical expert knowledge. Epistemic asymmetry is
strictly related to the issue of medical dominance and power.

Rather than pursuing patient agency as if it were unconditionally the right

thing to do to be patient-centered, the educator evaluates its local appropriate-
ness at that moment in the interaction. In the first phase of the visit, where the
patient is the epistemic authority regarding his clinical history and reasons for
the visits and can communicate with a few words (e.g., yes or no answers) and
some gestures, the educator works to maximize the patient’s agency and makes
the doctor align with his own professional mandate. On the contrary, in the
second phase of the visit—where the crucial issue at stake is the understanding
of the diagnosis and treatment recommendations—the educator aligns with
the physician’s attempt to maximize understanding of clinical information, col-
laborates in pursuing this phase-specific goal, and locally downgrades his pro-
fessional agenda.
Through an ongoing interlaced upgrading/downgrading of reciprocal pro-
fessional priorities and mandates, the educator and the doctor collaborate to
ensure full understanding (therefore necessarily excluding the patient from the
ongoing interaction) or to enhance the patient’s agency (therefore including
the patient in the ongoing talk) in ways sensitive to the local, phase-specific
goals and constraints of the encounter. We suggest that it is precisely because
of their respective and different overarching institutional goals and professional
248 L. CARONIA AND F. RANZANI

cultures as well as the reciprocal attunement of their different—and at times

opposite—institutional mandates and even models of communication that they
succeed in pursuing the incompatible goals of this kind of visit and accomplish
teamwork as an emergent structure of interprofessional care.

Concluding Remarks
Investigating observable interprofessional collaborative practices actually
deployed in healthcare encounters (Pullon et al. 2016; Fox et al. 2021) shows
how interprofessionality can be—and actually is—pursued and accomplished
through endogenous communicative resources regardless of professionals’
awareness. Our exploratory study sheds light on a way of working together that
we call “interprofessional attunement”: by being locally responsive to each
other’s moves and taking into account the constraints and possibilities set by
the specific phase of the visit, professionals work as a team and reach an out-
come (pursuing the incompatible goals of this kind of medical visit) that would
probably not be attained without engaging in this (possibly unintentional)
form of emergent interprofessional team-based care.
What appears to make the difference in providing effective and patient-­
centered care to UFM patients is less the flattening of interprofessional hierar-
chies as put forward by the so-called “clinical democracy” (see Long et al.
2006) than the professionals’ interactive coordination and respect for each spe-
cific domain of expertise as well as a moment-by-moment orientation to the
other professional’s communicatively displayed stance. This reciprocal orienta-
tion is not a vague attitude but the outcome of identifiable communicative
practices (such as the oscillating addressivity, the pivot move, the alignment to
the other professional’s stance) and communicative resources (e.g., recipient-­
designed lexical choice, gaze direction, body orientation).
We contend (and have empirically illustrated) that the necessary and suffi-
cient conditions to provide “interprofessional team-based care” are few: pro-
fessionals’ co-presence and the deployment of what we call “interprofessional
attunement.” If the first condition is system-based, policy-dependent, and
therefore professionals are not in control of it, the second condition is totally
in their hands. This is an important point. By making the case of interprofes-
sionally performed “ways of communicating” (e.g., distributing addressivity,
engaging in the “pivot move”), we advance that the resources for providing
“interprofessional team-based care” are already part of professionals’ commu-
nicative repertoire. Once made observable and recognizable through analysis,
they become formalizable, learnable, and transferable, that is, ways of commu-
nicating that transcend the here and now of the single case study and can be
reflectively adopted in similar workplaces and circumstances.
 14 THE INTERPROFESSIONAL TEAM AS AN EMERGENT STRUCTURE… 249

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 CHAPTER 15

Independent Mindedness, Patient Safety,

and Interprofessional Communication within
Rural Trauma Medicine Teams

Theodore A. Avtgis

Emergency medical situations are characterized by high stress and high-stakes

outcomes. Effective, accurate, and efficient information exchange between and
among team members can critically influence decision making and patient out-
comes (Avtgis et al. 2015). Examples of emergency medical situations include
specific episodes such as 911 calls, ambulatory interactions as well as other
communication exchanges associated with pre-hospital care. Pre-hospital care
refers to the medical care and processes that are engaged in before definitive
hospital care is administered in facilities that are equipped to deliver all neces-
sary required medical treatment. Variations in pre-hospital care team members’
organizational status, education, power, and control can impact how these pro-
fessionals work together in high-stress situations (Kanki 2019), influencing
patient safety and the number of medical errors. For example, a pre-hospital
healthcare team may include both emergency medical technicians and surgical
specialists. Although each contributes to effective patient treatment, each
member has markedly different roles, expectations, and organizational status,
which shape how they react and interact in the high-stress environment that is
trauma medicine. Thus, it can be conjectured that when people engage in deci-
sion making under conditions of pressure and stress, performance can be either
enhanced or hindered depending on the situational factors at hand (Starcke
and Brand 2012).
This chapter adopts an information transmission perspective of communica-
tion to examine interprofessional (IP) communication in emergency medical

T. A. Avtgis (*)
Department of Communication, Western Illinois University, Macomb, IL, USA
e-mail: [email protected]

© The Author(s) 2025 253

S. Fox et al. (eds.), Interprofessional Communication in Health and Social
Care, https://doi.org/10.1007/978-3-031-70106-1_15
254 T. A. AVTGIS

situations and, in particular, pre-hospital trauma team care in rural settings.

The chapter first outlines the contextual and situational challenges to IP com-
munication in this context. Next, crew resource management (CRM), an
approach to communication for reducing errors imported from the aviation
industry, is presented as a universally accepted participative model of decision-­
making in emergency trauma contexts. The communication practices associ-
ated with CRM are advocated by the theory of independent mindedness
(TIM). To illustrate these concepts, two vignettes are presented comparing
and contrasting high and low levels of independent mindedness and the impli-
cations for interprofessional communication.

Situational and Contextual Challenges

to Communication in Emergency Trauma Care

Effective communication has profound implications for emergency and trauma

medicine. In particular, timely, concise, and complete information exchange
often makes the difference between life and death for the patient. Insights from
the discipline of communication can help better understand and hopefully
improve decision making in such environments, such as how information is
communicated between various professionals during the treatment of the
patient and the patient hand-off process. In this section, I outline some com-
mon communication challenges in emergency trauma team care.
In a narrative review of decision making studies focused on clinical emergen-
cies between 1980–2015, Zavala et al. (2017) found six factors that influence
decision making in emergencies: organizational systems, workload, time pres-
sure, teamwork, individual factors, and case complexity. The authors concluded
that successful clinical outcomes require the development of “pathways” that
optimize decision making processes. Such efforts have long been advocated in
different forms such as in the standardization of information exchange to
increase the accuracy of information transmission (see, for example, Reason 1990).
However, the standard exchange of information needed in interprofessional
communication in pre-hospital care can be hindered by differences in profes-
sional and communication training and the knowledge base of the personnel
involved. To standardize emergency communication, the majority of pre-­
hospital personnel training and education in the United States has been based
upon Mosby’s Paramedic Textbook (Sanders et al. 2012). This particular training
approach advocates that information exchange be restricted to the SOAP sys-
tem. SOAP stands for subjective, objective, assessment, and plan: subjective
refers to elements that are self-reported by the patient, such as symptoms, past
history, and allergies; objective refers to information obtained by direct observa-
tion and examination by the responder, such as the patient’s vital signs; assess-
ment refers to the responder’s clinical impression; and plan involves their
proposed patient management. The SOAP system is believed to result in opti-
mal care delivery by paramedics because it is designed to reduce interference or
noise associated with factors such as power differences between the clinical
 15 INDEPENDENT MINDEDNESS, PATIENT SAFETY, AND INTERPROFESSIONAL… 255

personnel involved in pre-hospital care whose expertise and experience can

vary greatly (e.g., nurses, emergency care doctors, other specialists, etc.). For
example, consider the likely interactions between an emergency medicine phy-
sician and an EMT-Basic (emergency medical technician who receives minimal
training) who is limited in their skills and can only perform basic life support
functions, compared to the interactions between the same emergency medicine
physician and an EMT-Paramedic (who receives more training) who can pro-
vide oral and intravenous medication, monitor electrocardiograms, and per-
form tracheotomies, among other tasks. By utilizing tools such as SOAP, team
members can standardize their information exchange and diminish the poten-
tial impact of negative influences such as difficult past experiences, limited
training, and relational difficulties between team members.
Yet, despite the advantages of the SOAP system, Talbot and Bleetman
(2008) reported that only 19.4% of ambulance personnel in the U.S. receive
any formal training in the standardization of information exchange. Such
efforts need to be expanded to other first-responding professionals with a spe-
cific focus on the interprofessional communication involved in the pre-hospital
care arena. If implemented, such comprehensive interprofessional communica-
tion training could improve the accuracy of information exchange, increase
patient safety, and decrease overall risk and the chance of medical error.
Another challenge to pre-hospital interprofessional communication is medi-
cal errors occurring during hand-offs. Medical error is reported by some
researchers as being the third leading cause of death in the United States, with
over 251,000 medical error-related deaths occurring in U.S. hospitals annually
(Makary and Daniel 2016). Communication-related medical errors happen
when incorrect information is relayed between and among healthcare provid-
ers. In the pre-hospital treatment of any given patient, there are many patient
hand-offs where essential information needs to be relayed completely and con-
cisely. According to the Joint Commission Handbook (2005), the primary
objective of hand-off communication is to provide accurate information
regarding the patient’s treatment, services, current condition, and any recent
or anticipated changes in their status. In an environment replete with educa-
tional, power, status, and individual differences among healthcare providers,
many barriers can impede effective hand-off communication. Such barriers
need to be accounted for and mitigated to reduce errors related to ineffective
hand-off processes.
Communication is at the heart of the logistical and coordination functions
of any hand-off event (e.g., timing and sequencing of interventions; questions,
and responses). While dozens of studies examine healthcare team communica-
tion training and assessment (e.g., Hathaway et al. 2023) and interprofessional
communication in the hospital environment (e.g., Dean et al. 2016), research
that focuses on interprofessional communication during pre-hospital processes
and encounters is scarce. Problematic communication in pre-hospital treat-
ment can negatively impact subsequent intra- and inter-hospital treatment,
especially for trauma patients, due to the complexity and severity of their
256 T. A. AVTGIS

injuries and the possibility of an altered cognitive state (e.g., unconsciousness

or the influence of illegal drugs or alcohol). For example, when an EMT squad
transports a motorcycle accident victim, who is conscious but under the influ-
ence of alcohol or drugs, to a trauma facility that they have not visited before,
the unfamiliarity of the EMT squad member and the personnel at the receiving
facility can negatively influence communication. Lack of personal familiarity
and an incoherent patient create barriers to the effective exchange of critical
care information during the hand-off process.
Timeliness is another contextual challenge. In emergency care, the impor-
tance of efficient triage is predicated on the assumption of the “golden hour of
trauma.” Simply put, timely treatment is critical to survival rates (see, for exam-
ple, Kotwal et al. 2016). The timely delivery of healthcare is also dependent on
communication flow, efficiency, and quality of such information exchanges.
Therefore, efficient and accurate communication between and among prehos-
pital team members, regardless of role, power, or status (e.g., EMT-Basic,
emergency management operator, attending emergency room staff, etc.) is
critical if the team is to engage in efficient, effective triage.
The quality of triage is another contextual consideration. According to the
American College of Surgeons (2006), an estimated 5–10% of trauma patients
are under-triaged (i.e., patients are prioritized as being less injured than they
actually are) while 50% of trauma patients are over-triaged (i.e., patients are
prioritized as being more injured than they actually are). Accurate triage deter-
mination is essential as data indicates a 15–20% reduction in death rates for
otherwise under-triaged patients. Simply put, accuracy saves lives. On the other
hand, providers need to be careful stewards of fiscal and medical resources, as
avoiding over-triaging leads to significant financial and medical resource sav-
ings. A study of a regional hospital system (Newgard et al. 2013) revealed that
of the 248,342 low-risk patients (i.e., patients not requiring transport to a
definitive care trauma center) who were treated, 85,155 (34.3%) were still
transported, resulting in a 40% increase in the overall cost of patient care. It was
projected that the annual cost saving associated with addressing such over-­
triaging within this regional hospital system could have been approximately
136.7 million dollars. Other studies have indicated similar results (Cremonesi
et al. 2015; Jurkovich and Mock 1999).
The geographical context in which trauma occurs also impacts patient out-
comes in emergencies. Factors such as population density, weather conditions,
quality of transportation and communication infrastructure, resource availabil-
ity, and distance to professional or institutional resources can impact trauma
victims’ access to care (Esposito et al. 1995), sometimes resulting in delays in
the initial reporting of injuries. Therefore, an injury considered routine in an
urban setting can turn out to be fatal in a rural setting where a healthcare facil-
ity is geographically distant and less equipped for such injury. This disparity
between rural and urban trauma response is further complicated by funding
gaps for both technology and training: There are more resources for urban
environments than rural ones. Several efforts targeting rural trauma medicine
 15 INDEPENDENT MINDEDNESS, PATIENT SAFETY, AND INTERPROFESSIONAL… 257

and interprofessional communication have revealed promising results for

increased patient safety. Such efforts include teaching mnemonic devices for
improved hand-off communication and the implementation of constructive
communication techniques (Avtgis and Polack 2010; Kappel et al. 2011).
As evidenced thus far, researchers are beginning to investigate the non-­
medical factors that contribute to both positive and negative outcomes of
patient care. One of the more comprehensive frameworks through which to
analyze error in high stakes and high-stress situations such as trauma medicine
is crew resource management.

Crew Resource Management

Crew resource management (CRM) is a functionalist, industrial training
approach that highlights the impact that team-related behaviors and attitudes
have on safety, performance, and the reduction of error (Helmreich et al. 2001;
O’Connor et al. 2008). The underlying assumption of CRM is that certain
communication and coordination behaviors are effective for teams that work in
high-stakes environments (e.g., emergency response medical teams) and that
these behaviors are identifiable, teachable, and generally applicable. These
behaviors, which are initially unstandardized (i.e., taken-for-granted assump-
tions), become established protocol through education, training, and rein-
forcement (Morey et al. 2002).
Within health care specifically, CRM allows interprofessional collaborators
to analyze and develop processes and procedures that either directly or indi-
rectly reduce the number of sentinel events (i.e., events that lead to death).
One such effort focusing on vital information exchange during trauma patient
treatment was conducted by Avtgis et al. (2015). The researchers developed
and tested the MISER tool specifically for rural settings, where the acronym
MISER stands for mechanism of injury; injury to the patient; vital signs of the
patient; environment in which the trauma occurred (e.g., all-terrain vehicle
accident, hunting, or coal mine); and patient response to treatment. This rural-­
centric acronym accounts for the impact of prolonged exposure to environ-
mental elements that are not usually encountered in urban settings but that can
result in complications and require modifications to the treatment protocol.
Most organizational structures, especially healthcare structures, have some
degree of hierarchical power arrangement that directly affects the type, amount,
and perceived relative value of any communication or information exchange
between organizational members. When faced with the chaotic, time-­dependent
nature of health care in general, and emergency-related health care specifically,
such hierarchy can not only hinder positive outcomes but actively contribute to
negative outcomes (see Chap. 8). Hence, CRM emphasizes functionality over
hierarchy. That is, CRM focuses on what works best as opposed to operating
through any official bureaucratic or organizationally prescribed structure.
Another key CRM assumption is that any barrier to effective communication
should be mitigated or at least identified for future analysis and remediation.
258 T. A. AVTGIS

Efforts to implement CRM also take into account the broader cultural con-
text within which the medical team operates. For example, Western cultures
tend to value individual expression and self-validation. As such, communica-
tion training, regardless of the specific organizational and healthcare context or
profession in which it is applied, should follow suit in design and implementa-
tion. For example, training should validate and encourage voice, or the ability
to express one’s point of view, by organizational members who may otherwise
be marginalized or ignored. Consider an EMT who provides information that
is not specifically requested by the attending ER physician. In a situation that
validates and encourages interprofessional voice, such information would be
accepted as a valuable part of the hand-off process. This is consistent with the
conceptualization of interprofessional communication (Kreps 2016; see Chap.
2) and the interprofessional core competencies (IPEC 2011) that consider the
ability to voice one’s contribution as a key communication competency.
CRM contends that the key to reducing errors is collective situational aware-
ness, comprised of self- and other-awareness (Endsley 1999). In other words,
increasing each healthcare team member’s recognition of their emotional state
and awareness of others and the group dynamic helps to create and maintain
productive and meaningful communication (Wood 2008). Both are critical to
message exchange among team members who differ in their institutional
power, expertise, and relational history. For example, consider an exchange
between a newly certified emergency medical technician and a seasoned surgi-
cal nurse: each professional’s expectations about communication, information
exchange, and the protocols associated with each role can vary greatly and be
further impacted by their organizational, social, and professional experiences.
In other words, communication exchanges are constrained by as well as help
create the constraints within which team members function, such as the
profession-­specific mental models that shape perceptions of events and the time
constraints that influence professionals’ performance of their roles. As such,
successful communication requires a situational awareness of such constraints.
Yet, a limitation of CRM is that it may not function effectively if entrenched
communication patterns reduce interprofessional team members’ ability to
work with each other. For example, a doctor who does not seem particularly
aware of others’ contributions and interacts aggressively with nurses, personal
care attendants, social workers, and the hospital’s cleaning staff will not encour-
age others to express their opinions. The theory of independent mindedness or
TIM (Infante and Gorden 1987) allows us to consider how communication
predispositions (a person’s general tendency to engage in specific types of ver-
bal and nonverbal behaviors when interacting with others) influence CRM and
thus healthcare team efficacy and patient safety. TIM specifically focuses on the
role that communication traits such as verbal aggressiveness, argumentative-
ness, and communicator style play in the interaction of healthcare team work-
ers at all levels of the organizational hierarchy (Rossi et al. 2009).
Given that physical and verbal aggression is well-documented as an impedi-
ment to quality healthcare delivery both in the United States (Gormley et al.
 15 INDEPENDENT MINDEDNESS, PATIENT SAFETY, AND INTERPROFESSIONAL… 259

2016; Schnapp et al. 2016) and internationally (Jenkins et al. 1998; Partridge
and Afflect 2017), understanding destructive behavior is critical. For example,
in studies of emergency medicine residents, 90% reported being the target of
verbal abuse and harassment (e.g., Schnapp et al. 2016). Such astonishing rates
of aggressive communication and its deleterious outcomes must be addressed
from a theoretically grounded perspective to provide a comprehensive explana-
tion and development of effective intervention management strategies. I turn
now to a more in-depth explanation of TIM.

Theory of Independent Mindedness

The theory of independent mindedness is an organizational communication
theory in the neopositivist and functionalist tradition that seeks to promote
employee voice (i.e., positive perceptions of being able to express oneself) at all
levels of the organization while respecting the Western cultural norm of hierar-
chical structure (Infante and Gorden 1987). To be independent minded is to
have the ability and opportunity to openly advocate and express one’s opinions
and voice in situationally appropriate and effective ways. Such open expression
is often thwarted in hierarchical structures common in Western culture-based
healthcare organizations, yet Western healthcare systems could benefit from
efforts to encourage the appreciation and practice of voice expression at all lev-
els. As such, the application of the TIM to the healthcare arena can serve as an
effective explanatory and predictive tool for evaluating health-related outcomes
(Callout 15.1).

Callout 15.1 The Theory of Independent Mindedness

The theory of independent mindedness (TIM) is an organizational com-
munication theory that emphasizes the importance of fostering employee
voice (i.e., team members voicing their concerns) within hierarchical
organizational structures, in ways that resonate with broader cultural
norms, such as the freedom of expression in Western contexts.
Independent mindedness enables professionals to express themselves
openly and advocate for their point of view. Independent mindedness
exists on a continuum and involves three types of communication behav-
iors: argumentativeness, verbal aggressiveness, and communicator style.
Argumentativeness refers to the ability to articulate and defend a specific
position on controversial issues while attempting to refute the positions
that others take on those issues (e.g., “This medication can cause
unwanted side effects, so we need to explore other options like X or Y”).
Argumentativeness helps members of interprofessional teams speak up as
well as attend to the alternative perspectives of others. Verbal aggressive-
ness, by contrast, describes what happens when people engage in personal
attacks, rather than focusing on the arguments and counterarguments
presented. Verbal aggressiveness can take many forms: criticizing others’

(continued)
260 T. A. AVTGIS

Callout 15.1  (continued)
abilities or professionalism (e.g., “I don’t know where you did your
training, but it’s obvious you learned nothing there”), threats (e.g., “If
you don’t help me get this heavy patient in the chair right now, I’ll let the
charge nurse know that you were late arriving to your shift today”), and
nonverbal aggression (e.g., shaking a fist). Verbal aggressiveness reduces
employees’ willingness to express divergent opinions. According to the
TIM, communicator style, or how the traits of argumentativeness and ver-
bal aggressiveness are displayed, explains how a person uses verbal and
nonverbal behaviors to relay to others how what they are saying or doing
should be interpreted.

By focusing on the modification of argumentative and aggressive communi-

cation predispositions (i.e., enduring communication traits that transcend situ-
ations yet that can be altered through skill development and training), the
theory of independent mindedness has been empirically tested and supported
by organizational research primarily in the United States (Avtgis and Chory
2010). Within health care, scholars have identified triggering agents that can
lead to escalating verbal and physical aggression (Avtgis and Madlock 2008).
Triggering agents include healthcare professionals’ exhaustion and stress,
patient distrust, patients who view themselves as consumers, and interaction
with the American managed care system (i.e., coordinated activities designed
to reduce the cost of providing health care while improving the delivery of that
care). The use of aggressive communication is so prevalent that healthcare sys-
tems throughout the United States provide explicit “codes of conduct” for
both patients and providers that identify both constructive and destructive
forms of aggressive communication. Codes specify which verbal and nonverbal
behaviors are acceptable and which verbal and nonverbal behaviors are prohib-
ited within the healthcare facility. Some examples of unacceptable messages
include threats, profanity, maledictions, and defamatory language.
The theory of independent mindedness is based on two communication
predispositions: argumentativeness (Infante and Rancer 1982) and verbal
aggressiveness (Infante and Wigley III 1986). Argumentativeness is the predis-
position to advocate one’s positions on controversial issues while simultane-
ously refuting the positions that others take on those issues. This communication
trait is thought to be constructive (see Rancer and Avtgis 2014). That is, the
ability to formulate, advocate, and engage in issue-focused communication is a
valued characteristic associated with competent communication as it allows for
perspective-taking (e.g., considering the arguments/counter-arguments of the
other person) and conversational sensitivity when interacting with others. On
the other hand, verbal aggressiveness is a trait focused on attacking the self-­
concept of another person instead of, or in addition to, the positions they take
on controversial issues. Unlike argumentativeness, verbal aggressiveness is
 15 INDEPENDENT MINDEDNESS, PATIENT SAFETY, AND INTERPROFESSIONAL… 261

destructive because the communicator acts purposefully to inflict psychological

harm through attacks on the other person’s self-concept or self-esteem. Such
verbal attacks are perceived negatively and associated with incompetent
communication.
The theory of independent mindedness proposes that communicator style
(Norton 1978) moderates the two communication traits (i.e., argumentative-
ness and verbal aggressiveness) and thus determines whether or not communi-
cation fosters independent mindedness.
Communicator style, or how the traits of argumentativeness and verbal
aggressiveness are displayed, explains how a person uses verbal and nonverbal
behaviors that relay to the other person how literal meaning should be “taken,
interpreted, filtered, or understood” (Norton 1978, 99). Such exchanges are
the means through which communication can be seen as either successful (i.e.,
effective and appropriate) or unsuccessful (i.e., ineffective and inappropriate)
(Callout 15.2).

Callout 15.2 Affirming and Non-affirming Communicator Styles

An affirming communicator style is a way of communicating that serves
to validate the face, or self-concept, of another person. It involves express-
ing opinions and feedback in a supportive and positive manner, contrib-
uting to constructive dialogue, and fostering mutual respect and
understanding. This can be displayed by listening attentively, seeking to
understand the information or perspective that the other person is shar-
ing, or asking clarifying questions. An affirming style is generally associ-
ated with greater satisfaction at work, better supervisor and peer
relationships, longer job tenure, positive ways of expressing dissent, and
higher levels of situational awareness. A non-affirming communicator
style is a way of communicating that threatens the face or self-concept of
another person. It involves expressing opinions and feedback in a defen-
sive or negative manner, potentially hindering constructive dialogue, and
leading to conflict or misunderstanding, for instance, by being confron-
tational or insisting on taking control of the situation. A non-affirming
style has been linked with increased medical error in healthcare settings
and lower quality team relationships.

There are two main communicator styles: affirming (i.e., communicating in

ways that validate the face or self-concept of the other) and non-affirming (i.e.,
communicating in ways that threaten the face or self-concept of the other).
Being argumentative in a socially supportive, affirming way may be perceived
very differently than being argumentative in a defensive, non-affirming way.
Indeed, empirical research in contexts of healthcare collaboration has con-
firmed the positive and pro-social outcomes associated with an affirming com-
municator style and the negative social outcomes associated with a non-affirming
communicator style at all hierarchical levels within healthcare organizations
262 T. A. AVTGIS

(Buller and Buller 1987; Charlton et al. 2008; Coeling and Cukr 2000). For
instance, consider a surgical nurse who suggests to a surgeon that a particular
protocol needs to be revisited due to some potentially dangerous error-related
factors observed during the last procedure. By framing these arguments as a
way to reduce team-based error, contribute to quality improvement, and
enhance patient care, and doing so with an affirming communication style, the
suggestion will likely be better received than if it were presented as a complaint
or possible whistleblowing event and using a non-affirming communication
style. Another example can be found in the communication between an expe-
rienced surgical ward nurse and a surgical resident where both individuals have
unique specialty training, roles, power, and behavioral expectations. An affirm-
ing communication style may take the form of de-emphasizing the fact that
one professional has more years of experience than the other and emphasizing
the fact that they both are there to work toward optimal patient care. On the
other hand, the non-affirming communication style might hammer home the
greater power, authority, and control of the resident, power that is not only
officially given by the organization, but routinized and embedded within each
communication exchange.
Independent mindedness can be understood on a continuum. At one end is
full independent mindedness, where interprofessional collaborators communi-
cate in ways that are low in verbal aggression, high in argumentiveness, and
expressed using an affirming communicator style. This level of independent
mindedness is characterized by an acute awareness of situational factors regard-
ing what is deemed effective and appropriate. This normative interaction style
relies on critical thinking, empathy, assertiveness, and a high degree of indi-
vidual and shared communication competence (see Chap. 10). All of these
attributes have some skill-based component and, as such, are malleable and
thus teachable. On the other end of the continuum is a complete absence of
independent mindedness, which is indicative of communication patterns that
are high in verbal aggression and low in argumentativeness, and expressed
using a non-affirming communicator style. This level of independent minded-
ness is characterized by an inability to identify or a disregard for situational
factors regarding what is effective and appropriate communication behavior.
This normative interaction style is characterized by self-focusedness, aggres-
siveness, and a low degree of individual communication competence. All of
these attributes, similar to full independent mindedness, are the result of learn-
ing and socialization, and can be modified.
Positive organizational outcomes, such as greater satisfaction with work,
better supervisor and peer relationships, longer job tenure, use of articulated
dissent, and situational awareness are associated with independent-minded
communication within organizations at large, and in particular, healthcare
organizations. Indeed, the theory of independent mindedness can be used to
develop training and best practices to reduce error during the high-stakes
intensity of interprofessional communication exchanges in emergency and crit-
ical situations, including pre-hospital trauma care.
 15 INDEPENDENT MINDEDNESS, PATIENT SAFETY, AND INTERPROFESSIONAL… 263

The Theory of Independent Mindedness in Practice

The following two scenarios illustrate the socialization (i.e., onboarding) of a
newly hired EMT. The first scenario highlights the messages that create a cli-
mate that devalues voice and thus, induces the absence of independent mind-
edness. The second scenario illustrates communication patterns that foster and
develop independent-minded and team-oriented communication. Pay special
attention to the meta-messages (i.e., messages about the messages) being sent
by Darren to Elaine.

Scenario 1: It Is Better to Be Unseen and Unheard: Low Probability

of Fostering Independent Minded Communication
Elaine was an eager, young, newly certified emergency medicine technician at
the basic level (EMT-Basic). As part of her new position, she was partnered
with a long-time and senior-level employee, Darren, an EMT-Paramedic, who
served as an Army medic during the US-Iraq conflict in the 2000s. Darren,
having over ten years of experience on the job, was a bit jaded and was experi-
encing symptoms of employee burnout (i.e., feelings of overwhelming exhaus-
tion, anger, and cynicism associated with work). Throughout her onboarding
process as a member of the ambulatory team, Elaine was told to listen closely
to Darren as he knew how to be successful and how to “last” in the business.
Darren said to Elaine, “I have a couple of golden rules that have served me
well in my years here. First, ‘Speak when spoken to.’ Doctors don’t respect us
and they treat us as if we were idiots, so I simply don’t give them the opportu-
nity to do it. Second, ‘Stay out of the way.’ When we enter the facility with the
patient, just do your job and get out as soon as you can. When in doubt, get in
and get out. Deliver and go is what I say. When we hang around, we talk, and
when we talk, we get into trouble. The only thing better than being seen and
not heard is not being seen and not being heard. Finally, ‘Don’t become part of
the problem.’ We are at the bottom of the emergency care food chain. While we
are important, it is ‘those guys’ who make the decisions and it is those guys
who are on the hook for those decisions.”
In this scenario, we can repeatedly hear the warnings that Darren communi-
cates to Elaine. Do not speak up, express your voice, or contribute to anything
other than satisfying the most basic of communication requirements. Further,
it becomes clear that Darren has a rather skewed view of the other professionals
involved in the emergency medicine process by, among other things, speaking
of the condescending tone of the doctors and referring to the rest of the inter-
professional medical team in an objectifying way as “they.” These types of mes-
sages are all indicative of the patterns that create, re-create, and concretize
cultures of low independent-mindedness and, thus, ineffective interprofes-
sional communication.
264 T. A. AVTGIS

Scenario 2: It Is Better to Be Seen and Heard: High Probability

of Fostering Independent Minded Communication
Elaine was an eager young newly certified Emergency Medicine Technician at
the basic level (EMT-Basic). As part of her new position, she was partnered
with a long-time and senior level employee, Darren, an EMT-paramedic, who
served as an Army medic during the US-Iraq conflict in the 2000s. Darren,
having over 10 years of experience on the job, embodied the essence of a team
manager with a participatory philosophy that was predicated on open, timely,
and relevant (OTR) communication. He endearingly referred to his approach
as his OTR philosophy. Right from the start, Darren reinforced the concept of
situational awareness to Elaine with an emphasis on the importance of both
speaking up and listening well. Being part of the larger healthcare community
and emergency response system, Darren sought to transmit the following
basic tenets to Elaine: “First, ‘Intelligence exists at every level of the healthcare
encounter.’ This includes the patient and everyone involved in the patient’s
care. What you see as a first-responding EMT is something that is not wit-
nessed by the attending ER doctors and nurses or anyone else for that matter.
Therefore, you are the eyes, ears, AND mouth for such witnessing. Second,
‘See something, feel something, say something.’ What this means is that some of
the most non-­ obvious symptoms and/or ‘facts’ may be equally or more
important than the obvious facts. Third, ‘Relevance is in the eye of the beholder.’
If you believe something to be relevant, relay that information to other people
on the healthcare team and let them do what they will with that information.
Finally, ‘Display respect and professionalism for everyone in the healthcare
encounter.’ This includes everyone from the patient on up to the highest rank-
ing member of the emergency care team.” Darren concludes the conversation
with Elaine by saying, “Kindness, respect, and professionalism may not directly
save a life, but lack of kindness, respect, and professionalism may contribute to
the loss of a life.”
As these two scenarios illustrate, the way members of an interprofessional
healthcare team are socialized to use their voice and the agency they perceive
they have over how and when to use their voice can have a significant impact
on the quality and success of interprofessional communication. As the practice
of independent-minded communication becomes institutionalized, so too do
the benefits of such practice on both the healthcare team and each individual
on that team. In addition to reducing medical error, independent minded
communication has been shown to lead to lower employee turnover, less burn-
out, and better quality interprofessional relationships. As such, communication
skills training needs to be a critical component of healthcare team onboarding
and professional development.
 15 INDEPENDENT MINDEDNESS, PATIENT SAFETY, AND INTERPROFESSIONAL… 265

Independent Minded Communication

and Interprofessional Communication:
Future Directions
Funding for research in the field of emergency medicine has generally targeted
technologies that boost patient safety and reduce response times at the expense
of studies that focus on interprofessional communication. Examples include
implementing synchronous video technology between first responders and
receiving medical facility personnel (Doheny-Farina et al. 2003) and circum-
venting local medical care instead of direct patient transport to designated
trauma centers (Young et al. 1998). These studies highlight the importance of
streamlining prehospital trauma care procedures and processes, especially dur-
ing trauma patient transfers.
However, improving patient outcomes also requires researchers to pay
attention to healthcare teams’ communication skills in general, and their inter-
professional communication skills in particular. A team culture characterized by
independent mindedness and situational awareness correlates with reduced
trauma transfer times which, as evidenced in this chapter, is a critical factor in
determining mortality rates. Both independent mindedness and situational
awareness are more likely when teams use communication interventions that
reduce the authority gradient embedded within healthcare contexts and
encourage all members of the interprofessional trauma team to express them-
selves concisely and precisely (e.g., crew resource management approaches like
the SOAP system or the MISER tool).
Although this chapter focused on improving interprofessional communica-
tion within rural trauma teams, such efforts can easily be adapted to bring
about independent mindedness, situational awareness, organizational cultural
change, and overall team efficiency in a wide range of healthcare contexts (e.g.,
rehabilitative, palliative, and hospice care). As healthcare researchers and prac-
titioners continue to investigate the situational factors associated with effective
interprofessional communication, they need to develop, adopt, and assess other
communication protocols in a continual quality control process to achieve the
ultimate goals of patient safety, reduced error, and competent interprofessional
communication. The path forward is abundantly clear should we choose to
follow it.

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 CHAPTER 16

Reflections on Future Directions

Stephanie Fox, Leena Mikkola, and Kirstie McAllum

Knowledge about interprofessional practice has grown immensely over the past
thirty years (Schot et al. 2020; Reeves et al. 2010; McNaughton et al. 2021;
Rawlinson et al. 2021). Yet, theorizing about interprofessional communication
has been limited. Our goal with this book was therefore to go beyond the con-
ventionally accepted yet conceptually limited wisdom of claiming that “good”
or “competent” communication is an essential “component” of effective inter-
professional collaboration. We wanted instead to explore and explain how com-
munication shapes, facilitates, constrains, and constitutes the various practices
of interprofessional working together. We also argue that collaboration hap-
pens in and through communication.
To this end, we presented and discussed three different approaches to
understanding communication. Two of these approaches were likely fairly
familiar to readers from the health and social care professions, namely the
transmission model, which views communication as the exchange of informa-
tion, and the transactional model, which considers the influence of the context

S. Fox (*)
Département de communication (Department of Communication), Université de
Montréal, Montréal, QC, Canada
e-mail: [email protected]
L. Mikkola
Faculty of Information Technology and Comunication Sciences, Tampereen yliopisto
(Tampere University), Tampere, Finland
e-mail: [email protected]
K. McAllum
Department of Media and Communication, Te Whare Wānanga o Waitaha | the
University of Canterbury, Christchurch, New Zealand
e-mail: [email protected]

© The Author(s) 2025 271

S. Fox et al. (eds.), Interprofessional Communication in Health and Social
Care, https://doi.org/10.1007/978-3-031-70106-1_16
272 S. FOX ET AL.

in which communication occurs on how communicators relate to one another

and co-create meaning. However, the third—the constitutive approach to
interprofessional communication—was likely novel to many readers; it explains
how collaboration and other forms of working together are literally communi-
cated into existence: without communication, there can be no interprofessional
practice.
We also designed this book as a space for interdisciplinary dialogue. We
invited contributions from our colleagues in organizational, health, and inter-
personal communication as well as in management studies, and from interpro-
fessional education scholars and practitioners, specifically from nursing,
occupational therapy, and social work. Together, these authors explored how
communication influences interprofessional practices in contexts that range
from primary to intensive care and from small team dynamics to the integration
of care across organizations. Some contributors proposed new ways of theoriz-
ing interprofessional communication, thereby blowing open the conceptual lid
on interprofessional processes that are thought to be well understood, such as
the intractable professional hierarchy, notions of communication competence,
trust and role awareness, taken-for-granted similarities and differences across
professional cultures, and relational tensions inherent to collaborating across
boundaries. Other contributors demonstrated how patient- and family-­
centered care starts in communicative practices.
We also note the potential for dialogue between chapters: Concepts, tools,
and strategies evoked by one chapter could improve the care trajectory for
patients and contribute to a more meaningful experience of work for health
and social care professionals. For instance, cancer survivors (described in Chap.
13) might benefit from well-coordinated case management (as explained in
Chap. 11). Families struggling to navigate the complexity of the NICU (as
Chap. 12 documented) would be comforted by compassionate team- and
organizationally based practices (as laid out in Chap. 6). Teams that move flu-
idly between hierarchy and equality and those that have difficulty doing so (as
Chap. 8’s explanation of hierarchy, power, and status) could point out why
tensions exist by drawing upon the theory of relational dialectics (described in
Chap. 7). We hope that you see other links, too.
In addition to its usefulness for health and social care professionals and those
who research interprofessional collaboration, we hope that this book will find
its way into the hands of every person responsible for interprofessional educa-
tion–and their students. Indeed, the book was also designed as a pedagogical
and practical resource for interprofessional learners, teachers, mentors, practi-
tioners, and decision-makers. We strongly believe that learning about different
conceptualizations of communication, in particular the constitutive approach,
will enhance understanding of interprofessional collaboration. So far, the study
of interprofessional collaboration has been motivated by an understandable
desire to increase the effectiveness of interprofessional practices. However, this
has in turn translated into focusing on communicative effectiveness, an instru-
mental and (we would say) limited understanding of communication. Hence,
 16 REFLECTIONS ON FUTURE DIRECTIONS 273

the enormous potential that communication research has to offer the interpro-
fessional field has been largely bypassed. Yet understanding communication as
the origin of interprofessional collaboration, rather than a tool in its service,
offers new ways of seeing, defining, and understanding interprofessional situa-
tions. For instance, the very notion of effectiveness is turned on its head when
we think of communication as not (only) the transmission of information but
as meaning-making that is situated in our interactions.
Furthermore, we claim that is reductive to understand interprofessional
communication as an individual competence or skill that professionals learn
once and for all to carry with them in all future interactions (see Chap. 10).
Indeed, viewing competence in this individualistic manner can limit opportuni-
ties to learn and work together in satisfying ways. The constitutive approach
suggests that interprofessional communicating is an ongoing process that col-
laborators negotiate, are accountable for, and work on in every interaction.
From a constitutive perspective, “effective” communication is complex and
hard to measure, in part because meanings are constantly negotiated and
because context both informs and is informed by our interactions. In other
words, effectiveness is not a one-size-fits-all proposition.
Re-thinking interprofessional communication and interprofessional collabo-
ration in this way has far-reaching practical implications. It means that educa-
tors and professionals must resist seeing interprofessional communication as a
set of “soft skills” that can be easily learned through an optional workshop
during one’s studies. At worst, these skills are taught as patterns of behavior,
without theorizing them. Instead, we suggest that interprofessional communi-
cation is best grasped through problem- and practice-based learning—both as
part of mandatory curricula and as ongoing professional training—because
competences cannot be conceptually divorced from the contexts in which they
are made relevant. Similarly, building an applicable knowledge base about
interprofessional communication requires a deeper theoretical understanding
of this process that is so vital to interprofessional work.
We also recognize the enormous organizational hurdles faced by those who
coordinate interprofessional education activities across multiple professional
programs. We tip our hats to you! We hope the illustrative vignettes at the end
of most chapters will help you to show how communication theory can be used
to understand the challenges and successes of interprofessional collaboration
and teamwork. For the most part, the vignettes are open-ended: Practitioners
can identify issues, envisage possible courses of actions, and evaluate paths
(not) taken. As we close this book, we offer some thoughts about what future
research on interprofessional communicative practices could or should consider.

Thoughts on Future Directions

As health and social care has changed over the past two decades, interprofes-
sional practice has evolved as well, becoming an established feature in this ter-
rain. Interprofessional collaboration will undoubtedly continue to adapt as
274 S. FOX ET AL.

health and social care systems around the world face new and continuing chal-
lenges, such as austerity measures and budgetary constraints; technological
advances; staffing shortages; epidemiological challenges from demographic
shifts such as an aging population, increases in migration and refugee status
claims, and future health crises, to name just a few. These changes and chal-
lenges will call for new questions, new theories, and new research regarding
interprofessional communication. We foresee that observational studies will be
especially needed to tease out and understand the communication complexities
in this fluid interprofessional landscape.
One key area that we see for future research is interprofessional networking
practices (Chap. 1; see Reeves et al. 2018), a looser form of interprofessional
working together that requires communication across different contexts of
care. Networking can, for instance, involve inter-organizational collaboration
in order to integrate health, social care, and wellbeing services (see Chap. 4;
Karam et al. 2018). Such networking is becoming increasingly common in
countries such as Finland where systemic reforms to health and social care have
resulted in new organizational arrangements that require much greater integra-
tion of the contributions of various professionals, for instance, between schools
and pediatric healthcare providers (see Chap. 5). Despite its potential benefits,
such interprofessional networking can end up resembling a circus more than a
well-integrated collaborative effort; such initiatives take time and effort to
establish and they highlight issues of national- or state-level management and
political decision-making regarding health and social care. Countries and
regions experiencing rapid immigration, especially those welcoming large
numbers of refugees and asylum seekers, might also find themselves facing
multifactorial problems in care (see Chap. 3) that will require professionals
skilled in interprofessional communication, such as case managers (see Chap.
11), and even patient navigators (Wells et al. 2018; Kelly et al. 2019), to col-
lectively make sense of such problems across the care trajectory (see Chap. 13).
Important communication challenges to interprofessional networking include
awareness of professional and organizational roles (see Chap. 6), as responsibil-
ity for care may vary by jurisdiction or even become blurry.
Other contextual influences on interprofessional working together that
merit deeper consideration include space and time. For example, the design of
the built environment has a profound impact on the type and frequency of
interprofessional interactions that are possible (e.g., Dean et al. 2016; Trzpuc
and Martin 2011). Professionals may well wish to share information, ask ques-
tions, and create interpersonal bonds, but distance between workspaces or
walls that impede visual connection can make this far harder to do. Likewise,
interprofessional communication is also shaped, and sometimes warped, by
managerial and institutional pressures that constrain the time available for
interprofessional work. For instance, when a family physician is required to
maintain a very high patient roster, other collaborating professionals may feel
that every interaction they have with her is bothersome to her and that her time
is institutionally considered as more valuable than theirs (S. Fox et al. 2023).
 16 REFLECTIONS ON FUTURE DIRECTIONS 275

Therefore, prioritizing interprofessional communication requires careful think-

ing in the face of finite budgets, quality improvement initiatives, and time
pressures.
Moreover, the very experience of time can vary across collaborative situa-
tions (e.g., urgency in the Emergency Department versus contemplative reflec-
tion in palliative care), which can modulate the forms of interprofessional
practice and communication adopted (e.g., rushed yet structured information
exchange (see Chap. 15) versus collective pondering of a dying person’s wishes
as they make sense of the end of their life). This is obviously related to the
intention behind each instance of situated interprofessional interaction (e.g.,
rapidly informing others to ensure quality care and avoid error versus maximiz-
ing patient agency and voice; see Chaps. 3 and 14). Although the way that time
is experienced may fall outside of concerns about organizational and collabora-
tive efficiency, we may indeed find that it affects patient satisfaction and their
perception of quality care.
Patient participation in interprofessional communication is another area ripe
for deeper investigation. Interprofessional discourses often insist on the partici-
pation of patients and their families in interprofessional practice (e.g., CIHC
2010; IPEC 2023). However, A. Fox and Reeves (2015) noted a schism in the
research literature. On one hand, patient-centered discourses are most preva-
lent in research focused on patient-provider communication, where patients
are encouraged to express their preferences, values, and concerns, and to par-
ticipate in decision making. On the other hand, the interprofessional literature
tends to privilege a task orientation (see Chap. 6) where the issue of patient
voice is not necessarily taken into account, perhaps because much interprofes-
sional communication tends to take place in the clinical “backstage,” away
from patients (Ellingson 2003; S. Fox et al. 2021). Our understanding of ten-
sions that can appear in team communication when the patient is (or is not)
participating in the discussions is still in its infancy (see Chap. 7). Thus, one
way forward might be the development of patient-centered guidelines for
interprofessional interactions that encourage the expression of patient prefer-
ences and values with regard to their participation in interprofessional discus-
sions and decisions about their care (see the vignette in Chap. 3). Such guides
should also include recommendations for how health and social care profes-
sionals can advocate for the patient and share their wishes with the rest of the
team when the patient is not present.
The influence of technology on interprofessional communication is another
interesting challenge for future research. For instance, electronic health records
can serve as repositories of both patient information and traces of previous
interprofessional sensemaking, thus constituting a “hub” in a network of inter-
professional collaborators. However, their usefulness for information sharing is
often limited to intra-organizational collaboration because system compatibil-
ity issues can stymy the coordination and integration of care across organiza-
tional boundaries. Nevertheless, technology’s role in facilitating or constraining
interprofessional practice remains understudied. Similarly, little is yet known
276 S. FOX ET AL.

about how the recent enthusiasm for telehealth or virtual care affects interpro-
fessional communicative practice. Jurisdictional variation–some professional
orders permit the use of virtual care while others do not (e.g., Sweatman and
Laviolette 2021)–and practical concerns about the quality of care (e.g., the
feasibility of conducting a physical or functional evaluation via video) can have
a significant impact on which professionals can participate in interprofessional
interactions and at which points in the care trajectory they can intervene.
Relatedly, while previous research has suggested the importance of co-location
for interprofessional communication (e.g., Morgan et al. 2015), future empiri-
cal research may find that virtual care actually facilitates some forms of inter-
professional working together.
Another area for future research is interprofessional communication in the
Global South. This book’s chapters only consider interprofessional communi-
cation in the Global North, and, more specifically, in Western contexts. Yet,
interprofessionality in the Global South may play out very differently than in
the Global North (e.g., patient participation in interactions with the interpro-
fessional care team; positioning of various professions in the professional hier-
archy; professional status may intertwine with other cultural traditions and
gender roles). Similarly, future research ought to consider how the cultural
context and integration of Indigenous perspectives shape how interprofessional
communication can and should be enacted in culturally safe ways. Attending to
questions of culture necessarily raises the question of what health, illness, and
wellbeing mean in any given context.
Although our suggestions are not exhaustive, we trust that they will provide
a starting point for a richer, more nuanced, and contextualized understanding
of interprofessional communication. As researchers, educators, practitioners,
and public decision-makers collectively shape the future of interprofessional
research, education, and practice, we hope that the interdisciplinary dialogue
we have tried to foster here will continue, and that communication, and com-
munication scholars, will find a seat at the table.

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 Author Index1

A Couturier, Yves, 20, 189

Amadasi, Sara, 151, 154–156, 158 Craig, Robert, 14
Antaki, Charles, 235
Apker, Julie, 19, 123–125, 138, 139,
141, 200 D
Avtgis, Theodore A., 21, 253, 257, 260 D’Amour, Danielle, 5, 50
Dean, Marleah, 12, 53, 255, 274
Dervin, Fred, 150, 151, 154, 155, 157
B
Babrow, Austin S., 217
Banghart, Scott, 115–116, 119–121 E
Barbour, Joshua B., 20, 138, 200, 203 Edmondson, Amy, 106, 143
Baxter, Leslie A., 115, 116,
118–120, 125
Belzile, Louise, 189 F
Berthoz, Alain, 157, 158 Fairhurst, Gail T., 9, 10
Bodenheimer, Thomas, 97 Fox, Stephanie, 13, 18–20, 46, 48, 50, 83,
Bower, Peter, 231 102, 106, 108, 134, 138, 140–143,
Brashers, Dale, 217, 218 150, 157, 200, 232, 248, 274, 275
Fulmer, Ashley, 171, 173

C
Careau, Emmanuelle, 9, 18, 43, 53, G
232, 233 Giddens, Anthony, 133, 139, 236
Chittipeddi, Kumar, 190, 201 Gill, Rebecca, 200, 201
Chollette, Veronia, 216, 224, 225 Gioia, Dennis A., 190, 201
Coeling, Harriet Van Ess, 261 Gittell, Jody Hoffer, 99–101, 108
Comeau-Vallée, Mariline, 50, 134, Gray, Barbara, 140, 141
138, 140–143 Gross, Zehavit, 151, 157

1
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S. Fox et al. (eds.), Interprofessional Communication in Health and Social
Care, https://doi.org/10.1007/978-3-031-70106-1
280 AUTHOR INDEX

H O
Haggerty, Jeannie, 221, 222 Obstfeld, David, 83–87, 91, 92, 200, 201
Hathaway, Julia, 255
Heritage, John, 247
Holliday, Adrian, 150–152, P
154–156, 158 Pomey, Marie-Pascale, 53
Propp, Kathleen M., 124
Putnam, Linda L., 115, 116, 119–121
J
Jahn, Jody, 200, 201
Janis, Irving L., 33, 34 R
Ramezani, Tahereh, 202
Rancer, Andrew S., 260
K Reeves, Scott, 6–8, 73, 216, 232, 237,
Kanki, Barbara G., 253 271, 274, 275
Kersbergen, Anne Liners, 188 Reid, Robert J., 190
Keyton, Joann, 98, 172, 174
Kitto, Simon, 105
Kreps, Gary L., 18, 26, 30–35, 84, 168, S
232, 234, 258 Scharp, Kristina M., 116, 120
Kunimoto, Elizabeth, 31–33 Sias, Patricia M., 98, 117, 169, 170
Kuo, Dennis, 203 Sinsky, Christine, 97
Spitzberg, Brian H., 165–167, 170
Stivers, Tanya, 235, 238
L Sutcliffe, Kathleen M., 50, 89, 134, 135,
Lewicki, Roy J., 104 200, 201
Lewis, Laurie K., 4
Lingard, Lorelei, 134, 171, 173
T
Thomas, Lindsey J., 120
M
McAllum, Kirstie, 19, 106–108
McKendry, Rachael, 190, 221, 222 W
McPhee, Robert D., 15, 200 Weick, Karl E., 50, 83–87, 89, 91–93,
Mead, Nicola, 231 200, 201
Mikkola, Leena, 19, 98, 107, 116, 152, Wiethoff, Carolyn, 104
159n1, 177n3
Montgomery, Barbara M., 115,
116, 118–120 Z
Morgan, Sonya, 27, 101, 276 Zabava Ford, Wendy S., 124
 Object Index1

A I
American Cancer Society, 217, 220 Institute of Medicine (IOM), US, 73,
199, 215, 217, 220–225, 227, 228
Interprofessional Education Collaborative
C (IPEC), 3, 63, 65–67, 125, 165,
Canadian Interprofessional 168, 175, 258, 275
Health Collaborative
(CIHC), 63, 64, 67, 102,
103, 275 R
Réseau de collaboration sur les pratiques
interprofessionnelles (RCPI),
D Québec, Canada, 42, 54n2
Direction collaboration et partenariat
patient et Comité Interfacultaire
Opérationnel -Université W
de Montréal (DCPP and World Health Organization (WHO), 3,
CIO-UdeM), 63, 67–69 6, 83, 233, 234

1
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S. Fox et al. (eds.), Interprofessional Communication in Health and Social
Care, https://doi.org/10.1007/978-3-031-70106-1
 Subject Index1

A Collaboration
Agency, 16, 17, 21, 61, 109, 231, 232, interdisciplinary, 185
236–247, 264, 275 interorganizational, 16, 60, 140, 141,
Argumentativeness, 21, 258–262 187, 274
Asymmetry intraorganizational, 275
epistemic, 237, 247 Collaborative practice, 4, 6, 14, 18, 41–44,
hierarchichal, 124, 237 48, 50, 53, 54, 60, 62, 65–69, 73, 84,
interprofessional, 237 86, 108, 156, 157, 172, 248
linguistic, 237 definition, 59
social, 237 The Collaborative Practice and Patient
Asynchronous communication, Partnership in Health and Social
46, 48, 225 Services Competency Framework
(DCPP), 63, 67–69
Collective experience, 84
B Collective memory, 92
Block narrative, 156, 158 Collective wellbeing, 106
Boundary crossing, 137 Collegial relationship, 98, 100
Boundary negotiation, 137 Communication as constitutive, 90
See also Negotiation of boundaries Communication competence, ix, 20, 26,
51, 66, 74, 75, 165–179, 206,
262, 272
C Communication interventions, 20, 84,
Care coordination, 61, 225 100, 202, 203, 205–207, 265
Case management, viii, ix, 7, 18, 20, 61, Communication-in-the-disciplines
185–197, 272 perspective, 167
definition, 20, 186–187 Communication skills, viii, x, 20, 25, 37,
Clarity of roles, 6, 7, 67–69 51, 59, 71, 72, 74, 166–168, 170,
Co-creation of meaning, 14 173, 174, 176, 193, 204, 216, 224,
Code, 11, 260 225, 264, 265

1
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© The Author(s) 2025 283

S. Fox et al. (eds.), Interprofessional Communication in Health and Social
Care, https://doi.org/10.1007/978-3-031-70106-1
284 SUBJECT INDEX

Communication traits, 258, 260, 261 Core competencies, 14, 19, 59, 65–67,
Communicative practice, 14, 15, 21, 99, 74, 165, 168, 258
106–108, 165, 172, 176, 192, 232, Crew resource management (CRM),
234, 246, 248, 272, 273, 276 254, 257–259, 265
Communicator style
affirming, 21
non-affirming, 21, 261 D
Compassionate communication Decision making, 18, 20, 25, 28, 29, 34,
practices, 19 41, 48, 59, 61, 69, 72, 87, 99, 106,
Competence 109, 123, 125–129, 134, 140–142,
collective, 171, 173 157, 158, 167, 168, 170, 171,
relationally constructed, 20, 170 173–175, 178, 196, 207, 218, 253,
as a team level quality, 170 254, 274, 275
Concerted practice, 44, 49–50, 55 Decoding, 13, 33
Conflict, 19, 21, 28, 33–34, 48, 51, 66, Dialectical contradiction, 19, 119, 125
101–103, 106, 115, 122, 123, 134, Dialectical tension, 5, 52, 115–130,
135, 138–141, 150, 152, 168, 173, 235, 245
175, 192, 261, 263, 264 Dialectics, 117, 119–130
management, 25, 29, 37, 74 Dialogic communication practice, 42
prevention, 68 Disciplinary knowledge, 44–47, 49, 50
resolution, 61, 63, 68, 171 Discourse
Constitutive model of communication, competition of, 118, 119
14, 15, 43, 50, 200, 234, 238 struggle of, 118
Constitutive theory of Domain of communication competence
communication, 14 affective, 166
Consultation practice, 49, 55 behavioral, 166
Context cognitive, 166
cultural, 13, 100, 120, 258, 276 Dominance, 117, 134, 137, 247
physical, 12
psychological, 13
relational, 13, 170 E
social, 13, 85, 120, 138, 155 Effectiveness, 4, 8, 18, 29, 31, 36, 64,
Contingency approach of collaborative 65, 67, 73, 99, 106, 108, 109, 135,
practice, 6 141, 143, 166, 167n2, 173, 176,
Continuity of approach, see Management 179, 205, 272, 273
continuity Electronic health records, 46, 275
Continuity of care, 20, 189, 192, 195, Emergence in teams, 172
221, 222, 225 Emergency communication, 254
Conversation analysis (CA), see Emergent leader, 29
Interaction analysis Emotion, 35, 68, 90, 93, 111, 142, 166,
Cooperation, 26, 29, 32, 34, 36, 37, 171, 209, 221
202, 233 Emotional support, 106, 207, 220
Coordinated care, 49, 186 Enactment, 84, 86–89, 92, 94, 99
Coordination, vii, 6, 7, 20, 25, 26, 37, Encoding, 33
61, 99–101, 108–110, 157, 158, Epistemic authority, 239, 242, 246, 247
171, 172, 186–189, 191–193 Epistemic status, 246
activities, 16, 61, 72, 216, 220, 221, Equal status groups, 134
224–227, 233, 246, 248, 255, Essentialism, 150, 151, 154, 155
257, 275 Ethics, 65, 67, 167n2, 168, 171
 SUBJECT INDEX 285

F Indigenous, 276
Family adjustment and adaptation Individually located competence, 169
response (FAAR), 206, 207, 210 Informal leader, 29
Family-centered care (FCC), ix, Informal rules, 104
20, 199–210 Informational continuity, 189, 190, 196,
Feedback, 10, 11, 13, 29, 33, 48, 49, 55, 222, 227, 228
64, 65, 87, 92, 100, 121, 145, 167, Informational support, 207
168, 174, 176, 261 Information exchange, vii, x, 42, 197,
Fixed and fluid constructs of professional 202, 245, 253–258, 275
identity, 150 Information transmission, viii, ix, 4, 10,
Formal rules, 104 11, 18, 21, 46, 189, 253, 254
Four flows theory, 15, 16 Informed healthcare decision, 27
Institutionalized patterns of
movement, 138
G Integrated care, 19, 61, 85, 186,
Generative power, 14 189, 191
Global North, 276 Integrated care system, 59, 61
Global South, 276 Interactional skills, 84
Group communication, 25, 166, 167, Interaction analysis, 21, 235, 238,
169, 170, 173 238n3
Intercultural communication,
31, 149–162
H Interdependence, 6, 7, 41, 42, 46,
Hand-off communication, 255, 257 48–51, 89, 97, 99, 103, 121,
Health and social care sector, v, vii–x, 3, 157, 160
4, 6, 14, 18–20, 26, 28, 43, 50, 53, Interdependent practice, 44
59, 61, 83, 92, 98–100, 105, Interpersonal relationship, 21, 34, 36,
115–130, 134, 136, 138–142, 149, 98, 106, 116, 117, 120, 121,
158, 186–191, 232, 271–275 129, 156
Healthcare communication Interpretive tools, 87
interventions, 203 Interprofessional attunement, 232,
Health information, viii, 27, 31–33 234, 245–248
Hierarchy Interprofessional collaboration (IPC),
hierarchy-challenging, 140, 143 viii, x, 3–5, 8–10, 14, 19–21, 28,
hierarchy-reinforcing, 140, 143, 145 41–45, 49, 52, 59–61, 63–65, 67,
hierarchy-relaxing, 140 70, 72, 83–85, 88, 90–95, 97–111,
Higher status professionals, 111, 115, 118, 121, 124–126, 134, 135,
139, 141–143 138, 140, 143, 149–162, 166–168,
High-reliability organization (HROs), 172, 176, 185, 186, 192, 193, 197,
200–202, 207 199–210, 215, 216, 224, 228,
Hospital-centric model, 189 231–235, 237, 271–273
definition, 43, 60
Interprofessional communication, viii–x,
I 3–5, 8, 10, 12, 13, 17–21, 31, 32,
Imagined community, 153, 155 41–55, 60–65, 67, 70–71, 74–75,
Independent mindedness 83–95, 99, 105, 121, 124,
high level, 254 133–135, 142, 165–179, 185–197,
low level, 254 199–210, 216, 224, 225, 227, 228,
Independent practice, 43, 157 233, 253–265, 271–276
286 SUBJECT INDEX

Interprofessional competency, ix, 3, 19, Mechanism-injury-signs-environment-

59–75, 102, 225 response (MISER) tool, 257, 265
Interprofessional education (IPE), 4, 19, Message, 8–13, 33, 44, 46–48, 54, 55,
52, 60–68, 70–74, 100, 137, 169, 71, 74, 116, 117, 190, 200, 210,
175, 216, 224, 225, 228, 272, 273 234, 260, 263
curriculum, 60, 68–70, 74 Message exchange, 258
interprofessional education Meta-communication, 36, 206
framework, 62–68 Metacommunicative competence, 175
Interprofessional Education Collaborative Mindful organizing, 200
(IPEC), 3, 63, 125, 165, 168, 175, Mixed-status groups, 134
258, 275 Mother-infant transaction program
Interprofessional hierarchy negotiation, (MITP), 205
19, 134, 138–143 Multiagency, 6, 20
Interprofessional interventions, 70, Multidisciplinary, 5, 42, 44, 45, 53, 93
205, 206 Multidisciplinary practice, 44, 47
Interprofessionalism, 137 Multifactorial complexity, 45, 51, 93
Interprofessionality, 5, 6, 157, 233, 238, Multimodal, 234, 238n3, 239,
248, 276 240, 246
Interprofessional power struggles, 139 Multiteam systems (MTSs), 224
Interprofessional practice, viii, ix, 3–21,
42–45, 49, 50, 63, 65, 85, 117,
135, 137–138, 151, 168, N
271–273, 275 National Interprofessional Competency
Interprofessional relationship, 19, 28, 34, Framework (CIHC), 63–65
97–99, 102, 105–109, 115–130, Negotiation, 16, 19, 64, 123, 129, 134,
200, 205, 264 137–143, 172, 175, 203
Interprofessional skills, 5, 73 of boundaries, 137
Interprofessional trust, 104, 105 of meaning, 15, 51
Intervention, 12, 27, 45–48, 53, 54, 61, Neonatal intensive care unit (NICU), ix,
64, 69, 73, 89, 99, 100, 167, 168, 18, 20, 108, 199–210, 272
187–194, 196, 201–207, 210, 235, Networking, 6, 7, 16, 18, 93, 189, 274
236, 255, 259 Noise, 9, 10, 254
Non-essentialism, 151, 154, 155
Nonverbal communication, x, 66, 117
L
Leadership, 28, 29, 37, 63, 67, 68, 74,
103, 122, 142, 173, 193, 224 O
Listening, 3, 33, 64–66, 94, 99, 107, Occupational wellbeing, 98
167, 168, 173, 261, 264 Organizational culture, 61, 92, 101, 105,
Lower status professionals, 139, 141–143 107, 108, 117, 119
Organizational reality, 84

M
Maintenance role, 29 P
Management continuity, 189, 190, Parallel practice, 43, 45–48, 54
194, 222 Patient agency, 21, 246, 247, 275
Meaning making, 12, 13, 20, 41, 43, 83, Patient-centered care, 53, 125, 215–217,
117, 125, 150, 173, 174, 210, 224, 248, 272
234, 273 Patient-professional relationship, 116,
collective, 99 117, 125, 126
 SUBJECT INDEX 287

Patient-provider relationship, 118, Relational development, 35–37,

125, 205 108, 154
Patient records, 16, 92, 128 Relational dialectics, 19, 115–130, 272
Phase-specific goals, 236, 247 Relational, dimensions, 19, 52,
Plug-and-play teaming, 13, 103, 61, 97–111
105, 156 Relational expectations, 35–37
Power, vii, ix, x, 14, 16, 19, 20, 35, 60, Relational maintenance, 35, 197
66, 108, 116, 118, 124, 128, Relational tensions
133–146, 154–156, 168, 200, 201, autonomy-connectedness, 124, 129
237, 247, 253–258, 262, 272 certainty-uncertainty, 127
imbalance, 118, 134, 138–140 expression - non-expression, 120,
relationships, ix, 19, 105, 125, 126
118, 133–146 hierarchy-equality, 128, 129
Pre-hospital interprofessional Relationship orientation (of
communication, 255 communication), 98
Problem-presentation phase, 236, 239 RESPECT, see Reflexive Endeavours in
Procedural skills, 167, 206 Supportive Practice for Engaged
Profession, viii, ix, 4, 5, 9, 12, 19, 35, Centred-on-people Teamwork
44, 50, 59, 60, 63–66, 68, 71, 72, Retention, 85, 87, 92
86, 89, 102, 103, 107, 116, 118, Role
120, 133–138, 150, 151, 153, 156, blurring, 102, 111
158, 165, 173, 175, 176, 188, 203, clarity, 16, 61, 102, 105, 224
204, 220, 232, 258, 271, 276 dysfunctional, 29, 37
Professional autonomy, 5, 118, 120, 121, flexibility, 60
123, 128, 193, 235, 245 organizational role, 274
Professional culture, 13, 20, 31, 62, 71, Role awareness, 3, 19, 101–106, 272
72, 135, 155, 173, 234, 245, definition, 47
247–248, 272
Professional identity, 5, 20, 52, 70, 71,
74, 116, 149–162 S
Professional practice, 48, 120, 189, 200 Selection, 84, 86, 87, 89, 92, 94, 239
Professional relationships, 100 Self-disclosure, 35, 66
Professional role, 28, 50, 89, 101–104 Sensegiving, 190, 200–202, 210
Profession-specific skills, 167 Sensemaking
Psychological safety, 105, 106, 108, collective, 18, 44, 51, 90, 94, 193
141, 143 definition, 19, 87
interprofessional, 84–93, 275
Service coordination
R inter-organizational, 187
Reference practice, 44 intra-organizational, 187
Reflexive Endeavours in Supportive Service integration, 186, 187, 189
Practice for Engaged Centred-on-­ Shared communication competence
people Teamwork (RESPECT), 107 definition, 172, 173
Relational continuity, 187, 189, 190, emergency, 172–175
194, 222 temporality, 192
Relational contradictions, 115, 119, 120, Shared healthcare practice, 44, 51, 55
122, 126 Shared mental model, 98, 171
Relational coordination, Shared responsibility, 6, 93, 122, 153,
99–101, 108–110 175, 234
definition, 99 Shared team identity, 6, 7
288 SUBJECT INDEX

Simplexity, 151, 157, 162 Teamworking, 6–8, 18, 224

definition, 151, 157, 162 Telehealth, 224, 276
Situational skills, 168–169 Tensions, ix, 5, 19, 29, 52, 61, 103,
Small culture, ix, 151, 155–158, 161 115–130, 134, 179, 186, 235, 238,
Small culture formation on the go, 151, 239, 245, 272, 275
155–158, 161 Theory of independent mindedness
Social category, 150–154, 156 (TIM), 21, 254, 258–264
Social force, 14 Thread narrative, 151, 156, 158, 161
Social interaction, 115, 118, 150, 152, Time, viii, 15, 18, 21, 28–30, 32,
157, 235, 236 35, 36, 41, 47, 50, 52, 54,
Social norms, 104 59, 66, 68, 71, 85, 87, 91–93, 98,
Social order, 19, 134, 139–140, 143 99, 101–104, 107–109, 111, 117,
Social structure, 14, 139, 140 119, 120, 123, 129, 136, 138, 139,
Social support, 99, 106–107, 227 144, 153, 158, 159, 162, 166, 169,
Status, ix, 5, 13, 16, 20, 44, 55, 100, 171, 172, 174, 175, 178, 179, 189,
103, 111, 119–123, 125, 137, 190, 193, 194, 197, 200, 202,
139–145, 150, 152, 160, 195–197, 206–209, 217–219, 221–223, 226,
200, 202, 206, 237, 246, 247, 253, 232–234, 248, 254, 258, 265,
255, 256, 272, 274 274, 275
hierarchy, 133 Transactional model of communication,
professional status, 120, 124, 133, 276 12, 98, 190, 234
Stereotypes, 152, 153, 155, 174 Transactional model, 9, 11–14, 16, 17,
Subjective-objective-assessment-plan 98, 190, 216, 271
(SOAP) system, 254, 255, 265 Transmission model of communication,
Supportive communication, 13, 106, 9, 10, 33, 46, 48, 135, 190, 193,
107, 111 200, 210, 216, 234
Supportive relationships, 99, 106 Transmission of information, 9–10, 46,
Supportive teamwork, 107 152, 273
Survivorship care planning, 215–228 Triadic medical visits, 236
Trust
building, 88, 90, 92–94
T history-based, 104, 105
Task orientation, 19, 98–106, 109, 275 role-based, 104, 105, 110
Task-oriented small group, 167 rules-based, 104, 105, 111
Team-based practice, 272 Two-way process, 11
Team care, 106, 107, 111, 125, 129,
140–143, 254
Team cognition, 171 U
Team communication competence, 169 Unaccompanied foreign minors,
Team decision, 29–33, 174, 175 21, 231–248
Team-emerging communicative Uncertainty, 7, 21, 47, 93, 99, 104, 109,
practice, 234 127, 128, 178, 179, 199, 201, 204,
Team role, vii, 6, 18, 28, 103, 110, 123, 209, 210, 216–221, 223,
167, 176 224, 226–228
Team strategies to enhance performance Uncertainty management, 217, 218,
and patient safety (TeamSTEPPS), 220, 227
205, 206 Unidirectional, 14, 42, 54
 SUBJECT INDEX 289

V W
Values, 13, 16, 53, 61, 65, 68, Wellbeing at work, 106
84, 105–107, 121, 123, See also Collective wellbeing
124, 135, 151, 168, 170, Workplace communication, 98
171, 206, 210, 216, 233, 257,
258, 275
Verbal aggressiveness, 258–261 Z
Virtual care, 276 Zero-history collaboration, 101