An exploration of collaborative practice and non-formal interprofessional education by medical and nursing students in the primary care setting

This study critically explores how Bourdieu’s (1985; 1989) concept of social space impacts on the experiences of medical and nursing students in the primary care setting when non-formal work based learning (WBL) is used as a model for interprofessional education (IPE) (Moore, 2012). Current ways in which professionals conduct their relationships with each other are also examined and factors that impede collaboration are also explored using Bourdieu’s theory of social life (1979; 1985; 1989; 1992; 1996; Bourdieu & Wacquant, 1992) as a theoretical lens.
Bourdieu (1979) uses the concept of social space as a means of exploring power and hierarchical relationships arguing that social space influences relationships so that whilst groups of people can be located in the same physical space, they can remain socially distant (Bourdieu & Wacquant, 1992). In the United Kingdom (UK) different professions are now located together, within GP (General Practitioner) Practices, in the belief that it will enhance CP (DH, 2005; Hudson, 2007). However, there are a number of factors influencing how doctors and nurses work together and these include the powerful position of the doctor in relation to the nurse (for example: Coombs & Ersser, 2004; Davis, 2003; Fagin & Gaerlick, 2004, Malloy et al 2009, Vogwill & Reeves 2008). Therefore, students placed in this environment are likely to be immersed into practices where power relationships occur and supervised by those who are involved in them. As such it is likely that they learn the implicit, hierarchically influenced, rules of engagement that are practiced by their qualified counterparts (Collin et al., 2011).
The study drew on critical ethnographic principles and took place in a city in the north of England. Participants were selected purposively and were comprised of the staff from three GP Practices, as well as medical and nursing students who were on or had recently completed a clinical placement at one of the three Practices. Data were collected predominantly through uni-professional focus groups alongside a selection of observations. Field notes were made at the time of the observations and a reflexive diary kept throughout. I transcribed the focus groups verbatim and uploaded them into NVIVO8 with analysis undertaken using template analysis (King, 2004).
Whilst CP is now accepted as a fundamental part of contemporary health care (Barr et al., 2005; Dickinson & Sullivan, 2014) there is little clarity regarding either its meaning (Haddara & Lingard, 2013; Lingard et al., 2012) or of how it should be achieved (King et al., 2013) and could be the reason that measurements of its effectiveness are limited (Barr et al., 2005; Zwarenstein & Reeves, 2006). Exploration of CP within an emancipatory discourse
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however suggests a multitude of interplaying influences on how professions engage (Ansari et al. 2001; Haddara & Lingard, 2013). Indeed, findings from this study showed that whilst staff groups perceived CP to be positive, there remained a complex interplay of factors that impacted on how it occurred. In particular the dominant position of the doctor remained problematic influencing how, when and if it occurred. Physical space, elusiveness, communication methods, titles, language and tasks performed were all found to be significant in relation to the level and type of capital held and therefore the social space between professions. However, these were frequently masked by the physical space and distance between the staff groups.
Bourdieu (1985; 1986) argues that the habitus of the individual is also influential in relation to social relationships as it is an inherent element of who a person is: influencing how they think as well as what they say and how they say it. The individuals’ habitus will ultimately manifest itself as a set of ‘tastes’ which shape their identity (Bourdieu, 1979) and how they engage with their environment (Bourdieu & Wacquant, 1992). The socialization of students into uni-professional practices resulted in their becoming indoctrinated into the epistemological norms of the profession to which they aspired: adopting similar tastes to their qualified counterparts. In this way the official criteria of WBL became lost in the unofficial criteria of social compliance to the hierarchical position held by their qualified counterparts (Billet, 2001a). The conclusions from this study argue that collaboration is complex and that greater recognition is required of those factors that impact on it: and in particular the power imbalance between doctors and nurses. Equally, current assumptions regarding students’ learning in this setting need also to recognize the complexities of CP, rather than simply relying on the experiences into which they are immersed to enable them to attain the goals of IPE and become ‘collaborative practice ready’ (WHO, 2010) at the point of qualification