Collaborative Learning at the Boundaries: Hallmarks within a Rehabilitation Context

Theoretical background

In a review article, Reeves et al. (2011) found that theoretical perspectives have been minimally employed in the development and evaluation of interprofessional intervention studies. Nevertheless, there seems to be a general agreement among scholars that interprofessional collaboration facilitates learning and development of practice, which involves negotiations pertaining to the contributions that are significant in joint activities (Akkermann & Bakker, 2011; Wenger, 1998). Wenger (1998) argues that learning at the boundaries is necessary for dynamism within communities of practice. Learning at work is understood in its broadest sense including change and development which also may involve cross-disciplinary work. Referring to Suchman (1994), Akkermann and Bakker (2011) denote the term boundary crossing as the need for professionals from time to time to enter into territory they are not only unfamiliar with, but in which they also are unqualified to some extent. Thus, interprofessional collaboration at the boundaries also includes an understanding of how markers of difference between the professional groups are played out in daily practice (Akkermann & Bakker, 2011; Johannesen & Olsen, 2008). In 1989, Star and Griesmer paved the way for research on boundary crossing and learning, introducing the concept of boundary objects to indicate how some artefacts fulfil a specific function in bridging intersecting practices. They explain boundary objects as being both plastic enough to adapt to local needs and the constraints of several parties employing them, yet robust enough to maintain a common identity across sites. The authors underscore the need for analysing the different viewpoints of actors in order to understand how boundaries are encountered and crossed. Boundary objects are viewed as organic arrangements that allow different groups to work together (Star, 2010). Referring to a wider community of practice, Wenger (1998) describes boundary objects as entities such as artefacts, documents, terms, and/or concepts that can link communities together as they allow different groups to collaborate on a common task. Akkermann and Bakker (2011) review the research literature on boundary crossing and boundary objects to determine current insights into the learning potentials of boundary work. Most studies focus on boundaries within disciplines discussing how groups and individual professionals with different expertise, tasks, and cultural backgrounds collaborate during work, also within a health care context. Some of the studies use the term boundary object with reference to a shared problem space such as the health of a patient with a chronic and complex disease that needs to be solved in collaboration (Edwards & Fowler, 2007). Akkermann and Bakker (2011) conclude that vagueness at boundaries triggers a dialogue and the negotiation of meaning “explaining why encounters at boundaries are not only described as challenging, but also as worthwhile to investigate in relation to learning” (Akkermann & Bakker, 2011, p.150).

Previous studies identify a variety of factors concerning interprofessional collaboration and learning at the boundaries. Drawing on the empirical data, Edwards (2011) regards boundaries as spaces where the resources from different practices are brought together to expand interpretations of multifaceted tasks and work problems. This teaches the ability to integrate one’s own interpretations with those made by other professionals. The learning that occurs in these spaces does not only pertain to learning how to do the work of others, “but involves gaining sufficient insight into purposes and practices of others to enable collaboration” (Edwards, 2011, p. 34). A study focusing on interprofessional collaboration within medical staff in the physical emergency clinic shows different kinds of learning from failures, problem-solving and through collaboration across professional groups. Thus, a team or a working community can be a context for workplace learning if it offers an opportunity for discussion about work situations (Collin, Valleala, Herranen, & Paloniemi, 2012). Quinlan (2009) found that knowledge work within multi-disciplinary primary health care teams is carried out in the context of collective decision-making and involves the negotiation of knowledge claims. Croker, Trede, and Higgs (2012) identify interpersonal and activity-related collaborating capabilities (engaging, entering, establishing, envisioning, effecting) across team members’ professional affiliations. A study conducted within the practice of community rehabilitation found ten competencies, even though the authors warned that the development of such competency lists could inhibit the promotion of reflective, holistic, interprofessional practice (Kendall et al., 2011).

Facilitators and barriers in interprofessional collaboration have also been the focus of several studies. In a systematic review, Supper et al. (2014) finds that the principal facilitators of collaboration were the workers’ common interests in collaboration and their perceptions of opportunities to improve quality of care. The challenges of definition and awareness of one another’s roles and competencies and responsibilities are perceived as some of the main barriers. Based on a qualitative study, MacNaugthon, Chreim, and Bourgeault (2013) finds that empowering team members seems to enhance collaborative interactions. They argue that more interchangeable roles might help to lessen the workloads of team members and prevent power struggles, because of less differentiated professional roles. As can be seen, boundaries facilitate complementary and overlapping practices among professional groups (Højhold, 2016; Johannesen & Olsen, 2008). Duner (2013) finds that social workers, physiotherapists and occupational therapists have some overlapping areas if responsibility for the everyday life activities and routines of older people. MacDonald et al. (2010) identify behavioural indicators for acknowledging the professional roles of other disciplines, such as seeking out the contributions of other team members and identify overlapping professional skills amongst team members. In a recent study, Falk, Hopwood, and Dahlgren (2017) explore how knowledge emerges and is passed along as a chain of actions among health care professionals. Despite valuable insight into how knowledge sharing unfolds in a particular practice, their study also reveals a need for further exploration of the complex nature of knowledge seeking and learning during interprofessional work.

After reviewing the literature, there still appears to be a paucity of knowledge concerning how interprofessional learning plays out at disciplinary boundaries within rehabilitation contexts. Within rehabilitation services in Norway, professionals in nursing, occupational therapy, physiotherapy, physicians and—less frequently—social workers collaborate on providing necessary support for a patient’s own efforts, aimed at achieving the best possible combination of function and coping abilities (Ministry of Health and Care Services, 2011). In addition to regular meetings to negotiate and agree on how to solve complex care problems, these professions also work together closely to provide rehabilitation services on a daily basis.

The empirical study

The research that informs this article is drawn from an ethnographic project, conducted in two rehabilitation contexts. Participant observation of healthcare professionals in shared workspaces and patients’ rooms was followed by interviews with the professionals. This combination meant that we could access intentions and understandings concerning interprofessional work in the wards. Participant observation is a suitable method for investigating patterns and connections between caregivers’ actions, relations, and collaboration in the practice locations (Fangen, 2010). A general goal of qualitative research is to develop an understanding of phenomena associated with persons and situations in their real social context (Fangen, 2010; Tjora, 2012)—in this conjunction, what characterizes collaborative learning in the boundary areas of health professions.

Findings

Discussion

Findings showed that collaborative learning was stimulated when staff made a concerted effort to acquire an overall perspective on the patient’s situation. This involved everyone sharing and soliciting each other’s profession specific knowledge about the patient in question, usually during joint meetings. Our findings demonstrate how the professions are dependent on one another in order to achieve this “overall” perspective: The absence of one profession (nurse) from a network meeting means a lack of a response to a medically related question. Sharing of knowledge can be associated with complementary competence, whereby professional groups with different knowledge and skills bring their special competence into a team (Bjørke, 2012; Orvik, 2015). In a qualitative study of teamwork in different health institutions, Kvarnström (2009) found that team members learned from one another when they took part in the way other professional groups reasoned concerning various patients. In our findings, this pattern of collaborative learning became particularly clear when patients presented with problematic, complex health care situations in which the professions were unsure as to whether or not they had overlooked something. They then proceeded to enquire in an open environment where ideas crystallized into solutions through the efforts of the entire team. The acknowledgement that knowledge was lacking entailed further mapping of the patient’s situation, such as in the case when the nurse encouraged the occupational therapist to assess the patient a second time. The findings in this study serve to illuminate aspects of “knowledge work” among professionals (Quinlan, 2009), specifically those where they fill in knowledge gaps and open up questions for exploration. In order to get a deeper and broader understanding, Schön (1983, 1987) highlighted the significance of an open and explorative attitude when naming and framing problems in practical situations. The quest for an overall perspective on the patient’s situation might also bring about conflicts of opinion and negotiation—in our findings, these especially took place in conjunction with a patient’s transfer from the rehabilitation ward to their private home. Based on the organization of the municipal health services (Birkeland & Flovik, 2014), one staff member with a professional background from the Service Request Office participated as a decision-making intermediary when decisions were to be adopted regarding whether the patient would stay on in the institution or be discharged. Contexts such as these demanded a professionally reasoned argument grounded in the perspectives that the professional groups already had, regarding the patient’s situation and functional level. As Edwards (2011) claims, meetings that focus on finding solutions are rarely neutral; there are strong emotional elements that reflect how discourses connect with identities.

Collaborative learning was also stimulated when the professional groups requested and disseminated context-dependent expressions and knowledge about how the patient functioned. Our findings showed, for example, that the patient’s physical function ability could vary from the training room to nursing ward. A cognitive test conducted by the occupational therapist could likewise be verified by information from the nursing staff about how the patient handled activities of daily living on the ward. Together they created a more nuanced view of the patient’s function and coping, which resulted in increased insight for each professional, along with significance for further follow-up. According to Edwards (2011), relational engagement with the knowledge of others can produce a form of common knowledge, which comprises a partially shared understanding of what matters for other contributing professionals. Thus, this knowledge can mediate responsive professional action (Edwards, 2011).

Another pattern in collaborative learning was characterized by an awareness of similarities and differences among the professional groups. We saw examples of this when the occupational therapist and physiotherapist stated that they might have overlapping work tasks, and that the occupational therapist and nurse perceived that they had knowledge in common, although the difference in theoretical background coloured what they observed in the same patient situation. This form of collaboration between health professions may have elements of role overlap, as Booth and Hewison (2002) and Nancarrow (2004) found between occupational therapists and physiotherapists working in rehabilitation and intermediate health services. One study of interprofessional collaboration in a hospital setting showed that close collaboration among professionals of equal status facilitated learning (Keshet, Ben-Arye, & Schiff, 2012). An overlapping collaboration is situation-specific—it is the aspects in the given situation together with professional caregivers’ technical assessments that create this form of collaboration. Overlapping collaboration and an awareness of similarities does not mean that professional groups take over tasks that they are unqualified to perform. What happens is that the boundaries between professions become more open, and we are simultaneously made aware of a separate and distinct core competence. The example of the physiotherapist who felt uncomfortable, but not necessarily disqualified, when she helped a patient in a toilet situation illustrates an increased awareness of the specificity of her own professional knowledge. The example also raises some questions that need to be further investigated: how boundaries between professionals seem to coincide with particularities of situations, which may have the potential for both helping/caring and training patients (as in the case above). The example also sheds some light on the status of different work tasks (such as helping patients use the bathroom), and how this affects where the boundaries are drawn.

Interprofessional collaboration at the boundaries fosters opportunities for learning and development (Akkerman & Bakker, 2011; Edwards, 2011; Hagland, 2015; Wenger, 1998). Close collaboration and overlapping increases the opportunities, as Barr (1998) has expressed it, for the professions to learn from, with and about one another. Examples in our study illustrate how the spirit of professional community and development is stimulated when professional groups realize that they share much knowledge in common, or when profession-specific techniques were disseminated to the others in the shared practical environment; as when moving patients and describing principles in ADL therapy. According to Wenger (1998), learning at the boundaries is necessary for dynamism within communities of practice.

In our study, the notion of training gave rise to an awareness of similarities between the professional groups, since training was central in the patients’ rehabilitation process in the form of activities to which all of the professions related in various ways. Training can be understood as an abstract boundary object concept that, according to Wenger (1998), can create a sense of community and connection between the professional groups. What is crucial is that a boundary object facilitates collaboration between the various professional groups and helps to interconnect the knowledge and activity of the professions (Star, 2010; Star & Griesmer, 1989). Training as a boundary object had particular significance for the way nurses and assistant nurses viewed their own role when the patient tried to master activities in a normal, routine day.

As a profession, nurses usually differentiate between themselves and others when it comes to ways of working. Whether nurses work independently, collaboratively or both, caring for patients and next of kin is deeply rooted as a primary responsibility (Henderson, 1997). Within rehabilitation, nurses usually work more comprehensively compared to other professionals like physiotherapists and occupational therapists who have a more specialized, therapeutic approach towards patients. Earlier studies have indicated that nurses may have difficulty describing their role and responsibility in interdisciplinary rehabilitation (Burton, 2000; Dahl, Romsland, & Slettebø, 2014; Christiansen & Feiring, 2016). Expectations regarding each other’s roles contribute to the way situations are defined and build lines to follow in the interaction (Album, 2010). Thus, patients often have particular expectations about how they should be treated by nurses, physiotherapists, and occupational therapists within rehabilitation contexts. Despite the fact that the physiotherapists and occupational therapists were seen through their own and others’ eyes as the central staff in rehabilitative training, our study shows that the assistant nurses and nurses perceived themselves as trainers when they stimulated patients to self-help in performing daily activities. Thus, caring and therapeutic perspectives and approaches towards rehabilitative patients were more aligned. Training as a boundary object stimulated learning in terms of identity development (Wenger 1998), with a particular significance for nurses and assistant nurses in rehabilitation contexts. The perception of oneself as a “trainer” can be understood as a form of self-categorization relating to the term a person chooses to denote themselves as, in terms of being a member of various social groups (Chatman et al., 1998). It can underpin and support a feeling of equality between the professional groups in their legitimization of their own roles in a rehabilitative team.

Conclusions

The ethnographic approach of this study enabled us to reveal nuances in interprofessional collaboration and learning at the boundaries, as seen on two rehabilitation wards. The study contributes to understandings of how local interactions between different professions may promote joint learning, although to a greater extent for nurses and assistant nurses (AN) than for occupational therapists (OT) and physiotherapists (PT). Collaborative learning was stimulated when the professional groups shared and solicited one another’s knowledge and insight about patients. What created a particular incentive for such collaborative learning was the acknowledgement that knowledge was lacking in terms of problematic and complex patient situations, which bolstered an open and investigative attitude. A similar pattern emerged when the participants together created a more nuanced and more valid notion of the patient’s functional level and ability to cope, based on context-dependent, profession-specific input. Both patterns in collaboration at the boundaries thereby led to the construction of new knowledge that became significant for the further follow-up of the patient, and in addition, fostered learning for the staff.

The study exemplifies the learning potential when boundaries between professions become more open in an overlapping collaboration. This enables awareness of one’s own boundaries and the fact that one has a wealth of shared knowledge. Additionally, it entailed the learning of techniques and procedures from other professions, which augmented and developed one’s own professional repertoire. Training, understood as an abstract boundary object, served as a unifying artefact in collaboration, underpinning a feeling of equality and legitimacy, especially among the nursing personnel in the rehabilitative team. Nevertheless, findings in this and other studies show a need to more fully explore nurse roles and participation within interprofessional teams in rehabilitative contexts. We also need to know more about how learning and knowledge development at the boundaries takes place in the field of rehabilitation, not least in conjunction with the profession-specific student groups’ experiences with interprofessional collaboration. In a time when patients’ co-determination and influence on decision-making processes are being emphasized to a great extent, there is also a need for further studies addressing how such matters impact on collaboration between professions, patients and next of kin.