Introduction
Accounts of interprofessional teamwork rarely draw upon theory. For example, while imbalances of power are often mentioned in studies of teamworking, theory is seldom used to provide deeper insights. In this chapter we draw together a number of social science theories from psychodynamics, systems, social psychology, sociology and organisational sources. We frame this discussion using our four teamwork factors – relational, processual, organisation and contextual – to show how different theories can yield different insights and understandings of interprofessional teamwork. For readers who have only a limited knowledge of the role of social science theory, we initially provide an outline of its nature and how we have used social science perspectives to inform our own work. We then present, discuss and critique a range of pertinent social science theories in order to provide a better understanding of the complexities of interprofessional teamwork. For each of those that we discuss, we illustrate how the theory has been applied to a study of interprofessional teamwork.
Understanding the nature of theory
Social science theories provide complex and comprehensive understandings of phenomena that are not easily explained, such as how societies work, how organisations operate and why people interact in certain ways. Theory provides different ‘lenses’ through which to look at complicated problems and social issues, focusing on different aspects of a phenomenon and providing a framework for understanding them. Theories also generate knowledge that can be generalised across settings.
Merton (1968) outlined three types of theory:
- Grand or macro theory – which is non-specific and constructed from relatively abstract concepts that are difficult to operationalise and empirically test.
- Mid-range theory – which is more limited in scope, as it addresses specific phenomena and has a limited number of concepts relating to a restricted range of contexts.
- Micro or practice theory – which has the narrowest range of interest, as it is focused on specific phenomena and contexts.
Theories can be generated explicitly from data or developed implicitly from personal constructions about particular phenomena. Data-driven theories are easier to implement in practice, as their development is usually recorded and therefore easier to follow. Implicit theories (sometimes termed ‘armchair’ or ‘guru’ theories) are different as they are more:
Akin to an experienced cook who knows the basic components, how they interact, and how many pinches or handfuls of ingredients are required to produce the desired product. (ICEBeRG, 2006, p. 4)
As a result, such theories are more difficult to implement in practice.
For those interested in reading more about the nature, role and contribution of social science theory see, for example, Crotty (1998).
Using a social science lens
As we noted previously, we have adopted a social science approach to seeing the world – a standpoint which we use in this book to explore and understand the nature of interprofessional teamwork. In offering this particular perspective we are mindful of Wright Mills (1959) who, just over 50 years ago, argued for the need to employ a social science lens to view the world and understand the nature of people’s actions and interactions. He went on to note that as, ‘neither the life of an individual nor the history of a society can be understood without understanding both’ (p. 3), exploration of the links between individuals and their societies was critical. For Wright Mills, developing of an understanding of the social world requires connecting research with social science theory. Without making connections between theory and research, he argued, such accounts offer nothing more than abstracted empiricism. Social science perspectives are therefore needed to generate more comprehensive and meaningful accounts of the nature of the social world.
We have selected a number of different social science theories to help us comprehend the intricacies of teamworking in health and social care – these theories are listed in Table 5.1.
While we recognise that there are a vast number of other social science theories that could be selected, we have chosen those above for three main reasons:
- They help to illuminate all of the different elements – relational, processual, organisational and contextual – of our conceptual framework
- They offer different micro-level (e.g. Goffman), mid-range (e.g. Freidson) and grand theory (e.g. Foucault) perspectives, thus providing a diversity of ideas that can be applied to multiple phenomena
- They were developed, in part, from studies within the context of health care and/or are applied widely in health and social care.
For some, the inclusion of a range of different theoretical approaches, each with its own distinct epistemological roots, might be considered simply providing a ‘theory soup’. However, it is useful to remember that a number of seemingly contrasting theoretical approaches can have more in common than one may initially suspect. For example, Hacking (2004) argues that despite apparent theoretical differences, Goffman’s and Foucault’s perspectives are complementary. The former focuses on understanding how people interact within an existing institution while the latter provides ways in which to understand how individuals’ interactions are shaped by the culture (e.g. norms, behaviours and language) they live and work within. Both approaches are therefore useful for understanding the nature of interaction and the nature of the surrounding institutions in which interactions occur. Furthermore, our pluralistic stance encourages us to embrace a range of contrasting theoretical contributions as this can provide more comprehensive insights into the nature of a particular phenomenon.
In this section we draw on social theories from three different traditions – psychodynamics, social psychology and sociology – that help understand relational perspectives.
Unconscious processes in teams
We discuss the psychodynamic work of Wilfred Bion, Isabel Menzies and Peter Marris, which aims to theorise about the role that unconscious processes can play in interprofessional teamwork.
Early work by Bion (1961) on work-group mentality theory attempts to explain the unconscious processes involved in groups and teams unable to manage their (collective and consciously agreed) ‘primary task’. According to Bion, groups will often waste time and avoid making decisions in order to prevent members from tackling potentially difficult group issues which arise in the completion of their primary task. Bion’s work was later applied to hospital teams by Menzies (1970) in the development of her theory of social defence. For Menzies, members of hospital teams have two tasks: the primary one of patient care and a secondary one of maintaining the team (e.g. managing team relations). Menzies noted that under stressful circumstances, and in certain teams with poor clarity of goals and leadership, the secondary task can replace the primary one as a mechanism of dealing with the stress. For example, individuals who normally collaborate well with other professions to deliver care can become defensive during times of anxiety (for example due to staff shortages), and find it difficult to achieve the primary task of delivering care. One coping mechanism for dealing with this anxiety might be to withdraw from their collaborative work. Menzies also noted that the following psychodynamic processes could emerge in teams:
- Denial – where individuals continue to reject viewpoints or arguments despite overwhelming evidence
- Splitting – the separation of ‘good’ or gratifying objects or actions from ‘bad’ or frustrating ones
- Projection – where individuals’ personal attributes, thoughts or emotions are ascribed onto others.
More recently, Marris (1986) developed a theory centred upon loss and change which suggests that individuals often experience emotions of loss when change occurs. Marris maintains that fear of such changes may contribute to unconscious feelings of anxiety, which could in turn create resistance to change. Box 5.1 provides an illustration of the use of Marris’s work to illuminate the nature of interprofessional collaboration within an older adult care setting in the UK.
Box 5.1 The use of Marris’s psychodynamic theory on loss and change.
In their study of an interprofessional initiative for staff working together in an older adult care setting, Holman and Jackson (2001) found that unconscious processes between team members played an important role in the way that they worked together. Participants included nurses, a psychologist, a bereavement officer and a chaplain. The initiative focused on bereavement and combined information giving with reflective workshops. Findings from interviews with these participants indicated that their approach to interprofessional collaboration and teamwork was not altered, although they enjoyed their interprofessional experiences. The authors drew on Marris’s psychodynamic theory in their analysis to argue that the failure of staff to change their practice after participating in the workshops was due to resistance generated from unconscious feelings of anxiety about possible changes in their interprofessional work practices.
Obholzer and Zagier Roberts (1994) have drawn on the theories developed by Bion and Menzies to provide an analysis of how psychodynamic processes operate across a number of health and social care organisations, and to describe some of the problems (e.g. denial and projection) which can occur between professionals working together in interprofessional teams. Van Der Walt and Swartz (2002) have also used this approach to explain the persistence of task-oriented nursing and the difficulties of instituting change in clinic teams within a tuberculosis control programme in South Africa.
Social identity and conflict
Two related social psychological theories are presented in this section – the work of Tajfel and Turner (1986) on social identity theory and of Brown et al. (1986) on realistic conflict theory.
Social identity theory proposes that a person will identify more closely with members from their own social group (e.g. family, profession or organisation) than with members from other groups. The theory was originally developed by Tajfel and Turner (1986) to understand the social psychological basis of intergroup discrimination and the conditions that would lead group members to discriminate in favour of the ‘in-group’ to which they belonged and against other ‘out-groups’. Tajfel and Turner argued that the act of individuals categorising themselves as group members was sufficient to lead them to display in-group favouritism. After being categorised as a group member, individuals would seek to achieve selfesteem by positively differentiating their in-group from a comparison out-group.
A closely related approach is realistic conflict theory (Brown et al., 1986) which assumes that groups holding divergent objectives will have hostile and discriminatory intergroup relations, whereas groups with common objectives will display conciliatory behaviour. Hostility between groups is regarded as a result of direct competition for limited and valued resources. If the outcomes of two groups are competitively interdependent (gains for one group result in losses for the other), intergroup hostility will be maximised. Consequently, negative out-group stereotypes, increased in-group solidarity and cohesiveness will be emphasised. If the groups are cooperatively interdependent (e.g. there are shared goals), intergroup hostility will be reduced, cumulatively improving intergroup relations.
These theories have been used widely in the interprofessional literature to help explore the nature of tensions which can arise when two or more professionals come together in a practice or educational setting (e.g. Carpenter and Hewstone, 1996; Hind et al., 2003; Pollard et al., 2006). Box 5.2 provides an example of the application of social identity theory.
Box 5.2 The use of Tajfel and Turner’s social identity theory.
Mandy et al. (2004) employed social identity theory to help understand the findings of a study that evaluated the impact of an interprofessional education programme delivered to physiotherapy and podiatry students. The programme’s aim was to provide learners from these two professions with an opportunity to understand and value their respective roles within an interprofessional health and social care context. Survey findings indicated that students’ initial negative stereotypes of one another’s professions were reinforced following the delivery of the course. In discussing their findings, Mandy and colleagues argued that the limited effect of this interprofessional experience can be usefully understood by drawing upon social identity theory. They note that, ‘the different professions each have their own distinct occupational culture, which will lead to distinct tribal groups. Each professional group will develop its own characteristic style of communication and language, which in turn leads to stereotypical judgements’ (Mandy et al., 2004, p. 165). In employing social identity theory, the authors argue that negative stereotypes are difficult to change, given the nature of intergroup discrimination.
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