Ethical Deliberation in Multiprofessional Health Care Teams

Chapter 5. Synthesis of Part 1

Chapter 5 Synthesis of Part 1 Jean-Marc Larouche and Tim Flaherty The objective of this part of the study was to use the tools of ideal type, a "portrait," to provide the background to examine both the waysin which conflicts of values are lived and the ways in which ethical decisions are made in long-term care units of pediatric hospitals. The most fruitful result of this documentary research has come as insights into the professional interaction of physicians, nurses and social workers. This interaction is considered on both intraprofessional and interprofessional levels. PROFESSIONAL INTERACTION Analysis of professional interaction shows three points of interest: 1. It is significant to note that in sketching the portraits in the three preceding chapters, the distinctions in portraits between physicians and nurses were much more evident than those for social workers.The degree of distinction was greatest for the physiciansto the point of being mutually exclusive as, for example, with the physician as Expert and the physician as Collaborator. This suggests the possibility of intraprofessional conflict that may exist before involvement with other professionals. Nurses face a similar problem. As noted, they exhibit no common understandingof roles such as "Advocate," where definitions vary from a legal mode of rights protection against incompetent others in health care to a philosophical promotion of the existential self. There is a level of conflict suggested here that may arise from confusion more than disagreement. Social workers present a more united philosophical and practical front. There seems to be a more common understanding of professional goals and standards of practice. Although there is some evidence of a hierarchy within social 89 IMPLICIT ETHICS OF PROFESSIONALS IN THE FIELD OF PEDIATRIC CHRONIC CARE work itself, conflicts from this source are minimal in the literature surveyed. 2. In the area of interprofessional interaction, a significant indicator is found in the number of references made by each profession of the others in the literature database prepared for this documentary analysis. The numbers tell an interesting story. In the "physician" database, nurses are mentioned in seven of 114 texts consulted; social workers are mentioned in two texts. The "nurse" database mentions physicians in 38 of 145 texts and social workers in three. The social worker database, on the other hand, includes mention of physicians in 95 of 107 texts and nurses in 19. The suggestionraised by these numbersfalls intothe area of collaboration. If the number of references is low, is it an indicator of the true nature of collaboration or is it an indicator of one profession's evaluation of another? If the number is high, is it an indicator of an effort of inclusion in collaboration or an indicator of the social reality of the hierarchical structure of the health care enterprise? These are questions for further research. 3. The third area of interest in professional interaction is suggested by each profession's approach to hierarchy in health care. By tradition and in the literature surveyed, physicians see themselves, for the most part, as leading the medical hierarchy. Where professional interaction is acknowledged, it is (except in some texts that provide indicators of the physician as Collaborator) understood that the physician is leader or in charge. The literature on nursing seems to acknowledge this view. Nurses appear to challenge this indirectly in practice throughadopting the role as Coordinator, which moves all players on to a more level playing field. Evidently, nurses have adopted this role because they see themselves as the most qualified for the role due to their particular skills and their consistent presence in all levels of medical care for children. These qualifications are acknowledged among the other portraits only by the physician as Collaborator. Social work presents a very different understanding of the medical hierarchy. Social workers very clearly see themselves as the most qualified to coordinate collaboration and case management. The rationale for this position is their unique position in health care. Although non-medical in orientation, they have adopted medical language for their practice. Social workers diagnose, treat and assess patients. They offer therapy as well as counselling. Social workers see part of their role in the education of physicians and nurses in formal settings and curriculumdevelopment for these professions. They also include among their qualifications the social science background, which they perceive as having broader and 90 SYNTHESIS OFPART 1 more patient-centred goals than medicine or nursing. Social workers see themselves possessing...