Exploring power dynamics and their impact on intraprofessional learning

Natasja Looman,Dieneke Van Asselt,Jacqueline De Graaf,Nynke Scherpbier‐De Haan,Tamara Van Woezik,Cornelia Fluit

doi:10.1111/medu.14706

Abstract

BackgroundDuring postgraduate training, considerable efforts for intraprofessional education are in place to prepare primary care residents (PC residents) and medical specialty residents (MS residents) for intraprofessional collaboration (intraPC). Power dynamics are inherently present in such hierarchical medical contexts. This affects intraPC (learning). Yet little attention has been paid to factors that impact power dynamics. This study aims to explore power dynamics and their impact on intraPC learning between PC residents and MS residents during hospital placements.MethodsThis study expands on previously published ethnographic research investigating opportunities and barriers for intraPC learning among residents in five Dutch hospitals. We analysed transcripts of observations and in‐depth interviews using template analysis. A critical theory paradigm was employed. Discourse analysis additionally informed the data.ResultsWe defined five interrelated themes that describe characteristics of power dynamics in intraPC learning during hospital placements: beliefs; power distribution; interaction style; subjection; and fearless learning. Power dynamics operate both within and between the themes: power distribution between PC residents, MS residents and MS supervisors seemed to be an attribution affected by underlying beliefs about professional norms or about other professions; beliefs influenced the way PC residents, MS residents and MS supervisors interacted; power distribution based on inequity could lead to subjection of PC residents; power distribution based on equity could lead to fearless learning; and open interactions enabled fearless intraPC learning.ConclusionsPower dynamics have an impact on intraPC learning among residents in hospitals. Constructive power dynamics occur when power distribution is based on equity, combined with sincere open interactions, actively inviting each other into discussions and enlisting the support of MS supervisors to foster fearless learning. This can be achieved by creating awareness of implicit beliefs and making them explicit, recognising interaction that encourages intraPC learning and creating policies that support fearless intraPC learning.

Highlights

We defined five interrelated themes that describe characteristics of power dynamics in intraprofessional collaboration (intraPC) learning between primary care (PC) residents and medical specialists (MSs) residents during hospital placements: (i) beliefs; (ii) power distribution; (iii) interaction style; (iv) subjection; (v) fearless learning
The observations and interviews indicated that power dynamics occurred both within the themes and between the themes
We found five main types of power dynamics in intraPC learning between PC residents and MS residents in hospitals: (i) beliefs impact power distribution; (ii) beliefs impact interaction style; (iii) power distribution based on inequity impacts subjection; (iv) power distribution based on equity impacts fearless learning; TABLE 1 Themes that describe characteristics of power dynamics in intraPC learning between primary care (PC) residents and medical specialty (MS) residents in hospitals

Summary

Introduction

Collaborative practice between primary care (PC) physicians and medical specialists (MSs) is vital and requires mutual trust and respect.[1,2,3,4] In the deep-rooted hierarchical contexts of hospitals, it could be a measure of status for MSs to disrespect lower-status professionals with impunity,[5] such as PC physicians.[3,6,7] Power dynamics based on traditional hierarchies are inherently present in (intra)professional interaction and learning processes[5,6,8,9,10] and could have an adverse effect on collaborative practices[5,8] leading to adverse events in healthcare.[3,11] Often power dynamics are not openly discussed, but referred to implicitly, contributing to the hidden curriculum.To prepare PC residents (PC residents) and medical specialty residents (MS residents) for collaborative practice, the learning of intraprofessional collaboration (intraPC) through intraprofessional education (intraPE) is an emerging part of postgraduate training.[12,13,14,15,16,17,18 18] For example, hospital placements, where PC residents and MS residents work together at the same department, provide several opportunities for intraPE.[15]. Power dynamics are inherently present in such hierarchical medical contexts Results: We defined five interrelated themes that describe characteristics of power dynamics in intraPC learning during hospital placements: beliefs; power distribution; interaction style; subjection; and fearless learning. Constructive power dynamics occur when power distribution is based on equity, combined with sincere open interactions, actively inviting each other into discussions and enlisting the support of MS supervisors to foster fearless learning. This can be achieved by creating awareness of implicit beliefs and making them explicit, recognising interaction that encourages intraPC learning and creating policies that support fearless intraPC learning

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Conclusion