Practices of Ethics: At the Crux of Interprofessional Collaboration

Contributor: David Schenck, Ph.D.
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Ethics is best thought of not as a set of judgments, but a set of practices.  These practices are, ideally, habits that guide and govern professional lives and everyday activities.  
The increased efforts to develop interprofessional teams present decidedly demanding ethical challenges.  We are familiar with the kind of teams that “medical homes” involve.  These are made up of several professions, held together by the dominance of the disciplines of medicine.  And we know about hospice teams, with their more inter-disciplinary variety held together by that remarkable set of organizational practices, hospice continues to nurture and deepen.
But these newly evolving interprofessional teams present us with a “disciplinary multiculturalism,” if you will, unlike anything we have known so far, to the point that we might sometimes want to say “multi-professional,” than “interprofessional.”  What I want to focus on are the ethical challenges involved in the deepening realization that each profession has its own culture, its own practices, and, to this degree, its own “ethic.”  How would we describe, for instance, the differences found here among quite common activities of three professions?:  Developing and utilizing a formulary (pharmacy); versus making a diagnosis (medicine); versus establishing an hour-by-hour, sometimes minute-by-minute care plan for a patient (nursing).  We are talking different rhythms governing each day; different priorities for what counts as emergent and not; different skills and training.  How then do you bring those distinct ethics together under a single umbrella?  Part of the answer is that we need to be quite intentional about grounding our ethical practices in this new and complex and still shifting territory.  
The Wharton Healthcare Quarterly has just run an important four-part series on Interprofessional Collaboration - Stronger than the Sum of Our Parts (Part 1Part 2Part 3Part 4):  I especially appreciate the emphasis in these pieces on the importance of practice, on defining organizational culture as “what people do, rather than what they say they do.”  “We can think of culture as a collection of behavioral practices . . .”  as well as the importance of the “practice” of ethics, and the ethical aspects of the practices those four pieces bring to the fore. Let me demonstrate what I mean by taking up themes introduced in Parts 3 and 4 of the Interprofessional Collaboration series.
Creating a Level Playing Field.  When we think carefully about professions as cultures, we realize that, in terms of interprofessional teams, we are not even on the same playing field yet.  Moving skillfully here begins with not underestimating how complex this will be.  This will require the kind of listening to each other that we need always to be doing with our patients.  It will require looking for subtle clues that communicate without words – the kind we learn to read as we develop cultural competencies.
The crux of the practice of interprofessional ethics lies in the realization that each profession, and each discipline and specialty within each profession has its own funny little quirks; its obscure terms and maddening acronyms; its own history of developing and of relating to other professions; and its own assumptions (not all of them complementary) about the other professions they are to work with in these teams.  Ever hear pharmacists talk about doctors?  Nurses about doctors?  Doctors about almost any other profession?  
How do we get on the same playing field?  Much of this has to do with economics and status; much has to do with the recalcitrance of professional societies and leadership.  Change in these structural dynamics will be a long time coming, as necessary as it is.  It is for just these reasons that I think a first emphasis on ethical practice is so important.
Training Different Disciplines Together.  Here at the Medical University of South Carolina, we recently held a campus-wide, full-day retreat for all of our students in our five different colleges (nursing, pharmacy, allied health, medicine, and dental). The program involved forming interprofessional teams of students and assigning them a simulation in which they disclosed a significant treatment error to a family.  
Here we confront “multi-professionalism” in the field:  Are there different practices for error disclosure in different professions?  Do we even know what they are?  Won’t this be important if, as a team, you are having to disclose a significant error together?  There may not even be agreement amongst team members about what constitutes an error, or an error of significance.  Pharmacists may have very different ideas about what counts as a medication error than doctors or nurses.  Teams must be prepared to start at ground zero, without being discouraged or feeling like such prep time is wasted.  This “wasted time” is an essential investment – for professional her- or himself, for the team, for the patients, and for the families.
And then think about how very different error disclosure by a team is from such a disclosure by an individual.  Who will be the initial spokesperson for the team? Who actually makes the disclosure to the patient/family?  Who takes responsibility for the error?  Error is, after all, seldom one person’s doing. Medication errors might involve: MD, RN, Pharmacy.  Falls: OT, PT, MD, RN.  You will need disclosure and assumption of responsibility within the team, before your team can skillfully, and with integrity, disclose the error to the family and/or the patient.
Think about how a medication error is to be analyzed.  Are we looking for the person “whose fault it is”?  If this is so, we are operating as a collection of individuals, not as a team.  A more promising approach from a developmental perspective would be to think of the team as a system and to look for the flaw in the system that led to the error.  In this case, there is acknowledgment of collective responsibility combined with collective commitment to improve performance of key practices. 

We need to view the development of teams from the standpoint of ethics, not just from that of group psychology, performance studies, or management efficiency – as important as those things are.  Our interprofessional teams must have robust ethical capacity.  They need to have mastered the skills of ethical practice.
Contact David at:  [email protected]