JOURNAL OF INTERPROFBSSIONAL CARE, VOL. 12, NO. 3, 1998 303

Tribalism, loss and grief: issues for multiprofessional education

Jo ATIUNS School of Health Care, Oxford Brookes University, Oxford, U K

Summary This paper examines tensions between a sense of loss of professional identity and drivers for change in achieving multiprofessional education and practice. Key ideas of Marris (1 986), including feelings of ambivalence and ‘the conservative impulse’, are used as a framework for the paper and are linked to the vivid anthropological metaphor of ‘tribalism ’ (Beattie, 1994; 1995). The issues are considered to be important for innovations in multiprofessional education since they point to a dilemma which cannot be safely ignored. Legitimate expressions of resistance, arising fiom confusing expressions of ambivalence, conflict and p ‘ e J occur when boundaries of distinct groups appear to come under threat from integration of various professional groups and tribalism is often viewed as a negative expression of retreat and rejection of change. However, both can be seen as legitimate laments for betrayed traditions with elements of bereavement processes. As such they present a challenge for educationalists to adopt teaching methods conducive to open discussion and expression of feelings in a safe and non-judgemental atmosphere. Teaching in the affective domain recognises the legitimacy of cultural continuity and the need for professionals to wake transitions towards collabora- tive, professional, health care practices. The author concludes that the need to maintain the selfconfidence of different professional groups is vey real, as are the possibilities of failure if the issues of professional traditions are ignored.

Key words: Tribalism; ambivalence; %onservative impulse > transition; affective domain.

Introduction

The aim of this paper is to encourage discussion on some of the effects and experiences of change that can arise from the current thrust towards multiprofessional learning and practice. The ideas introduced include the notion of boundary constructs between health care professional groups, a sense of belongingness to sets of traditions and to an identified professional culture, and the normal resistance to change that can be interpreted as a ‘conservative impulse’ (Marris, 1986). The ideas of Marris can be used to explain symptoms of distress and grief that may be exhibited by individual health care professionals who may be struggling with feelings of ambivalence when confronted with a choice between a rational and sensible innovation and what may be experienced as a sense of bereavement and loss. It is suggested that unless ambivalence among health care professionals is raised as a reality, and addressed through appropriate teaching strategies in the context of multiprofessional learn- ing, then effective collaboration in practice may fail.

__.______ - _ _ _ _ _ ~ - . - ~- Corrcspondcncc to: Jo Atkins, Principal Lecturcr, School of Health Care, Oxford Brookes University, John RadcliKe

Hospital, Oxford OX3 9DU, UK. Tcl: 01865 221 557; Fax: 01865 220 188; E-mail: jmatkins@brookes.ac.uk

1356-1 820/98/030303-05 0 Marylebonc Centre Trust

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304 J.ATKINS

Boundary constructs and a sense of belongingness

The notion of ‘tribalism’, coupled with the concept of ‘culture’, has begun to emerge as a useful metaphor applicable to the distinctions being made between health care professional groups (Beattie, 1995). Research by social psychologists, sociologists and social anthropolo- gists since the 1950s and 1960s has drawn attention to the profound impact of specialist training schools on the sense of identity and the values of the separate health care professions (Hugman, 1991; Johnson, 1972; Parkin, 1979). By a process of secondary socialisation, individual students have been initiated into new sectors of the social world and into the criteria for ‘success’ that are distinctive for each sector. Hughes (1956) and Merton (1957), for example, identified the transmission of a unique culture in medical schools. Other authors point to the initiation rituals in nursing schools through which identity was changed in the transition into an occupational culture (Davis, 1972; Melia 1989; Menzies-Lyth, 1988).

Having gained a sense of identity and adopted the shared meanings, skills and practices of some clearly identified professional group, often with some degree of struggle, pain and coping, practitioners are now being asked to amend their boundary concepts and undergo a considerable degree of sociocultural change (Soothill et al., 1995). While these authors acknowledge that these are ‘troubled times’ (p. 5), full of individual, professional and organisational complexity, it is unclear just how health care professional educators should, or could, help individuals manage their own transitions into a collaborative culture in a multiprofessional world.

Resistance to change and the ‘conservative impulse’

‘We expect resistance (and defensiveness) to change as a fact of life’ (Marris, 1986, p. 5). Such reactions can be interpreted as ignorance, a failure of nerve, or the obstinate protection of untenable privileges as if the resistance could be broken by exposing its irrationality. However, our need to conserve the status quo, the familiar pattern of relationships, and the harmonious purposefulness of our lives mean that disruption and change (however it is generated) can cause ambivalence and distress. Why should this be? It appears that the anxieties of change centre upon the struggle to defend or recover a meaningful pattern of relationships and to be able to defend the predictability of life. Such struggles can emphasise our impulses to maintain, or ‘conserve’, our traditions and may inhibit straightforward adjustments.

Marris (1 986) develops an argument about the relationship between conservatism, be- reavement and innovation which could be influential in helping to manage instances of sociocultural change, in particular, in helping to understand one aspect-the sense of loss. For example, we have deep-rooted needs for attachment and continuity. Without them we cannot interpret what events mean to us nor explore new kinds of experience with confidence. If our familiar patterns of life are irretrievably broken we experience feelings of bereavement and grief similar to those found in the reactions of people to the death of loved ones, the clearance of their geographical communities or the loss of their familiar work environments.

However, Marris suggests that social and psychological reorganisations, or transitions, are possible in a similar manner to the recovery that can happen through the bereavement process. The argument rests on the premise that because we have a need to conserve ourselves we begin to assimilate new experiences into our existing ‘structures of meaning’-to be adaptive. But this happens only gradually over time and within limitations. ‘Structures of meaning’ include aspects of attachment as well as understanding, for example, when we say that something ‘means a great deal’ to someone. Grieving reactions are evoked when adaptive

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TRIBALISM, LOSS AND GRIEF 305

abilities are threatened and since this is so a certain kind of ‘counselling’ approach by educators may be required before innovation and change can be assimilated.

Symptoms of distress in health care professionals caused by feelings of ambivalence

Some of the new curriculum ideas €or collaborative and shared learning emphasise students actively making connections between things in an integrated code rather than emphasising the autonomy and separation of subjects (Beattie, 1995; Bernstein, 197 1 : Goble, 1994; Pietroni, 1994). However, multidisciplinary collaboration will always also pose questions at the personal (micro-structural) level for the individual practitioners who participate. The boundaries between sensible exploration of shared subject matter and ‘ownership’ of the specialism still need to be addressed. Indeed, the consequences of interprofessional learning for practice have hardly begun to be researched (Owens et al., 1995).

That traditional, ‘tribal’ boundaries between health care professionals are being redrawn is evident. Studying the process by which this is happening can be illuminating. For example, Beattie (1995) provides examples of studies in the structuralist anthropology of education which show us that transformations in the structuring of educational knowledge can be expected to be strongly linked to changes in cultural values and social arrangements. In this light, the recent growth of interprofessional health studies can be seen as part of a far- reaching shake-up of the belief systems that underlie the traditional division of labour in health. Beattie suggests that this creates role conflicts and dilemmas that are created by the pull and push around poles of strategic planning about interventions in health.

Meanwhile, if the arguments from the work of Marris (1986) are utilised in this context, practitioners are also confronted by their own personal feelings of ambivalence, and possibly by those of considerable loss and grief as they struggle to gain or regain a sense of meaning which includes dealing with traditional attachments as well as trying to understand the complexities of change.

Teaching approaches which include addressing the affective issues discussed above

The predominant experience of joint work for many, perhaps most, practitioners is of anxiety and stress (Woodhouse & Pengelly, 1991). In encounters with other professionals such emotional undertows remain unspoken about, hidden and sometimes actively denied by the participants themselves (Wilson & Wilson, 1985). These authors suggest that group relations management methods, that seek to bring these affective effects out into the open, may be the key factor in the successful achievement of multidisciplinary collaboration-whether through multiprofessional training events or multi-agency initiatives.

Beattie (1994), writing in the context of health promotion, identifies affective challenges of multidisciplinary encounters and cites Bion (1961) and Lawrence (1979) as examples of educational methods which encourage and legitimise the open telling of ‘personal tales of trouble’ (p. 119). While Beattie (1994) does not elaborate, he does advocate experiential and group work methods which, the author suggests, can be interpreted as reflection in small action learning sets, role play, small group discussions and individual situational analyses, each possibly with plenary sessions depending on the size of the whole group and degree of resistance to public disclosure. The point is that such methods can help to overcome the exclusion or ignoring of the psychosocial effects of change and encourage true partnerships between health care practitioners. For example, Beattie (1994) recommends that to get people from different disciplines and backgrounds to collaborate effectively an investment needs to be made in systematic, shared reflection informed by appropriate analytic frame- works.

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306 J.ATKINS

Although Beattie (1994) does not elaborate on what he means by systematic shared reflection it can be assumed that positive, facilitative effects are intended. If we turn to other authors, it is possible to establish some positive ideas to feed into Beattie’s (1994) suggestion of the development of an appropriate analytic framework. For example, Schumacher and Meleis (1 994), in their comprehensive review of the literature on transitions, indicate components of transition experiences which could be used to identify a framework of content for shared reflection. These include meanings, expectations, level of knowledge and skill, environmental factors and emotional and physical wellbeing of individuals and groups. The exploration of meanings, for example, refers to a subjective appraisal of an actual or anticipated transition and the positive or negative effects it is likely to have on one’s life. Interpretations of transitions may be uniquely individual, hence the need for sharing thoughts and feelings about the meaningfulness of either existing situations or the anticipated sense of loss, or relief, that the change may incur.

Schumacher and Meleis (1994) also point to another subjective appraisal that can affect the transition experience. It is the need to establish realistic expectations. Having some certainty about what to expect may help to alleviate feelings of ambivalence. Uncertainty can also indicate a need for new knowledge and skills. An exploration of what these might be, how preparatory training can be introduced, and how new roles can be developed, can usefully form part of shared reflection among individuals and groups of professionals in the contexts of education and practice.

In terms of the environment of transition and change in an organisation such as the health service, educationalists can be seen as key people among a team of planners, managers and other stakeholders, all of whom could benefit from shared perceptions and reflection (Atkins & Walsh, 1997). Interactions among teams, persons and sub-systems can impede or facilitate the process of change. The extension of an analytic framework to encourage shared reflection among planners could result in a greater awareness of the socio-cultural environment, as well as the rationality of planned change for those who are driving the movement towards multiprofessional education and practice. To these ideas the author would suggest that the work of Marris (1986), including the concept of ‘conservation’ as a normal, sociological phenomenon in the face of change, could be included in the development of an analytic framework for exploring issues of transition into multiprofessional health care education and practice.

Conclusion

In this paper the author has argued that educators, in the context of multiprofessional health care education, need to consider the socio-cultural, psychological and affective issues for change in the way that the distinctions, or professional boundaries, of health care profession- als are constructed. The movement towards collaborative, multiprofessional practice requires that educators take steps to improve the transitional experiences of practitioners. The metaphor of ‘tribalism’ has been discussed, in terms of the shared values, meanings and practices attributable to clearly defined cultures, and the suggestion has been made that health care professionals, having been socialised into their individual professional culture, can experience a sense of loss and grief when the boundaries of that cultural group appear to be under threat.

The ideas of Marris (1986), principally that of the ‘conservative impulse’, have been introduced, in addition to key concepts from the work on transition experiences from Schumacher and Meleis (1994), as content for an analytical framework to use in teaching in the affective domain. The aim is to develop a strategy for teaching that encourages open explorations of feelings of ambivalence and possible experiences of grief that can arise among

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TRIBALISM, LOSS AND GRIEF 307

health care professionals in the face of uncertain and pervasive change. In particular, the framework could be developed to include these ideas as content for shared reflection in the light of the move towards multiprofessional practice, a movement which can affect individu- als’ sense of identity and affiliation with the culture of existing, professional groups.

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