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Rev. Latino-Am. Enfermagem vol.15 no.1 Ribeirão Preto Jan./Feb. 2007
Professional roles of a health team: a view of its components
Sandra Regina da Costa SaarI; Maria Auxiliadora TrevizanII
IRN, Brazilian Army Reserve Officer, PhD in Nursing, e-mail: email@example.com
IIRN, Full Professor, University of São Paulo at Ribeirão Preto College of Nursing, WHO Collaborating Centre for Nursing Research Development, CNPq Researcher 1A
Based on the Theory of Roles, this study aimed to examine health team professionals' views on the role played by their colleagues. We interviewed 39 health professionals: 01 nutritionist, 02 psychologists, 02 nurses, 03 physiotherapists, 04 pharmacists, 10 dentists and 17 physicians. The results showed that the participants considered that teamwork shares responsibility, which relieves stress and is a way of learning; they also indicate that expectations regarding the professionals' role are not very clear and that most participants have little knowledge about their colleagues' professional role. The most clearly described professional roles are those of physicians, nurses and pharmacists. The most obscure is the psychologist's role.
Descriptors: patient care team; professional role; health
This paper is based on data obtained through an empirical research, carried out in the framework of a nursing doctoral dissertation presented at the Ribeirão Preto College of Nursing, which investigated the specificity of nurses. During data collection, in order to avoid asking informants directly about the specificity of nurses, we asked them to talk a little about their professional experience and expectations about the performance of other health team professionals. We found that some of the informants faced difficulties to describe the attributions and competences of their work colleagues. This attracted our attention and made us elaborate this paper.
In the attempt to historically recover the origins of the health team as we know it today, we looked back in time and managed to outline three "health team" models(1), which were active from the 18th century onwards. Each of them had distinct characteristics, but the three had something similar: their concern with the population's health condition.
The author does not mention the term "health team" but, in describing the formation steps of social medicine, he allows us to picture a team that works for the benefit of or in the name of health. These three models are:
a) State Medicine, developed in Germany at the start of the 18th century, in which a "health team" consisted of: physicians, central administrative organization that supervised and guided medical work and medical employees appointed by the government;
b) Urban Medicine, developed in France at the end of the 18th century, in which a "health team" included: physicians, chemists and physicists;
c) Workforce Medicine, developed in England in the second third of the 19th century, in which a health team was constituted by: physicians who took care of the poor, physicians who took care of general problems like epidemics and private physicians who took care of whoever could pay their services.
In the 18th century, when the hospital emerged as a place of cure and no longer as a place for dying, and when the hospital space was medicalized and disciplined, we can witness the appearance of the "health team" we are more familiar with. This "health team" is present in the ritual of medical visits, which is followed by the entire hospital hierarchy, that is: assistants, students, nurses and others. We will consider that the health team was constituted on the basis of this event(1).
The above "health team" models display little similarity with the health teams we live with today. We are accustomed to see a health team constituted by: physicians, nurses, other nursing professionals, psychologists, nutritionists, dentists, physiotherapists, pharmacists and social workers. This group is commonly called the multiprofessional or interdisciplinary health team.
This multiprofessional character is considered as a strategy that guides and allows for integral care delivery. It is mistakenly mixed up with interdisciplinarity. The former indicates the juxtaposition of different disciplines, in which each professional acts according to his/her specialist knowledge; the therapeutic process is fragmented. The latter implies interaction between two or more disciplines, reflected in the integration of key concepts, in epistemology and in teaching and research organization(2-3).
The first multiprofessional studies appeared in the 1930's and 40's and were related to mental health. In the 1960's, a quantitative increase occurred in the health work force. These facts derived from a mental health care humanization proposal, the increased demand for health services and the incorporation of increasingly complex technologies(2-3).
To elaborate this paper, we departed from a number of premises, which were: individuals play countless roles in the social system they are inserted in, including professional roles; the roles individuals perform are outlined according to the roles played by the other persons present in the respective social system; the definition of the situation represented by a certain participant constitutes an integral part of a representation that is fed and maintained through cooperation with more than one team participant; each participant in this group or team has to give his/her definition of the role (s)he performs; the team is a group of individuals who cooperate in the realization of a particular routine, of a task; there exists a bond of mutual dependence that links members of the same team with one another(4-5).
In view of these premises, we attempted to examine health team professionals' view about the role performed by their team colleagues.
To carry out this study, we followed the precepts of qualitative research and adopted the framework of Discourse Analysis to analyze data(6).
The empirical research was realized at a military hospital located in the State of Minas Gerais, Brazil. This small hospital offers medical clinics, surgical clinics, nursing, dentistry, psychology, pharmacy, physiotherapy, laboratory and nutrition, as well as support and administrative services.
Data collection only started after the project had been approved by the Research Ethics Committee at the Ribeirão Preto College of Nursing, and after the board of the military organization and informants had given their consent.
We interviewed thirty-nine health professionals, distributed as follows: 01 nutritionist, 02 psychologists, 02 nurses, 03 physiotherapists, 04 pharmacists, 10 dentists and 17 physicians (approximately 80% of the health professionals who work at the hospital). Interviews were recorded with the informants' consent and, after transcription, we proceeded with data analysis. In order to guarantee the informants' anonymity, they were identified with an alphanumerical code that consisted of the profession's first letters, followed by the interview order number. To distinguish between pharmacists and physiotherapists, the first three letters were used to designate the latter (PHY).
Data analysis allowed us to construct thee analytic categories. These are: teamwork, perception of professional roles and multiprofessional team, with two subcategories: how it is considered and expectations.
Teamwork is considered essential but difficult. It is seen as a way of sharing responsibilities and achieving the patient's health recovery faster. This view is justified by the fact that each professional perceives the situation differently, and that the "union" of different perceptions facilitates the comprehension of the whole, making it possible to picture the patient as a whole. It requires interplay in order to avoid blunders and (re)work. Teamwork is considered a source of learning, because it permits contact with other experiences through professional dialogue and case discussions. This can be illustrated by the following statement.
In teamwork you expand your knowledge, you can solve doubts, [...] when you work with people from other areas you improve your diagnosis, your ability to see the patient as a whole is better.
Perception of professional roles
All informants pictured differentiated roles for health team members. They alleged that this definition is difficult when the number of staff is insufficient. Different reasons were appointed for this differentiation, condensed in: existence of hierarchy, existence of laws regulating the professionals and impossibility to know everything about everything, giving rise to complementary roles. The informants' statements displayed that physicians discriminate against/disqualify other professionals.
That's how I see it, perhaps it may even be anti-ethical to be talking like this, I see a very large discrimination by the physician against the rest of the white-coat, that is, health staff.
The pharmacist's role
Pharmacists' role was clearly delimited in three activity areas: management, biochemistry and pharmacy in itself. Physicians, nurses and dentists show greater expectations in terms of orientation and clarifications about collateral effects and drug interactions. The second most wanted activity referred to biochemistry, justified by these professionals' help in clinical diagnosis. Management was characterized by responsibility, granted by the informants; and by the acquisition, control and distribution of drugs and medical-hospital material. Another area indicated as belonging to pharmacists' competence was the Hospital Infection Control Commission, however, without explaining the activities they would perform. It should be mentioned that one of the informants believed the pharmacist was not necessary in the health team. According to him, it is the biochemist who plays an essential role.
I really don't see the need for a pharmacist in a multidisciplinary team. I believe it's the role of a biochemist that's important, to be able to help us by supporting some additional tests. As to the pharmacist, I can't see an important role for him, no.
Some informants affirmed that, although they managed to pictured pharmacists' activities in the pharmacy and the laboratory, their role was not clear.
The physician's role
Physicians were seen as professionals who serve as the patient's "entry door", that is, they receive patients, reach the clinical diagnosis, elaborate the therapeutic plan and refer them as necessary. Informants established clinical diagnosis as the physician's main role. Some disagreements appeared in terms of treatment. Most informants considered that this is the physician's responsibility, but that it is executed jointly with other professionals. Other professionals considered treatment as a complementary action performed by different professionals, in which each bears his/her own responsibility.
Physicians were also considered as coordinators of health team actions, being responsible for guiding and supervising the other professionals' work. They were defined as: professionals with little vision, prejudiced, resistant against teamwork, centralizing, and "the almighty"
Look, the doctor is trained to be who he is. [...] older doctors are very resistant against teamwork, [...] People who graduated some time ago are very prejudiced. [...] They really feel superior.
The dentist's role
The image constructed of dentists is not clear. They are perceived as "people who treat teeth" and as professionals who are technically capable of diagnosing and treating oral pathologies with systemic repercussions. Therefore, they are responsible for important differential diagnoses, among which oral cancer was mentioned rather frequently. References to their participation in the health team range from insignificant and dispensable to fundamental and essential. Most informants consider that dentists' work belongs in outpatient clinics, separated from the health team.
It seems to me that the dentist is very much into questions characteristic of dentistry. It seems to be a very characteristic sector, I see little articulation with other health professionals.
Informants expressed a change process in dentists' activities, deriving from the Family Health Program strategy which, in a way, has contributed to integrate these professionals in the team.
The psychologist's role
Psychologists were considered important in the health team but their activities were not clearly defined.
As the name itself says, the more subjective, psychological part and he is more generalist, he does not only focus on one aspect, he sees the patient as a whole, I think.
Most informants express that psychologists are responsible for giving emotional support to patients, families and teams. Only one informant referred to the psychologist's activities as someone who is capable of diagnosing, establishing and conducting a therapeutic plan. When describing psychologists' role, some informants mentioned actions related to solving patients' and their respective families' socioeconomic problems, ignoring the existence of social workers.
… their role stands out in that they have worked in psychological support, social assistance, orientation.
The physiotherapist's role
Rehabilitation was the most mentioned activity. This was divided into motor, respiratory and social rehabilitation; the latter refers to the patient's reintegration into the social environment (s)he belongs to. Some informants indicated that physiotherapists' role was to help medical work.
I think it is a cooperative role. [...] But we do work as assistants, yes.
Others perceived them as professionals who are capable of promoting health, establishing diagnoses and treating diseases that involve different organic systems and limit individuals in their daily actions. Two informants referred to the fact that physiotherapists in general prefer outpatient clinical work and interact little with the health team.
The nutritionist's role
Discourse evidenced that nutritionists' main function is to help with patients' and professionals' diet. Other descriptions of their role were nutritional assessment and food education. The nutritionist is considered to be a professional who depends on the physician to act and helps in this professional's work
Orientations about diet, suggestions about what diet to prescribe. [...] When he so to say prescribes a diet, the physician has to approve it first.
Nutritionists are seen as not very participative, but important for the health team. Two informants mentioned that, besides clinical nutrition, nutritionists play an important role in the food industry. One informant considers the nutritionist as the only professional capable of elaborating healthy menus that are adequate to patients' individual needs, without placing a burden on the hospital or domestic budget.
The nurse's role
Informants' views in this respect were multiple. They attribute administrative, care and educational actions to nurses. The most mentioned nursing role was administrative. Administrative functions were subdivided in three activity areas: work process, institutional environment and health team. Described actions referred to resource provision for health acts to take place, equipment maintenance, care unit organization and cleaning, besides interactions with all health team members, whether by providing what is necessary for patient care or by giving information.
Informants outlined two ways for nurses to act in patient care, expressing that nurses act both directly, exemplified by more complex invasive procedures, and indirectly, mentioning care delivery supervision.
With respect to education, the informants expressed that nurses are responsible for training other nursing team members, giving technical advice, transmitting the necessary knowledge to perform procedures and training them for service and in service.
The multiprofessional team
How it is considered
We have mentioned before that informants consider teamwork as important and a source of learning. Based on their statements, we picture the team as a "puzzle", in which all pieces fit in "perfectly" and the end product shows a complex whole.
Informants referred to the fact that not all professionals know the role, function or competence of their team colleagues. They mentioned a struggle for power and fear of losing professional space and status, as well as the existence of professional "feuds" that are hard to penetrate. According to them, this difficulty derives from the lack of dialogue among professionals, which impairs interrelations among team members. They justify these facts by the lack of an adequate place to hold meetings or encounters.
Participants indicated greater distancing between physicians and other health team members, saying that these professionals commonly put themselves on a pedestal, which makes any approximation difficult. They held universities responsible for the lack of knowledge about professional roles and the reduced interplay among team members as, during their education, no joint/integrated activities were promoted. Professionals also mentioned that, when an uncommon situation occurs, outside work routines, that is, when "something wrong" happens, the responsibility for the event is shoveled on from one team member to another.
The interviewed professionals revealed their desire to have a better definition of work goals and a better interplay among team members. They want each professional to do his/her part and that all team members become capable of listening to and respecting the others.
They think that, when one knows well what one does and what the other person does, performance is better, thus improving patient care. They affirm that daily contact among team members tends to improve interrelations and decrease the overload and stress of and inside work.
Discourse revealed that some professionals depend on the physician for decision making. Physicians, in turn, position themselves as the center of decision making and attract the supervision of other professionals' work.
Some authors(7-12) have studied the theme of this paper. One of them(7) specifically looked at multiprofessional care for hypertensive patients and appointed a clear definition of each professional's role, given the specificity characteristic of each and indicating that some actions within the team are obvious. In our study, we found the opposite. Health team members had little knowledge about their team colleagues' professional roles. This fact evidences the absence of clear expectations about what each professional should/can do in this team, and the lack of clarity about how one professional could complement a colleague's work.
The relationship among team members is directly related to the institution they work in and to the type of task it aims to perform(8). This relation "defines" the objectives and obstacles the team is confronted with. The team we examined is inserted in a military organization. We infer that the context shared by these institutions (hierarchy, prioritization of military activities) may have influenced the collected data, although all interviewees were active in other health organizations as well.
It was evidenced that, among multidisciplinary team professionals, physicians have the most clearly defined role, followed by nurses and pharmacists. Psychologists' role is the most "obscure". Informants mentioned their support to patients and families during hospitalization, as well as to the team. However, their statements did not explain how this support occurs and what it means.
Although nursing was the profession with the second best delimited role, nurses' specific role is surrounded by a series of expectations. Particularly physicians expect that they dedicate themselves more to care but affirm that they are essential in administration.
We found that, although they are considered as health team members, dentists, physiotherapists, nutritionists and psychologists were appointed as very distant from the team, because they mostly develop their work at outpatient clinical level. This fact makes us think that, according to the informants, teamwork is restricted to daily hospital work. Only three of them looked beyond hospitals. This situation evidences and reinforces a hospital-concentrated health care practice, centered on a biological-curative therapeutic intervention model(3).
Nowadays, interdisciplinarity is discussed and appointed as a cure-all for "failures to meet in the current world". However, data from this study make us inquire about how to develop interdisciplinarity if daily work is marked by lack of knowledge about what disciplines are and how they complement one another. How can we practice interdisciplinarity if we ignore each team member's professional role?
We agree that "interdisciplinarity is only successful as a form of knowledge and scientific practice to the extent that the using discipline (and, to the same extent the subject who practices it) assumes the used discipline and strictly moves through its problem"(13).
In this sense, interdisciplinarity represents any activity developed and experienced from different foci, integrating various contents and converging them towards a certain goal. In other words, it covers a phenomenon that must be analyzed from the perspective of several knowledge areas, so that the different professionals involved can picture it as a whole(14).
We found that, once again, the dichotomy between theory and practice was evidenced. The academic discourse is interdisciplinary but, in the practical world, it is disciplinarity that reigns (the "feuds" of specialties prevail). In this study, we found that it is the academy itself, through its education process, which perpetuates disciplinary practice. Joint activities are little explored and, when they occur, they do not allow participants to perceive the importance of the professional roles different members play and how they are connected with their own professional role.
Our approach to health team members' view of their colleagues was fast, restricted to one single practice site and, therefore, limited. We believe similar studies with a larger number of informants should be developed. These could support the construction of a health practice that truly involves teamwork.
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Recebido em: 28.9.2005
Aprovado em: 3.7.2006