lnterdisciplinarism is a broad concept which indicates the idea of something happening between disciplines of mutual, reciprocal nature. In the health care arena, where the potential in collaboration between nursing and medicine has not been fully actualized in terms of patient care benefits, there is promise in educationbased interdisciplinary efforts. Currently, much rhetoric supports concepts of interdisciplinary activities, but actual programs which exist and are reported to be successful are few in number. Factors related to this situation, and issues to be considered in interdisciplinary curriculum planning are the concern of this article. In addition, the focus will be work between nurses and physicians from a nursing point of view.
Current Data and Future Needs
Although little research evidence exists to support positively outcomes of interdisciplinary education, reports of several favorable experiences have been cited. In particular, student groups have been identified as highly responsive to such curriculum patterning.1"3 Further recommendations from leading policy groups strongly support interdisciplinary planning asa way of fostering collaboration between disciplines which ultimately leads to more effective utilization of human resources."
Health care delivery in the latter part of the century will require vastly different attitudes and perspectives among health disciplines. The knowledge explosion and advancing technologies will require a broadening of perspectives to include not only what nurses and doctors can accomplish, but how they are to accomplish best their related purposes. As cited by one author, "Our planet and our civilization face many crises that will yield to human interdisciplinary effort more easily than they will to specialization."8 In considering relationships between nurses and doctors, the National Joint Practice Commission summarizes the issue succinctly by stating "In view of their growing interdependence, it becomes increasingly evident that successful or effective delivery of health care cannot be achieved through unilateral determination of functions by either medicine or nursing
Consumers will address interdisciplinary effectiveness from both an economic as well as quality care perspective. The costliness of health care in terms of time, money and personhood is often increased through lack of interprofessional communications and understanding. As consumers become increasingly sophisticated about their role in health, as well as understanding better what the "professional's" role can and should be, they are not likely to remain quiet about concerns related to their needs.
Educators will need to give a hard look at what constitutes appropriate education for tomorrow's practitioners. In the current time of increasing diversity of services, complexities of health and illness, changing values, and increasing specialization, there is more than evera need for students to be able to function effectively on an interprofessional level. Leininger cites that "from an anthropological point of view, there are few health systems in the world that are as stra tified a nd sta t us-bo u nd a s the America ? system, yet there is limited discussion of the impact of this structural feature on health education and health care delivery."* Indeed, there is need to assess relevancy in current educational systems and to adapt curriculum patterns appropriately.
It is questionable how best to accomplish interdisciplinary efforts, Traditional learning about "other" disciplines as one becomes a member of a given work force generally has not been satisfactory. Efforts which occur on the educational level make sense, yet are also fraught with difficulties. In order for a given program to be developed effectively, numerous issues need consideration.
Persons who make up faculty groups today most likely have not been involved in interprofessional educational opportunities themselves as students. More often than not, a gap may exist in what a group perceives as another's role in the provision of health care. Faculty in nursing and medicine are well acquainted with issues of power, status, and role stereotyping which traditionally have affected work relationships. To propose interdisciplinary methodologies which require them to alter their usual frame of reference to one which incorporates interprofessional views and perceptions is to require a very changed focus. Uncertainty related to this kind of role expectation can be significant and be cause for resistance to program development.
Concepts integral to membership in a profession may be viewed as inherently contrary to interdisciplinary ventures. The issue of autonomy is especially critical to consider.10 "Self-governing" bespeaks of independent activities common to a given group. Where nursing is presently struggling to establish autonomy, the idea of participating with those of other disciplines indicates the need for compromise, negotiation and most likely change. The point for collaboration on a professional level can be viewed as threatening to self management and therefore problematical.
Trust in Relationships
Because educational programs historically have carried out course work unilaterally, the developmental period of health professionals has not held the opportunity for interprofessional relationship development. How ironic this is when considering the fact that there is a profound need for reliance upon and understanding between professionals when persons enter and function in posteducational work settings.
Development of trust occurs where personal, environmental and behavioral factors facilitate its growth. Security of self in a given role is a prerequisite to the capacity to extend self to others, and to provide the "give and take" which builds the foundation of a relationship. As a part of hospital-based nursing roles, nurses traditionally have had to coordinate interprofessional relationships. However, system, social, and cultural factors have interfered in interprofessional trust development.
The historically dependent position of women, and therefore nurses in society, the frank need of many nursing activities being subject to "doctor's orders," and the resistance of some physicians to accept nursing judgments as valid have been sources of irritation and anger. Further, system factors of high staff turnover rates, and the variable - and at times unreasonable - RN practice expectations have sapped time and energies available for relationships. In addition, the value of interprofessional collaboration and its important relationship to patient care services may have never been emphasized in the educational process; hence, it simply may not have been recognized as an issue needing work. These factos add up to "interference" in the state of trust between nurses and physicians.
To present the idea to nurses of joint efforts with physicians is to address an area where basic foundations for such work are highly variable and largely undeveloped. Some in nursing will respond positively to the potential while others will respond based on their ingrained, more mixed or even largely negative attitudes developed over the years. Interdisciplinary planning maybe too much to ask or expect of nurses without there being cause for suspicion of underlying agendas and purposes in collaboration.
Concepts of power and control are related inherently to membership within a profession. Depending on how these concepts are applied, there exists the potential within nursing and medicine to bring together ideas and abilities to develop a better "product," or outcome for the patient, or to have competing and conflicting interests which may jeopardize ultimate services. How power potentials are utilized relates, in part, to professional patterns of development.
Nursing generally has held an orientation of service to the patient, without conscious concern for power while physicians, on the other hand, have held a service orientation with traditionally recognized power. The work setting also has served to highlight differences in role relationships and in origin of power.
In the hospital, the most active and frequent training ground for health professionals, the focus of nurses has been one of caring for the whole patient and family over an extended, round-the-clock period of time. A physician's orientation generally has been directed differently to disease and cure, and the time a doctor spends with any given patient has been limited comparatively in nature. Both orientations are in keeping with role responsibilities and have been necessary. They also suggest the potential to hold common and overlapping as well as totally different concerns in care. Both bespeak of special knowledges related to the patient, and a certain kind of "power" related to that knowledge.
In care settings where interprofessional relationships are not well developed, pressured times often precipitate forces and feelings counter to constructive activity. Stress often relates to the self and one's ability to get a job done in the best interest of the patient. What may interfere greatly in activities are conflicts and power struggles over role expectations, ambiguities about who is responsible for what, different knowledges about patient care, and whose assessment will be counted. Nurses frequently have not been well understood or recognized for their contributions, and have been overridden by physician "power." In planning for interdisciplinary ventures, such activity may be perceived as a potential arena for further struggle, and hence be resisted.
Professional group orientation in nursing also may counter interdisciplinary efforts. Traditionally, nursing has not been well organized on a collective basis. The historical role of women in society has been related directly to the more politically naive position of nurses. With evolving health care needs as well as roles in nursing, there is a new, clear desire to achieve a different recognition, status and sense of professional respect. In attempts to develop a power base, nursing is asserting itself collectively. To some, the proposal to join forces with others simply may seem counter to group needs, and hence be opposed.
To become involved in collaborative efforts requires openness and exposure. Current, ongoing struggles within nursing are demanding and may include ambivalent feelings about professional membership. It is no secret that nursing forces are divided over many issues and that a special vulnerability exists in relation to issues of professional fragmentation and self -alienation." A legitimate point to consider is that some faculty may not feel comfortable in representing their profession in an interdisciplinary format, especially when it may appear that other professional groups are not having to deal with such developmental problems.
A further point to consider is that of faculty "backlash" related to nurses working with other disciplines, especially medicine. There are risks in becoming aligned with others of non -nursing interests. "Nursing, in spite of its numbers, is still a developing profession, with all the selfconsciousness of youth. In this sense, nurses are intolerant of members of their profession who deviate from 'real nursing'."12 To the extent that involvement in interdisciplinary efforts is perceived as a "side step" to needed efforts within nursing, so too will support for such planning be jeopardized.
Pressures within nursing related to the knowledge explosion and the limited time available to offer nursing content to students present additional stresses to interdisciplinary program viability. Choices related to curriculum content undergo constant evaluation and change. Feelings often exist related to the preference of specific, internal nursing content over that which may be offered in an interdisciplinary format. When consideration is given to the issue of solving problems related to the values of a given community, it is evident that the concept of developing interprofessional understanding and effective collaborative abilities may still be disregarded and little understood by those in educational planning positions. Persons in decisionmaking groups may devalue such efforts, and present obstacles to such planning.
What is the content or purpose in interdisciplinary education that is different from that which occurs within a discipline? It is the opportunity to exchange and practice face to face with others about curriculum content, design and practice unique to a given profession as well as to consider and act upon the most advantageous use of identified resources. It is the learning that transcends profession-bound norms in the interests of patient care problems at hand. It is learning how to function effectively together, to develop understandings about team development and maintenance, goal setting, decision making, negotiation and conflict management.
Content that is addressed in theory as well as practice experiences leads to lively and meaningful education. Via interdisciplinary activities, students are given the opportunity to begin development of skills and attitudes which facilitate total broadbased care in the best interests of a patient. A major course outcome can be the beginning development of the idea that "health care is most completely delivered through a partnership of various practitioners, for their combined expertise can offer more to consumers than professionals who practice in isolation can provide."13 Persons whose primary investments rest within the confines of a given discipline perhaps will not have interest in facilitating interdisciplinary curricular activity. Skillfulness is needed for effective interpretation, acceptance and support of such activity.
Today's student population is older, brighter and brings a new diversity of background to the educational setting. It can be stated generally that students find learning expectations in baccalaureate programs to be demanding. Appropriately, they question why academic pressures are so great, and how the learning expectations will help them in a future role. Specifically, students ask "for more training in the skills they see as necessary for professional survival - the ability to live with conflict, the art of negotiation, the use of power, and the development of selfknowledge - and find these experiences to be lacking in many schools."14
Students benefit from some mechanism which assists them to place perspective on their efforts and what it is that is unique to nursing. Where the opportunity is established for dialogue with persons from other disciplines, there is a greater chance for students to learn how they "fit in" to the health care delivery picture. Interdisciplinary dialogue holds such potential.
Ongoing Faculty Education
Among issues related to interdisciplinary program development, a very major one requiring special attention and support is that of faculty development. It has been cited that faculty have basic needs which are "affected by any approach to education. There are desires for security, for property, for territoriality, and for fast effectiveness."15
In interdisciplinary education, potential course participants need to be apprised adequately of how teaching in this area differs from the methodology used to teach discipline-related theory and content. In essence, faculty need to be ready to become "learners" in relation to a different kind of focus, that is, the teaching of concepts and values across and between disciplines.
For faculty who have functioned in multidisciplinary settings, as well asothers, there may be questions raised as to the necessity of the time needed and rationale related to their participation in onging course related education. One author cites that many persons who think they have functioned on an interdisciplinary basis have really functioned very autonomously. "Health team members tend to talk as if they are 'truly' interdisciplinary, but in reality, they function as separate professional entities in a physical structure that houses different disciplines.""
The process which leads to true sharing and effective problem solving in patient care takes time - to develop leadership styles supportive to course purposes, to exchange about values and relationships to patient care, and to discuss basic educational preparation which makes those of a given profession different from others. It is critical that faculty be brought together prior to and during the process of course implementation in order that they are able to look at common concerns, questions and developments. For many, this may seem too much to ask especially where specific rationale for such programming is difficult to identify.
What about terms related to collaborative planning? Several aspects bear consideration. What are the financing mechanisms established to support nursing? Are they written in such a way to give nursing an appropriately representative "voice" in program planning and administration? There is no room for tokenism in such efforts, and nursing is clearly in a position to be sensitive, and even overly sensitive to such possibilities. Awareness is needed related to this potential, and so too is the ability to risk in such ventures.
In addition, nursing faculty support to persons in interdisciplinary planning positions suggests the need for understanding and acceptance of the "give and take" process inherent to planning. The person who will of necessity win as well as lose issues in the negotiating process of curriculum design walks a fine line in an effort to meet the needs of collaborating discipline interests as well as the needs of nursing. Support for the position and the energies required to meet broad program objectives is necessary if program development and administration is to be carried out effectively.
New learning brings with it growth. However, for faculty involved in interdisciplinary course work, there may be significant conflicts felt in the kind of growth experienced. Faculty are asked to broaden their orientations beyond their usual profession-linked boundaries. Further, they are asked to support their own investments in health care as well as the contributions of others in an egalitarian manner. And, for those in nursing who historically have held an often defensive position toward physicians about nursing's role in patient care, they are asked again to be interpreters of their role. In addition, course-related student benefits are part of a long-term process. Their learning relates to attitudes, broadened perspectives and values, areas which are difficult to measure. A faculty member may question his involvement especially in view of outcomes which are difficult to identify.
Promises to Behold
There are no easy routes to the development of interdisciplinary education programs. The multiple variables which make disciplines different from one another also complicate joining forces. For program planners, it is important to identify those who are in tune with interdisciplinary concepts and to activate their interests. The sooner that programming occurs, so too will exchange on student and faculty levels, and significant progress in this field be achieved.
Recognition is needed by nurses that "others" do not understand nursing in part because educators have not extended themselves beyond their own professional boundaries in the educational process. This issue is not one that is exclusive to nursing, but needs to be addressed by nurses, physicians and others if there is to be understanding and effort to educate across disciplines. Additionally, emphasis is needed in that to propose interdisciplinary activities is not to dilute individual or collective nurse power. Rather, such activities need to be viewed as an opportunity to make strides forward in interprofessional understanding, on behalf of improved patient services.
Where shared learning occurs between disciplines, broadened perspectives are developed by participants. It is energizing and exciting to meet with those from other disciplines, and to learn about disciplinerelated values, purposes and abilities. In such a process, participating members learn a great deal about themselves in ways that can never occur where dialogue is restricted to the practice setting and to those within a profession.
For nurses, there is considerable value in identifying personal and professional values and interests in relation to those of other disciplines. An outcome of such activity is the identification of professional assets and the development of a stronger nursing identity. In turn, this leads to enhanced professional pride and status. In the current evolution of health professions, such development is highly significant.
Where joint program efforts occur, all participants will be moved forward in the educational process. More often than not, faculty will not have had the opportunity to address interprofessional issues in an interdisciplinary education forum. Through guided work together, faculty develop greater understandings about the stresses, responsibilities and rewards which are integral to a given discipline. Such exchange can lead to a new and different interprofessional orientation and sense of respect for others. For developing students, the demonstrated interactions and learning activity of mature faculty also will convey strong messages.
In addition, faculty will have the opportunity to counter directly the stereotypes they themselves as well as students hold. Faculty also can take pride in reducing the too often painful learning that was most likely a part of their experiences as newly graduated health professionals. Although they may not have a readily identifiable understanding about what is "better" about interdisciplinary education, they gain from a commitment toan educational pattern which they deem to be "in the right direction."
Additional satisfactions also can be derived from the issue that student learning which occurs in an interdisciplinary format is progressive and a part of sound preparation for tomorrow's practitioner. Graduates of programs which sponsor such efforts will have understandings integral to their own discipline as well as to others. This will affect how they as individuals relate to health care, as well as how they are a part of a greater health team. Students will be better equipped to be at work on behalf of consumer needs.
No one plan of interdisciplinary action can be projected as optimal to meet a given setting. The variables within a particular set of circumstances need to be assessed closely before mechanisms are developed to support a program. Faculty willingness motivation and commitment to such planning need clear identification. Clearly, student groups are ready for such opportunities.
More and more, recognition is being given to the fact that survival of any one health discipline cannot occur in "solo" form. Manpower issues of the future will demand optimal utilization of human resources. Issues related to territoriality will continue, but should be diminished in nature as those in pioneering positions within interdisciplinary programs begin to experience changes in faculty and student orientation.
Through such programs, a cadre of future clinicians can be developed who will address health delivery issues from a more effective perspective. A major learning outcome will include understandings related to the concept that few problems of major significance can be handled sucessfully by any one discipline.8 That, in and of itself, will be a major learning point which will be useful to all future health care practitioners as well as recipients of care.
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