Pluralistic dialoguing: A theory of interdisciplinary teamworking

By Antoinette McCallin, Ph.D., M.A. (hons), B.A., RGON

Abstract

The aim of this emerging grounded theory study was to discover the main
concerns of health professionals working in interdisciplinary teams, and to
explain the processes team members used to continually resolve practice
problems. Data collected from forty-four participants from seven disciplines in
two teaching hospitals in New Zealand, included eighty hours each of
interviewing and participant observation. In this paper the theory of pluralistic
dialoguing is presented. It is argued that interdisciplinary work is possible when
the team replaces the discipline focus with a client-focused care and thinks
differently about service delivery. Thinking cooperatively requires individual team
members to dialogue with colleagues, thereby deconstructing traditional ways of
thinking and reconstructing new approaches to interdisciplinary practice.
Although dialoguing was an informal process occurring within clinical spaces, as
the effects of health reform and restructuring intensify teams also need to
establish formal dialogue groups to facilitate team practice development and
support team learning in the continually changing fast-paced practice context.

Introduction

Over the past decade the interdisciplinary team has received mixed reviews.
While the interdisciplinary team is generally seen as a means to change
professional practice and foster interprofessional collaboration (Leathard, 2003;
Sullivan, 1998) it is also viewed as a means to promote clinical improvement in
care and the outcomes of care, thereby improving public health and quality
service provision (Lax & Galvin, 2002; Manion, Lorimer & Leander, 1996). As
the care needs of clients have changed health care organisations have
challenged traditional models of service delivery and endorsed the
interdisciplinary team as a new model of practice that will supposedly reduce
costs and improve the quality of care (Dodge, 2003). Interdisciplinary teams are
usually expected to provide efficient, effective integrated care in restructuring
health organisations (De Back, 1999). While team effectiveness is important
(Millward & Jeffries, 2001; Schofield & Amodeo, 1999) integrating the disciplines
in practice is much more challenging. This suggests that the process of
teamworking has received less attention despite the fact that no one discipline
can provide integrated care for clients with multiple needs, which often crosses
many disciplinary boundaries (Gillam & Irvine, 2000).

The interdisciplinary team is defined as one in which clinicians from various
disciplines such as medicine, nursing, occupational therapy, physiotherapy, and
social work cooperate with each other, sharing leadership, assessment, goal
setting, problem-solving and decision making so that care is coordinated and
client outcomes optimised. While the assumption that clinicians from different
disciplines will automatically integrate care effectively is a worthy goal the reality
may be somewhat different (Long, 2001; Masterton, 2002) suggesting that
interdisciplinary team members may lack understanding of what is involved
(O’Connell, 2001). Too often interdisciplinary teamwork seemingly evolves from
trial and error learning. Indeed, Long (2001) observes that while there is
longstanding general support for interdisciplinary work many variables limit
implementation in less-than-ideal environments. Long though urges colleagues
to concentrate on the successes.

In this paper one of the successes, some of the findings from an investigation
into interdisciplinary teamwork in the acute care hospital are presented
(McCallin 1999a, McCallin 1999b). The theory of pluralistic dialoguing is
introduced and hopefully offers insights into interdisciplinary teamworking
explaining how health professionals from different disciplines support colleagues
as they put aside disciplinary differences, thinking through and learning new
ways of working cooperatively for the common good of the client. Discussion
begins with a brief outline of the research topic, the approach and the findings
of the research. Next, the meaning of pluralistic dialoguing is presented and
explored as thinking processes involving breaking stereotypical images,
grappling with different mind-sets, negotiating service provision and engaging in
a dialogical culture. Implications for practice are considered in the discussion
and the limitations of the study are evaluated.

Refining the Research Topic

Research began with a general interest in examining nursing practice in the
health reform context. Nursing practice was challenged by organisational
change and wider social reform on a scale that was unprecedented in the
history of health service delivery in New Zealand. However, perusal of the
literature suggested that the magnitude of changes was such that reform could
not help but affect all health professionals (McCallin, 2001, 2003). Scrutinising
one professional group in isolation from others raised questions. Even though
nursing practice was the general area of interest maybe it was unwise to view
nursing as a separate entity when practice responsibilities and professional
boundaries were blurring for all health professionals. But, what exactly was the
research problem?

The topic was eventually refined becoming interprofessional practice. An initial
literature review suggested that while there were anecdotal accounts of
interprofessional work there was little published research in the area (Bishop &
Scudder, 1985; Casto & Julia, 1994; Gabe et al. 1994; Leathard, 1994; Ovretveit,
1993; Petersen, 1994; Soothill et al. 1995). Existing literature emphasised power
issues and problematic professional relationships (Ashley, 1976; Daniel, 1990;
Davies, 1995; Hugman, 1991; Willis, 1989; Witz, 1992). Although literature
heightened sensitivity to interprofessional tensions questions were raised about
predetermining problems that possibly supported unsubstantiated myths and
assumptions as well.

The Research Approach

Glaser’s (1978, 1992, 1996) style of grounded theory was selected for the
project because it supported the emergence of problems as identified by the
participant group. Grounded theory is based on the belief that, as individuals
within groups comprehend events personally, common patterns of behaviour are
revealed (Glaser, 1998). As a group interacts together people do in fact make
sense of their environment despite apparent chaos (Hutchinson, 1993). While
there was a new emphasis on the development of interdisciplinary teamwork
there was no research-based knowledge documenting how health professionals
worked together in an increasingly complex, changing context. The method was
well suited to understanding the social processes inherent in interdisciplinary
teamwork in a seemingly chaotic environment.

One of the strengths of grounded theory is that it explains what is actually
happening in practical life, rather than describing what should be going on. The
premise was useful as issues were varied making it difficult to identify a
particular problem. The method created a scientifically legitimate space whereby
participants could explain their main concern and how they continually resolved
that. Concepts did not have to be identified as predetermined variables, but
would emerge from participant observation and interview. The goal was to
present an “integrated set of hypotheses [that accounted] for much of the
behaviour seen in a substantive area” (Glaser, 1998, p. 3).

Therefore, the aim of this research was to discover the main concerns of health
professionals working in interdisciplinary teams, and to explain the processes
team members used to continually resolve practice problems in a restructuring
workplace in New Zealand. In the study the term interdisciplinary referred to
people with different training and preparation (e.g. management, medicine,
nursing, occupational therapy, physiotherapy, dietetics, and social work) who
shared common objectives but made differing, complementary contributions to
patient care (Leathard, 1994). Forty-four participants from three teams in two
major acute-care teaching hospitals joined the study. In total there were eighty
hours of interviewing and eighty hours of participant observation.

The Research Findings

In this research it was clear that health professionals working in interdisciplinary
teams were concerned about the client service and meeting service needs.
Concerns were resolved using the process of pluralistic dialoguing. This was a
means for discussing differences that supported team members who were
thinking through and constructing new ways of working together. It emerged as
clinicians integrated multiple perspectives, which contributed to the clinical and
organisational management of the client service. Pluralistic dialoguing had two
complementary phases. These were rethinking professional responsibilities and
reframing team responsibilities that reshaped thinking and team learning. Thus
health professionals learned to think differently about meeting service needs as
they broke stereotypical images and grappled with different mind-sets. Thinking
continued to change as team members negotiated service provision and
learned how to engage in the dialogic culture (McCallin, 1999a; McCallin
1999b).

The Meaning of Pluralistic Dialoguing

The one variable that recurred constantly in this research was communication.
Participants were always talking, talking, talking. Talking is so commonplace that
we tend to regard it as a ubiquitous process although it is the means by which
people confirm what is happening and why (Hewitt, 1997). In this study, most
team members had specialist knowledge, but in order to function cooperatively,
they had to pool information, share ideas, consult and network so they could
manage service needs. Clinicians talked formally and informally, collectively and
casually as they moved around the clinical spaces. Clinicians agreed, disagreed,
discussed, debated, explored, explained, liaised, listened, networked,
negotiated, questioned, challenged, connected, and communicated. Over and
over again team members were observed conversing together, propping up
walls, liaising in lifts, chatting in corridors, musing at meal breaks, and
discussing disciplinary differences at team meetings or in spontaneous
conversations taking place as they worked together. Dialoguing, the basic social
process, pervaded practice and was confirmed as the essence of successful
interdisciplinary teamworking.

Pluralistic dialoguing was the means for drawing together diversity and
difference as professionals from various disciplines learned how to work
cooperatively with complex patients in a context where change and complexity
prevailed. Discussions supported clinicians coordinating individual actions and
interactions so that teamworking was possible. Clearly, pluralistic dialoguing
helped clinicians redefine situations as they focused on the client and searched
for shared meaning in practice. Dialoguing eased cooperation between
disciplinary groups, and was the medium for channelling differences into a new
form of interdisciplinary practice.

Dialoguing was possible because many participants in this study were willing to
think differently about their professional work as they deconstructed traditional
thinking in order to provide client-focused care. Clinicians changed thinking by
breaking stereotypical images and grappling with different mind-sets. Thinking
differently helped experienced practitioners to respond to restructuring, as they
sought new ways of fulfilling functional responsibilities for the organisation. They
also made sense of their world by reframing team responsibilities, discussing
new approaches and resynthesising thinking while negotiating service provision
and engaging in the dialogic culture. In this study, the client was the catalyst for
cooperative work that facilitated political and cultural change in increasingly
pluralistic organisations.

As health services are modernised hospitals have become pluralistic as
widespread interests, conflict, and power influence the organisation (Morgan,
1997). Pluralism is a political concept, which challenges authoritarian control as
it emphasises integration across diverse, powerful interest groups. Pluralism is
not new in society (Drucker, 1989) yet its introduction into health service
management has challenged the historical disciplinary power bases found in
hierarchical hospital bureaucracies. Pluralism emphasises function and
performance impacting on professional practice in the knowledge based
pluralistic organisation (Drucker, 1989). While professional practitioners respect
specialised knowledge, skill and expertise, today knowledge must support
organisational task and function (Drucker, 1995). Effective function in the teambased
organisation is promoted if people work together in small teams, which
share a vision, goals, and a meaningful purpose (Zohar, 1997).Yet, this
approach requires a radical new way of thinking to understand a world where
meaning is paradoxical, uncertain, and complex.

Changing Thinking

The process of pluralistic dialoguing is about changing thinking. Interestingly, the
thinking processes revealed in this study, rethinking professional responsibility
and reframing team responsibility, mirror the dialogue process described by
David Bohm (Bohm & Peat, 1987). Bohm described a dialogue process that
encompasses deconstruction and resynthesis. During the deconstructive stage
people let go of personal viewpoints that are compared and considered in
dialogical conversations (Zohar & Marshall, 1994). All points of view are
analysed for meaning and underlying assumptions so that deep understandings
surface as insights are revealed (Bohm, 1994). As self-understanding, prejudice,
and emotions are uncovered the flow of meaning between people begins.

Dialogue has the potential to affect collective thinking (Nichol, 1994, p. xv). As
individuals redefine thoughts in conversation with others, possibilities are
explored and interpretation and understanding of the whole changes (Bohm,
1994). In order to dialogue meaningfully with others clinicians had to let the
usual ways of thinking go by breaking stereotypical images. Comparisons and
analysis proceeded as team members grappled with different mind-sets when
they examined alternative worldviews in team learning situations. Frustration
lessened once clinicians realised that professional responsibilities could be
realised differently if thinking changed. In this sense rethinking was an unlocking
process. Clinicians had to identify the routine images first in order to find out
exactly what shaped existing agreements before they were free to explore
conventional thinking, and consider changing interactions and behaviour.
Rethinking did not happen as a neat and tidy process but took place as
clinicians discussed options for client-focused care in the changing context.

In the second stage of dialogue, resynthesis is possible. “When the rigid, tacit
infrastructure is loosened, the mind begins to shift in a new order” (Bohm &
Peat, 1987, p. 244). Bohm (1994) argues that dialogue moves forward again
when people discover they are listening to others because they have found a
common ground. As a new way of looking at the world emerges, previous ideas
and experiences are blended into shared understandings. In this study,
differences were diffused when clinicians centred on client-focused care. It was
easier to let go of the traditional disciplinary thinking if the patient was the centre
of attention when the team negotiated service provision. Likewise, after
clinicians accepted that the many different approaches to client-focused care
supported improved service delivery, the team was ready to engage in the
dialogic culture. Thinking differently was relatively straightforward once clinicians
realised that thinking outside of the square was acceptable. The stages of
thinking are summarised: [please see PDF version for all digrams]

Breaking Stereotypical Images

Clinicians broke stereotypical images as clinicians integrated individual
responsibilities for meeting service needs with the other disciplines. Thinking
differently was challenging. Cultural stereotypes pervade interprofessional
interactions in the health professions, and traditionally, these have blocked
exploration of disciplinary differences between colleagues. Before thinking could
change disciplinary contradictions and tensions had to be exposed.

That word equality is an awkward word really because it brings in all sorts of
connotations about the hierarchy of systems and professionals. It’s to do with
stereotyping and some professions are seen to be much more superior in the
sense of comparing them to others. To me, equality is really about being able to
work together with mutual respect. The people identify each other’s role and
place within that team and respect that. … That is what makes you equal. It is
not that your responsibilities are equal or training, or skill. That is varied. But I’m
just as good as they are. The trouble is there is an awful lot of historical
stereotyping that goes on. I think the health system is changing incredibly fast
and I don’t think people’s perceptions are changing at the same speed. It is
probably up to us to forge the understanding.

Part of the deconstruction process was undoing existing images of the world so
that the team could think about the client and focus on working together.

So much is about chaos. I might have a rule now but suddenly
something else has come along and …… we’ve changed our minds!
[Some people] are pedantic black and white thinkers – there is no gray
in their world.You can get away with chaos until you come up against
the black and white thinker. The black and white view tells her that the
beds have been closed, staff have taken annual leave and she’s sticking
to her guns! … We should not be compromising patient care because
we won’t open the beds. I’ve rung around the other wards and had a
conversation and we think we’ll be able to discharge someone else.
Those people are patient focused enough to understand that it is a bit
gray here but we need to get patients out. Let’s not make an issue of it.
Let’s have a conversation about it and move the others upstairs. The
patients keep coming and a little group has collaborated here …

Conversations were critical in pluralistic dialoguing and a means to break down
the stereotypical images of reality so teamworking could proceed. Sometimes a
team retreated into familiar disciplinary territory.

For all the groups in the hospital the patient is still the strongest tie. So
if ever there’s an issue they don’t think as an interdisciplinary team to
sort it out at the team level. They go back to their disciplines and fight
from that corner. That’s where their strength is. And that’s also their
greatest weakness because they are seeing things from their own point
of view rather than looking at the whole aspect.

The impulse to resort to disciplinary defensiveness (Senge, 1990) that
undermines cooperative action protects unconscious assumptions and emotions
thereby blocking thinking. Then, the interdisciplinary team struggled to cooperate,
as individuals had to change their thinking first if the team was to change.

It’s about people and how they manage change … they have been
exposed to so much change … and it’s the face-to-face communication
and talking through the issues that is important. If people are
threatened they go into siege mentality without really thinking through
that there may be a better way to do things…. Politically you may not
have much time to do things. Politically we have to respond quickly so
we end up with emergency meetings and planning strategies. That’s not
a good way to manage…. The ones who are moving forward by
themselves are the ones who come and talk.… We just chat.We talk
about ideas and they come and bounce ideas off me and I bounce
ideas off them. And then they go off and move the others forward.

This deconstructive stage of pluralistic dialoguing was an active learning
process whereby individuals challenged familiar ways of looking at the world.
Freire and Shor (1987) suggest “dialogue seals the act of knowing, which is
never individual, even though it has an individual dimension” (p. 4). Pluralistic
dialoguing helped team members to suspend differences until they were ready
to examine situations openly, honestly and talk with colleagues.

Grappling with Different Mind-Sets

In this study grappling with different mind-sets referred to the way an individual
questioned familiar patterns of thinking that were out-of-step with either
colleagues of the changing organisation. It was founded on a commitment to
understand. Conversations were a means not only to learn, but to discuss
problems and ideas.

There is an expectation of discussion—it’s not necessarily agreement
but if there’s a problem, let’s talk about it. … I’ll start a conversation
because I honestly don’t know what something means.… Team
members are usually very good at something so often we will have a
conversation where there’s this learning thing going on. And we learn
from each other. So it’s not just discussion.We want to understand.

Conversation was critical to understand the whole as too often fragmented
thinking has unexpected consequences if individuals think and act individually
(Bohm, 1994). Some participants spoke of the disciplinary socialisation that
tended to emphasise disciplinary differences. Once this was put aside, dialogue
followed.

I see the doctor-nurse relationship as absolutely symbiotic.We need
them and they need us. Our knowledge bases are totally different.We
come from different perspectives but the two complement each other….
Now, the client is getting a less fragmented approach to care and
everybody knows what everyone else is doing…. They are sharing and
asking questions and beginning to work as a team…. If you are going to
sit together everyone has to feel confident that while the professions
don’t necessarily agree they do have a relationship where there is
potential to discuss issues without conflict.

The struggle to explore conflicting views was seemingly impossible for some
though. Bohm (1994) observes that when automatic thinking is well entrenched,
thought is fixed, static, rooted in the past. Sometimes an individual had such
different values and beliefs that any sort of teamworking was simply impossible.

I worked in a setting where I had very different beliefs and values of
how a patient should be treated as opposed to the other staff … was
following my training. Going into a situation where people had different
views and different attitudes—it was hard to change those attitudes
especially when I was dealing with people who hadn’t had much
education. They had life experience but they didn’t have formal
education. And they hadn’t learned the reason why we did things like
that. The result was that I battled on and that upset me so much I had
to leave because I couldn’t change. I didn’t want to compromise my
beliefs and myself so I left the situation. I just couldn’t work like that. It
would have meant losing what I believed in, just to conform.

Compromise was fraught with tension if a collective purpose was lacking. Those
who struggled to think differently insisted on defending their thoroughly
entrenched thought processes despite the changing context.

There are always some that won’t see themselves as changing, or
growing…. That doesn’t work very well in teams.… People who adapt
most might be the people who are able to listen.… Change is only
possible if there’s dialogue among teams so that what is possible, or not
possible, is clearly spelled out. And that will probably cut some
professionals out. Not necessarily just doctors but those people who are
not able to recognise that they are finding it harder to change.

While experienced clinicians were used to working through differences to
improve client care there were others who had strong disciplinary allegiances,
who did not appreciate that traditional adversarial interactions threatened
interdisciplinary teamworking. Changing thinking was easier when the team had
a common goal.

So, where do we start from when the world views are wide apart? Do
we accept the world’s really complex out there? What is the common
ground in our work? We can’t marry the worldviews of the disciplines.
There is just no way health and commerce will come together! If you
are trying to manage doctors and nurses and physios and OTs and you
are coming from management, you look through management’s eyes.
Don’t look through medical eyes, or nursing eyes! So I do think there is
a common thing and it depends what the goal is. If you are trying to
manage a ward, well where is management sitting there? Which
perspectives are useful and which arguments do you value in the
group? Do you agree on this approach? Yes, we do! OK! That’s how
we’ll approach it! And there the compromise occurs for the discipline.

Compromise though was not necessarily healthy as it implied powerful
interactions clarifying winners and losers that thwarted the cooperative spirit
(Zohar, 1997).

Negotiating Service Provision

Nonetheless, new understandings and meanings emerged as clinicians
negotiated service provision, integrating individual contributions with the
common purpose and the activities of the wider organisation. Negotiation of
interests was consistent with Bohm’s (1996) idea that resynthesis as a continual
movement, backwards and forwards between people, that draws out shared
ideas. In dialogue, “each person does not attempt to make common certain
ideas or items of information that are already known to him. Rather, it may be
said that the two people are making something in common, i.e., creating
something new together” (p. 2). When every discipline focused on the client
pluralistic dialoguing was dynamic.

The team is a two-way thing. It’s like a jigsaw—a moving jigsaw. It is a
moving pattern. And so a new person has got to fit in and the team is a
new pattern once they come in.You’ve got to have that pattern working.
It’s not just the new person but it is the team as well. And that leaves us
free for re-creation. That way everyone gets involved and it builds in
itself…. People can go out from the team as individuals completely and
they are entitled to do that. And we are very happy that they do that.
They go out in their own right and stand as an individual.Your persona
belongs to you but it gives to the team and the team gives back to it.

Much of the negotiation in pluralistic dialoguing centred on problem solving for
clients. Although Bohm (1996) questions whether dialogue is possible in
bureaucratic organisations where superior-subordinate relationships prevail,
clinicians questioned contradictions and confusions, seeking what Bohm (1994)
calls some coherence in an incoherent whole. In this sense negotiation was a
delicate process:

A team that works well has a collective responsibility for the patient. I
would never talk about anyone else’s work. Although I might know what
should be done I am not the practitioner registered to give that
information. I am very careful there. I have been in the team a long time
and I know how far to go and what appropriate dialogue is in relation to
patients and our roles.… I leave the [discussion] to the other
professionals but at the same time I have to have a good understanding
of what the other team members do and what they might say.

Talking through patient-focused care was more than persuading others to
change thinking. Dialogue was important to support collective thinking. As
clinicians understood each other better, collective thought became more
coherent. Bohm (1996) argues that when the thinking process is shared,
communication becomes explicit, as “we have to share our consciousness and
to be able to think together, in order to do intelligently whatever is necessary” (p.
15). Free, open discussion involving everyone was important to work through
different points of view and find a place for team agreement.

It’s communication! If there is a team involved then you need to talk not
just to the nurses who are there most of the time, but to the OTs and
physios who are in and out. So that is a responsibility to try not to make
too many unilateral decisions. There are certainly unilateral decisions
about medication changes, which aren’t a problem, but in terms of the
overall aim for the person who needs to get people on board, there
needs to be an opportunity for discussion. Ideally I would like to talk to
people, and agree where we’re going as a group and make sure that
the team was happy about that.

Engaging in the Dialogic Culture

In this study clinicians engaged in the dialogic culture when they shared ideas
freely and frankly, while they consulted over the most effective means of fulfilling
functional responsibility for meeting client needs. Both-and thinking underpinned
dialogue and reflected the clinician’s ability to think simultaneously in parts and
re-look at the whole, that was always much greater than the sum of the parts.
Both-and thinking is Zohar’s (1997) quantum thinking that “gives us our intuitive,
insightful, creative thinking, the kind of thinking with which we challenge our
assumptions and change our mental models” (p. 120). When collective thinking
emerged, anything was possible.

Everyone gets involved in the team. And the way the new person sees
us all relating—that builds on itself. … It’s role modelling from every
single person in the team. It’s become a culture and it builds on itself….
It’s our expertise and it’s our manner of relating to people…. It’s a very
synergistic thing. I would not have the reputation I have without this
team. I wouldn’t know about a lot of the things I do. It builds on itself—
like a snowball! The team keeps on building and we all build on each
other. But it is a win-win situation.

The team culture changed gradually as clinical experts looked beyond the
familiar disciplinary boundaries to engage in a new approach to interdisciplinary
practice. It was easier to change thinking when team members listened carefully
to colleagues.

Now we work as a group and the consultants are listening and
prepared to admit that they don’t know what is the best type of
treatment for this patient. But perhaps the physio knows? Or, perhaps
the OT? Or, perhaps today it’s the nurse who’s doing the transferring.
Ten years ago the House Surgeon would have been doing that … the
complexity and uncertainty of the work are part of the problem. At least
people are aware that teamwork is complex but it’s not fragile. In the
past the team was too fragile for a new grad to give their opinions at a
team meeting, whereas now the team is not going to fall apart if
someone says something out of place.

Acceptance of diversity created a climate whereby team members talked
together as they sought a common understanding that was client focused.
Dialogue certainly challenged traditional cultural patterns of domination (Freire &
Shor, 1987). If thinking was to change openness and honesty were essential.

It’s about how you create a team and what gives it meaning. A lot is to do
with where the ownership lies and whether people are more willing to give
things a go or not. Kiwis have more of that English reserve where you say
one thing and probably think another. People do think and yet they are
running counter to what they probably feel. People really aren’t direct
when they’ve got a problem or an issue. It tends to filter back through
other people and is addressed in a roundabout way and that lacks
honesty…. If we were being facilitative we could be open and talk honestly
… it’s all about developing a culture. When new people come in, can they
actually fit in with what’s there?

Sharing ideas, opinions, and thoughts frankly was very much a part of everyday
teamworking. Building a team and engaging in the dialogic culture was an
ongoing, dynamic activity.

We have been to management and team building days away … team
building is a fallacy! I think you need to get to know each other and get
on with each other and understand each other before you can challenge
each other and be open with each other for the better. This whole
business of going away together and going on hikes together is
nonsense! Team building happens as the team works together day by
day by day.You can’t build a team by going away for two days.You build
a team over three hundred and sixty-five days of the year.

Engaging in interdisciplinary teamworking also involved a genuine desire to
understand and work cooperatively with colleagues. In this study, the team
person who accepted individual responsibility for the collective team outcome
was highly valued.

Communication is what it is all about. It’s someone being clear about
what they do, so it’s clarity of roles. The person who fits into the team
talks about what they are doing with other team members being
discursive, being flexible, and being a good listener. It’s the person
who’s even in their mood, who has a sense of humour, and can keep
their sights clearly focused on what we are really about. Someone who
appreciates what people do. So someone who is reflective—someone
who talks! When it comes down to it, it doesn’t matter what they say as
long as they will talk and be open and not get upset when they are
challenged—that is part of learning. So, what makes a good team
member? Someone who is willing to put forward their ideas, talk about
it, reflect on it, focus on what the client requires the team to do for them,
and listen to what others have to say.

Thus pluralistic dialoguing was fundamental to the culture of care that is based
on shared meanings. It supported Bohm’s (1996) beliefs that, in dialogue, the
stream of meaning flows among, between and through people and “is the ‘glue’
or ‘cement’ that holds people and societies together” (p. 6). In this study, shared
meanings were the essence of pluralistic dialoguing.

Discussion

Pluralistic dialoguing did not evolve in a purist, theoretical sense. Dialogue was
self-activated by highly motivated practitioners who were committed learners.
The dialogue process was self-generated because individuals invested in the
team and accepted an individual-collective responsibility for cooperative
practice. While pluralistic dialoguing was well developed in the smaller teams
studied Bohm (1996) warns that small groups are accomplished at making
“cozy adjustments” (p. 13) whereby people are polite to each other as they avoid
dealing with the contentious issues. Bohm (1994) suggests also that dialogue is
unlikely to happen if a group does not set out with the deliberate intent of
entering into dialogue per se.

According to Bohm, dialogue begins when there is discussion about thinking
processes and talk about dialogue, as conditioned social responses and
reflexive thinking block the openness of thinking required. “If people who have
no notion of this whole process of thought and dialogue get together it’s
possible that they might find a way, but chances are they would not” (p. 194).
The teams studied in this research project were rather different. Although Bohm
(1994) believes that dialogue works best in a dialogic seminar of thirty to forty
people representing a microcosm of society, in this study the dialogical groups
were teams working in a changing context. The dialogical culture was the
everyday reality; it was a constantly moving construction that was not fixed in
time and space.

The basic social process of pluralistic dialoguing is possibly tenuous and
dependent on particular personalities in a certain context, because it emerged
in practice and not from a forum separate from the usual activities of practical
life. Clinicians had to dialogue in action because it was well nigh impossible to
release complete teams from specialist acute-care areas for weekends of
dialogical seminars. However, clinicians learned quickly how to share meaning
as they worked closely together discovering common problems, which had no
easy answers. Close connections in adversity foster fellowship and cooperation
(Bohm, 1994). Professional and team responsibilities were explored in action.
There was no other way in the acute care environment.

The focus on dialogue in action suggests that conversations may have
concentrated on tasks at the expense of process-based teamworking issues,
which are just as important. While organisations value efficiency and
effectiveness if more than lip service is to be paid to the interdisciplinary team
as a means to improve quality service provision, the organisation must also
recognise that interdisciplinary teams may be changing professional culture and
require learning support if team practice development is to progress. Health
reform encompasses cultural change so health professionals need time,
coaching and mentoring, to work through changing values, beliefs, and
attitudes, as they assimilate new ways of thinking into new approaches to
practice.

Limitations

While it is recognised that theoretical coding needs strengthening the main
limitation of this research concerns theoretical sampling. Data was gathered
from hospital teams and although the original research design included study of
community teams, as well as clients and families who were the recipients of
care, the latter two groups were not interviewed or observed due to time
constraints associated with doctoral research. Further research to evaluate
differences, if any, working in teams in the hospital or community and more
importantly, to talk to the often unrecognised team members, the lay members
(clients and their caregivers) who also shape interdisciplinary teamworking is
necessary.

Conclusion

In this paper it has been argued that, pluralistic dialoguing is unique in that it is
a form of dialogue in action, which is created by clinicians challenged with
health restructuring in acute care hospitals. Dialogue is a fluid, evolutionary
process that is time-dependent and affected by constant change. Involvement in
pluralistic dialoguing was always individual, as people always chose to be
involved with others, or not, as the case may be. Successful team practice
respected individuality, welcomed it, and integrated it into a cooperative practice
that benefited clients, colleagues, and the organisation. Pluralistic dialoguing
facilitated interdisciplinary teamworking.

Author

Antoinette McCallin PhD, MA (Hons), BA, RGON
Senior Lecturer
Division of Health Care Practice
Faculty of Health
Auckland University of Technology
Private Bag 92006
Auckland, NEW ZEALAND

Correspondence

Phone: 64 09 480 7667
E-mail: mccallin@ihug.co.nz (Home)
amccalli@aut.ac.nz (Work)

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