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ISSN: 1356-1820 (print), 1469-9567 (electronic)
J Interprof Care, 2015; 29(2): 113118
! 2015 Informa UK Ltd. DOI: 10.3109/13561820.2014.954284

ORIGINAL ARTICLE

Interprofessional collaborative patient-centred care: a critical

exploration of two related discourses
Ann Fox1 and Scott Reeves2

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Department of Nutritional Sciences, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario Canada and 2Faculty of Health,
Social Care and Education, Kingston University & St. Georges, London, UK
Abstract

Keywords

There has been sustained international interest from health care policy makers, practitioners,
and researchers in developing interprofessional approaches to delivering patient-centred care.
In this paper, we offer a critical exploration of a selection of professional discourses related to
these practice paradigms, including interprofessional collaboration, patient-centred care, and
the combination of the two. We argue that for some groups of patients, inequalities between
different health and social care professions and between professionals and patients challenge
the successful realization of the positive aims associated with these discourses. Specifically, we
argue that interprofessional and professionalpatient hierarchies raise a number of key
questions about the nature of professions, their relationships with one another as well as their
relationship with patients. We explore how the focus on interprofessional collaboration and
patient-centred care have the potential to reinforce a patient compliance model by shifting
responsibility to patients to do the right thing and by extending the reach of medical power
across other groups of professionals. Our goal is to stimulate debate that leads to enhanced
practice opportunities for health professionals and improved care for patients.

Interprofessional collaboration,
patient-centred practice,
professional practice

Introduction
The past 20 years have witnessed the emergence of a number of
approaches to health care practice that aim to draw together health
and social care professionals in order to collaborate for the
delivery of safe and effective patient care (Adair, 1986; Curley,
McEachern, & Speroff 1998; Xyrichis & Lowton, 2008;
Zwarenstein, Goldman, & Reeves, 2009). This focus on enhancing
interprofessional collaboration acknowledges the unique expertise
of various health and social care professions while encouraging
them to work together to coordinate care, streamline services, and
optimize treatment. This is generally accomplished through
interprofessional education that enables mutual understanding
and appreciation of professional roles, team development
strategies, implementation of communication tools, and establishment of protocols that make best use of professional expertise
and specialization (e.g. Boyce, Moran, Nissen, Chenery, &
Brooks, 2009; Reeves, 2008). Key goals for these collaborative
efforts between professions are to improve care delivery and
enhance patient outcomes through efficacious and efficient care.
These collaborative discourses are often accompanied by
pronounced attempts to put the patient at the centre of the care
team (e.g. Herbert, 2005; Legare & Witteman, 2013). These
efforts can be seen in health and social care professional mandates
to direct care in ways that make patient needs the priority, and in

Received 10 April 2014

Revised 13 June 2014
Accepted 10 August 2014
Published online 2 September 2014

health professional efforts to involve patients in decision-making

about their care (Constand, MacDermid, Dal Bello-Haas & Law,
2014; Elwyn, Edwards, Kinnersley, & Grol, 2000; PeresteloPerez, Gonzalez-Lorenzo, Perez-Ramos, Rivero-Santana, &
Serrano-Aguilar, 2011; Shyu, Chen, Chen, Wang, & Shao,
2008). While most citizens and health professionals would
support these approaches to care, there are several assumptions
that we suggest are worthy of consideration. Efforts to build
collaborative interprofessional teams largely ignore the
inequitable social, political, and economic conditions in which
health care providers work, and efforts to put patients at the
centre of the team assume that patients want and are able to
take on the responsibilities that come with that role. Furthermore,
the encouragement of enhanced involvement in decision-making
and care by a range of professions, as well by patients themselves,
is often noted as a divestment of physician power and authority.
We argue, however, that rather than redistributing power to others,
these seemingly altruistic interprofessional, collaborative,
and patient-centred discourses extend medical power across a
broader scope of players, thereby expanding its reach and
reinforcing professional roles.1
In this paper, we explore the evolution, principles, and
underlying assumptions associated with collaborative and
1

Correspondence: Dr Ann Fox, Department of Nutritional Sciences, Dalla

Lana School of Public Health, University of Toronto, Fitzgerald Building,
155 College Street, Toronto M5S 3E2, Ontario, Canada. E-mail:
ann.fox@utoronto.ca

History

We have employed the term patient centred care in this paper as it is

arguably the most common term in the literature. Its use in this paper also
covers other similar initiatives such as shared decision-making,
patient partnership, and relationship centred care which while
aiming to increase involvement of patients in the organization and
delivery of their care, contain the same issues (e.g. inherent inequalities
between providers of care and the recipients).

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114

A. Fox & S. Reeves

patient-centred approaches, which together embody so much of

the current discourse on patient care. We begin by describing the
evolution of both interprofessional collaboration and patientcentred care discourses with a view to teasing out some of the
taken-for-granted elements of these projects. Drawing on social
theory of the health professions, we offer a critique of some of the
conceptual approaches and raise questions for further consideration. Our goal is to stimulate dialogue, critical thought, and a
deeper understanding of the complexities involved in implementing such strategies.
We employ the term discourse in its post-structuralist
sense, to refer to each of these patient care approaches. We
borrow from Foucault (1972) who saw discourse as a system of
thoughts composed of ideas, attitudes, courses of action, beliefs,
and practices that systematically construct the subjects and the
worlds of which they speak (Lessa, 2006, p. 285). From this
perspective, discourse both reflects and legitimates power and
knowledge. This definition of discourse lends itself to our
exploration of collaborative and patient-centred care in that it
encourages us to consider the broad social processes involved, and
the relations of power through which health care is carried out.

Interprofessional collaboration
Effective interprofessional collaboration among the various health
and social care providers has long been regarded as essential for
delivering high-quality patient care (Cooper, OCarroll, Jenkin, &
Badger, 2007; Evers, 1981; Pethybridge, 2004; Reeves, Lewin,
Espin, & Zwarenstein, 2010). As Larson and LaFasto (1989)
explained over 25 years ago, because health problems have
become defined in complex and multi-faceted terms, health
organisations have discovered it is necessary to have the
information and skills of many disciplines in order to develop
valid solutions and deliver comprehensive care to individuals and
families (p. 17). This early view was echoed by Firth-Cozens
(1998) who argued that effective interprofessional collaboration
in teams can tackle the potential fragmentation of care;
broaden skills; address the complexity of modern care, and
generally improve quality of care for the patient (p. 3). Such
arguments continue to be voiced across the health professions and
health services literature (Forman, Jones, & Thistlethwaite, 2014;
Onyett, 2003).
Similar sentiments have been regularly re-emphasized in the
health care policy literature (Department of Health, 2001; Frenk
et al., 2010; Health Canada, 2008; National Academies of
Practice, 2013; World Health Organisation, 2010). Building
upon these policy statements, Canadas federal government, for
example, funded a number of interprofessional initiatives, which
encouraged health care organizations to implement projects
demonstrating how health care teams could work together on an
interprofessional basis (Health Canada, 2008). More recently,
funding was provided to establish a national center in the US to
coordinate the development and implementation of a range of
interprofessional activities (Brandt, 2013).
Encouragingly, a growing number of research studies have
indicated that interprofessional collaboration can be effective in
reducing staff absenteeism, educating health professional learners,
creating a more satisfying work environment, enhancing patient
safety, and improving the quality of care (Cooper et al., 2007;
Deen, Fortney, & Pyne, 2011; Towle & Godolphin, 2013). These
studies have also helped to delineate the range of factors required
for effective interprofessional collaboration, including a commitment to collaboration, shared trust, regular discussion/feedback on
collaborative goals, open communication systems, clear shared
objectives, a high level of interaction between staff, and low
turnover of personnel. Furthermore, collaboration among health

J Interprof Care, 2015; 29(2): 113118

professionals may be seen as a prerequisite for providing patientcentred care, especially in situations where patients require
specialized expertise from multiple clinicians in order to manage
complex chronic conditions (Keruso, 2010).

Patient-centred care
While many health professionals describe their approach to
practice as being patient centred or patient focused, definitions
vary. Common elements, however, include the involvement of
patients in decision making, sharing of information, power and
responsibility with patients, and demonstrating respect for patient
needs and choices. Ironically, notes Marshall, Kitson, and Zeitz
(2012), these definitions have been developed by health professionals with little input from patients themselves. The roots of
patient-centred care can be linked to various social trends
including the consumer rights movement, the rise of risk
management, and the emergence of quality assurance as a fiscal
management tool within health care organizations (Laine &
Davidoff, 1996; Moloney & Paul, 1991). Moloney and Paul
(1991) have characterized the 1950s and 1960s as the start of
replacing the passive/active relationship between patient and
physician with a model of guidance and cooperation. During this
period, Balint and colleagues (1964) introduced the term
patient-centred medicine to encourage physicians to focus on
patients rather than on disease. The consumer and patient rights
movements of the 1960s and 1970s, as well as the increasing
threats of litigation that emerged during this period, however,
propelled the notion that health care should be more patient
focused (Laine & Davidoff, 1996; Moloney & Paul, 1991). This
more collaborative form of patientphysician relationship represented a significant departure from the previously held belief that
patient participation in health care meant compliance with
doctors orders (Emanuel & Emanuel, 1992; OBrien, Petrie, &
Raeburn, 1992). The rapid development of technology and the
explosion of medical advances during this period also created the
need for more complex decisions to be made and professionals
sought patient involvement to help make difficult treatment
choices (Laine & Davidoff, 1996). The provision of patient
information and the encouragement of patient participation, while
responsive to consumer demands, were also useful health provider
strategies for minimizing legal risk and for arriving at difficult
health care decisions (Laine & Davidoff, 1996).
As patient-centred care became more broadly accepted, health
professionals recognized the need for new humanistic communication, education, and negotiation skills to support patient
decision making (Laine & Davidoff, 1996). Many health
researchers and professional groups have taken up the charge of
humanizing health and social care by developing specific
patient-centred definitions, care models, and tools (Bournes,
2000; Johnston & Cooper, 1997; Mitchell, Closson, Coulis, Flint,
& Gray, 2000; Stewart, 2001). By the beginning of the new
millennium, The Institutes of Medicine (IOM) featured the concept prominently in two key reports Envisioning the National
Health Care Quality (IOM, 2001a) and Crossing the Quality
Chasm (IOM, 2001b).
The elements of patient-centred care, such as respect for
individual beliefs and values, active listening to patients,
involving patients as leaders and experts, family inclusion in
care and decision-making (Mitchell et al., 2000), are similar to
elements of patient empowerment models. Indeed empowerment
is frequently identified as an objective of patient-centred care
(Mead & Bower, 2000) and health professionals are called upon to
help people assert control over the factors which affect their lives
(Elliott & Turrell, 1996; Funnell et al., 1991). Proponents of
patient-centred care, therefore, claim that the approach serves

DOI: 10.3109/13561820.2014.954284

patients, whose self-determined needs become paramount, as well

as health professionals who are able to share responsibility with
patients for making difficult decisions and achieving desired
health outcomes (Fox, 2010). In fact, patient-centred approaches
at the systems level of health care are also being developed, to
ensure that both patients and providers needs and expectations
are met with regard to organized healthcare processes and infrastructure (Juhnke & Muhlbacher, 2013).

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Combining forces: collaborative patient-centred

practice
Thus far, we have treated collaborative and patient-centred care
discourses as discrete entities. It is important to note, however,
that these, as well as other discourses related to patient care, may
be simultaneously in play at any given time. In addition, elements
of various discourses may be borrowed and repackaged to
create new and distinct ones. For example, in Canada, the
collaborative patient-centred practice project, backed by over
800 million dollars in government funding, is described as the
continuous interaction of two or more professionals or disciplines,
organized into a common effort, to solve or explore common
issues with the best possible participation of the patient
(Herbert, 2005, p. 1). The approach is designed to promote
the active participation of each discipline in patient care,
enhance patient- and family-centred goals and values, provide
mechanisms for continuous communication among care givers,
optimize staff participation in clinical decision making within and
across disciplines, and foster respect for disciplinary contributions
of all professionals (Herbert, 2005, p. 2).
How can interprofessional practice and patient centred
care not be good?
It goes without saying that encouragement of health professionals
to work together in the best interests of their patients is desirable.
The reality of doing this, within the context of daily practice,
however, raises questions around feasibility as well as whose
interests are served by such endeavours. As governments and
health care organizations invest significant resources in these
approaches, careful analysis of potential consequences is
warranted.

Interprofessional collaborative patient-centred care

115

boundary tensions often occur (Booth & Hewison, 2002; Reeves

et al., 2010). Furthermore, work by authors such as Hugman
(1991), Wilkinson and Miers (1999) and Baker, Egan-Lee,
Martimianakis, and Reeves (2011) have explored how hierarchies
of power which exist between these groups, create interprofessional friction and conflict, and undermine their abilities to
collaborate in an effective manner.
Research in this area continues to indicate that interprofessional collaboration can be problematic. For example, a number
of studies suggest that that collaboration is often undermined by
boundary infringements, a lack of understanding of one anothers
professional roles/responsibilities, limited communication, and
poorly co-ordinated teamwork (e.g. Allen 2002; Pethybridge,
2004; Reeves et al., 2010; Walby, Greenwell, Mackay, &
Soothill, 1994). A useful illustration of the nature of the inequality
that exists among health care professionals is offered by Cott
(1998) who examined the meanings and structures of healthcare
teams who worked in a hospital-based long-term older adult care
unit. Interviews with team members revealed the existence of two
distinct subgroups: a sub-group consisting of multidisciplinary
professionals (EG rehabilitaiton therapists, dieticians, and social
workers who occupied a high position in the team hierarchy) and
a sub-group consisting of direct care nurses and unregistered
workers who occupied lower positions in the hierarchy.
Supervisory nurses provided the link between the two groups.
While it was found that the multidisciplinary sub-group
collaborated as equals on the team, discussing and agreeing on
aspects of patient care, the sub-group consisting of direct care
staff viewed teamwork in less positive terms, suggesting they
were being told what to do by their senior colleagues (Cott,
1998).
In addition to research studies which have empirically explored
the nature of interprofessional collaboration, a number of highly
publicized failures of interprofessional collaboration have been
reported. In the UK, for example, the Bristol Heart Surgery
Inquiry (Kennedy, 2001), and more recently the Francis Inquiry
(2013) all indicated that health and social care professionals failed
to communicate effectively and to raise clinical concerns with one
another due to issues of status and power differences, resulting in
poor clinical practice and patient deaths.

Patient-centred care challenges

Collaboration challenges
Identifying the implications of any approach to health professional
practice requires an understanding of the complexities involved in
becoming a professional. Freidson (1970) asserts that professionalisation is a process undertaken by occupational groups to
secure exclusive ownership of specific areas of knowledge and
expertise. He argues that in obtaining exclusivity, occupational
groups secure autonomy of practice, which in turn leads to
economic reward and status enhancement (Freidson, 1970). He
suggests that to protect the gains obtained from professionalisation, all groups guard the areas of knowledge and expertise they
have acquired, primarily through the regulation of entry and the
maintenance of professional standards (Freidson, 1970). He
further posits that tension is likely to arise if it is perceived that
a member from a different profession is infringing upon ones
own area of expertise. Freidson (1970) notes that because
medicine was the first occupational group to professionalize,
they secured high status areas of knowledge and expertise, which
resulted in achievement of the highest economic and social
rewards, relative to other groups that professionalized later.
A number of studies support this assertion and have
demonstrated that interprofessional collaboration can be a
particularly problematic activity in which role overlap and

A Cochrane review of patient-centred interventions in clinical

consultations noted effective transfer of patient-centred skills to
health care providers, however, the impact on patients was
variable (Dwamena et al., 2012). While these professionals might
adopt patient-centred approaches in their practices, the effect on
patient satisfaction and health behaviour is not clear (Dwamena
et al., 2012). Although the main features of patient-centred care
are closely tied to what most would consider to be desirable goals
(e.g. patient empowerment, family involvement and support,
individualized care, compassion, and empathy), this assumes that
patients want and are able to be part of the health care team and to
assume responsibility for their own health and health care. Not
only do patients require the informational and economic resources
to be able to take this on, but the increasingly complex technical
landscape of the health care enterprise raises ethical and practical
questions as to the appropriateness of delegating decision-making
to patients. Some critics have described this as the off-loading
of professional responsibility in order to make individuals
responsible for their own fate (Lupton, 1995). In other words,
patients are seen to be responsible for their own disease should
they fail to take responsibility for making the right decisions
and doing the right things to maintain health and prevent
disease.

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A. Fox & S. Reeves

For example, patients with chronic diseases such as diabetes,

cardiovascular disease, asthma, and osteoporosis are expected to
take charge of daily self-care regimens that involve diet, blood
testing, exercise, stress management, and pharmacological interventions in order to prevent the long-term complications
associated with these conditions. When complications do arise,
even among those who have carefully managed their diseases for
years, the outcomes are seen to be the result of self-care neglect
and failure to take responsibility for ones own health (Fox, 2010).
Grog (2013) echoes this concern and suggests that when predetermined outcomes [such as prevention of disease complications] become the focus of patient-centred care, healing
relationships are transformed into ever more sophisticated
strategies for increasing patients compliance with what providers
prescribe (p. 460).
Furthermore, significant debate has arisen as to the degree to
which patients can actually challenge medical authority, should
they wish to take charge of their care. Almost 30 years ago,
Silverman (1987) argued that changes in power relations are
possible only when the challenge for more patient control comes
from patients themselves rather than from health professionals.
More recently, social class, age, education level, gender, and
ethnicity have been shown to influence patients information
needs (Rademakers, Delnoij, Nijman, & De Boer, 2012) and
capacity to challenge medical authority (Lupton, 1994), with
those who are socio-economically disadvantaged and have less
access to education and other resources being less likely to overtly
exert their rights. We question, therefore, whether patient-centred
approaches favour more privileged socio-economic groups. The
literature notes many examples of ways that less advantaged
groups effectively resist medical authority through acts of noncompliance, such as missed appointments, refusal to speak the
dominant language, and concealing health-related behaviours
(Reeves et al., 2010). These patients, however, often run the risk
of being blacklisted or labelled as non-compliant by the health
professional community (Lupton, 1994). Lupton (1994) also cites
examples of patients who attempted to become knowledgeable
about their diseases in order to assert control over the medical
encounter, only to be reprimanded by their physicians for taking
on the expert role.
The relationship of knowledge to power is an integral aspect of
the patientprofessional encounter. French theorist Michel
Foucault viewed the two concepts as closely entwined and used
the term knowledge/power to emphasize this. In The Birth of
Clinic, Foucault (1973) described the powerful medical gaze of
the physician over the docile body of the patient during the classic
clinical examination. This gaze, he argued, was possible only
through the specialized knowledge of the physician, and exerted a
form of control over patient bodies. The act of physician
surveillance was, therefore, essentially an act of knowledge/
power. In his later work, Foucault described ways that the
dispersion of knowledge, and hence power, throughout contemporary society, encouraged individual citizens to cast the gaze of
authority upon themselves as a means of monitoring and
controlling their own conduct. Patient-centred care, with its
emphasis on patients taking responsibility for their own health
decisions and behaviours, may be seen as an example of this
mechanism. By encouraging patients to become active participants in health decisions, the medical system encourages them
to become knowledgeable about their bodies and diseases, to
monitor and survey themselves and to take appropriate action to
become as healthy as possible. In other words, patient-centred
care may be viewed as an approach to health care citizenship
(Fox, 2010) in which individual patients, armed with the right to
advocate on their own behalf, also become responsible for
maintaining their own good health.

J Interprof Care, 2015; 29(2): 113118

Fox (2010) interviewed 50 health professionals specializing in

diabetes care and found that the health professionals efforts to
practice patient-centred care focussed on encouraging patient selfmonitoring, self-management, and self-responsibility for meeting
optimum blood glucose, lipid, weight, and other health goals. Van
Mossel, Alford, and Watson (2011) analyzed interviews with
oncologists to understand how they explain treatment options to
patients and how this played into decision making around cancer
treatment. They noted that there was a semblance of choice
[with regard to treatment options], but also subtle influence
(p. 282) whereby the oncologists would suggest what they would
do in a similar situation, or subtly try to sway patients toward one
option or another. Van Mossel and colleagues also noted that
choice becomes muddied by inferences of best treatment,
or omission of other options. These studies collectively demonstrate that patient-centred care may be seen not as a route to share
medical power, but rather as a mechanism to extend its reach even
further so that compliance with medical directives is enforced by
patients themselves.
A similar argument about dispersion of power could be made
with regard to interprofessional collaboration. By sharing
power with other professions, physicians may not necessarily be
relinquishing power, but rather extending their reach beyond their
own profession. While interprofessional collaborative care affirms
a place on the team for a number of recognized professions,
physicians remain the main gate keepers of patient access to a
range of other health professionals and services. In addition, they
remain the sole profession that can prescribe most medications
and treatment interventions, and the authority to which most
patient reports are submitted. It should be noted that some
professions such as nursing and midwifery have been successful in
establishing advanced independent practice roles. In many
countries, however, these are relatively limited in number and
often situated in underserviced communities where it is difficult to attract physician practices. It will be interesting to see
how these roles evolve and share power with physicians,
colleagues within their own profession as well as those in other
professions.
Physicians centralized authority is not necessarily a bad thing
in that it provides accountability and a clear chain of command
with regard to patient care. It never-the-less enhances physician
power by formally including other professions within the domain
of patient care, a domain that physicians essentially still control.
Furthermore, equal participation by various professions in the
patient care process and assumption of responsibility and
accountability for patient care outcomes are strongly influenced
by a host of other factors that fall outside the realm of clinical
care. Legislation that delineates scopes of practice, collective
agreements that outline terms and conditions of work, institutional
quality assurance protocols, profession-specific legal and risk
management strategies, and significant differences in remuneration across professions, significantly impact how individual
professions carry out their work and interact with each other.
While there may be general philosophical consensus about the
value of interprofessional collaboration, institutional structures
challenge the degree to which this can actually be realized.
Beyond more collegial relationships among health care providers
and enhanced communication about patient care, it is difficult to
see how the conventional power structures, including legal,
political and economic ones, have been eroded by these emergent
discourses.
Many would argue that improved working relationships and
communication are in and of themselves worthwhile goals and we
agree. We are concerned, however, that their feel good effect
has the potential to mask and perhaps even enhance, inequitable
relations of power that exist among health providers and imposes

DOI: 10.3109/13561820.2014.954284

an unwanted burden of self-care and decision-making upon some

patients.

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Concluding comments
The ebb and flow of health care trends reflects and reinforces
multiple health professional discourses that, on the surface, seek
to improve care and service in one way or another. We believe that
health professionals strive to provide effective and compassionate care, yet operate in conditions that require them to balance,
sometimes, competing demands. These demands necessitate a
degree of professional vigilance and critical reflection that
encourage us to question whose needs are being served and
whose needs may remain unattended by whatever approaches are
taken up. We have argued that while collaborative and patientcentred care discourses, and their multitude of related models, are
adopted with best intentions, they never-the-less serve some
groups more than others and have the potential to reinforce rather
than challenge conventional medical paradigms. Further debate
and discussion around the professional hierarchies that exist in
health care, the power that comes with knowledge and expertise,
and the impact of this on interprofessional practice are required in
order to provide care that equitably addresses the needs of
patients.

Declaration of interest
The authors declare that they have no conflicts of interest. The authors are
responsible for the writing and content of this paper.

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