Background
The need for health professionals from different disciplines to work in teams, instead of in silos, has been emphasized on both political and managerial levels to meet population needs and to improve cost-effectiveness, quality, and access to health services [
1,
2]. Consequently, interprofessional teams have become more common in diverse settings, such as in hospitals [e.g.
1,
3‐
8] and in dental care clinics [
9‐
11]. During the past few decades, it has become more common for professionals to work in interprofessional teams in non-clinical settings, such as in home visiting programmes for parents with young children [
12,
13], in care at home for older persons with multimorbidity [
14] and in advanced care at home for patients with significant healthcare needs or chronic illnesses [
15].
This article focuses on interprofessional teams in a home visiting programme for first-time parents in the south of Sweden to promote more equal health amongst young children and support these parents in maintaining good health practices. Home visiting programmes for parents with young children typically utilize professionals from different disciplines, such as nurses, social workers, psychologists, physicians, and counsellors [
13,
16]. The rationale behind the development of interprofessional teams in home visiting programmes is that early prevention and professional collaboration is believed to ensure children’s health and growth and improve parents’ self-efficacy and health [
17]. Thus, the home visiting programme in question required that child healthcare nurses conducted home visits together with midwives, social workers, or dental hygienists/dental nurses [
18]. The professionals in the home visiting programme in question had not previously worked together in the teams.
The outcome of interprofessional collaboration in healthcare might not be self-evident as professionals might have different interests, values, and views on how to take care of patients and clients [
19]. These differences might cause the collaboration to be hindered or aggravated by professionals’ attempts to defend boundaries between their professions [
6,
7]. On the other hand, professionals can also collaborate well by blurring and downplaying boundaries between them. Previous studies have mostly focused on boundaries in relation to collaboration in hospital or clinical settings, so there is a need for more studies on collaboration in patients’ homes [
1]. Conducting home visits means changing the setting of work for healthcare professionals from formal spaces, such as hospitals, to a more informal setting [
20]. The home setting should not be regarded as just an extension of a work organization but as a distinct sphere of practice and experiences in its own right [
21]. That is, the home visit is conducted in a terrain that is ‘not intrinsically connected to any particular profession’ as it is away from the clinic or the office where professionals work [
22, p.349]. This article contributes knowledge on interprofessional collaboration provide healthcare in the home setting by focusing on the professionals’ boundary work and its implications on their collaboration when conducting home visits with first-time parents.
The need for individuals from different professions to work together has implications for how they coordinate their work tasks and roles. Despite regulations of task division for professionals within healthcare, dental care, and social services, there is room for negotiations in daily work through professionals’ boundary work, in which they construct, maintain, blur, cross, or downplay professional boundaries [
23‐
26]. Thus, professionals’ boundary work is significant in the understanding of interprofessional work relations [
8] and it has been described as a form of “floor politics”, that is professionals’ struggles and negotiations that takes place in everyday work [
3].
Professional boundaries are not static; they can be ‘understood as socially constructed demarcations that establish what is, and what is not, a profession’s sphere of competence and a legitimate domain of activity’ [
6]. As boundaries are constructed, it opens for negotiations on work division and work roles at workplaces. Negotiations take place primarily during conditions of change, uncertainty, and ambiguity [
23], which may occur when professionals have to work in newly created teams. When engaged in boundary work, professionals can stress both similarities and differences between themselves and members of other professions [
27]. The distinction between ‘them’ and ‘us’ can be drawn in various ways depending on the individuals’ perspectives and experiences [
1]. For example, healthcare professionals’ specific norms and values concerning patient care might differ from those of other professionals. Professionals can have different views on what constitutes evidence, safe practice, correct patient treatment, and high-quality patient care [
7].
Professionals’ boundary work can be interpreted as competitive and collaborative. Competitive boundary work concerns how professionals construct, defend or extend boundaries to distinguish themselves from others to achieve some kind of advantage [
28]. Competitive boundary work may have consequences for health professionals’ work on patients. Defence of existing professional boundaries and roles may impede meeting the complex needs of patients [
6] and can hinder interprofessional collaboration for high-quality patient care [
7]. Similarly, studies on the Swedish dental care [
10,
11] and healthcare [
29] have revealed interprofessional tensions and conflicts about work tasks which may hinder different professional groups’ skills to be utilised in the best ways in the caring of patients.
However, maintaining boundaries around a certain practice and knowledge can also be interpreted as collaborative boundary work, for example, when professionals respect their different niches of expertise [
30] and when they appreciate their different contributions in the care of patients [
1]. Collaborative boundary work also refers to professionals’ negotiation, blurring or downplaying of boundaries in interaction with others in order to collaborate to get their work done [
28]. For example, nurses’ role may require negotiations over performing tasks in a hospital context, and nurses can cross boundaries and undertake doctors’ tasks based on assumptions about what is best for the patients and based on the nurses’ aspirations to provide good care [
3].
Summing up, families’ home is a place that is described as more informal compared to health professionals’ workplaces and as a place that doesn’t belong to any specific profession. This gives rise to the question of the significance of the families’ home as a specific setting for interprofessional collaboration and boundary work. This article demonstrates how the professionals in the home visiting programme performed boundary work that enabled collaboration.
Research context
Child healthcare in Sweden is a service that is offered free of charge to all children up to the age of five years. The service aims to promote children’s health and development, to prevent disease, and to initiate inventions when needed. All families are offered home visits by a child healthcare nurse at one to two weeks and at eight months after birth. In recent, there has been a development of extended home visiting programmes conducted by interprofessional teams. This development is a result of funds from the Swedish government to promote more equity in health and to meet the needs of families with young children [
31].
The home visiting programme in question was supported by politicians at the regional level. The project ran from September 2019 until the end of 2022. The project started with four teams in 2019; thereafter, twenty-four teams joined, but two of these dropped out. The programme entailed a collaboration between professionals from child healthcare, maternal care, social services, and dental care, who worked in teams and visited first-time parents in their homes. The programme included six home visits during a child’s first 15 months. The home visits were carried out by a child healthcare nurse together with a midwife (1–2 weeks after birth), a dental hygienist or a dental nurse (8 months after birth), or a social worker (2–3 weeks then 4, 10, and 15 months after birth). The home visits focused, for example, on breastfeeding, parenthood, the health of the child, and good oral health habits. The professionals had guidelines for each home visit but some freedom to meet the needs of the visited parents and children and adapt their information and support.
Discussion
Professional boundaries are important for how health professionals operate and work together [
7], but little is known about collaborative boundary work in the home setting [
1]. In this article, we have analysed interprofessional collaboration in newly created teams in a home visiting programme for first-time parents. Our findings show that the professionals experienced having clear and distinct professional knowledge and roles. However, although differences in expertise and responsibilities were emphasized, they were not regarded as a catalyst for conflicts or barriers, as they might be when professionals work together in new teams [
35]. Rather, the professionals’ collaboration was characterized by downplayed and blurred boundaries, humility with each other, and lack of prestige regarding their own roles and expertise. Accordingly, this study is in line with the contention that the increasing demand for health professionals to work together does not have to be burdensome for the professionals [
36], and that professionals’ boundary work does not have to be competitive but can be collaborative [
28,
30].
The success of the interprofessional collaboration explored in this study may be attributed to several factors. One reason can be that it took place in the home setting. The home is an informal environment compared to hospitals and other formal institutional settings [
20]. Consequently, the interactions between the professionals and between the professionals and the visited families were also informal. That is, the informality of the setting seemed to have a positive influence on the collaboration and relationships between the professionals. The home is also a work environment not belonging to any particular profession [
22]. As indicated in this study, the home setting reduced the professionals’ territory and claim over a particular role when they met the families. Further, the opportunities for the professionals to reflect on their own and the others’ roles likely played a role. Thus, the home setting and the opportunities for meetings before and after the home visits were important contextual conditions that underscore the merit of conducting home visits.
Still another reason for the good collaboration could be that the professionals worked for the best of the families. The professional differences were stressed as significant in supporting the families because the team members’ knowledge and perspectives on children’s development and parenting complemented each other, which in turn enabled a more holistic approach to family needs. The results are in line with previous studies which showed that the maintenance of disciplinary boundaries can contribute to collaboration when professionals perceive their specific and different knowledge as necessary for the good care of patients [
1] and when they respect the differences between themselves and others [
30]. It may also be the case that the professionals in this article contributed to a successful collaboration through blurring and downplaying boundaries because they worked towards the shared goals of meeting the families’ needs and supporting the parents in the best possible ways. A study in a hospital setting showed that different health professionals together acted in what they believed to be the best interest of the patients and were driven by an ideology of caring [
3]. Consequently, the expectation of the professionals in the home visiting programme to collectively support parents in their parenting, which was set by political intentions [
18], seemed to be realized.
The successful collaboration could also be the result of all the different professionals being members of semi-professions, so-called welfare professions. Such professions have shorter university training and a lower status compared to physicians, dentists, and lawyers, and other high-status professions [
37]. It has been argued that welfare professionals are likely to be more welcoming compared to high-status professionals. Welfare professionals have limited exclusive knowledge compared to their high-status counterparts, which means they set fewer or weaker boundaries around their work tasks compared to high-status professionals. Further, welfare professionals are described as embracing an ideology of person-centredness, making them more open to collaboration [
38]. However, studies on the working relationship between professionals from different hierarchical levels– for example, between nurses and doctors [
39] and between dentists and dental nurses [
10]– have also shown blurred boundaries. Nevertheless, the types of professionals in the home visiting programme explored in this article seemed to be suited for collaboration and for support adapted to the needs of the individual families.
Strengths and limitations of the study
This article focused on the views of midwives, child healthcare nurses, social workers, and dental professionals regarding how they worked together. This is a strength as it provided us the opportunity to describe the interprofessional collaboration from all these different professional perspectives. Moreover, the data were first interpreted by the first author and then discussed by both authors to strengthen the interpretation. One limitation of this study is that it only concerned the four initial teams in the programme. However, its explorative character was not affected negatively by the small number since it contributed valuable qualitative knowledge on professional boundary work in the home setting. Further research is needed on the collaboration between the studied professionals in other countries and in relation to other approaches to home visiting programmes, as well as on boundary work and interprofessional collaboration in the home setting with another compositions of professionals. It should also be valuable to use the combination of interviews and observations in further studies for deeper understanding of interprofessional collaboration in the home setting. Another limitation of this study might be the short period of this study as possible conflicts of interests and values due to different professional and organizational backgrounds might be more visible after a while [
40].
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