We have no way of knowing what doing it right is.
(Fraser, a paramedic working interprofessionally in a mental health emergency)
We have volumes of information telling professionals in different sectors how to work together, and why they should. We have a flurry of interprofessional education programmes to drive home the message, often embracing collaboration as inherently a good thing with an evangelical flair that has raised sceptical eyebrows (see Paul Warmington, Janice Chesters, and colleagues). We also have some genuinely robust research, such as the large study of multi-agency child protection services by Anne Edwards and her team, showing the complex contexts and processes of different professionals actually trying to work together. But what we don’t have, at least for Fraser, is a better understanding of how different ‘knowings’ materialise and move around these diverse worlds – sometimes enabling, but often baffling or even blocking practitioners trying to work together.
Interprofessional work typically involves a collision of different practices, terminology, instruments, and forms of knowing. Imagine this happening in mental health emergencies, which were the focus of our ProPEL research. An emergency call for mental health crisis may be related to attempted self-harm or suicide, substance overdose, or acute psychotic or aggressive episodes related to a mental health disorder. Or it may be a dementia-related episode – a disoriented person discovered wandering a busy road. Designation of mental health emergency is notoriously slippery: calls to situations of domestic violence or public disturbance, for example, can turn out to be mental health crises. These emergencies often involve paramedics and police officers, working with hospital admission staff, psychiatric nurses, and doctors in A&E (Accident & Emergency).
The question we asked ourselves was: What forms of knowing are circulating, and how, among the various professionals and para-professionals involved in mental health emergencies?
As usual, we were particularly interested in the materiality of knowledge – how knowing becomes embodied and enacted in practice, and how the materials of practice elicit particular kinds of knowing. All practitioners involved in mental health emergency enact distinct knowledges. Police and paramedics often are called to the same incident. Think of handcuffs and breathalysers compared to the ambulance van of stretchers and medical equipment – paraphernalia of arrest or healing. Most express a genuine desire for knowledge to circulate more reliably across the different phases and practitioner groups involved in a crisis event. But the problem is not a simple matter of communicating more clearly and effectively: knowledge is not a package to be simply transmitted at inter-professional boundaries. It is negotiated materially, often recreated and re-materialised.
In our study, we found that both police and paramedics enacted a knowledge of attunement: attuning to one another in working out a physical choreography of response, attuning to the situation that emerges including the effects of their own presence, attuning to latent sources of threat. Unpredictability seems to be the only predictable dimension of such calls. First responders developed various knowing strategies for ‘dealing with it’, not just working out options for intervention but also managing their own emotions and uncertainty. Mark’s story is not atypical:
Can we cuff her? Probably not. She’s a thirteen year old girl but she’s scratching and slapping people and things like that. Is she acting up? Is she psychotic? Is she depressed? Is she scared? Is she all of those things? Probably, yeah, all of them.
Other knowledges become enacted as different practitioners confront each other’s framing of the ‘problem’. Is it clinical, criminal, theatrical? Or perhaps just attention-seeking? In any case, protocol demands that first responders move the person in difficulty to a place of safety. For mental health emergencies this is typically the hospital. But for those being moved, the hospital can be a disturbing or frustrating place. Some refuse to go, which is where police force can be used to restrain and then ‘physically assist’ a person into a police car. Some erupt in sudden anxiety at the prospect of being moved out of their home. Paramedics talk about police using their bodies and voices strategically to defuse, persuade, reassure. In some cases patients seem to be inhabiting a distinctly different material place than the responders, as in Siobhan’s story of a man struggling in the night grass, immersed in his own world of the Gulf War. James observed that the back of his police vehicle sometimes offered the safest quiet place to calm a person in distress, removed from the materials that were escalating fear and aggression. But – a police car? ‘You then start to question, what does place of safety mean?’ How, after all, is ‘safe’ performed?
What we saw in our study were different sociomaterial worlds at play, each with their own gatherings of instruments, bodies, languages and material settings. Each world both embeds and invites particular knowings-in-practice. The apparatus of the paramedics and police distinguish two different mobile worlds, organised around different purposes and practices. But both must negotiate through full-on bodily encounters, often volatile, a framing, a first response, and a passage from a crisis to something else. In contrast the material practices of the hospital contain, order and control the encounter: the charge nurse labelling the situation, the waiting room, the curtained treatment cubicle, the standardised assessment protocols and diagnostic language, the patient record that becomes the only official text traveling beyond the many phases of the situation. The hospital aggregates power because it becomes, in Bruno Latour’s vocabulary, an ‘obligatory point of passage’ through which objects, bodies and texts must flow. Local sites depend on their line of connection to the hospital, but the hospital doesn’t depend on any one circuit feeding it. Material worlds are not just different, they also wield very different influence on the outcomes as well as what counts as knowledge.
These heterogeneous method assemblages, or material worlds, relate to one another in ambiguous, sometimes contradictory ways. Police and paramedics found productive strategies to ‘overlap’ the different objects produced through their respective practices: handcuffing can be patient care and arrest can be transport to hospital, just as ‘softly softly’ talking and empathy can produce public security. These different worlds of practice become juxtaposed in a single emergency encounter, juggling and attuning to what is emerging in the situation, but not tidily joined-up or coherently linked in ways that inter-professional practice is often imagined.
We need to know, yeah, we need to know our role and our responsibilities and our remit, we need to know what authority we have to act, or not to. We need to know that we’ll be supported by management and senior clinicians depending on the actions that we takeIt’s a shared responsibility, you know, rather than passing the responsibility we’re looking to share it. (Gillian, paramedic)
Meanwhile, the complex worlds of mental health distress or despair that trigger the emergency call overflow all of these circulations.
The complete article is published in the Journal of Vocational Education and Training (2014, vol. 66, no.3, pp. 264-280). Available at: http://hdl.handle.net/1893/21299
Chesters, J. & Burley, M., (2011). Beyond professional conflict: Cultural and structural barriers to interprofessional health care teams. In: S. Kitto, J. Chesters, J. Thistlewaite, S. Reeves, (Eds.), Sociology of Interprofessional Health Care Practice (pp. 105-118) New York: Nova Science Publishers.
Edwards, A., H. Daniels, P. Gallagher, J. Leadbetter, and P. Warmington. (2009). Improving inter-professional collaborations: multi-agency working for children’s wellbeing. London: Routledge.
Latour, B. (2005). Reassembling the social: An introduction to actor-network theory. Oxford: Oxford University Press.
Warmington, P. (2011). Divisions of labour: activity theory, multi-professional working and intervention research. Journal of Vocational Education and Training 63(2), 143-157.