Interprofessional negotiations in biopsychosocial pain rehabilitation: a need for silent bargains

ABSTRACT

Communicating effectively, including the ability to negotiate, has been claimed to be key competencies in interprofessional practice. However, these day-to-day contributions to interprofessional teamwork are not yet sufficiently understood. The aim of this article is to explore the day-to-day interprofessional negotiations in biopsychosocial pain rehabilitation. A qualitative design with an ethnographic approach was applied to the overall study. Participant observation of interprofessional encounters and clinical encounters in a pain rehabilitation ward was undertaken in 2016 for a period of 19 weeks. Intermittent interviews with 12 professionals were conducted. Data were analyzed in an abductive process using thematic analysis. We present the results as two themes: 1) Silent conflicting interests in the office, and 2) Silent dissatisfaction with meetings. The study showed that the team members had opportunities to negotiate in interprofessional offices and meetings, while they perceived insufficient time for discussion, and their individual work being interrupted by each other in the offices. They did not discuss their dissatisfaction, but silently bargained on how to spend time together. Professionals can contribute to teamwork through silent bargains that can promote a low level of conflict and thereby preserve a good workflow.

KEYWORDS:

• Biopsychosocial
• chronic pain
• interprofessional teamwork
• negotiations
• rehabilitation
• time

Introduction

Communicating effectively has been claimed to be a key competency of interprofessional practice. This involves the ability to negotiate (Interprofessional Education Collaborative [IPEC], 2016; Suter et al., 2009). Some key elements in professionals’ day-to-day contributions to collaboration are negotiating overlaps in tasks and roles, and creating spaces for negotiations (Schot et al., 2019). However, these contributions are not yet sufficiently understood (Croker et al., 2012; Schot et al., 2019).

Interprofessional teamwork in biopsychosocial pain rehabilitation invites for negotiating different cultural and professional beliefs. The intent of interprofessional biopsychosocial pain rehabilitation programmes is to optimally address the complexity of chronic pain, and these programmes have shown promising results in relieving pain and disability (Kamper et al., 2015; Oral, 2019). More knowledge on what characterizes day-to-day interprofessional negotiations in pain rehabilitation could strengthen teamwork for the benefit of patients. In this article, we further explore what characterizes interprofessional negotiations in the interprofessional teamwork setting of biopsychosocial pain rehabilitation.

Background

Interprofessional teamwork in biopsychosocial pain rehabilitation

According to Xyrichis et al. (2018) interprofessional teamwork is characterized by very high levels of shared team identity, shared commitment, clear roles and responsibility, clear goals, integration between work practices and interdependence between team members. Interprofessional biopsychosocial pain rehabilitation can be defined as at least two collaborating professions addressing at least two of the following types of components: physical, social, psychological, and work-related (Oral, 2019). In our study, following Xyrichis et al. (2018) framework, six professions collaborated in addressing all four above-mentioned components within a teamwork practice.

Today, professionals often consider limited time a constraint on interprofessional teamwork (Schot et al., 2019; Washington et al., 2017). In contemporary Western health care systems, the New Public Management (NPM) movement has urged cutting costs and effective resource usage (Nugus, 2019; Thylefors, 2012). Limited time may thus be allocated for interprofessional problem-solving and learning, in favor of primary tasks such as patient contact and interventions (Thylefors, 2012).

Struggles and boundaries between the professions’ knowledge bases, world views, ways of communicating and collaborating can obstruct collaboration (Powell & Davies, 2012; Schot et al., 2019). Traditionally, one possible obstacle to teamwork is the struggle to obtain boundaries and exclusive control of professional expertise, which is central to the existence of the professions (Abbott, 1988). In pain rehabilitation, there may be tensions between a biopsychosocial perspective and a widespread biomedical perspective regarding chronic pain management (Battin et al., 2021; Hervik & Stub, 2021). A possible way of handling the tensions in biopsychosocial pain rehabilitation is through day-to-day negotiations.

Negotiated order in interprofessional teamwork

In this article, we are inspired by Strauss (1978) concept of negotiated order. “Negotiation” is one possible means of getting something done when parties have to deal with each other to accomplish it, and there is some tension between them. The tension is the reason for negotiating, while an agreement can also be accomplished without negotiation when there is no tension between the interests. Thus, negotiations differ from other day-to-day communication because they unfold in a process where there is tension between different interests. For example, Fox and Comeau-Valée (2020) found tension in interprofessional teamwork stemming from the asymmetry in the hierarchy of professions, which was negotiated through interactions in team meetings. However, some means of accomplishment among actors with tension between interests are not negotiations but rather coercion, manipulation, and persuasion (Strauss, 1978).

We use the term “interprofessional negotiations” in the same manner as Reeves et al. (2009), who used it to refer to interactions among two or more professions where tension between different interests is handled. Negotiating involves sub-processes such as compromising to find middle ground, paying off debts, reaching negotiated agreements or making trade-offs (Strauss, 1978). Negotiations can also be silent bargains using non-verbal actions, as Strauss (1978, p. 231) pointed out with an example from a study among professionals and patients in a geriatric ward, where the patients would express minimal complaints about pain in exchange for good relations with the professionals. In our context of interprofessional teamwork, we find it plausible that the professions may use such means of action in negotiations to accomplish work.

A social order can be explained as the relatively stable features of organizations, groups, nations, international orders or societies, which yield structural conditions (Strauss, 1978, p. 12). Strauss (1978) claims that studying negotiations is at the heart of studying social order. The negotiation process is important for enabling people to accomplish things, resulting in rules, agreements, contracts, or understandings, which are central aspects of social orders. From this perspective, the social order of a group within an organization, such as in the interprofessional teams in our study, is constructed through day-to-day negotiations. The organizational rules and policies will give some direction and limitations to the negotiations. At the same time, the negotiations can be reactions toward and contribute to changing the relatively stable features of a group, organization, or society (Strauss, 1978).

Following the negotiated order concept, the nature of organizational life such as interprofessional teamwork, is shaped by negotiations between individuals, e.g. bargaining or compromising (Reeves et al., 2010; Strauss, 1978). Strauss’ negotiated order concept has been applied to previous studies exploring interprofessional social processes in health care settings (Fox & Comeau-Valée, 2020; Goldman et al., 2015; Lutz, 2019; Nugus, 2019; Reeves et al., 2009).

Although some recent studies have explored aspects of interprofessional negotiations (Fox & Comeau-Valée, 2020; Goldman et al., 2015; Lutz, 2019; Nugus, 2019), they do not characterize negotiations in teamwork to any great extent. There is a gap in the research concerning knowledge of the characteristics of interprofessional day-to-day negotiations in teamwork.

Method

Research design

This paper is part of a larger study with an ethnographic approach (Hammersley & Atkinson, 2019), which explored social processes characterizing interprofessional collaboration in pain rehabilitation. The data were gathered in 2016. The extent to which the data are relevant today can be seen in the continuation of issues shaping teamwork, such as the pressure on Western health care systems for effective resource usage. There are calls to use teamwork to deliver optimal services to patients, while the time for interprofessional work is limited. This is reflected with increased focus on teams and cost-effectiveness in IPECs (2023) draft of changes to the core competencies for interprofessional collaboration which was published in 2016.

Using participant observation combined with semi-structured interviews enabled us to explore actions and accounts of interprofessional teams and their patients (Morgan et al., 2015). In this paper, we focus on data from interviews with professionals and fieldnotes from observations of professionals.

Participants

In total, 19 professionals participated in the study. The two interprofessional teams represented six professions. Among the participants for observation were three registered nurses, four physiotherapists, one physiotherapist in training, one physiotherapist working as a team coordinator, two occupational therapists, one occupational therapist student, two psychologists, three medical doctors and two social workers. For the interviews, two professionals from each of the six professions were included. The professionals represented different views from each profession and from both teams. Professionals with longer experience and different perspectives that could broaden the data were selected for interviews.

Research setting

The fieldwork took place in a biopsychosocial pain rehabilitation in-patient ward in a hospital in Norway. The approach was focused on the patients’ cognitive coping through a learning process involving patient education and physical activities. Two intertwined interprofessional teams administered the rehabilitation programme, in a close-knit team setting (Schot et al., 2019).

In the final stages of writing this article, we have given the teams fictive names that capture some of their distinctive features to enable the reader to keep track of them. One team, “the Chatters,” had patients on individual admissions and in a group-based programme, while the other, “the Hushed,” only had patients on individual admissions. The setting was selected because it reflects a complex interprofessional teamwork approach to patients suffering from chronic pain. A single ward was selected to facilitate in-depth investigation of the social processes (Hammersley & Atkinson, 2019).

The two teams in the ward were intertwined, with some members sharing an office across the team borders and with some holding functions in both teams (Figure 1).

Figure 1. Depiction of how the professionals and offices were configured.

Data collection

The first author conducted participant observation of interprofessional encounters in the pain rehabilitation ward, which took place in 2016 for a period of 19 weeks (40 days). Intermittent interviews with 12 professionals were conducted. The observations took place Monday-Friday during the daytime because this was when the interprofessional activities, both with and without patients present, occurred. Most professionals only worked during the daytime and on weekdays. As recommended by Hammersley and Atkinson (2019), one researcher did all the participant observation and interviews in order to gradually explore and become familiar with the field over a prolonged period, which enhanced access to information and the contextual understanding of the information given.

The first author had training in conducting qualitative research interviews but was a novice in participant observation, while the second and the last author were experienced researchers in both data gathering methods. During the data collection phase, fieldnotes and transcribed interviews were shared among all the authors and discussed in regular meetings.

Observation

The observer was introduced to the field by a nurse from one of the teams. The observer was a registered nurse herself, with no previous relationships with team members or experience from pain rehabilitation. Further, the observations were scheduled consecutively, based on agreements with the team members concerning their plans of relevance to the study.

The observation sessions aimed at acquiring rich data about the social processes in the teamwork, and it was a goal to conduct participant observation in all arenas of interprofessional contact in the setting. Informal and formal interprofessional interactions were observed in arenas such as scheduled meetings, activities in the offices, and interprofessionally-led patient education sessions. To gather data about social processes, the first author, for example, observed potential tensions between the professions’ pain management focuses, in addition to the social atmosphere in terms of, e.g., non-verbal language.

An observational guide was used to guide the choice of which settings and aspects to observe. The observational guide was constructed through collaboration between the authors. It was based on our preunderstanding of the field, informed by literature about interprofessional teamwork and health care professionals’ work with patients suffering from chronic pain. It was constructed with an awareness of preserving an openness with respect to what was going on in the field. It included prompts such as “Routines and habits for interaction between the staff: Where and in relation to which situations do the staff interact? Regular meetings? Written documentation? Informal meetings?.” The observer was mindful of observing non-verbal interactions and the social atmosphere.

The observational role varied from active participation in for example discussions with professionals in the offices about their thoughts concerning the teamwork, to a less participating role in for example quietly observing scheduled meetings. Switching between a less and more participative role was determined based on the need for more explanation about observed talk and actions, an aim to not disturb the natural occurring setting, and an attempt to make the situation comfortable for the participants. Fieldnotes were written from each of the 40 days of observation and totaled 51,010 words.

Interviews

To obtain a better understanding of the observed social processes among the professionals, the first author carried out semi-structured interviews during the observation phase with two professionals from each profession involved (12), after one month of initial observations. The average length of the interviews was 54 minutes.

The first author had some features that were similar to most of the professionals, such as her being a Norwegian woman and health professional. This could have had an impact on her being welcomed into the field and actively included by the professionals. This familiarity contributed to a deeper understanding between researcher and interviewees, but the researcher was aware that it could also mean that alternative data did not appear as clearly. In 11 of the 12 interviews, the interviewee spoke a lot, with reflections and examples, while in one interview the interviewee gave shorter answers.

An interview guide, constructed on the same basis as the observational guide, was used. It said such as: “Can you tell me about a recent situation where you experienced good collaboration with colleagues from other professions related to a patient with pain?” and “Can you tell me about a time when you experienced that the collaboration was challenging or did not turn out quite as you had hoped for?” The interviews were recorded and then transcribed verbatim, half of them by the first author and half by a professional transcriber.

Data analysis

We used Braun and Clarke (2022) thematic analysis because it provides flexible guidelines for the analysis that are compatible with the design of this study, which was guided by Hammersley and Atkinson (2019) descriptions of an ethnographic approach with a constructionist lens. It was compatible since it, as Braun and Clarke (2022) state, allows for interpreting the versions of events created by the participants through their use of language and other interactions and the implications that these versions of reality could have. We applied an abductive attitude in the analysis, being more inductive initially and more deductive in the interpretations toward the end (Timmermans & Tavory, 2012). This helped us to do what Braun and Clarke (2022) call developing latent understandings of the data. Throughout the process, all authors actively discussed the emerging analysis.

The first phase of the formal analysis was to familiarize ourselves with the data by reading and re-reading it. Ideas about patterns in the data were noted, which, in line with the second phase, provided the basis for creating initial text-based codes. Further, in the second phase, we systematically created an overview across all data by coding relevant text to each code. An example of a code is “Office location challenges,” with data showing dissatisfactions concerning the office situation. We had 270 codes prior to further refinement from systematically re-reading the coded data. We used the qualitative analysis software HyperRESEARCH (ResearchWare, 2019) in the coding of the data. In the third phase, codes were collated into potential themes, where the content was compared and merged into eight initial overarching themes. One initial theme was named “Helping each other with everyday challenges,” showing a pattern of a low level of conflict, including some dissatisfactions about work arrangements.

The fourth phase was a further development of the initial overarching themes, checking how the themes worked in relation to the coded extracts and the entire data set. In this phase, the analysis became further refined by relating the content to the literature, which helped develop the interpretation and make it into the two distinct themes found in this article. We considered Strauss (1978) concept of negotiated order useful in our interpretation of the means of action used to negotiate.

A fifth phase was defining what should be included in the two themes and giving them suitable names, which we used in the results chapter in this article. Finally, the sixth phase involved writing the article, where we first present our findings as themes at a fairly semantic level, and then align the analysis in a constructionist frame in the discussion section.

Ethical considerations

All participants signed a written informed consent letter. The first author informed participants about the study in interprofessional meetings, in group sessions with patients or one-to-one. The Data Protection Officials at the hospital approved the study, on behalf of the Norwegian Data Protection Authority that collaborates with the Regional Committee for Medical and Health Research Ethics.

Results

In the rehabilitation ward, a great deal of the interprofessional interaction took place in the two interprofessional offices and in scheduled team meetings twice a week. In this article, we have given the teams fictive names to help keep track of them: the Chatters and the Hushed. We found two themes characterizing the interprofessional negotiations: 1) Silent conflicting interests in the office, and 2) Silent dissatisfaction with meetings.

Silent conflicting interests in the office

We found differences between the interactions in the two interprofessional offices: in the Hushed team’s office, asking questions and giving short messages was a frequent form of interaction, while lengthier discussions were more frequently observed in the Chatters’ office. A social worker from the Hushed team expressed in a conversation that they collaborated slightly less in their office compared to the Chatters, which she explained meant that they simply asked each other about things rather than sitting down to discuss it.

In interviews and one-on-one talks with the first author, the members of the Hushed team expressed a desire for more discussion of patient cases. A psychologist explained in an interview that they did not have enough time together to develop an interprofessional synthesis about the individual patient case:

I think that to have good interprofessional collaboration, you first need time to meet and discuss cases. We don’t have that. (…) we do meet and discuss a bit, but to reach those syntheses, and in a way bring each other’s analyses to the fore, let them, in a way, collide with each other and arrive at an understanding of the problem and a treatment plan, rehabilitation plan, which really captures the interprofessional perspective, is very, very difficult. (Interview, psychologist, the Hushed)

In the Hushed team’s office, discussions took place occasionally, and were typically less about patients and more often concerned frameworks or worries about the work situation, as in the following example:

The atmosphere in this room seems good, open and close. They can talk to each other about how they experience things. One topic of concern is where this rehabilitation option should be in the health care system - that pain rehabilitation for the patient group they have here may not be assigned to the specialist health service anymore. Where else could it be possible to offer such an interprofessional option? Some people (health care professionals/leaders) are sceptical of this kind of pain rehabilitation programme. (Fieldnotes, the Hushed team’s office)

When the professionals in both teams had lengthier informal discussions in the offices, the interactions were characterized by outspokenness, equality in terms of listening to each other and making comments, and eventually reaching a consensus. Among the Chatters, all team members were often involved with the same patients due to the organization of a group version of the rehabilitation programme. The characteristics of discussion can be illustrated by a discussion in the office about introducing self-help groups for their patients, where the end of the following excerpt describes a consensus that was embraced by the team:

The physiotherapist says that after experiencing how the patient group that was here this week acted, she is critical of how a self-help group would have worked for them. Maybe it would help them to maintain their role as helpless? The occupational therapist responds by repeating that they can’t control this (…). The nurse addresses whether all patients really want self-help groups? Could some of them feel pressured to join? The physiotherapist and the social worker agree that this is something to think about. (…) The social worker says that she supports giving information about self-help groups provided the patient group focuses on coping, not on maintaining the condition. (Fieldnotes, the Chatters’ office)

Professionals in both teams expressed their dissatisfaction with other professionals, based in separate offices, being unavailable. Some professionals in each team were based elsewhere and several stated that this limited the threshold and time available to talk and collaborate. This was especially evident among some nurses, one of the psychologists and the medical doctors. Medical doctors were rarely involved in the informal interactions:

In relation to the doctors, it can sometimes be a bit problematic, because they’re at the other end of the hospital. Many of them don’t have a landline, and many of them are often out of reach when we try to get hold of them. And it … can be a bit unfortunate if any major medical issues arise. (Interview, psychologist)

At the same time as the professionals expressed a need for informal interaction in the offices, several of them also expressed being frequently interrupted there. All the informal interaction could also be considered interruptions; people asking questions, discussions, professionals dropping by looking for someone, phones ringing or people talking on the phone. The professionals on both teams appeared to expect the interprofessional offices to be a space where they should be able to sit uninterrupted on a computer and carry out the required duties of writing in the electronic journal and reports, as illustrated in the following situation when a social worker was interrupted while working in the office:

The nurse leaves the room for a short while, then her phone rings. The social worker answers it. It is another nurse, again. Right after hanging up, the social worker tells me: “this is one of the hardest things; getting your writing done when so much is going on. When I feel tired and get interrupted, I have to try to get back into what I was doing before the interruption.” (Fieldnotes, the Chatters’ office)

In contrast to the Chatters’ office, the Hushed team’s office appeared to observe a stronger norm of keeping quiet and respecting individuals’ need to work alone. This could for example be the non-verbal interaction of concentrating on the computer screen while others were entering or leaving the room, as if the individual’s work was the only thing of relevance in the office. A physiotherapist from the Chatters team had even decided to move to the Hushed team’s office partly to avoid being interrupted by the talk in the Chatters’ office. As she explained, she had felt the need to withdraw a little because there was so much talk in the Chatters’ office.

It was apparent that interactions, though often considered interruptions to individuals’ work, were, at the same time, sought-after and considered advantageous. These conflicting interests were only observed to be discussed among the professionals to a limited extent, and were instead expressed in interviews and other one-on-one talks with the first author. At the same time, the office interactions did allow a norm to be observed of working individually and silently. Being available for each other in the office for questions and discussions was important to the professionals’ workflow, and provided a safe place to share their thoughts about patient cases and other work-related topics.

Silent dissatisfaction with meetings

Professionals in both teams considered sharing an office necessary in interprofessional terms for being able to discuss all the patients in depth, since the scheduled team meetings only allowed limited time for discussion:

.. now we are in an interprofessional office, and it is positive that we can discuss things there, and that we have each other nearby and are available that way. Having that opportunity is very good, since we have so little time for meetings. We have scheduled meetings on Tuesdays and Thursdays for one hour. (interview, member of the Hushed team)

There was a widespread expectation in relation to the teamwork that there should be room for discussion and that all team members involved in the patient under review should have time to speak at scheduled meetings. One member of the Hushed team expressed that the professionals did not actively contribute enough. Another member of the Hushed team said that the short time allocated for each patient meant it was hard to make comments, and those who were most outspoken spoke most. Such complaints concerning the meeting discussions were not observed to be expressed in plenum in the team, but rather in one-on-one talks with the first author. This could also be expressed non-verbally, for example by a professional leaving a meeting due to frustration concerning the discussions:

She (team member) says that there was no structure at the interprofessional meeting today. Those who talk the loudest get to talk. She didn’t have the chance to speak. In the end, she left the meeting five minutes before it was finished. (fieldnotes, talk in office with member of the Hushed team)

A list of rules for team meetings was displayed on a notice board in the Hushed team’s office, which provided some explanation for the short time allocated for each patient at the meetings and the low level of discussion. The rules stated that about six minutes should be spent on each patient, that discussion should be short and concise, with as little talk as possible not concerning the patient review and that medical doctors were to lead the meetings.

These meeting rules officially applied to both teams. However, we found differences in how the meetings unfolded, despite the fact that the teams shared the same medical doctors and team coordinator. One notable aspect was the time the medical doctor spent reading background journal information out load. In a typical review of a patient in the Hushed team, the medical doctors dominated about half of the meeting by talking about what was written in the journal. This was followed by some of the professionals making short comments. It appeared that lengthy discussions were often not necessary to be able to agree on the patients’ process. At the same time, voices could have been missed:

6^th patient [to be talked about at the meeting. A medical doctor speaks]: Problems at work with for example dressing children, due to pain. Neck problems for a long time. Prone to cricks in the neck. Been to a chiropractor. Works 100%. The nurse says that the patient perceives this as their final stay. The team coordinator agrees with this. A physiotherapist asks why the patient is on a specific medication. The medical doctor says that she doesn’t use it when she doesn’t need it. The team coordinator asks: “Are we done?” The meeting ends. (Fieldnotes, meeting, the Hushed team)

In contrast to the typical patient review by the Hushed team, the Chatters’ team reviews involved almost no journal reading. The medical doctor had little room to talk, as the other team members would spontaneously start talking when patients were mentioned:

4^th patient [to be talked about at the meeting]: The social worker says that the patient feels very well taken care of. The nurse says she feels better. The nurse talks a bit about this. The patient wants to go on a trip to a café. The medical doctor says that the infection levels have decreased. (…) They discuss whether a café trip is a good idea. The physiotherapist is afraid that the patient may be worn-out the following day. The occupational therapist asks: “Could it be that this is because we think there is more rehabilitation in going for a walk than going to a café?” The social worker supports this reflection. (Fieldnotes, meeting, the Chatters)

However, outspokenness and discussions that were rich in content could also emerge at the scheduled Hushed team meetings. During a meeting on one occasion, the professionals became particularly engaged in a discussion. Prior to this meeting, a few of them had a 30-minute “small team” meeting about a complex patient case. Semi-formal meetings with fewer participants, in addition to the scheduled meetings, seemed to boost outspokenness and longer discussions among team members.

The team coordinator expressed that she was dissatisfied with how the meetings were held. She felt there was too little time to collaborate properly in interprofessional terms and that there was not enough focus on each individual patient. The meeting rules had been implemented by the management to achieve the same meeting structure across work groups. The Hushed team complied with the meeting rules to a greater extent, limiting time for discussion and spurring them to review all patients, which could be seen as effective work. However, they expected more room for discussion about the individual patients to achieve satisfactory teamwork. At the same time, they did not discuss this expectation with each other.

Discussion

The aim of this study was to explore interprofessional negotiations in the teamwork setting of biopsychosocial pain rehabilitation. We found that the professionals had opportunities for informal interactions such as discussions and asking questions in their offices, which they considered advantageous for teamwork. This is consistent with Morgan et al. (2015) who found that the opportunity for frequent informal interaction was highly important to the success of teamwork. The discussions we observed were about patients and occasionally work conditions, and were characterized by seeking compromise and consensus, which according to Strauss (1978) can be viewed as negotiations.

We found that common rules for the formal interprofessional meetings across the hospital wards affected the interprofessional discussions. The teams were dissatisfied with the amount of time allocated to discussing patient cases in the formal meetings twice a week. Previous studies show that professionals often consider limited time a constraint on interprofessional teamwork (Schot et al., 2019; Thylefors, 2012; Washington et al., 2017). At the same time, the team discussions seemed to function well as the members were able to reach a shared understanding through terse discussions. According to Nugus (2019), such formalized structures, e.g. common meeting rules across a hospital, are the result of the NPM movement, which urges greater accountability and efficiency in health care. Like Strauss (1978), we find that the organizational rules set limits on negotiations. Our findings support awareness of how formal structures, such as meeting rules, affect specific interprofessional teamwork and whether fulfilling the professionals’ expectations of lengthy discussions in meetings could improve the teamwork.

While team members in both teams in this study expressed dissatisfaction with how the formal meetings unfolded, we found that the teams also had a certain autonomy in relation to how the rules were practised as demonstrated by the great difference between the two teams’ formal meetings.

Strauss (1978) stresses that both explicit and implicit negotiations can be used to make strict rules less strict in order to get a job done. Our findings show that the professionals did not openly complain about how the formal meetings should be held. However, one team implicitly and autonomously restructured their meetings by enabling team members to speak up rather than waiting for a medical doctor or team coordinator to structure the meetings. No one attempted to put a stop to the reorganized meeting structure. There were contrasts in the respective social orders of the two teams in our study concerning the norms governing their interactions, which persisted throughout their time together in offices and meetings.

The professionals in our study expressed that they were highly dependent on informal interactions in the offices due to limited time for discussion at meetings. Our findings differ from previous research in that we identified a paradox whereby desired informal interactions were curtailed by the professionals practising a norm of not disturbing each other in the office. Each professional needed to work individually to fulfil the documentation requirements, which can be seen as formal structures for hospital work based on the NPM movement (Nugus, 2019). We found that the professionals in one team, the Hushed, in particular used non-verbal action to keep talk and discussion in the interprofessional office to a minimum. There was thus a paradox in their expressed wish for more discussion in both the office and at meetings, while, at the same time, they did not want to be disturbed by others in the office and wanted to have structured meetings.

In the discussion to this point, one intriguing finding is that the dissatisfaction was expressed when professionals talked one-on-one with the first author, while barely verbally expressing these views among themselves. We find this to be due to the professionals’ silent bargain. When exclusively non-verbal gestures are used in negotiations, it can be labeled a silent negotiation (Strauss, 1978). The professionals silently negotiated how they should spend time together, which shows that this was an area where they had a certain autonomy despite the formalized structures of their work. Previous research on interprofessional negotiations has not found silent bargains concerning how to work together as characterizing interprofessional teamwork (Fox & Comeau-Valée, 2020; Goldman et al., 2015; Lutz, 2019; Nugus, 2019; Reeves et al., 2009).

When exploring why the bargains were silent, we find that making these kinds of conflicting interests and complaints explicit was avoided because an open verbal conflict could threaten getting the job done. On the one hand, due to how the actors’ complaints were embracing paradoxical desires in how to work together, complaining out load would be accompanied by a risk of limiting the opportunities for a good workflow. For example, saying that there should be no spontaneous talk in the office could limit opportunities for work to be immediately continued if it relies on interprofessional discussions.

The participants in this study did not express awareness of the paradox in their complaints. More discussion concerning how to work together could possibly develop awareness and new solutions in interprofessional teamwork. However, given the restrictions of limited interprofessional time and meeting rules, following work structures based in the NPM movement (Nugus, 2019), the time for much-needed interprofessional patient-centered discussions is scarce and there may often not be time allocated for interprofessional discussions concerning how to work together. This may evoke a need for silent bargains.

On the other hand, staying silent about something that could trigger open conflict could be what Strauss (1978, p. 227) describes as staying away from topics likely to lead to a forbidden ground where they expose a fiction they are attempting to sustain. By “shared fiction” we refer to an underlying story-like structure that can be created in professional collaboration, helping them to both see what they have in common and motivate their work forward (Battin et al., 2021; Kohn, 2000; Loftus & Greenhalgh, 2010). The interprofessional fiction they were trying to present could be as shown in Battin et al. (2021) where the professionals were working to maintain a shared plot where the professions had to act conciliated in order to motivate themselves and the patients toward a desired outcome. Moreover, enabling interprofessional teams to be united in their views and not in open conflict may influence whether they appear aligned in encounters with patients.

Our study shows that professionals in interprofessional teamwork can have strict formalized structures for their work, and also, despite this, a certain autonomy which enables them to bargain on how to spend their time together. At the same time, they may have an internal culture that constrains the bargains in order to avoid conflict and obtain a good workflow in the teamwork. To strengthen interprofessional day-to-day contributions to teamwork, further research is needed concerning the best practice for interprofessional offices and meetings in a health care service with limited time for interprofessional negotiations.

Limitations

There are limitations to this study concerning the purposive sampling of members of two interprofessional teams in biopsychosocial pain rehabilitation from one single institution. Including more teams from several institutions could have provided more variation in the data. However, we chose one setting to explore it in depth. Another limitation to the study is that including other informants from the institution, such as leaders, in interviews could have broadened the data by explaining the intent and story behind the formalized structures.

The observer was familiar with interprofessional teamwork as a health care professional. This could have limited the observer’s ability to see what is taken for granted regarding how professionals interact.

Conclusion

Our study showed that the team members had opportunities for negotiating in interprofessional offices and meetings, while they perceived insufficient time for discussion and their individual work being interrupted by others in the offices. They did not discuss this dissatisfaction, but silently bargained on how to spend time together. Professionals can contribute to teamwork by employing silent bargains to promote a low level of conflict and thereby preserve a good workflow.

There is a risk, however, that the silence may be a barrier to improving other aspects of how space and time together is spent. Furthermore, our findings raise important questions about what the best practice is when sharing an interprofessional office as there may be conflicting interests and expectations of what the office should be used for. This also applies to how time in team meetings should be structured to meet the specific needs of the practice.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

The author(s) reported there is no funding associated with the work featured in this article.

Notes on contributors

Gudrun S. Battin

Gudrun S. Battin, RN, works as an associate professor at the Department of Public Health at the University of Stavanger. The research project from which the current article originates was conducted during her doctoral studies in health sciences at OsloMet – Oslo Metropolitan University. Her research interests include interprofessional teamwork, chronic pain management, patient experiences, and nursing.

Grace I. Romsland

Grace I. Romsland, PhD, RN, holds a PhD in medical anthropology and is affiliated with the Research Department at Sunnaas Rehabilitation Hospital. Additionally, she has worked as an associate professor at OsloMet – Oslo Metropolitan University. Her research has primarily centered around nursing in rehabilitation, rehabilitation services, and patient experiences.

Bjørg Christiansen

Bjørg Christiansen, PhD, RN, holds the position of professor emerita at the Department of Nursing and Health Promotion at OsloMet – Oslo Metropolitan University. She earned her doctoral degree from the Pedagogical Research Institute at the University of Oslo. Her extensive research has focused on learning and knowledge utilization within the realm of nursing education and practice. Additionally, she has also conducted research on interprofessional collaboration.