Running Head: PROFESSIONAL BOUNDARIES AND ROLE ADOPTION IN MDT

Professional Boundaries and New Role Adoption in a Multidisciplinary Healthcare Team Kyra van der Zee

S2353660

Supervisor: dr. J.F.J Vos

Second assessor: dr. M.A.G. van Offenbeek Date: 31/7/2019

Word count: 16614 (appendices excluded)

MSc BA Change Management Faculty of Economics and Business

2 Preface

With this, I present my master thesis of Change Management. I enjoyed to conduct the research independently and I learnt a lot from it.

This thesis would not be what it is now without the help and participation of many people. First of all, I want to thank Janita Vos. She was very considerate and supportive during the project. She jumped in whenever needed.

Also, I would like to thank the project leaders and managers of Coaching in Home & Place Making. Especially Ant Lettinga. She opened the doors of their project for me and provided ideas for research direction and support during the process. Furthermore, I would like to thank the organization, that also opened its door for me. In particular, the three coaches. They all were very collaborative and flexible. Despite their limited time, they continuously made room for me in their work and provided me with lots of information. I learnt a lot from them.

Lastly, I would like to thank the rest that contributed to my thesis in one way or another. For example, Brend van der Horst, he helped me create the data structure and Phillip Aulmann who performed a language check. Lastly, I would like to thank the people that provided me a ride to the different locations.

3 Abstract

Multidisciplinary teams (MDTs) are crucial in the rehabilitation sector to deliver integrated, client-centered and efficient care. However, professional boundaries that demarcate the various professional identities can form a source of misalignment or even conflict. Especially in the light of new role adoption. Professionals need to shift, open, cross and blur established inter-professional boundaries in order to adopt a new role as a team successfully. This research provides insights into the role of professional boundaries within an MDT in which only a part of that team adopts a new role. Consequently, it does not only concern inter-professional boundaries but also intra-individual boundaries that demarcate the different roles occupied by one person. This research is a qualitative case study that concerns three members of a multidisciplinary rehabilitation team that adopt a new role as coach. The study consists of document studies on the roles (4), interviews (3) and observations (13). The findings show that the role of boundaries in the role adoption process is determined by the boundary work of the professionals. Different patterns emerge between the role adopters and the other team members. On intra-individual level, thick role boundaries is an important determinant for subsequent boundary work in the role adoption process. Besides these contributions to the literature, this research holds practical relevance in that it guides MDTs and change managers in the process of new role adoption.

4

Table of Content

Shared collaborative identity. ... 10

Professional Boundaries ... 10

Additional Role Adoption and Boundary Work ... 11

Inter-professional boundaries. ... 12

Intra-individual Boundaries. ... 14

Multidisciplinary Rehabilitation Team and Additional Role Adoption ... 15

Methods ... 16

Research Approach ... 16

Case Setting ... 16

The H&P coach role. ... 17

Data Collection ... 17

Method of Analysis ... 18

Results ... 21

Case Speech Therapist: Expanding Old Role Boundaries... 21

Case Occupational Therapist: High Boundary Flexibility ... 23

Case Rehabilitation Nurse: Thick Role Boundaries ... 24

Cross-case Analysis ... 26

Inter-professional boundaries ... 26

Intra-individual boundaries. ... 28

Discussion and Conclusion ... 31

Inter-professional Boundaries ... 31

Intra-individual Boundaries ... 33

Theoretical Implications ... 34

Practical Implications ... 36

Future Research and Limitations ... 36

Conclusion ... 37

5

Appendices ... 47

Appendix I: Interview Protocol (Dutch) ... 47

Appendix II: Documents Used ... 52

Appendix III: Overview of Observations and Interviews ... 56

Appendix IV: Codebook ... 57

6

Introduction

Recently, the need to provide integrated healthcare is rising. This is due to the continuous growth of healthcare costs, the rising lack of access to care, the complexity of patients, and the disparities in healthcare (Hudson, Comer, & Whichello, 2014). The implementation of multidisciplinary teams (MDTs) is a popular means to integrate care (Baker, Day, & Salas, 2006; McKee & Healy, 2002). “MDTs consist of health providers from a range of professional and disciplinary groups, with different and complementary knowledge, experience, and skills” (Liberati, Gorli, & Scaratti, 2016, p. 31). This form of collaboration is believed to not only improve health but is also related to better responsiveness to patients (Greenwell, 1995), their increasingly complex needs (McKee & Healy, 2002), and more efficient use of healthcare resources (Loxley, 1997).

However, bringing the various healthcare professionals together does not automatically mean that they will cooperate effectively (Miller, Ross, & Freeman, 2001; Clarke et al., 2014; Hewitt, Sims, Greenwood, Jones, Ross, & Harris, 2014). The extant literature addresses multiple barriers that need to be overcome in order to reach effective inter-professional teamwork and integrated care. Well known challenges of MDTs are the blurring of extant role boundaries, established professional assumptions about other disciplines, and communication and decision-making difficulties (Sheehan et al., 2007; Unsworth, 1996).

These collaboration challenges arise from the different professional identities that constitute an MDT (Lingard et al., 2004). The current state of scientific knowledge on boundary work in the healthcare sectors proves that healthcare professionals are particularly protective over their professional identities (Ferlie, Fitzgerald, Wood & Hawkins, 2005; Fitzgerald & Dopson, 2005; Martin, Currie, & Finn, 2009). Healthcare professionals deploy defensive behavior to protect their specialized knowledge and profession-related practices that constitute their professional identity (Atwal & Caldwell, 2002; Oborn & Dawson, 2010). Albeit, the goal of MDTs is to integrate the different and complementary knowledge, experience and skills (Liberati et al., 2016).

7

do treat professional boundaries as static, they remain working autonomously and in isolation, creating no aggregated value as MDT. As a result, tension or conflict may arise.

Thus, static professional boundaries may create conflict in MDTs (Hall, 2005; Mitchell & Boyle, 2015). Research shows that the chance of conflict increases when clarity around roles and responsibilities is lacking (Molleman & Rink, 2014) or when new roles are created (Currie, Lockett, & Finn, 2012; Kilpatrick et al., 2011). Integrating a new role into an MDT requires blurring of extant roles (and boundaries) and role-redesign. Therefore, greater flexibility in individual roles and skills is created (Skills for Health, 2006). Moreover, professionals need to cross professional boundaries to integrate their specialized knowledge and practice with other professionals (Cross, Ernst, Assimakopoulos & Ranta, 2015; Kislov, 2014). Professionals represent an active role in establishing and changing boundaries (Abbott, 1988; Fournier, 2000). Consequently, the boundary work of the professionals determines the success of inter-professional collaboration and the role adoption process in an MDT. They need to overcome the potential hampering effect of professional boundaries (Akkerman & Bakker, 2011; Wenger, 2000).

Thus, MDTs are prone to boundary conflicts that obstruct the integration of knowledge and skills. Especially in cases that the team encounters changes in current roles and responsibilities (Molleman & Rink, 2014; Currie et al., 2012; Kilpatrick et al., 2011). Relevant literature largely omits social factors that influence the integration of knowledge and practice across disciplinary domains (Liberati et al., 2016). Moreover, it is common practice to focus on a novel and thus additional group of people as the role adopters (Currie, Lockett, & Finn, 2012; Kilpatrick et al., 2011). The extant literature falls short on the role of boundaries in an MDT where only some members adopt a new role. In this paper, the role of both inter-professional, as well as intra-individual boundaries, is examined. Individuals that occupy multiple roles are faced with internal role boundaries (Chreim et al., 2016).

This thesis contributes to the gap of social factors which influence the integration of knowledge and practice in an existing MDT in which only some members adopt the new role. Our goal is to understand the role of both inter-professional as well as intra-individual boundaries in the role adoption process. We, therefore, formulate the following research question: How are professional boundaries influenced by the development and adoption of a new additional role within an existing MDT?

This paper contributes to the extant literature on professional boundaries by providing insights in three areas. Firstly, the effect of additional role adoption on the established professional boundaries in an MDT. Secondly, the role of the professional boundaries in the new role adoption process, and ultimately, the role of intra-individual boundaries in a role adoption process. The relations are determined by the way the professionals address boundaries, the so-called boundary work.

8

boundaries in different ways, affecting the role adoption process. Insights into the role of inter-professional boundaries during role adoption help the change manager to modify the change approach. A different approach is needed for the role adopters versus the remaining team members. Different patterns of boundary work emerge between these groups, yielding a distinct role of professional boundaries. The entire team functioning determines the success of the role adoption process within an MDT. Information on the intra-individual boundaries will teach change managers about the concept of successful role adoption. At intra-individual level, the perceived role contrast determines the amount of support and guidance the professional requires in adopting the new role. MDTs and change managers that are confronted with similar projects can use these insights in their role adoption process.

9

Theoretical Background

This research contributes to the literature on the relationship between new role adoption and professional boundaries in multidisciplinary healthcare teams. The relationship is determined by the boundary work performed by the professionals. In order to provide a clear image of the extant literature, this chapter is structured as follows: first, the concept of professional identity is discussed and its role in MDTs. Professional identities are both the building blocks of inter-professional teamwork, as well as a potential source of tension. A shared collaborative identity should be created to unite the professionals. Interaction between professional identities takes place at the boundaries of these identities. The second subsection will discuss the meaning of professional boundaries and how they may create conflict or misalignment within an MDT if not dealt with properly. Creating and adopting a new role in an MDT requires changes in existing roles and boundaries. The third subsection elaborates on the role of inter-professional boundaries and intra-individual boundaries in the role adoption process. Adequate boundary work performed by the professionals is a precondition for successful role adoption. The potential hampering effect of extant boundaries should be overcome. Fourthly, in cases that an additional role is adopted by one individual, boundary work at intra-individual level will arise as well. For that, intra-individual role boundaries are discussed shortly. Lastly, the empirical setting, the rehabilitation sector, and the importance of inter-professional collaboration for this sector are displayed. Also, the gap in the literature and the contribution of this research are summarized.

Professional Identity

Professional identities are the occupational identities stemming from ‘specialized knowledge and activities, reinforcement through governing bodies, and intense socialization processes’ (Lammers, Atouba, & Carlson, 2013). They constitute out of moral and normative values and help to distinguish appropriate goals, tasks, beliefs and behaviors for every profession (Nicolini, 2012). Consequently, professional identities guide professionals in their work practices and determine work jurisdiction and boundaries (Abbott, 1988). It provides healthcare professionals with ownership over a certain profession. Put differently, professional identities determine where the work of one professional stops and the work of another professional begins. The professional identity provides professionals with qualifications or credentials to practice within a discipline or area. The professional identity is a source of power for healthcare professionals (Currie, Finn, & Martin, 2012).

10

(Ashforth & Mael, 1989). Professional identities lie at the basis of inter-professional teamwork (Lingard et al., 2004; Kvarnström, 2008; Sicotte, D’Amour, & Moreault, 2002), they form the precondition of inter-professional collaboration and integration of care (Sarwar & Devlin , 2017). The professional identities all constitute different types of knowledge, skills and experience (McKee & Healy, 2002). If the professionals know how to collaborate effectively, they can integrate their expertise and deliver holistic care. However, Sarwar & Devlin (2017) also find potential negative effects of professional identities in inter-professional collaboration. Tensions or misalignments between different identities may emerge and can lead to de-professionalization, de-skilling, and feelings of loss of authority and professional expertise. If the tension between various professional identities is not addressed appropriately, MDTs will not yield any additional advantage. No integration of professional knowledge, skills and expertise will take place but remains isolated instead. Consequently, the professionals in an MDT need to create shared mental models and a collaborative identity.

Shared collaborative identity. Effective interprofessional collaboration can only be successful when professionals create ‘shared mental models’ (shared knowledge and understandings) through the sharing of profession-specific knowledge (Jeffery, Maes, & Bratton-Jeffrey, 2005). Put differently, the professionals need to transfer their specialized knowledge and understanding and integrate it into a shared domain. Carlile (2004) supports these findings. He states that in order to connect, professionals need to develop ‘a common knowledge’ to gain access to each other’s domain-specific knowledge.

Moreover, researchers are unambiguous about the need to unite and connect the diverse professional identities in a MDT under a shared collaborative identity (e.g. Cain et al., 2018; Dovidio, Gaertner, & Saguy, 2007; Gaertner, Rust, & Dovidio, 1994; Liberati et al., 2016; Wageman, 1995). This superordinate identity transcends various professional identities. Overarching goals and philosophy should be established at the beginning of the project (Kislov, 2014). However, Dovidio et al. (2007) caution not to replace the current professional identities with the superordinate identity. This will impede team effectiveness since the value of MDTs lies in the integration of these professional identities.

Professional Boundaries

In distinguishing between professional identities, the boundaries between them play an important role. Professional identities and their boundaries are developed in conjunction (Wenger, 2000). Professional boundaries are the “socially constructed demarcations that establish what is, and what is not, a profession's sphere of competence and a legitimate domain of activity” (Liberati et al., 2016, p. 32). Professionals themselves have an active role in creating, negotiating and maintaining these professional boundaries (Abbott, 1988; Fournier, 2000). Professional boundaries thus have a dynamic character.

11

requires blurring of old professional roles and responsibilities (Boon, Mior, Bamsley, Ashbury, & Haig, 2009; Cobley, Fisher, Chouliara, Kerr, & Walker, 2013; Fisher et al., 2011; Harris, Sims, & Hewitt, 2013) and the (re)creation of boundaries that enable integration of the various professions (Ashforth & Mael, 1989; Hyde, 2006; Wenger, 2000). However, professionals tend to be protective regarding the jurisdiction over the knowledge domain related to their professional identity. When professionals feel that other team members overstep their professional boundaries, they become defensive since they want to protect their professional identity (Jones, 2006; Kvarnström, 2008; Long, Kneafsey, & Ryan, 2003). For example, Abbott (1988) his research on division of labor and spreading of profession related expertise, showed that a sense of competition between different professional groups might emerge. He established that this competition develops in order to protect the legitimacy and expertise a certain profession yields over a specific domain (Abbott, 1988). Not only may healthcare professionals be resistant towards the intrusion of other professionals on their knowledge and tasks, but also towards the addition of new activities (Nancarrow & Borthwick, 2005; Powell & Davies, 2012).

Furthermore, Bechky (2003) found that misunderstanding stemming from differences in language impedes the integration of professions as well. With her research on knowledge sharing across different types of occupation communities, she concludes that the differences in language and locus of practice between professions prevent integration of these professions (Bechky, 2003). Wenger (2000) found similar results with his research on communities of practice. In differentiating one activity system from another, professional boundaries might lead to interaction difficulties across these systems. Akkerman & Bakker (2011) conclude with their research on boundaries and boundary objects that in case the previous difficulties are not overcome, professional boundaries might lead to fragmentation, separation and disconnection of disciplines.

However, Akkerman and Bakker (2011) and Wenger (2000) do recognize the potential of boundaries to establish collaboration and communication between the systems separated by these boundaries as well. If the activity systems are effectively united, learning, innovation, and cross-fertilization take place at these boundaries. The professionals constituting an MDT do have an active role in overcoming the potential hampering effect of boundaries and to create integration and learning instead. To successfully create and adopt a new role in an MDT, the professionals should overcome the potential hampering effect of the existing role boundaries. Only then, new forms of interprofessional collaboration can be established and the new role successfully implemented in a team.

Additional Role Adoption and Boundary Work

12

Kreiner, & Fugate, 2000, p. 474). A role constitutes one’s position and the requirements attached to that position. They are bound to time and place (Ashforth et al., 2000). It is important to realize that professional roles and identities evolve interactively (Ashforth & Saks, 1995; Ibarra, 1999). Individuals adjust aspects of their identity to fit their role and modify their role to enact important aspects of their identity (Nicholson, 1984). On inter-professional level, the addition of or changes in roles influence the existing roles and boundaries. If roles in an MDT change, the professionals perform boundary work to deal with existing boundaries. Put differently; boundary work is the mechanism that forms the relationship between role adoption and professional boundaries.

The tactics that are performed to establish, obscure and dissolve boundaries are called boundary work (Gieryn, 1983). When professionals choose to protect their professional boundaries, knowledge and skills remain fragmented. Here professional boundaries will impede inter-professional collaboration and joint role adoption. In contrast, professionals can also open, cross and blur professional boundaries, leading to integration of knowledge and skills. Successful creation and integration of a new role in a multidisciplinary healthcare team depend on the boundary work performed by the various professionals (Kilpatrick et al., 2011). Boundary work takes place at inter-professional level, as well as intra-individual level in case an intra-individual occupies multiple roles. Boundary work at inter-professional level will determine the role of professional (role) boundaries in the creation and adoption of a new role in an MDT. Boundary work constitutes activities as boundary shifting, blurring, crossing, preservation and creation.

Inter-professional boundaries. In an MDT, each professional fulfils a discriminating role. Tension may emerge at the role boundaries, that discriminate the various roles and responsibilities of each professional in an MDT. The chance that boundaries do become a source of conflict increases when clarity around roles and responsibilities within the team is lacking (Molleman & Rink, 2014), or when new roles are created (Currie et al., 2012; Kilpatrick et al., 2011). The professionals need to perform adequate boundary work to overcome the hampering effect of boundaries (Chreim et al., 2016; Kilpatrick et al., (2011). For example, Kilpatrick et al. (2011) investigate the boundary work in existing healthcare teams in which the new role of an acute care nurse practitioner is introduced. An additional group of people occupies the new role. They find that professionals need to shift in their existing boundaries to integrate the additional role. Otherwise, tensions between the roles arise (Kilpatrick et al., 2011). Thus, new role adoption in an existing MDT requires some role blurring and role-redesign, bringing greater flexibility in individual roles and skills (Skills for Health, 2006).

13

domains to happen, previous professional boundaries need to blur to certain extent. Evans and Scarbrough (2014) speak of boundary blurring when the established professional expertise of domains integrate into a more synthetic form, and professional boundaries are reduced. Flexibility in boundaries is then reached and creates room to create this shared domain (Skills for Health, 2006). Moreover, flexibility in boundaries is required to implement the new role successfully in the team.

Besides the blurring of existing boundaries, professionals need to cross their current role boundaries to provide the team with their specialized knowledge. Otherwise, knowledge and information do not cross professional boundaries from one discipline to another (Currie et al., 2012), interfering the integration of this knowledge. The team needs to create bridges that connect the different disciplines or professions (Akkerman & Bakker, 2011), they need to cross and open professional (role) boundaries (Michaelsen & Johnson, 1997; Nippert-Eng, 1996a,b; Zerubavel, 1991). For example, Kislov (2014) concludes with his research on interprofessional teams, that the professionals should promote open knowledge sharing and joint work at their boundaries to overcome their differences in practice. Bate & Robert (2002) also state that professionals need to share their knowledge across boundaries in order to transform separate practices into mutual working practices. Only then, the team can jointly create and adopt an additional role in their MDT successfully.

Boundary crossing implies how professionals “enter onto territory in which they are unfamiliar and, to some significant extent therefore unqualified” (Suchman, 1994, p. 25) and “face the challenge of negotiating and combining ingredients from different contexts to achieve hybrid situations” (Engeström, Engeström, & Kärkkäinen, 1995, p. 319). It is characterized by confrontations between disciplines and by continuous joint work between them. Boundary-crossing activities form a precondition in establishing new forms of interprofessional collaboration, including new role creation. However, Akkerman & Bakker (2011) caution that boundary crossing is not a process of moving from multiplicity and diversity to homogeneity and unity. It establishes continuity in practice across different domains.

14

Indeed, the research of Chreim et al. (2016) on leadership in interdisciplinary teams confirms the need to balance between changing and preserving existing role boundaries. In some teams or instances, the role boundaries impede collaboration between different healthcare professionals. In these cases, the team leader should promote role flexibility in the team. Existing role boundaries should be crossed and shift. Moreover, in some instances, the team leader worked to reduce the existing role boundaries in order to increase the scope of a certain role. In other instances, the team leader should emphasize the role boundaries between professionals. The roles and responsibilities remain separated, providing clarity in team roles. It proves that adequate boundary work depends on the context and goal of the team and its leader (Chreim et al., 2016).

Lastly, in case only part of the MDT adopts the new role, a new team is formed. To unite the professionals that constitute the role adopting team, a shared collaborative identity should be created among them. The creation of this collaborative shared identity will influence the existing boundaries in the MDT. Kislov (2014) his research on the creation and implementation of a shared collaborative identity in a collaborative research partnership confirms the impact on boundaries. He finds that the existing professional boundaries blur. Moreover, this “new” team created new boundaries as a team as well (Kislov, 2014). Wenger (2000) goes a step further on this point. He states that boundary development is a precondition in creating a new shared identity. Boundaries that distinguish the team members from its outsiders have to become salient. The boundaries are based on the differences between the in- and out-group (Ashforth & Mael, 1989; Hyde, 2006; Wenger, 2000). Thus, to unite professionals assigned with a joint task, like creating and adopting a new role, a shared collaborative identity should be created. In turn, existing professional boundaries in the team will change. In case one individual adopts an additional role, the individual performs boundary work at intra-individual level as well. It determines the role of intra-boundaries in the role adoption process.

Intra-individual Boundaries. In case an individual occupies multiple roles, the boundaries that distinguish the roles from one another are of intra-individual nature (Chreim et al., 2016). The individual performs boundary crossing activities at a psychological level (Ashforth, et al., 2000). The intra-individual role boundaries are interpretive entities that an intra-individual perceives as demarcations between different roles (Chreim et al., 2016).

15

to integrate. Role integration indicates “roles that are weakly differentiated (low contrast) are not tied to specific places and times (flexible boundary) and allow cross-role interruptions (permeable boundary)” (Ashforth et al., 2000, p. 479). Full role integration, which is rare, implies the complete removal of any boundaries. It refers to a “single, all-purpose mentality, one way of being, one amorphous self” (Nippert-Eng, 1996a, p. 568). Transitions between highly integrated roles tend to be more frequent and unpredictable given their similarity and high boundary flexibility and permeability (Ashforth et al., 2000). Thin boundaries may also result in role blurring. Ashforth et al. (2000) define role blurring as the diminishing clarity of the differentiation between roles and their associated boundaries. Strikingly, no research investigates the boundary work performed at individual level in case that an individual adopts an additional professional role.

Multidisciplinary Rehabilitation Team and Additional Role Adoption

Many researchers acknowledge the importance of MDTs in the rehabilitation sector. Rehabilitation patients are characterized by their complex and varied needs. They are treated in a variety of areas. Therefore, the joint expertise of various healthcare professionals is required (Clarke & Foster, 2015). Each professional brings in the knowledge of its discipline and collaborates with the other professionals during the rehabilitation (Ball, 2018). Consequently, high-quality and holistic patient-centered care can be provided. Thus, successful rehabilitation depends on the inter-professional collaboration in MDTs (King, Nelson, Heye, Turtorro, & Titus; 1998; Mickan & Rodger, 2000; Norrefalk, 2003; Wade, 2001). Here, professional boundaries blur and healthcare professionals fluently collaborate across their disciplines. The cornerstone in reaching adequate teamwork, with integrated knowledge and practices, is effective communication (Mosser & Begun, 2013; Unsworth, 1995). Given the strong dependence of the rehabilitation sector on MDTs, this research focuses on a multidisciplinary rehabilitation team.

Professional (role) boundaries should be adequately dealt with when facing new role adoption. The boundary work performed by the professionals will influence the joint role creation and adoption process. Thus, the relation between professional boundaries and role adoption is determined by boundary work in the research question: “How are professional boundaries influenced by the development and adoption of a new additional role within an existing MDT?”

16

Methods

To answer the research question, a qualitative case study was performed, constituting three cases. Since there is no research on the relationship between professional boundaries and role adoption by only a part of an existing MDT, this research concerns theory building. Under the case setting, we elaborate on the coach role. Consequently, intra-individual boundaries between the roles could be discovered.

Research Approach

The relation between professional boundaries and role creation and adoption by part of an MDT in the healthcare sector is not yet been investigated. Qualitative case studies are appropriate to generate new theory, to answer how questions, and to investigate dynamics in a single setting (Eisenhardt, 1989). This is in line with the characteristics of this study. To make an adequate analysis of the social processes in the MDT, the natural setting of the cases is included (Myers, 2009). Since all observations are on location, this condition is met. The qualitative approach enabled to obtain in-depth knowledge and to interpret the relationship between professional boundaries and the new role adoption (Hesse-Biber & Leavy, 2006).

Case Setting

The quality of rehabilitation depends heavily on the inter-professional collaboration within MDTs (King et al., 1998; Mickan & Rodger, 2000; Norrefalk, 2003; Wade, 2001). For this reason, we investigated an MDT in a rehabilitation center in the North of the Netherlands. The organization wanted to remain anonymous. The MDT consisted of six disciplines that were each represented by approximately three professionals. This MDT participated in the action research ‘Coaching in Home & Place Making’. The project aims at a smarter, more efficient, and more humane organization of healthcare for acquired brain injury (ABI) clients after they have left the rehabilitation center and went home (Universitair Medisch Centrum Groningen, 2016). Three members of the MDT participated in the project since April 2017 and adopted the role as a coach. Moreover, they were responsible for implementing coaching in their team and organization.

17

Naturally, the type of role to be adopted influenced the adoption process, inter-professionally and intra-individually. The important characteristics of the coach role based on a document study are presented below.

The H&P coach role. The Home & Place making coaches (further “coaches”) were trained to support people with ABI in their homecoming (after staying in the rehabilitation centre). Not the clinical setting but the direct (home) environment of the client was leading (DOC3). The consequences and impact of ABI after their return home are often hardly visible and are underestimated (Nanninga, Meijering, Schönherr, Postema, & Lettinga, 2015). Places that used to add to people their identity are suddenly (partly) inaccessible (DOC2), often caused by fatigue and over sensitivity to stimuli (McCarthy & Lyons, 2015). The coaches provided the clients with support to re-engage with their previous life. Old habits and reconnecting to important places and people were central (DOC2). This means that the role of a coach was not static. It conformed to the client-perspective. The work of the coaches depended on what the clients provided them with, and the client’s norms, values, and habits were leading (DOC5). The coach had to become a central figure to the client, who delivered integrated care and tackled the problems at home in an encompassing and coherent way. This means that the coaches needed to integrate the various rehabilitation disciplines into this role (DOC3). Consequently, the success of role adoption and implementation in the MDT depended on all the professionals, not merely on the individual coaches. The three professionals had to develop and adopt the coach role next to their current professional roles. Consequently, the coaches were faced with intra-individual boundaries as well.

Data Collection

To meet the requirements of triangulation, each case consisted of a document study, observations and an in-depth interview. An overview of the used documents in the document studies is provided in Appendix II. An overview of the interviews and observations per case, their titles and their reference codes, is provided in Appendix III.

In gathering the data, three steps were followed for each case. First, we performed a document study in order to compare the current professional role with the new coach role. This concerned documents on the current professional role, like the website of the focal organization, and the coach role, like a newsletter of the H&P project. The document study established differences and resemblances between roles and structured the subsequent observations.

18

example of the multidisciplinary consultations (MDCs) with representatives of each rehabilitation discipline, other meetings with professionals in the rehabilitation center (e.g. meetings with direct co-workers) and client sessions or meetings. Observations in the coach role were, for example, coaching sessions with clients, intervisions (weekly meetings with the coaching team), and training days (where coaches were trained and shared their experiences).

During the group meetings (e.g. MDCs) the interaction with other professionals was central in order to discover inter-professional boundaries and subsequent boundary work. Central points of attention were: How did the professionals collaborate across disciplinary boundaries? How did professionals refer to other disciplines? Were professional boundaries protected and how? How were previous roles changed by the addition of the coach role? We observed this both within the coaching team, as well as between the coaches and the other professionals in the MDT. Differences between these two groups regarding the role of inter-professional boundaries and subsequent boundary work emerged. The individual observations (e.g. client sessions) provided information, particularly on intra-individual boundaries and the role adoption process. What attributes did the coaches assign to their roles? How were these roles different or similar, and what did this imply for their boundary work? How did they shift between roles? Did they feel certain while adopting the coach role?

Thirdly, as the final step, we conducted an in-depth interview with each case. The interviews took approximately two hours. The protocol is shown in Appendix I. However, each individual interview included questions that were based on the observations. The individual reasoning, thoughts and experiences of each coach were central. Information was collected on both inter-professional boundaries, with questions that concerned interaction with and behavior of other professionals, as well as on intra-individual boundaries, with questions that concerned the relation between the two roles each case occupies. The in-depth interview was particularly relevant since the project is running since 2017. The coaches already experienced some changes in boundaries (both inter-professionally and intra-individually). Given the limited time-frame, no interviews could be done with ‘the others’ (non-coaches).

Method of Analysis

In order to analyze the observations and interviews the software program Atlas.ti was used. Based on the literature on inter-professional and intra-professional boundaries, some deductive codes were established. These codes are indicated with a D in the codebook shown in Appendix IV. During analyzing the data, additional inductive codes emerged as well. These concerned mainly codes related to intra-individual boundaries in role adoption since research falls short on this topic.

second-19

order themes that constituted the aggregated dimensions. Inter-professional boundaries displayed the professional identities that constituted the MDT that adopted the role and subsequent boundary work of professionals. Boundary work could both enable the inter-professional collaboration (e.g. joint role adoption process) and constrain it. Intra-professional boundaries displayed the content and attributes of the different roles an individual occupied and subsequent boundary work. Similarly, at individual level these boundaries may have enabled the role adoption process or constrained it. At both levels, boundary work determined the relationship between role adoption and professional boundaries. The complete data structure is shown in figure 1. The codes that formed the first-order concepts are provided in the codebook in Appendix IV, along with example quotes and a definition based on the literature or an alternative description of their meaning in this paper.

However, in some instances, theoretical definitions deviated from the operational definition we established in the empirical setting. Appendix V provides an overview with both the theoretical definition of concepts found in the literature and the iteratively established operational definitions. The operational definitions demonstrate how the concepts were measured in practice. Moreover, some of the concepts emerged at both inter-professional as well as at intra-individual level. For the sake of clarity, the overview in Appendix V provides definitions of these concepts at different levels as well.

20

21

Results

The results contain a combination of the data from the document studies, observations and the interviews, to answer the research question adequately. First, the important data on the within-cases is provided. Afterwards, the resemblances and differences between the cases will be discussed in the cross-case analysis. In this paper, the data is structured into inter-professional boundaries and intra-individual boundaries. The role of these types of boundaries during the role adoption process is influenced by the boundary work which the professionals perform. The role of inter-professional boundaries within the coaching team differs from the role between the coaches and other team members.

Case Speech Therapist: Expanding Old Role Boundaries

The speech therapists in the organization treat the elderly in the rehabilitation center for problems with communication, eating and drinking as a consequence of neurological disease. They do not only treat clients in the rehabilitation center, but also at home (DOC1). Speech therapists tend to focus mainly on the problems themselves and not on the source of the problem (DOC4). The scope of the speech therapist is relatively narrow compared to other professionals. However, ST her knowledge of ABI clients is extensive. She tends to work broader than mere speech therapy, which includes the integrating of other disciplines as well: “I always had a broader perspective, but coaching broadened it even further” (ST-I). She has a personal and holistic patient-approach. This was confirmed during a speech therapeutic session where she discussed personal matters, e.g. the client’s wish to commit euthanasia (ST-O1).

ST her vision on care advocates integration and client-centrality. Care should not be fragmentized into different disciplines. Disciplines should integrate advice and information of other disciplines, providing holistic care: “We (the MDT) all integrate the advice of the other disciplines. When I pick up a client for my treatment (from his/her room), I ask: “get your walker, how did they teach to use it?” (ST-I). This broad and encompassing work attitude was confirmed during the transport of an ST client downstairs: “Do you think you can manage to go downstairs with your walker (instead of a wheelchair), taken that you had a pretty intense day yesterday?” (ST-O1). She shows comfort in crossing the boundaries of other disciplines. The client’s total functioning is leading in her work. She does not address her discipline in isolation, resulting in the blurring of professional boundaries.

22

now who will continue treatment at home after rehabilitation… Now professionals transmit some of their work to the coach” (ST-I). Other disciplines need to provide the coaches with their discipline-related knowledge of clients. The coach integrates the knowledge of different disciplines. This was confirmed during a coaching session when ST paid attention to the discipline of occupational therapy: “Look, here the floor descends, I see that she installed wall handles here as well, for her own safety” (ST-O2).

ST perceives the coach role as an expansion of her speech therapy role. Speech therapists are restricted by the client’s request for help and the related treatment goals: “As an ST I set a goal, and I work towards that goal… So I work according to a plan, with a certain number of treatments, it is demarcated” (ST-I). Since ST is used to work towards goals in a structured manner, the emergent and broad character of the coach role was challenging to her in the beginning: “In my first home visit as a coach, I was really trying to find a goal to pursue, the reason for being there. I found it hard just to let it be” (ST-I).

As a speech therapist, she was confronted with the client’s problems that were not related to her discipline. As a coach, she is allowed to address these problems: “Now my focus lies much broader. Now I can discuss sexuality with clients. Before, as a speech therapist, I had absolutely nothing to do with subjects like these!” (ST-I). Previous professional boundaries are overcome, broadening her treatment scope.

The client’s norms and values are central to coaching. In her role as ST, she learnt to work according to the client-perspective: “If a client was not able to speak, I would have taught her to speak again… Now, this has changed. Maybe someone does not mind the disability to speak, I will not interfere in something that does not bother him/her at all” (ST-I). This explains why ST did not experience an intensive process of adjusting to the client’s life. Central elements of the coach role already emerged in her work as a speech therapist.

To collaborate with the two other coaches is important to ST during the project. They work on the same goals and share their experiences with coaching. For ST, the coaching team was a pre-condition in her role adoption process. The project brought them closer together, and they tend to collaborate beyond mere coaching subjects as well: “We approach each other more now” (ST-O4).

23

Case Occupational Therapist: High Boundary Flexibility

Occupational therapists are part of the multidisciplinary team. Their treatment scope is relatively broad. They support clients in their daily activities, e.g. dressing, preparing dinner, entering or leaving the car. These clients concern mostly elderly that suffer from complex health issues. Besides practicing daily activities, occupational therapists provide clients (and their relatives) with advice, e.g. concerning tools like a walker and toilet support. The client’s wishes are central in treatment (goals), as well as his/her total functioning in their home environment (DOC1; DOC7). This was confirmed by OT: “As an occupational therapist, you need to understand the client completely. I cannot impose my own norms and values on someone” and “You have to see the client in his entire environment” (OT-I). Because the central role of the client’s environment, the client perspective and focus on total functioning, occupational therapist and coach show significant resemblances: “You should address a client in his/her entire context. That is a resemblance with the coaching” (OT-I). The centrality of the client's habits, wishes and environment was confirmed during OT sessions. For example, she told the client: “When you receive your new corset we will start practicing the things you want to do by yourself” (OT-O1). This is in line with the coach role: “What the client wants, is leading during coaching sessions” (OT-I).

Her vision on care is characterized by concepts of integration and client-centrality. In the rehabilitation center, she works to integrate care. Disciplines should modify their work around the client and not vice versa: “Now the disciplines plan their own work in isolation, we should plan around the rehabilitation client instead” (OT-I). In order to reach the holistic and integrated care, collaboration across disciplines is important: “It is important that we all work together since we all work towards the same goal; the return home of the client” (OT-I). The coach role aligns with her vision on the integration of disciplines: “We are the central figure. You try to comprise it all… You need to understand what is needed” (OT-I). This means that current role boundaries in the MDT shift and blur to some extent.

The vision on client centrality requires a flexible attitude of OT. Consequently, her work as OT is dynamic despite the central and leading role of the client’s request for help and corresponding treatment goals. Her flexibility with professional boundaries was proved during an OT session. The client’s husband had caused problems in the bathroom. OT suspended the therapy and started to clean the husband and bathroom (OT-2). This explains why OT does not seem to have trouble with the emerging and dynamic character of the coach role: “As a coach, you build upon the things the client provides you with. You will not be digging yourself to find a problem” (OT-I).

24

that I could not address before… Coaching is actually an extension of occupational therapy. Before I had to restrict clients since I could not declare it, or I had to refer them to another professional” (OT-I). Coaching provides her with a broader treatment scope. As a coach she crosses boundaries into other disciplines: “I can do more myself, it is broader than occupational therapy. You find yourself on other disciplines as well” (OT-GO3). This was confirmed in a coaching session when she asked speech therapeutic questions to the client: “What about your choking? How is that going? … You use regular drinks? (instead of thickened)” (OT-O1).

OT feels that both roles influence each other. During rehabilitation, she works with the knowledge and skills she gains via coaching: “I start applying some coaching during rehabilitation already, to prepare them for their return home” (OT-I). OT never dissociates from her occupational therapist role. As a coach, she uses occupational expertise and skills. However, the boundaries between roles start to fade and eventually blur. Roles start to integrate and become one role: “Sometimes I am aware of the boundaries of the roles, sometimes I am not… It is not really clear anymore when I adopt which role. They are starting to blur” (OT-I).

Lastly, OT experienced some boundary protection behavior of others at the beginning of the coaching project. The coach role was yet to be implemented, little was known about the content of the role and its impact on the MDT: “Before people gained real knowledge on the coach role, they felt like: “Ooh, you guys think you can do everything like you’re super-therapists” (OT-I). Some of the members of the MDT negated the additional value of coaching: “Someone said to me about coaching: “Oh, I already apply that in my work, I wouldn’t need a course for that” (OT-I). Typical behaviors are triggered by fear of losing expertise or position on the coaches: “They fear to lose the position they gained within the organization” (OT-I). These forms of defensive behavior towards the additional role abated with the development of the project: “Since coaching is more communicated and better known within the organization, these defensive comments fade” (OT-I).

Case Rehabilitation Nurse: Thick Role Boundaries

In her current role, RN actively coordinates care around the client and integrates expertise, information and advice of different disciplines. She is the contact person for clients and monitors the MDT (DOC1). Her expertise is broader and more general compared to other health care professionals, crossing disciplinary boundaries more regularly (DOC8). The following quote of RN proves her broad and holistic expertise: “You need a helicopter-view. How are clients eating?... These things are crucial for their return home! We monitor this along the rehabilitation period. I also observe how they handle their walkers… Do they connect with other clients?” (RN-I).

25

collaboration between disciplines to create a complete image of the client. She thinks that every professional need to work with the information from other disciplines: “… Every discipline works with the information of other disciplines. That is our common task” (RN-I). This vision was indeed confirmed during her role as rehabilitation nurse during an MDC, where she told her team: “Everyone needs to remind him: “Put your breaks on the walker before you sit down” (RN-GO2).

The coach role suits RN’s vision on care. Coaches integrate various disciplines, which improves the efficiency of care: “Instead of continued treatment by all relevant disciplines, now only the coach pays the client a visit at home, ascertaining that everything goes well” (RN-GO4). The implementation of the coach role in the MDT asks for some professional boundary changes for every professional: “The others do not do solely their own thing anymore, they go a little further as well” (RN-O4). The others need to provide the coaches with relevant information about the client and the prospects of their return home. However, this willingness to cooperate with the coaches in adopting the coach role had to grow. In the beginning, some of the others were resistant to this additional role.

RN often emphasizes the benefits and importance of the coaching team to her. Their need to collaborate since this project unites them. They work on the same goals and share the same vision on healthcare. RN feels that communication between the coaches runs more smoothly due to shared understanding. RN feels that the coaches distinguish themselves from others in the way they try to integrate care and collaborate with other disciplines: “Others think in a more fragmentized way. The lines between us (coaches) became more fluent. While our work became more integrated, they stick to their own discipline” (RN-I).

RN encounters significant insecurities about the adoption of the coach role and where to draw boundaries, especially at the beginning of the project. The following examples illustrate her uncertainty: “I thought to myself: how far can I go? What lies within my range?” (RN-I) And “That was pretty scary! Was I allowed to put restrictions on this client?” (RN-I). RN never visited a client outside the rehabilitation center which she perceived as a big step: “I only worked internally. I had no idea what to do, what to ask… Look, ST and OT already did visit clients in their home environment” (RN-I). RN feels that she had to learn and adjust more compared to ST and OT.

Moreover, rehabilitation nurses comply with clear protocols in a controlled environment. As a coach, she did not have any form of direction. Coaches adjust themselves entirely to the client. She had to relinquish the established norms and values of the clinical setting and comply with the habits of the client. The contrast between the roles is emphasized by RN: “The roles differ from one another. As a coach, I need to integrate the lifestyle and habits of the clients more. I don’t need to follow clear protocols, which I do have to as RN” (RN-I). Consequently, the role boundaries are thick.

26

a coach)?” (RN-O2) and “What do you expect from me from now on?” (RN-O1). In addition, she searches for direction and guidance by the other two coaches. She perceives them as a great support in her role adoption process. It provides RN with more certainty and comfort in her coach role: “When I feel not sure about something, I discuss it with ST or OT. Sometimes they tell me: “woman, don’t stress about it, it’s all fine!” or they provide me with tips on how to handle something. I think it is really nice that we form a team together” (RN-I).

Besides her search for direction in adopting the coach role, she makes distinctions between the two roles. She makes the role boundaries more salient, for example, by putting off her nurse coat when she visits a coaching client (RN-O1). The reason for this is: “I don’t want them to see me as the nurse. I visit them as a coach. In the beginning, I also explained this difference in roles to them” (RN-I). This was confirmed during a coaching session, she explained to the client: “You do know that I am here as a coach, not as a nurse right? I still am a nurse of course, but that isn’t really visible right now” (RN-O1).

Even though RN still thinks of the roles as two separate ones, they start to integrate: “Primarily, I see myself as a rehabilitation nurse, but the coach role is starting to blend in more and more” (RN-I). Consequently, RN integrates coaching with rehabilitation: “Now, we are working towards the client’s discharge from the beginning of the rehabilitation period on” (RN-I). The example proves that the coach role is not bound to the home environment of the client. In the rehabilitation center, RN (and her team) already apply elements of coaching.

Cross-case Analysis

These results confirm the need for boundary changes in the entire MDT following the creation and adoption of the coach role. However, the role of inter-professional boundaries differs between the coaching team and the other members of the MDT. Within the coaching team, learning, cross-fertilization and integration occur at the boundaries. Within their team, professional boundaries do not impede inter-professional collaboration and joint role adoption; they are opened instead. The shared collaborative identity plays an important role in this process. Nevertheless, the coaches did encounter some forms of protective behavior expressed by a few others. The findings on the intra-individual boundaries display a divergent pattern for RN in adopting the coach role. This is explained by the change in treatment environment.

27

to conform to the clients’ needs. The coach role suits the professional identity of the coaches: “This might be the reason why we (coaches) did apply for the coaching-project instead of our colleagues. It fits us… We are not resistant to do things beyond our own discipline” (ST-GO4). For this reason, the three coaches did not experience large changes in their work behavior in the rehabilitation center after adopting the coach role. Instead, it legitimizes their ideal work attitude and provides them with an opportunity to transfer it to other professionals.

The coaches developed a shared collaborative identity. They share the same vision on healthcare and collaborate intensively as coaches. Their common goal is to jointly develop the role as coach as well as implement this role within their organization. The importance of a common goal within their team is displayed by RN: “You can really tell that we (the three coaches) are pursuing a common goal. No macho behavior or anything. I really like that. With other disciplines in our MDC I sometimes feel differently…” (RN-I). Coaching brings them closer together, blurring previous professional boundaries and create some boundaries between them as a team and the other members of their MDT. The shared collaborative identity leads to more understanding among the coaches compared to others as the following discussion during a project meeting shows:

RN: “We are discussing the clients with each other” ST: “We are approaching each other more”

OT: “Less frequently within our own discipline, but broader instead (with each other)” RN: “I feel that when I approach you personally, we can book results for the client sooner. When I would call you and ask if you could observe some client’s swallowing or whatever…” …

RN: “The lines between us are very short, I appreciate that” (GO4).

Their shared understanding, common goal and responsibility facilitate the information flow between the professionals, making the communication more effective as RN explains: “We focus more on the time after the client’s discharge. How will their return home go? What do we need to pay attention to? This connects us… making communication with each other easier” (RN-I). Especially RN emphasizes the importance of the coaching team and the support and guidance she drew from their collaboration.

The three coaches agree that their divergent professional backgrounds benefit them in the joint adoption of the new coach role. Together, they possess a wide scope of knowledge. This makes the coaches more all-round as a team while executing their coach role (during rehabilitation): “…we can decide together how to address certain things (during the rehabilitation period). We also know the client. The speech therapist knows him/her, the dangers, opportunities etc. The occupational therapist knows him/her. Together we can speak as one” (RN-I).

28

responsibility for the project and their coaching clients. For example, ST: “… there is an entire group of people that counts on us. What will happen to them (if we have to quit as coaches)!?” The coaches relate themselves to the project and are afraid of losing their position as coach. For example, OT: “We are working on this coaching-project now, while others might take over from us” (OT-GO2).

Moreover, some of the professionals in the MDT that did not adopt the new coach role, express forms boundary protection. The addition of this role requires some changes in current boundaries within the MDT. Coaches need to integrate the knowledge and expertise of other disciplines. Other professionals need to cross and open their professional boundaries to share information. Although this effect is stronger within the coaching team, boundaries in the MDT need to blur as well to provide holistic care: “Since the coaching project, we do not work in isolation anymore… You do not focus on mere speech therapeutic goals, but we work with the client in a holistic way” (ST-I). Consequently, professionals might encounter feelings of loss of their position and expertise. ST and OT both experience this with their peers: “The coach role moved me somewhat into the area of my colleague. I have to mind not to cross her domain too much. The neuro-rehabilitation is her baby. She does not want to give that up” (ST-GO4). Further, some instances of boundary protection are found as a reaction to additional work. OT: “… so my colleague might need to take over my (occupational) hours. That’s not always easy. I’m told once: “Then cancel coaching, just don’t go” (OT-GO4).

The boundary protection activities that some other professionals displayed did decrease over time. When the project began, little was known about the coach role and the impact it would have on other roles in the MDT. After the role was fully adopted within the MDT and the consequences for one’s own role or position became clear, defensiveness diminished. These examples show this process: “At the beginning of the project, people were not open to it, holding on to the old workways, saying: “Why should we change anything? It’s fine the way we do it now, right?” We had to get them on board, explain the reasons, then they started to acknowledge the value” (RN-I) and “… However, since we talk about coaching more and they understand what it implies, they are less negative” (OT-I).

Intra-individual boundaries. Not only the boundaries between different professionals play a role in the role adoption process. The findings on intra-individual boundaries show a different role adoption process for RN compared to ST and OT.

29

RN: “At the beginning of the project I was really searching… I had never treated someone outside the rehabilitation center”.

ST: “Yes, exactly! For you it started with paying someone a home visit in the first place”. OT: “We were already used to that, visiting people at home”.

ST: “This sure matters, whether you are used to paying home visits”. (GO4)

To cover this contrast between her old role and the new role, RN was searching for more direction and guidance in the role adoption process and accompanying role transitions. She did not know how to behave in the home situation of the client and had to learn to relinquish her established norms and values (based on her professional identity as rehabilitation nurse) and assimilate to the client: “I had to remember to let clients do their own thing, in their own way” (RN-I). Besides searching for more direction in adopting the new role, she distinguished the roles consciously towards herself and the client. She puts off her nurse coat when she visits a coaching client and she reminds the clients of the differences in roles. RN had to put more effort in creating and adopting the new role and in the role transitions compared to ST and OT.

In contrast to RN, ST and OT see the adoption of the coach role as an expansion of their previous role. ST and OT feel that they are provided with options to address new matters in their sessions. The scope of topics to address is much wider as a coach, depending on the client’s input. Being familiar with the home environment provides ST and OT with a benefit. In their previous roles, they faced “potential coaching topics”, but they were restricted by previous boundaries and the fact that they needed to declare their treatments. As a coach, the previous boundaries are dissolved.

OT displays little trouble in adopting the coach role that is characterized by its emergent and dynamic character. ST and RN, on the other hand, seem to look for certain standards and boundaries as coaches. This can be explained by the variety and broadness that characterize the role of the occupational therapist. OT already expresses a flexible attitude towards professional boundaries. She shifts within her field, and sometimes beyond, during treatments. Low role contrast and high boundary flexibility led to a relatively seamless role adoption process: “I think my occupational role was an advantage in adopting the coach role. My scope was already very broad, facing many elements in a client’s life, plus I treated at home often” (OT-I).

30

31

Discussion and Conclusion

In this last chapter, the results of our research will be discussed and compared to the extant literature. In the first subsection, the role of inter-professional boundaries in role adoption is discussed. The coaches formed a team within their existing multidisciplinary rehabilitation team. Within this group, a source of learning and knowledge integration was created at the professional boundaries, enabling joint role adoption. However, the role of the boundaries located between the coaching team and others was different. Less data is collected on the latter group. However, based on the interaction and experience of the coaches with this group, some conclusions could be drawn. Particularly, on boundary protective behavior. In the second subsection, the role of intra-individual boundaries in role adoption is examined. While relevant literature falls short on this topic, this thesis emphasizes the importance of these boundaries in the individual role adoption process.

Inter-professional Boundaries

This research confirms the need for boundary changes in case a new role is adopted by an MDT (e.g. Currie et al., 2012; Chreim et al., 2016; Ferlie et al., 2005; Kilpatrick et al., 2011). The way in which professionals deal with boundaries (boundary work) determines the role of these boundaries in the role adoption process. Professionals have an active role in creating, negotiating and maintaining these professional boundaries (Abbott, 1988; Fournier, 2000). Members of the MDT need to adjust their previous role boundaries and address them differently in the light of a new role. Professionals need to perform adequate boundary work to overcome the potential hampering effects extant boundaries may have on role adoption (Ferlie et al., 2005; Kilpatrick et al., 2011). Static boundaries may lead to tensions between roles in a team and impede integration of knowledge, skills and expertise (Ferlie et al., 2005). Thus, boundary work determines successful role adoption. Inter-professional boundaries within the coaching team did not hamper collaboration and integration of knowledge. The creation of a shared collaborative identity forms a precondition.

32

blurring of role boundaries within an MDT is a precondition for effective teamwork (Boon et al., 2009; Cobley et al., 2013; Fisher et al., 2011; Harris et al., 2013). The blurring of the role boundaries and the creation of shared knowledge and understanding (Jeffery et al., 2005) within the coaching team results in greater flexibility in roles and skills (Skills for Health, 2006). The coaches indicate that they collaborate more often with one another, even beyond the coaching project. They understand each other better, see their work behavior as more similar and perceive each other as more flexible compared to others.

Besides the blurring of boundaries, Kislov (2014) argues that the interconnected practices between different healthcare professionals could lead to the creation of new boundaries. This research confirms this finding. The coaches create new boundaries as a team. This paper adds to Kislov (2014) the potential to develop some feelings of defensiveness regarding these new boundaries within a short time frame. These light forms of boundary protection performed by the coaches stem from their strong shared team identity and their strong feelings of responsibility for the new role.

Another explanation for the absence of any obstructing effect of inter-professional boundaries within the coaching team lies in the professional identity of the coaches. Researchers state that roles and professional identities evolve interactively (Ashforth & Saks, 1995; Ibarra, 1999; Nicholson, 1984). As the coaches indicate, they choose to adopt the coach role since it suits their identity. The coaches value collaboration with other professionals. They are familiar with activities as boundary crossing and opening. Put differently; they tend to perform effective boundary work facing inter-professional collaboration. In contrast, some other professionals in their MDT are less comfortable and less familiar with activities of this kind.

The shared professional identity and the boundary work performed by the coaches both enable the joint adoption of the additional coach role. The potential hampering effect of boundaries on inter-professional collaboration was overcome in their team. Instead, the coaches create room at their professional boundaries for learning, cross-fertilization and integration which is in line with the findings of Akkerman and Bakker (2011). The coaches share their independent expertise and knowledge and integrate it into the new role. The advantage of the three different disciplines within the coach-team is emphasized multiple times by the coaches. The coaches communicate effectively across professional boundaries, integrating specialized knowledge and practices. This is in line with the results of Mosser & Begun (2013) and Unsworth (1995) on how successful multi-disciplinary teamwork can be established. This thesis shows that effective communication is facilitated by a shared collaborative team identity that is characterized by shared understanding (Jeffrey et al., 2005) and common goals and responsibilities (McCallin & McCallin, 2009; Clarke, 2010).