Journal of Interprofessional Care,

September 2009; 23(5): 455–473

Collaboration, professional identity and reflection across

boundaries
J Interprof Care Downloaded from informahealthcare.com by University of Newcastle Upon Tyne on 12/21/14

STEEN WACKERHAUSEN

Department of Philosophy, Aarhus University, Denmark & Centre for Practical Knowledge, School of
Professional Studies, Bodo University, Norway

Abstract
Three supplementary perspectives are presented arguing that interprofessional collaboration is both
necessary and desirable. Nonetheless, there are often too many serious intra-professional barriers and
For personal use only.

obstacles to interprofessional collaboration to make it successful. Some of these barriers, it is argued

and illustrated, are found in the multiple ways in which professional identity is tacitly acquired and
embodied in the practitioners’ habitual, everyday practice. The paper then explores ways in which
reflection, especially Second order reflection, can help to elucidate and overcome these obstacles, as
well as increasing professional adaptability and competence.1

Keywords: Interprofessional, collaboration, boundaries, identity, professions, reflection, network,

ontology, epistemology, ethics, philosophy, adaptability, competence, expert, learning, novice,
co-operation, working relationship, teamwork, tacit, embodiment, disharmony, colleagues, education,
community, apprenticeship, tolerance, dogmas, socialization

Why interprofessional collaboration?

Interprofessional collaboration is seldom sufficiently motivated intra-professionally and
consequently, adequate appreciation is lacking. Self-complacent, know-all practitioners and
professionals see interprofessional collaboration more as an (un)avoidable evil than a desirable
necessity. Nonetheless, there are very good reasons why interprofessional collaboration should
be cherished from the intra-professional standpoint. In what follows, I will present three
perspectives arguing for the need and desirability of interprofessional collaboration.2

(1) The ontological perspective. Ontology is the study of the basic structures and dynamics of
all existing phenomena. Given the scope and diversity of these phenomena, ontology is
necessarily a highly abstract and philosophical field of research, but it has nonetheless
produced results and insights of practical importance. I will focus on the following
ontological insights.

Correspondence: Steen Wackerhausen, Professor, PhD, Department of Philosophy, Aarhus University, Denmark.
E-mail: filsw@hum.au.dk

ISSN 1356-1820 print/ISSN 1469-9567 online Ó 2009 Informa UK Ltd.

DOI: 10.1080/13561820902921720
 456 S. Wackerhausen

Every phenomenon we encounter in life owes its existence to something else. Nothing
comes of nothing (and only ‘‘nothing’’ causes nothing). Metaphorically speaking, every
phenomenon is a child of many parents, grandparents, great-great-grandparents and so on.
And every phenomenon is itself the parent of other phenomena, or to put it less
metaphorically, every existing phenomenon is the effect of its own complex causal
background constituted by other phenomena, i.e., the causes of the phenomenon in
question, and every phenomenon is itself a member of numerous other phenomena’s causal
backgrounds (that is, partly responsible for these phenomena’s existence).
Let me illustrate these ontological insights by looking at a very concrete phenomenon: a
J Interprof Care Downloaded from informahealthcare.com by University of Newcastle Upon Tyne on 12/21/14

football player’s sudden pain in his left shoulder in the middle of a football game. If we were to
ask why this happened, we might get the following explanation: ‘‘Because the football player fell
on his left shoulder after he jumped as high as he possibly could trying to hit the ball with his
forehead’’. The explanation might very well satisfy our curiosity and even be true. Nonetheless,
from an ontological perspective the explanation is seriously incomplete. It only accounts for an
extremely small part of the causal background that made the football player’s sudden shoulder
pain come into existence. Lots of questions are simply left unanswered. For example, what are
the specific physiological and orthopedic conditions causing the sudden pain? Luckily,
medicine is able to tell us what these conditions are and, in the present case, affirm that these
conditions were caused by the fact that the football player fell hard on his shoulder. Even so,
medicine is not able to tell us why he fell hard to the ground, or even why he did not float
weightless up in the air instead! To answer these questions we need physics (or more
For personal use only.

specifically the laws of gravity and acceleration). But even physics cannot tell us why the
football player jumped up in the air in the first place! It would be fully consistent with the laws of
physics if he had chosen to sit down! To answer why he jumped as high as he possibly could, we
would have to turn to psychology. Maybe there we would get the answer that the player was
highly motivated trying desperately to prove his worth as a football player and increase his own
self-esteem. Although this psychological answer might be true and interesting, it does not
explain why the football player tried to hit the ball with his forehead. Actually, psychology per se
cannot make clear why the football player did not catch the ball with his hands instead. But
neither can medicine nor the laws of physics. To get an explanation, we need the ‘‘laws of
football’’. We need the socially constructed rules of football (soccer). So we could continue
expanding our causal explanation for a very, very long time! The point, of course, is that even a
simple phenomenon, like a football player’s sudden shoulder pain, has numerous causes – a
causal background – that exceeds the boundaries of every individual scientific discipline or
profession.
Not only is every existing phenomenon the result of its individual, complex causal
background (constituted by the causes of the phenomenon in question). Every existing
phenomenon, at any given time, is also open to the causal influence from a large and diverse
group of phenomena. For example, whatever the causal background might be, a certain
person’s headache can potentially be influenced by a host of phenomena, say by medication
making the headache go away (stop existing), or change for the better. Or the headache
might be causally influenced by a falling roofing tile making it much worse (or disappear for
a while if the falling tile knocked the person unconscious!). Of course, only a minor part of
any existing phenomenon’s potential causes become active (not every person having a
headache takes a pill or is hit by a falling tile). For better or worse, the major part of an
existing phenomenon’s potential causes remain inactive or ‘‘passive’’. And just like a
phenomenon’s causal background, i.e., its actual causes, clearly exceeds the boundaries of
every individual profession or scientific discipline, so does a phenomenon’s potential
(currently ‘‘passive’’) causes. Any given disease or health problem can potentially be
 Collaboration, professional identity and reflection across boundaries 457

influenced positively or maybe even cured by phenomena outside the reach of any given
profession or discipline.
Summing up: a phenomenon’s causal field is constituted, on the one hand, by its causal
background (the phenomena actively causing the phenomenon in question) and, on the
other hand, by its potential causes, i.e., the phenomena able to influence the phenomenon in
question given the right circumstances. As we have seen, both the active and passive causes
constituting a phenomenon’s causal field clearly exceed the boundaries of any profession
and scientific discipline. Additionally, outside the boundaries or reach of any given
profession are at least some of the causal effects produced by an existing phenomenon, i.e.,
J Interprof Care Downloaded from informahealthcare.com by University of Newcastle Upon Tyne on 12/21/14

the total sum of effects for which the phenomenon in question is causally responsible. That
is the case too with respect to a phenomenon’s potential causal effects, i.e., the effects a
phenomenon is able to cause given certain conditions.

(2) The epistemological perspective. The above presentation of some ontological insights has
prepared the ground for a short presentation of the epistemological perspective. As will
become clear, important epistemological implications follow from the ontological fact that
every existing phenomenon has a causal field that exceeds the boundaries or ‘‘domains’’ of
any profession or scientific discipline. Not least is the implication that the causal field
‘‘attached’’ to an existing phenomenon is partly or entirely outside the epistemic reach of any
individual profession or scientific discipline. One reason why this is the case, of course, is
that every causal field is inhabited by at least some phenomena located outside the
For personal use only.

established ‘‘domain’’ of any given profession or scientific discipline, such as the example of
the sudden shoulder pain. Because the knowledge (and research) of a given profession or
scientific discipline is focused on the phenomena ‘‘inside’’ its established professional or
scientific domain, only a part of the actual and potential knowledge about that
phenomenon’s causal field will ever be epistemologically available to the profession or
discipline in question. Expanding the scope or domain of a profession to include, say,
everything is of course no practical solution to the epistemic limitations of a profession, not
least by reason of the inherent cognitive and memory limitations of human beings.
Assuming that the adequate epistemological conditions are present, a profession is able to
tell the truth and nothing but the truth about the phenomena inside its own domain. But no
profession or scientific discipline will ever be able to tell the whole truth about any existing
phenomenon. Why not? Because the whole truth would imply that the phenomena
inhabiting a phenomenon’s causal field were inside the epistemic reach of the profession in
question. As we have seen, this will never be the case.
Consequently, no profession knows all that it is possible and relevant to know about the
phenomena inside its own domain (not to mention the phenomena outside its domain). The
implication is that professional epistemic humility is not only warranted, but also required.

(3) The ethical perspective. The ‘‘caring and healing professions’’ – like nursing, medicine,
physiotherapy, psychology, social work, dietetics, etc. – differ in numerous ways, but are
nonetheless united by a shared goal: to do what is best for the patient. This is their raison d’être;
it is their official reason for existence. To achieve this goal at the highest possible level, the
individual profession needs the highest possible level of skills and competence, which in turn
requires, directly or indirectly, the highest possible level of knowledge about the domain of
the profession in question, or, more specifically, the highest possible level of knowledge
about the phenomena and the causal fields related to the patient and her condition.
But as the ontological perspective made clear, no single profession (or scientific
discipline) is able to fully subsume the causal fields of the phenomena located in its own
 458 S. Wackerhausen

professional domain. Furthermore, not all the causal effects of phenomena located inside
the domain of a profession will take place within the boundaries of this domain. Outside
the domain of any given discipline are also some of the phenomena able to causally
influence the phenomena inside the domain of the profession including, say, many
phenomena able to heal, improve, or worsen a given disease in its domain. Clearly, the
fact that a certain phenomenon is not included in a given profession’s domain (its
traditional field of phenomena) does not guarantee that this phenomenon, as a matter of
fact, is irrelevant for understanding and handling the phenomena that are included in the
domain in question.
J Interprof Care Downloaded from informahealthcare.com by University of Newcastle Upon Tyne on 12/21/14

As a consequence of the above ontological points, no single profession will ever obtain or
even approach the highest level of knowledge about the phenomena in question. One reason
is that every causal field, belonging to a phenomenon inside the domain of a given
profession, is inhabited by at least some phenomena located outside the established domain
of the profession in question and accordingly, outside its epistemic reach. Consequently, the
level of skill and competence of any individual profession is limited by the profession’s
insufficient (ontological and) epistemic reach. No single profession has the skills,
competences and knowledge to do what is best for the patient.
No doubt, accumulatively ‘‘the caring and healing professions’’ know and can do more
than any single profession. Still, this does not guarantee that what has been done
accumulatively is the best for the patient. ‘‘Autonomous’’ (or too self-reliant) professions
working in parallel, each doing ‘‘their thing’’ with the patient is not what is called for. This is
For personal use only.

not genuine collaboration, but only ‘‘external’’ co-operation between ‘‘isolated’’ profes-
sions. It does not expand the knowledge and skill levels of the individual professions.
External co-operation only guarantees status quo; the individual profession is just as
knowable and ignorant, and as skill-full and insufficient, as the profession is on its own. In
contrast, genuine collaboration expands the knowledge base and, consequently, the skill-
level of my professional actions. Why? Because collaborative teamwork and decision-making
means that my professional actions are not only informed by my own profession’s
knowledge base, but also guided by the other professions relevant knowledge about the
phenomena and causal fields located beyond the ontological and epistemic reach of my own
profession.
Consequently, if the shared ethical goal of ‘‘the caring and healing professions’’ is to
do what is best for the patient, and genuinely collaborating professions (by
supplementary ontological and epistemological reasons) clearly expands the ability of
the professions, individually and collectively, to do what is best for the patient, then
interprofessional collaboration is indeed an ethical demand. As the fundamental
accomplishment of a profession is measured by its ability to achieve its goals, and
interprofessional collaboration increases any profession’s chance of achieving its goals,
then interprofessional collaboration should be highly valued and motivated from an intra-
professional standpoint too.

Professional identities, boundaries and barriers

Even though there might be interprofessional agreement (in a philosophical moment) about
the above ontological conditions, the epistemic limitations, and the resulting ethical
demand, such an agreement is by no means a guarantee for genuine and successful
collaboration. Why? Some of the barriers, I shall argue below, are to be found in the
constitution and roles of professional identity. In the present context, it will be helpful to talk
about professional identity at two levels, the macro-level and the micro-level.3
 Collaboration, professional identity and reflection across boundaries 459

The macro-level of professional identity

‘‘The macro-level of professional identity’’, metaphorically speaking, is ‘‘the public face’’
of a profession, not a homogeneous face as it is a ‘‘combination’’ of the profession’s
official recognition (authorization, regulations, privileges, duties, etc.), the public
perception of the profession, the related professions’ view of the profession in question,
e.g., its status and competences, as well as the self-image its leaders and ideologists
explicitly try to promote. This being said, it is clear that the macro-level identity of a
profession, e.g., its constitutive elements, domain, rights and status, is not the result of
J Interprof Care Downloaded from informahealthcare.com by University of Newcastle Upon Tyne on 12/21/14

an autonomous decision made by the profession itself. On the contrary, the (macro)
identity of a profession is given content and form by a diverse and open-ended group of
factors, including neighboring professions, technological developments, scientific pro-
gress, public opinion, national economy, etc. As a consequence, professional (macro)
identity is continuously in a process of gradual formation and transformation. Hence we
see identity negotiations taking place at many levels, even at the individual workplace.
For example, neighboring professions, like nursing and medicine, are often negotiating
who should do what in certain marginal or new fields of activity in the workplace not
formally regulated by the state or other high-level authorities. If the new or ‘‘vacant’’
fields of activity are prestigious, or by other reasons valuable to neighboring professions,
they will typical compete in the attempt to ‘‘colonize’’ the new or vacant activity fields in
question. Or if certain activities or duties are burdensome and/or of negative value or
For personal use only.

prestige, then the profession presently having these duties will quite often try to get rid of
them, say, by having neighboring professions, or maybe unskilled labour, take over these
arduous, low status activities.
As shown above, though neighboring professions like nursing, medicine, physiotherapy,
at least at some level have to work together or collaborate, these professions are also,
in varying degrees, in competition with one another. They share the same basic goal
(doing what is best for the patient), but they have less altruistic and more idiosyncratic,
intra-professional goals too. And these goals do not necessarily promote genuine
collaboration.

The micro-level of professional identity

‘‘The micro-level of professional identity’’, in my terminology, is a joint designation of the
qualities (whatever they might be) that a person must possess to be a fully acknowledged
member of a given profession. We are talking about professional identity at the level of the
practitioner, say, what it takes to be a nurse, a physiotherapist, a medical doctor and so on.
Of course, the person needs to attend specific schools, to pass certain exams, to show
evidence of possessing the essential theoretical knowledge and practical know how of the
profession to acquire an authorization certificate. Though necessary (formal) qualifications,
they are seldom enough to become a fully acknowledged member of a profession, to be
accepted as truly ‘‘one of our kind’’. The person also has to acquire and behave according to
the (tacit) ‘‘cultural dimensions’’ of the profession. These dimensions are not (or only with
minor exceptions) part of the formal curriculum. They are more like ‘‘good manners’’, the
unarticulated etiquette or customs of a profession. To put it differently, to become and
be ‘‘one of our kind’’ a fully acknowledged member of our profession, one has to behave
(in a broad sense of the term) as ‘‘our kind does’’. This includes following a number of more
or less overlapping rules for ‘‘good conduct’’. Let me illustrate and elaborate in the
following:
 460 S. Wackerhausen

(a) The anatomy of professional identity

Being ‘‘one of our kind’’ comprises, among other things, to talk like we do. That is, to use the
terms, concepts, phrases and metaphors we typically use. Every profession (and sub-
profession) has its favorite key-terms, the kind of terms or concepts used very often. For
example, listening to classical Freudian psychoanalysts you will hear terms like ‘‘Oedipus
complex’’, ‘‘castration anxiety’’, ‘‘sublimations’’ and ‘‘defense mechanisms’’ again and
again. They are the celebrated ‘‘star-terms’’ of psychoanalysis. Nonetheless, the same terms
may be totally absent from the established, everyday vocabulary of most ‘‘caring and healing
J Interprof Care Downloaded from informahealthcare.com by University of Newcastle Upon Tyne on 12/21/14

professions’’. Another example, the term ‘‘social network’’ is increasingly being used in
nursing when talking about patients, whereas surgeons hardly ever use the term when talking
about patients. As an acknowledged member of a given profession, you are quite simply
expected to ‘‘talk like we do’’. Recently, I overheard a somewhat heated discussion between
two nurses. Suddenly one nurse said triumphantly to her opponent: ‘‘Now you are talking
like a medical doctor!’’ I assure you, this was not meant as a compliment. It was harsh
criticism, a serious reprimand.
Being ‘‘one of our kind’’ also implies asking the type of questions we do. A nurse, for
example, is often expected to ask questions about the patient’s everyday life, eating habits,
social network, working life, etc., but it is not the standard questions of a traditional surgeon.
As a member of a certain profession, you are expected to ask the type of questions that ‘‘our
kind’’ typically asks and considers relevant for our profession. So, closely tied to or beneath
For personal use only.

the type of questions we ask, are the criteria of relevance we are expected to follow being
members of a given profession.
Understanding and explaining things the way we do is also part of the professional identity at
the micro-level. Say, a classical Freudian psychoanalyst is expected to approach and explain
his patients’ problems in certain ways (and in doing so using the ‘‘star-terms’’ of
psychoanalysis). Surely, two classical psychoanalysts might strongly disagree about the
causes and constitution of a specific patient’s ailment. One of them might assert that the
patient has an extraordinary high level of castration anxiety and assign it a major role in the
patient’s miserable mental life, while the other psychoanalyst blames the patient’s mental
ailments on a feeble and inadequate defense mechanism. The two psychoanalysts are
disagreeing, but they are disagreeing psychoanalysts exactly because both of them follow the
psychoanalytic ways of understanding and explaining, i.e., the same overall patterns of
understanding, the same available psychoanalytic explanatory templates. But let us imagine
that one of the two disagreeing psychoanalysts, in his attempt to explain the patient’s
ailment, suddenly made a serious explanatory reference to astrology and the patient’s
horoscope. What happened? We no longer have two disagreeing psychoanalysts; we only
have one psychoanalyst disagreeing with a believer in astrology. At the exact moment the
psychoanalyst tried to explain the patient’s ailment with reference to the patient’s horoscope,
this particular psychoanalyst stopped following the psychoanalytic ways of explaining and
consequently he stopped being a psychoanalyst!
Being an acknowledged member of a given profession is also, to a large extent, to see and
value one’s own profession as we do. That includes accepting and honoring our profession’s
symbolic capital, our prestige indicators, the intra-professional hierarchy, and so on. It
includes too accepting and telling the type of narratives we typically tell, not only about our
own profession, but also about our neighboring professions as well. As a matter of fact, the
narratives told are often rather ‘‘biased’’ in the sense of accentuating our virtues, victories, or
unjust suffering and their (the other professions’) vices, failures and undeserved victories.
This story-telling practice and ‘‘verbal grooming’’ serve several purposes, not least
 Collaboration, professional identity and reflection across boundaries 461

consolidating and maintaining professional identity and self-esteem. But if professional self-
esteem and identity rely too much on negative narratives about neighboring professions,
interprofessional collaboration can be severely hampered.
Clearly, the above description of the constitutive elements of the micro-level of
professional identity is in no way complete (neither quantitatively nor qualitatively). For
example, no references have been made to perceptual preferences, cognitive metaphors,
body language, walking style or dress code, although they all, in varying degrees, are
constitutive elements of professional identity. What is essential to have in mind in the
present context is the fact that being an accepted member of a profession implies attuning
J Interprof Care Downloaded from informahealthcare.com by University of Newcastle Upon Tyne on 12/21/14

oneself to, and consequently embodying a whole group of rules, beliefs, and habits: a way of
speaking, a way of questioning, a way of understanding and explaining, a way of seeing and
valuing, a way of telling narratives, etc. All the above are constitutive and necessary elements
of possessing a professional identity at the micro-level. Therefore the obligation of the
student is ‘‘to become one of our kind’’ and, when the student has succeeded, then his or her
obligation is ‘‘to be one of our kind’’ and ‘‘to stay one of our kind’’ ever after.

(b) Forms of identity possession

As illustrated above, to be an acknowledged member of a profession the person (the
practitioner) must possess the qualities constituting the relevant professional identity at the
micro-level (the level of the practitioner). But in what sense does an acknowledged
For personal use only.

practitioner of a given profession possess his or her professional identity? What are the forms
of identity possession?
No doubt, important elements of a practitioner’s professional identity are possessed
consciously, for example, the favorite key-terms of the profession and the practitioner’s
theoretical, articulable knowledge. But not every element and dimension of the
practitioner’s professional identity is possessed in an explicit and conscious form by the
practitioner. On the contrary, professional identity has, to a very high degree, an embodied
existence that is embodied in the practitioner’s everyday routines and habits, in the
automatized and familiar daily practices, or, to put it differently, in what you do, but don’t
think about. As practitioners of a profession, we do a lot of things professionally that just feel
so obvious, natural, or self-evident that we don’t hesitate at all or think about what we are
doing. We just do them.
Let me illustrate the embodied form of identity possession with a somewhat unusual
example and analogy. As a child I grew up on a farm where we had an old cow called Maren.
She was not the only cow we had. We had quite a few, but Maren was special in several
ways. First, she was clearly the undisputed leader of the cows, even though she was very
calm and good-tempered. Maren was always in front, but not because she was quick or
walking fast. On the contrary, she was actually a slow walker. She was in front because the
other cows waited for her to start moving. Second, Maren was extremely ‘‘loyal to
tradition’’, always following the established trails. As all farmers know, there are a lot of trails
on fenced grass fields ‘‘inhabited’’ by cows. That is, trails created over time by the cows
themselves while they feed off a field. The older the field and the longer it has been inhabited
by cows, the more established the trails. Maren was extremely loyal to tradition in the sense
that she hardly ever left or walked outside the trails when moving from one place to another,
say, when walking back to the farm at milking time. The grass field was nearly flat, but the
trails, say, to the farmhouse, were nonetheless highly curved and twisted – and for no
particular reason as far as I could see. Maybe the cows knew why the trails were curved, but I
doubt it. I believe the cows just walked the trails by force of habit without any kind of
 462 S. Wackerhausen

conscious planning or deliberation. Besides, why should they care to know, it seem fully
adequate cow behavior just to follow the trails of old, wise Maren and the other prestigious
members of the cow community. And these old and wise cows would surely know about the
trails and curves. Probably not; some of the trails had been there for ages, my father had told
me, even long before Maren was born. What would have been more natural for a young cow
like Maren than to follow in the footsteps of her older family and the other wise ‘‘community
members’’? And after a while, walking the trails would become second nature to Maren, the
natural thing to do, the kind of spontaneous everyday activity that does not require any
thinking, articulated justification, or prior planning.
J Interprof Care Downloaded from informahealthcare.com by University of Newcastle Upon Tyne on 12/21/14

Without intending to offend either practitioners or cows, I want to underline a few

heuristic analogies between the way practitioners (implicitly) possess their professional
identity and Maren’s (shall we say) ‘‘trail following practice’’.
Practitioners’ (implicit) possession of their professional identity is an ‘‘embodied
possession’’ constituted by the habitual following of the established, everyday trails of
professional practice. In several ways, this is similar to the way Maren’s ‘‘trail following’’ had
become her second nature. In both cases, we see automatized daily practices not requiring
conscious attention or deliberation. Both Maren’s and the practitioners’ spontaneous, but
still highly orderly and disciplined daily practices, are driven by the force of habit (not by
theory or reflection). In both cases, the trails of everyday practice just ‘feel’ so natural and
right that no hesitation or thinking is motivated. What becomes habitual gradually becomes
so ‘‘natural’’ and ‘‘obvious’’ that it no longer attracts our attention. It disappears,
For personal use only.

phenomenological speaking, from our mind. Habituation promotes phenomenological absence.

As the practitioner’s possession of professional identity, to a large extent, is an embodied
possession by virtue of habituation, it follows that professional identity, to a large extent, is
necessarily phenomenological absent and not in mind. And what is not in mind does not
thematize itself.

(c) Ways of acquiring professional identity

How is professional identity acquired? Surely, professional schools and their scholastic
teaching play a significant role, especially with respect to acquiring the necessary theoretical
knowledge. But in relation to the ‘‘cultural’’ and embodied dimensions of professional
identity, scholastic learning, book knowledge, and academic teachers do only play a minor
and secondary role. Contrary to many teachers’ (implicitly self-glorifying) opinions, it is not
the case that the school is the place where you learn and acquire knowledge and professional
practice in real life simply the place where you apply what you have already learned in
school. No, to become a fully acknowledged professional practitioner, ‘‘one of our kind’’, far
more learning is needed than scholastic learning and far more knowledge necessary than
book knowledge. Consequently, far more ‘‘teachers’’ than academic teachers are required.
What is needed, in addition to the scholastic contributions, is informal and tacit learning in
communities of practice. It is exactly by the informal (and often non-conscious) learning in
practice, by imitation and by actually following the ‘‘trails’’ of established practice (Maren’s
trails) that we gradually acquire a way of talking, a way of questioning and a way of
understanding ‘‘fitting for our kind’’.
The ‘‘teachers’’ involved in these rich, multi-dimensional processes of learning and
professional socialization are the colleagues and working collective, the members of the
community of practice. Intentionally or not, they are all in different ways and in varying
degrees ‘‘teaching’’ the novice (often by example) ‘‘to become one of our kind’’ as well as
‘‘teaching’’ and assisting their professional colleague ‘‘to stay one of our kind’’. And these
 Collaboration, professional identity and reflection across boundaries 463

intra-professional processes of learning and socialization continue without interruption day

after day, year after year, and consequently, have a deeper and longer lasting impact (at least
in some ways) than any scholastic studies at professional schools.
Summing up: it becomes clear why professional identity, in several ways, can hamper intra-
professional collaboration.
At the micro-level of professional identity, we find habitual ways of talking, explaining,
perceiving, valuing, doing and assuming often conflicting with neighboring professions, but
as these embodied dimensions of professional identity, by reason of habituation, are
phenomenological absent and not in mind, they are seldom the topic of discussion. Instead,
J Interprof Care Downloaded from informahealthcare.com by University of Newcastle Upon Tyne on 12/21/14

they live on as undisturbed barriers to interprofessional collaboration.

At the macro-level of professional identity, we often see limiting boundaries and other
barriers to interprofessional collaboration too, sometimes by reason of negative narratives
about a neighboring profession, sometimes because of competition regarding symbolic
capital or who gets the right to ‘colonize’ certain prestigious fields of activity or
responsibility.
We can safely conclude that there are too many unexamined (often embodied)
assumptions, ways of explaining, in the different professional identities resulting in serious
obstacles to interprofessional collaboration. Given these conditions, maybe reflection is the
solution?

Ways of reflecting4
For personal use only.

In the last 20 years or so, ‘‘reflection’’ has gradually become something like a term of fashion
in several ‘‘care and healing professions’’. In many quarters, the reflective practitioner is seen
as the crucial sign of the ideal practitioner. If you want to be a truly professional practitioner
you have got to become a reflective practitioner. This modern glorification of reflection has
historical roots (among those the philosopher John Dewey), but more recently the writings
of Donald Schön, especially his book The Reflective Practitioner (1983), have had a very
strong impact. They have made expressions like ‘‘reflection in practice’’ and ‘‘reflection on
practice’’ familiar to many practitioners.
Not everyone agrees, though, that truly professional or expert practitioners are or
should be reflective practitioners. According to Dreyfus and his followers, for example,
experts and real professionalism are characterized by the absence of reflection. Only
novices and beginners need to think about what they are doing. Expert practitioners, in
contrast, just do what needs to be done; they do it without thinking about it. As will be
clear below, I am critical both of the glorification of reflection and of the dismissal of
reflection.
It might very well be true, as Dreyfus and his followers say, that many well-established,
highly-acknowledged practitioners do not think about what they are doing. They simply do
it. Just like Maren is non-reflectively, following the trails of everyday established practice,
but, as we saw, this type of embodied and habitual practice can have problematic
consequences, among them the hampering of interprofessional collaboration. Besides, even
though Dreyfus’ ideal of the non-reflective expert might be a factually true description of many
highly acknowledged (Maren-like) practitioners, it does not make the description into a true
ideal. Just like a true description of human suffering does not make human suffering an ideal
either.
Is the reflective practitioner the ideal we have to pursue, like Schön and many others say?
Well, it depends on how the reflective practitioners are reflecting, the kind of reflection
actually taking place. Forgetting the ‘hype’ and glorification for a moment, it is sobering to
 464 S. Wackerhausen

remember that professional reflection (in a broad sense of the term) has always taken place
and reflective practitioners have existed long before Schön and others began talking
explicitly about and recommending reflection and reflective practitioners. Even Dreyfus
accepts the existence of reflective practitioners, but only sees reflection as apt for the novices
and beginners, not the experts.
Be it negative or positive, it is nonetheless a fact that at least some practitioners reflect
sometimes. Practitioners, novices or experts, reflect when they consider what to do in
somehow unusual situations, when they try to figure out how to handle a new and
unexpected problem, when they have to choose between two nearly identical options. As I
J Interprof Care Downloaded from informahealthcare.com by University of Newcastle Upon Tyne on 12/21/14

see it, the main difference between novices and experts, in the present context, is that the
experts, by reason of their long experience, less often than the novices run into new
problems and unusual situations. The experts can rely more often on and do what they
successfully did last time than is possible for the novices not yet having experienced a ‘‘first
time’’.

Reflection as usual – first order reflection

Now, if reflection takes place, at least occasionally, in professional practice, is what we need
(to help elucidate and transgress the intra-professional obstacles to interprofessional
collaboration) just more reflection of the usual kind? No, it is not. Nonetheless, this type of
professional reflection – ‘‘reflection as usual’’ – is necessary and irreplaceable in professional
For personal use only.

practice whenever practitioners are confronted with new situations, unusual problems or
changed problem solving conditions. On the other hand, this kind of reflection is implicitly
confirming, rather than transforming professional identity. It does not make professional
identity and its ‘‘established trails of everyday practice’’ a theme or a topic of reflection. On
the contrary, what becomes a topic of reflection is a hindrance to the uninterrupted flow of
everyday practice.
Let me illustrate my point by returning to Maren once again. Normally she was able to
walk on her trails, day after day, without any problems or disturbances. The walking seemed
to take care of itself without the need for any conscious monitoring, but one day a huge
tractor was parked across the trail that Maren normally used when walking back to the
farmhouse. What happened? Confronted with the tractor, Maren stopped. So did all the
cows following in her trail. After a while, a whole group of clearly confused and uneasy cows
stood still just watching the tractor, i.e., watching the monstrous obstacle to the easy and
pleasant flow of everyday practice. I hardly believe Maren had the capacity for reflection, but if
she did she would probably – like every reflective practitioner – have concentrated her
thoughts and problem solving powers on the obstacle and try to figure out how to get rid of
it. My general point, of course, is that what typically becomes the topic of reflection is not
the trails of everyday practice, but what (metaphorically speaking) is blocking them. The
trails do not thematize themselves (do not make themselves into topics of reflection). On the
contrary, as said earlier, the everyday trails are by reason of habituation ‘‘phenomenological
absent’’ or out of mind, but it is exactly the ‘‘absence’’ of the everyday trails that constitute
the background on which the obstacles of everyday practice become the topics of attention
and reflection, i.e, the reason why the obstacles become phenomenologically present and in
the foreground. It is the background (the trails) that makes, say, the tractor into a topic of
attention in the first place.
To sum up, the above type of familiar professional reflection does not elucidate and
challenge the trails of everyday practice (the tacit, embodied constituents of professional
identity), but confirms the trails implicitly by ‘‘acting’’ on their behalf. Consequently, this
 Collaboration, professional identity and reflection across boundaries 465

type of reflection (which I will call first order reflection) is not what we are looking for in the
present context.
But if reflection in everyday professional practice (first order reflection) is the loyal servant
of tradition, confirming rather than challenging the trails of everyday practice, what kind of
reflection, if any, has then the capacity to challenge and transform and, consequently, the
capacity to minimize or remove the intra-professional obstacles to interprofessional
collaboration? Before answering the previous question it will be helpful to look more
closely at ‘‘the anatomy of reflection’’.
J Interprof Care Downloaded from informahealthcare.com by University of Newcastle Upon Tyne on 12/21/14

The anatomy of reflection

No matter how narrowly or broadly you delimit the activities or phenomena you
are using the term ‘‘reflection’’ to designate, the different varieties of reflection all
share a basic ‘‘anatomy’’. In a simplified version, ‘‘the anatomy of reflection’’ is
constituted by the following four elements. First, when we are reflecting, we are always
reflecting on something (a theme, a problem, an idea, etc.). Second, when we are
reflecting on something, we are always reflecting with something (certain concepts,
beliefs, data, etc.). Third, we are also reflecting from something (a certain interest, a
perspective) when reflecting on and with something. Fourth, when we are reflecting on,
with, and from something, we are also reflecting in something (a context, certain
surroundings).
For personal use only.

Though extremely simplified, the above sketch of ‘‘the anatomy of reflection’’ is still
helpful when identifying significant differences between the conservative nature of first order
reflection and how a non-conservative, transformative form of reflection, second order
reflection, must look like. So, what is it that makes first order reflection self-affirmative and
the loyal servant of tradition? The topics which the practitioners are reflecting on are
restricted, on the one hand, to what ‘‘our kind typically thinks about’’, and, on the other
hand, to the topics implicitly thematized by the trails of our everyday practice. The concepts
and beliefs that we reflect with are primarily the kind of concepts and beliefs that ‘‘our kind’’
uses. As we have seen, possessing a professional identity includes possessing a certain
vocabulary, certain key-concepts, certain disposition to perceive, to understand and to
explain ‘‘the way we do’’, and so on. As well-established practitioners, we typically reflect
from certain interests and perspectives embodied in our profession when we reflect on
certain kinds of topics with the help of certain concepts with a purpose in mind. Our
professional reflection is basically done in the service of our profession. Whenever we reflect
professionally it is done, virtually or concretely, within our professional context and
surroundings.
Consequently, it is precisely because the individual ‘‘anatomical parts’’ of a given
profession’s first order reflection get their content by the professional identity in question,
that such reflection is implicitly confirming and not challenging to the trails and habits of
everyday professional practice and identity. In this sense, the topics, space, directions, and
results of a given profession’s first order reflection are (to a high degree) predetermined by
the profession itself. The loyalty of such reflection to traditional practice is not accidental.
Metaphorically speaking, first order reflection is the well-behaved child of precisely
traditional practice.
In addition to help elucidating the nature of first order reflection, the above sketch of ‘‘the
anatomy of reflection’’ is also a key to ways in which ‘‘disloyal’’ and identity-transforming
reflections can be constituted and become possible (that is, how second order reflection can
be implemented).
 466 S. Wackerhausen

Second order reflection

How do we transgress the boundaries and self-affirmative reflective patterns of first order
reflection, i.e., how do we create reflective activities that are not predetermined to stabilize
the already stabilized (tradition), but have the potentially to de-stabilized the stabilized?
Taking ‘‘the anatomy of reflection’’ into account, it becomes clear that changes in the
conceptual and knowledge background we use and reflect with will result in changes,
sometimes of radical nature, in our reflective spaces, possibilities, trajectories and results.
Ever so slight changes in what we reflect with might increase our reflective potentialities
J Interprof Care Downloaded from informahealthcare.com by University of Newcastle Upon Tyne on 12/21/14

quite dramatically. By increasing, say, our conceptual resources we will see that lots of new
questions, thoughts, ideas and answers become possible. A lot of thoughts formerly
impossible to think, because of the lack of concepts, do now become think-able as we
acquire the necessary concepts and put them to use. But it is not only the expansion of our
knowledge base and conceptual resources that will increase our reflective potentialities. So
will the rejection (or temporary suspension) of established professional dogmas and
concepts previously blocking or impeding several avenues of reflection.
Increased conceptual resources not only increase type and diversity of thoughts possible to
think when reflecting on certain topics, but also the number and types of topics on which we
can reflect. New questions can be raised bringing new topics to the fore. Additionally, if we
also increase the possible number of perspectives from which we reflect, still new avenues of
reflection turn up. Vary the context in which we reflect and the potential space of reflection
For personal use only.

increases further.
Increasing the combinatory variants (changing what we reflect on, with, from, and in) the
number of reflective possibilities increase dramatically and the reflective space becomes
theoretically infinite. Let say that you and I are reflecting on the same topic (A), but we do so
with different conceptual resources (B1 and B2), then different reflective possibilities and
trajectories open up to each of us. Let us now assume that you and I are not only reflecting
on the same topic (A), but also do so with the same conceptual resources, etc., (say, B1), still
the space and potentialities of reflection for you and me will be markedly different if we are
reflecting from different perspectives and purposes (C1 and C2). Let us furthermore assume
that we are in agreement with respect to what we reflect on (A), with (say, B1,) and from (say,
C2), but differ with respect to the context and surroundings we reflect in (D1 and D2). If so,
our reflective landscapes, trajectories, and results would most probably be different in
several ways. It certainly often makes a difference if we reflect alone or collectively, among
friendly or unfriendly people, in calm and relaxing surroundings or under intense stress.
Theoretically, the space for reflection is limitless (as guaranteed by the unlimited number
of combinatorial variants on each of the ‘‘anatomical elements’’ of reflection). From this
perspective, first order reflection is an intentional limitation of the possible space of
reflection (by means of a multi-dimensional, continuous process of professional socializa-
tion). But if that is the case, how is second order reflection then established? To become a
second order reflective practitioner a partial reversion of the process of socialization on the
cognitive level is required. This includes introducing variants on the different ‘anatomical’
levels of reflection and consequently breaking the profession’s ‘‘colonization’’ of and control
over the practitioners’ reflection. But to do so, quite a lot more is required as will be evident
below.
Becoming a stranger to oneself is the basic requirement to become a second order reflective
practitioner, but this type of desirable alienation does not happen by itself. On the contrary,
through our habitual practice and continuous socialization we experience every day in our
communities of practitioners make us so ‘‘familiar’’ to ourselves that we gradually become
 Collaboration, professional identity and reflection across boundaries 467

‘‘invisible’’ and consequently unknowable to ourselves. The irony is that only by becoming
strangers to ourselves will we learn to know ourselves. That includes knowledge about the
content of and the way in which we embody our professional identity.
So how does the practitioner become a stranger to himself? She needs to obtain
knowledge of, and become acquainted with concepts, theories, ideas and knowledge
‘‘outside’’ her own profession. Metaphorically, she has to visit ‘‘foreign territory’’, to learn
‘‘alien’’ concepts, and to be acquainted with ‘‘unfamiliar’’ perspectives; all contributing to
the conceptual and cognitive resources needed for her to see and describe the familiar in
unfamiliar terms and from unfamiliar perspectives and consequently, to become a stranger
J Interprof Care Downloaded from informahealthcare.com by University of Newcastle Upon Tyne on 12/21/14

to herself and attain a desirable degree of alienation. A level of estrangement required to

reverse the process of habituation and start seeing the ‘‘invisible’’, wondering about the
formerly obvious and unquestioned. To be astonished by and question the naturalness by
which ‘our kind’ do what we do and to make what is phenomenological absent or marginal
in everyday professional practice become phenomenological present and focal; to see the
trails of everyday practice and patterns of reflection and wonder about their rationality or
value.
To become a stranger to oneself the practitioner needs to obtain new knowledge, new
‘‘foreign’’ concepts, but how? We will return to this question shortly, but there is another
essential issue we have to confront first. The fact is, that becoming a stranger to oneself
professionally, and to destabilize the stabilized, can be somehow traumatic. Second order
reflection is not without risk. To question one’s doings, to become doubtful about one’s
For personal use only.

values, to destabilize the stabilized, easily generate some sense of insecurity and the
unpleasant experience of loosing identity. Of course, the more one has ‘‘taken over’’ ones
professional identity and made it an essential part of ‘‘who I am’’ (my personal identity), the
more threatening second order reflection may become. Absorbing one’s professional
identity into ones personal identity happens over time, sometimes to such a degree that it
actually appears as if it is the professional identity of the practitioner that has taken over and
totally absorbed the practitioner’s personal identity.
So, the situation is as follows: on the one hand, the practitioner might agree that second
order reflection is required for moral reasons (the well-being of the patients), on the other
hand, that initiating and carrying out such reflection is not without personal and professional
risk (at least temporarily loss of professional and personal identity). Intentionally acquiring
the necessary conceptual requisites for and actively doing second order reflection requires
virtue and courage on behalf of the practitioner. Indeed, it requires a higher level of virtue
and courage than indicated above, because professions do not love members questioning the
established and destabilizing the stabilized. As we will see, the professions’ ‘‘immune
system’’ will attack the attacker.

The immune system strikes back

The benefits and advantages of professional membership are many, but there is a price to be
paid, i.e., you have to follow the rules of conduct and membership or, in more general terms,
you have to be and stay one of your kind. That includes, as underlined in the preceding
paragraphs, talking like we do, explaining like we do, asking questions that befit our kind,
and so on. But if you are a well-mannered member following the established rules of
professional conduct, you are guaranteed professional acknowledgement, respect, self-
confidence, protection and financial security. On the other hand, if you break the rules, you
will easily start getting into trouble. The friendly side of professional socialization and
membership is inclusion and rewards, but the unfriendly side is punishment and exclusion.
 468 S. Wackerhausen

Assuming you have not done something really serious (like killing your patient), occasional
professional blunders and missteps are often tolerated or forgiven, but if you repeatedly do
something professionally unacceptable you will no longer be forgiven. You do not have to
make big professional mistakes (in the sense of causing harm to the patient), small
‘‘cultural’’ mistakes will do just fine. In both cases, the ‘‘immune system’’ of your profession
will be activated and you will feel its consequences.
Let me illustrate: while among her colleagues, a practitioner asks certain types of question
that somehow are ‘‘foreign’’ or ‘‘strange’’, i.e. not the type of questions ‘‘our kind asks’’. If a
question is felt to be really strange, the question might be seen as a joke and not taken
J Interprof Care Downloaded from informahealthcare.com by University of Newcastle Upon Tyne on 12/21/14

seriously, but if our practitioner insists on the seriousness of the question, or keeps asking
the same or similar type of questions regularly, he starts to get into trouble. Initially, he
might just be ignored by his professional colleagues (the local community of practitioners).
They may not respond to the question at all and start talking about something else.
However, let us now imagine that our practitioner did not get the message, but keeps asking
‘strange and weird’ questions, the next thing that probably will happen is that he will be
admonished or rebuked by his colleagues, either in the form of a friendly attempt to
rehabilitate (‘‘Trust me, my friend, it is not helpful to anyone to ask questions like that’’), or
an explicit warning (‘‘Stop trying to attract attention to yourself by asking those stupid
questions!’’). If our practitioner still has not got the message, or for other reasons keeps
asking ‘‘inappropriate questions’’, the next phase might very well be marginalization. The
colleagues will start avoiding our practitioner; he will gradually loose intra-professional
For personal use only.

status and becomes ‘‘incriminating’’ company. Now, if our practitioner nonetheless keeps
asking, talking, and generally behaving ‘‘strange’’, and not in accord with our formal and
informal rules of conduct, his colleagues might eventually try to get him totally isolated,
fired, or maybe even excluded from professional membership.
What our imaginary practitioner has experienced is a series of gradually more and more
severe attacks, all originating within his own profession or, to be more specific, in its immune
system. Professions (as well as organizations), like all biological systems, have their individual
‘‘immune system’’ with the purpose of neutralizing or demolishing the intrusion of
deleterious ‘‘foreign and alien elements’’, whatever they might be, into our (professional)
body. Of course, what makes something alien (foreign, strange, weird or unfamiliar) is its
divergence from the constitutive elements of the professional identity in question. What
makes something a deleterious or harmful ‘‘alien’’ element is not so easily defined because it
depends, to a large degree, on the sensitivity of the immune system. Some professions (as well
as some organizations, religious groups, and so on) have very sensitive or intolerant immune
systems leaving no room at all for divergent or non-orthodox elements, e.g., ideas,
questions, concepts and, perspectives. In such systems, all new or ‘‘foreign’’ elements are
considered harmful and must be attacked if found inside the profession or at its borders. A
hypersensitive immune system does not leave much space for second order reflection and
makes life risky and dangerous for the person engaging in reflection of this challenging kind.
Consequently, making second order reflection a reality is not guaranteed by the education
and existence of courageous practitioners qualified to reflect in a challenging and
transformative manner. A tolerant immune system is required too if second order reflection
is to become more than a very infrequent activity. In reality, however, such a system is not
only a problem for non-confirmative reflecting practitioners but also for the profession itself
and its survival. Why? Basically because the world is changing rapidly, not least by reason of
globalization and our increased interconnectedness. At the level of professions, this leads to
change of working conditions, new or additional goals, new tasks, new problems, or old
problems to be solved under new conditions. To survive as a profession under changing
 Collaboration, professional identity and reflection across boundaries 469

circumstances, the profession must have the resources needed to adapt. What are these? A
reference to the animal kingdom and the history of evolution may be informative. From the
studies of evolution we know that the species with the most diversified gene pool will have
the best chances to survive given radical environmental and climatic changes. Why? Because
the diversity makes the species better ‘‘prepared’’, so to speak, to handle the altered and
diversified living conditions. In contrast, a species with a narrow gene pool is only ‘‘tuned’’
to survive under very specific, unchanging (familiar) conditions; it will not survive as a
species if radical changes in living conditions take place. A harsh and intolerant professional
‘‘immune system’’ will minimize intra-professional diversity (in concepts, ideas and
J Interprof Care Downloaded from informahealthcare.com by University of Newcastle Upon Tyne on 12/21/14

perspectives). While streamlining the profession to survival under familiar, traditional

‘‘living conditions’’, that also makes it less likely to adapt to, and survive under, new and
changed conditions.
Not infrequently, I have heard practitioners say that they have never run into or otherwise
experienced the ‘‘immune system’’ to which I am referring. They say they can talk about
whatever they want without problems. I do not deny that this is the experience of many
practitioners, but before I congratulate them wholeheartedly on having a very tolerant or, as
some may say, a totally absent professional ‘‘immune system’’, it might be wise to note what
they actually said, i.e., that they could talk about whatever they wanted with no problems. Yes,
but what is it they want to and actually do talk about? As we have seen, a defining feature of
the well-behaved and successfully socialized member of a given profession (a fully
acknowledged member of ‘‘our kind’’) is that he only wants, and probably only has the
For personal use only.

knowledge and conceptual resources, to talk about (question, challenge or doubt) exactly
what our kind wants to talk about. And surely, that will not activate the immune system at all!
If you do not feel an urge to talk about something that ‘‘our kind’’ does not talk about, then you
will experience freedom, tolerance, and no limitations. But that would not be the experience of
someone actively engaging in second order reflection and, consequently, challenging the
established professional traditions by introducing ‘‘alien’’ ways of talking and questioning. This
practitioner will activate the ‘‘immune system’’ and be the victim of its attacks.
The question is not if a profession (or organization) has an ‘‘immune system’’; it has. The
question is how tolerant or intolerant it is. Too intolerant the ‘‘immune system’’, the more
infrequent, risky and short-lived second order reflection will be and the greater the barriers
to interprofessional collaboration.

A plea for the future5

The need for interprofessional collaboration is, and will be increasingly, essential for the
well-being of the patient. No single profession can handle, or take advantage of, all the
changes and challenges that will come in the future by reason of demography, altered health
and disease profiles, new scientific discoveries, technological inventions, and so on.
The more knowledge gathered about the causes, care, and healing of the patients’
ailments, the more can potentially be done to help them. But what any one profession is able
to do by itself (without interprofessional collaboration) will gradually become a smaller and
smaller subset of what collaborating professions have the capacity to do. Still, there are
barriers to interprofessional collaboration; some are located outside the professions (say
national health policy), but, as we have seen, many are to be found inside the professions
themselves. We have also seen that second order reflection can be essential in the process of
minimizing the intra-professional barriers to interprofessional collaboration, but, sadly,
engaging in such reflection is by no means a simple task or without risk. On the contrary, the
‘‘immune system’’ will attack the attacker.
 470 S. Wackerhausen

Hard as it might be, second order reflection is indispensable, but to engage in it does not
mean that we should be strangers permanently to ourselves and continuously question
whatever we intend to do. That would not make us efficient practitioners or help the patient.
(In fact, we would not do anything at all!). Second order reflection is more like maintaining
and repairing a sailboat at sea. You do not leave the rudder and sails to themselves and start
taking the boat apart, piece-by-piece. Doing so would not be repairing the boat; it would be
its destruction, turning it into a shipwreck. Instead, what you do is maintaining or repairing
first one thing, then a second, then a third, and so on in an unending process. Sometimes, in
that process, you will find a smart solution to an old problem, or maybe a way to avoid the
J Interprof Care Downloaded from informahealthcare.com by University of Newcastle Upon Tyne on 12/21/14

problem in the first place. Anyway, while all this is happening we are still at sea, we are still
sailing the boat, and the rudder and sail are being attended to.
For the well-being of the patient, second order reflection is a necessity, but who is
responsible for making it happen? Acquiring the necessary resource for such reflection, and
actively implementing it in practice, is not the individual practitioner’s own business and
sole responsibility. Rather, it is an obligation on the profession to make room for and help
established the resources needed for second order reflection. To some, it may sound rather
unrealistic and Utopian to call for a profession to create and make room for its own internal
critics. Not only unrealistic, because the ‘‘immune system’’ actively fights critics, but also
unrealistic because the major purpose of the formal and informal professional socialization is
indeed to make the practitioner talk like ‘‘we do’’, ask the questions ‘‘we do’’ and think like
‘‘we do’’. Left to themselves, professional socialization and the ‘‘immune system’’ (the
For personal use only.

professions internal police so to say) do not produce diversities, but similarities. In this
sense, the embodied, inherent ideal is the well-mannered practitioner (thoughtlessly)
walking the trails of everyday practice.
So, what is required is an intentional attempt to control the process of socialization and the
sensitivity of the ‘‘immune system’’, with the purpose of making space for second order
reflection. To do so, means recognizing the necessity and indispensability of second order
reflection, and consequently that intra-professional diversity is a virtue, not a vice. It is a virtue,
because diversity (supplemented by tolerance of diversity), makes room for a productive
disharmony, which is the antidote to professional rigidity and, as well, the facilitator of
professional adjustments and adaptation to the ever-changing internal and external
conditions of professional practice.
As I see it, professional education has, on the one hand, the purpose of giving the student
the necessary prerequisites to do the essential things and avoid serious professional blunders
and, on the other hand, giving him the conceptual and theoretical resources necessary to
learn reflectively from experience in practice. Gradually, he has to feel at home in, and
become one with, established practice, but he must also learn how to become an occasional
stranger to the habits and established practice of his profession, i.e., to see and question the
rationality of the trails of everyday practice.
For the above to happen, it is critical that we do not automatically and without reflection
allow the trails of everyday practice to become our ideal of professional identity. The
professional landscape will change over time and so will the trails, but the profession may
stay alive, walking new trails on different fields in different landscapes. But to survive under
changed conditions, the profession must fulfil two overlapping criteria: it must not consider
itself identical with the established trails, neither those of yesterday nor today, and it must
adapt to the changed conditions and let go of old habits and established trails. Fulfilling
these two criteria is not easy. Both professional socialization and ‘‘the immune system’’
spontaneously push in the opposite direction. It requires an intentional and conscious
re-education with respect to how we consider ourselves to be as professional practitioners.
 Collaboration, professional identity and reflection across boundaries 471

We have to re-think what we take to be the defining characteristics of our professional

identity, the essence of our identity.
The default definition of professional identity, formally and informally at play in
traditional professional education and socialization, is, as we have seen, the established
professional trails and habits. That is, our established everyday ways of thinking, talking,
behaving, prioritizing and so on. To a high degree, this is exactly what is ‘‘accidental’’ and
time bound about our professional identity. It is not our basic reason for existence as a
profession. Rather, it is our present (historically generated) means of fulfilling the purpose of
our professional existence, the raison d’être of our profession. That is, relentlessly searching
J Interprof Care Downloaded from informahealthcare.com by University of Newcastle Upon Tyne on 12/21/14

for and using the most excellent means available to do the best we possibly can for the
patient. In a historical perspective, our professional means come and go, but our
professional raison d’être stays. As professionals, we have to recognize that we live in a
rapidly changing world, a continuous and dialectic process of formation and transformation.
Invariance is the aberration, the exception and not the rule. In this world of transition, it is
our unending task as professionals to continuously search for new means and modify old
ones so they become contextually adequate, able to fulfil our professional raison d’être in our
present time and space.
Accepting our raison d’être as the essence of our professional identity also implies
welcoming second order reflection because this challenging type of reflection, in a context of
professional tolerance and productive disharmony, will keep us professionally agile and
prepare us for the changes needed to fulfil our unchanged raison d’être. The ideal practitioner
For personal use only.

is not the well-mannered practitioner who thoughtlessly and self-complacently follows the
trails of everyday practice. No doubt, we still need masters of everyday practice, we need
Maren too, but we need her to think now and then, to become a stranger to herself, or at
least we need her to accept that her less habituated ‘‘colleagues’’ most do so, without serious
risk of punishment.
Intra-professionally challenging and constructive reflection is essential, but not enough.
Increasingly, we need to establish interprofessional reflection too. The first precondition, of
course, to make this a possibility and a worthwhile endeavour is to make second order
reflection do away with some of the worst (explicit or implicit) intra-professional barriers to
interprofessional collaboration and to recognize the intra-professional advantages of
interprofessional collaboration, so that we (‘‘our kind’’) can come to know about and do
more for the patient by means of genuine collaboration.
Interprofessional reflection, if done in the right way and in a tolerant atmosphere, is akin
to second order reflection, because the individual professions will continuously be
confronted with ‘‘foreign’’ questions, terms, concepts and perspectives. But to avoid that
interprofessional reflection turns into yet another arena where more or less narrow-minded
and egocentric competition between professions takes place, it is necessary to engage in
second order reflection about ones intra-professional attitude to interprofessional reflection.
Hopefully professional humility and a co-operative spirit will be the result.

Declaration of interest: The author reports no conflicts of interest. The author alone is
responsible for the content and writing of this manuscript.

Notes
1. The present paper is a revised and expanded version of my keynote presentation at the conference Learning
together to work together, organized by The European Interprofessional Education Network in health and social
care (EIPEN), 12–14 September 2007, at Jagiellonian University, Krakow, Poland. The paper covers a very large
 472 S. Wackerhausen

and diversified field and summarizes different parts of my research over the last 10–15 years. This is a long period
and consequently, my research activities have been inspired by numerous sources, far too many to list in a single
paper. Nonetheless, these sources have all, in different ways, influenced my thoughts in the present paper. As a
kind of compromise, I have selected groups of references of special relevance to the individual themes discussed
in the paper and finally accumulated these references at the end. In addition, there are a few individual references
in different places in the text. The reader will find supplementary references in my own articles and books
mentioned in the accumulated list of references (Wackerhausen, 1992, 1996, 1997, 1998, 1999a,b,c, 2002,
2004, 2008).
2. See Pearl (2000), Mackie (1980), and Bunge (1959).
3. See Becker et al. (1961), Benner (1984), Bickel (2000), Bourdieu (1990), Bourdieu & Passeron (1977), Chi,
Glaser, & Farr (1988), Coy (1989), Ericsson et al. (2007), Feltovich et al. (1997), Feudtner & Christakis (1993),
J Interprof Care Downloaded from informahealthcare.com by University of Newcastle Upon Tyne on 12/21/14

Good (1997), Lave & Wenger (1991), Leder (1990), Polanyi (1958), Sinclair (1997), Wear & Bickel (2000),
Wenger (1998), Clark (2008), and Wilson (2004).
4. See for example Benner (1984), Boud et al. (2007), Dreyfus & Dreyfus (1986), Hogarth (2001), Hutchins
(1993), Mezirow (1990), Polanyi (1958), Reynolds & Vince (2007), Schön (1983), Sternberg (2002), Clark
(2008), Carruthers (2002), Gallagher 2006, and Wilson (2004).
5. See for example Hafferty & Franks (1994), Lloyd & Hendried (1990), Reynolds & Vince (2007), Selinger &
Crease (2006), Sinclair (1997), Sternberg (2002), and Wear & Bickel (2000).

References
Becker, H., Blanche, G. et al. (1961). Boys in white: Student culture in medical school. Chicago and London:
University of Chicago Press.
Benner, P. (1984). From novice to expert. San Francisco, CA: Addison Wesley.
For personal use only.

Bickel, J. (2000). Afterword. ‘‘Good seeds’’: Growing the physicians we need. In: J. Bickel (Ed.), Educating for
professionalism. Iowa City: University of Iowa.
Boud, D. et al. (Ed.) (2007). Productive reflection at work. London: Routledge.
Bourdieu, P. (1990). The logic of practice. Cornwall: Polity Press.
Bourdieu, P., & Passeron, J. C. (1977). Reproduction in education, society and culture. London: Sage Publications.
Bunge, M. A. (1959). Causality. The place of the causal principle in modern science. Harvard University Press.
Carruthers, P. (2002). The cognitive function of language. Behavioral and Brain Sciences, 25, 657–726.
Chi, M. T. H., Glaser. R., & Farr, M. J. (1988). The nature of expertise. New York: Lawrence Erlbaum.
Clark, A. (2008). Supersizing the mind. embodiment, action, and cognitive extension. Oxford: Oxford University Press.
Coy, M. W. (1989). Apprenticeship. New York: State University of New York.
Dreyfus, H., & Dreyfus, S. (1986). Mind over machine. Oxford: Blackwell.
Ericsson, K., & Anders et al. (Ed.) (2007). Expertise and expert performance. Cambridge: Cambridge University
Press.
Feltovich, P. J., et al. (Eds.) (1997). Expertise in context. Menlo Park, CA: MIT Press.
Feudtner, C., & Christakis, D. A. (1993). Making the rounds: The ethical development of medical students in the
context of clinical rotations. Hastings Center Report, 24, 6–12.
Gallagher, S. (2006). How the body shapes the mind. Oxford: Oxford University Press.
Good, B. J. (1997). Medicine, rationality and experience. Cambridge: Cambridge University Press.
Hafferty, F. W., & Franks, R. (1994). The hidden curriculum, ethics teaching, and the structure of medical
education. Academic Medicine, 69, 861–871.
Hogarth, R. M. (2001). Educating intuition. Chicago: The University of Chicago Press.
Hutchins, E. (1993). Cognition in the wild. Cambridge: Cambridge University Press.
Lave, J., & Wenger, E. (1991). Situated learning: Situated peripheral participation. Cambridge: Cambridge University
Press.
Leder, D. (1990). The absent body. Chicago: University of Chicago Press.
Lloyd, C., & Hendried, H. C. (1990). Educating competent and humane physicians. Indiana: Indiana University Press.
Mackie, J. L. (1980). The cement of the universe: A study of causation. Oxford: Oxford University Press.
Mezirow, J. (1990). Fostering critical reflection in adulthood. San Francisco, CA: Jossey-Bass.
Pearl, J. (2000). Causality: Models, reasoning, and inference. Cambridge, UK: Cambridge University Press.
Polanyi, M. (1958). Personal knowledge. London: Routledge.
Reynolds, M., & Vince, R. (Eds.) (2007). Organizing reflection. Burlington: Ashgate.
Schön, D. A. (1983). The reflective practitioner. New York: Basic Books.
Selinger, E., & Crease, R. P. (Eds.) (2006). The philosophy of expertise. New York: Colombia University Press.
Sinclair, S. (1997). Making doctors. An institutional apprenticeship. Oxford: Berg Publishers.
 Collaboration, professional identity and reflection across boundaries 473

Sternberg, R. J. (Ed.) (2002). Handbook of creativity. Cambridge: Cambridge University Press.

Wackerhausen, S. (1992). Teknologi, Kompetence og Vidensformer. In: F. Olesen et al. (Eds.), Teknologi og
Filosofi, Musik og Filosofi. Aarhus: Philosophia.
Wackerhausen, S. (1996). Apprenticeship, knowledge and representation. Journal of Nordic Educational Research,
16(4), 194–203.
Wackerhausen, S. (1997). The scholastic paradigm and apprenticeship. Journal of Nordic Educational Research,
No. 3.
Wackerhausen, S. (1998). Accounting for and changing practice. Nordiske Udkast. Tidsskrift for Kritisk
Samfundsforskning, 26.
Wackerhausen, S. (1999a). Det skolastiske paradigme og mesterlære. In: K. Nielsen & Steinar Kvale (Eds.),
Mesterlære - læring som social praksis. Viby J.: Hans Reitzels Forlag.
J Interprof Care Downloaded from informahealthcare.com by University of Newcastle Upon Tyne on 12/21/14

Wackerhausen, S. (1999b). Legemet som læringens subjekt. Kunnskab om Idrett, 3(2).

Wackerhausen, S. (1999c). What is natural? Deciding what to do and not to do in medicine and health care. British
Journal of Obstetrics and Gynaecology, 106, 1109–1112.
Wackerhausen, S. (2002). Humanisme, professionsidentitet og uddannelse. Copenhagen: Hans Reitzels Forlag.
Wackerhausen, S. (2004). Professionsidentitet, sædvane og akademiske dyder’’. In: N. B. Hansen & J. Gleerup
(Eds.), Videnteori, Professionsuddannelse og Professionsforskning. Odense: Syddansk Universitetsforlag.
Wackerhausen, S. (2008). Erfaringsrum, handlingsbåren kundskab og refleksion. AU: RUML-Skrifserie for Refleksion i
Praksis.
Wear, D., & Bickel, J. (Eds.) (2000). Educating for professionalism. Iowa City: University of Iowa Press.
Wenger, E. (1998). Communities of practice. Learning, meaning, and identity. Cambridge: Cambridge University
Press.
Wilson, R. A. (2004). Boundaries of the mind. The individual in the fragile sciences – Cognition. Cambridge, UK.:
Cambridge University Press.
For personal use only.