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Advances in Health Sciences Education

, Volume 21, Issue 4, pp 735–748 | Cite as

Interprofessional rhetoric and operational realities: an ethnographic study of rounds in four intensive care units

  • Elise ParadisEmail author
  • Myles Leslie
  • Michael A. Gropper
Article

Abstract

Morning interprofessional rounds (MIRs) are used in critical care medicine to improve team-based care and patient outcomes. Given existing evidence of conflict between and dissatisfaction among rounds participants, this study sought to better understand how the operational realities of care delivery in the intensive care unit (ICU) impact the success of MIRs. We conducted a year-long comparative ethnographic study of interprofessional collaboration and patient and family involvement in four ICUs in tertiary academic hospitals in two American cities. The study included 576 h of observation of team interactions, 47 shadowing sessions and 40 clinician interviews. In line with best practices in ethnographic research, data collection and analysis were done iteratively using the constant comparative method. Member check was conducted regularly throughout the project. MIRs were implemented on all units with the explicit goals of improving team-based and patient-centered care. Operational conditions on the units, despite interprofessional commitment and engagement, appeared to thwart ICU teams from achieving these goals. Specifically, time constraints, struggles over space, and conflicts between MIRs’ educational and care-plan-development functions all prevented teams from achieving collaboration and patient-involvement. Moreover, physicians’ de facto control of rounds often meant that they resembled medical rounds (their historical predecessors), and sidelined other providers’ contributions. This study suggests that the MIRs model, as presently practiced, might not be well suited to the provision of team-based, patient-centered care. In the interest of interprofessional collaboration, of the optimization of clinicians’ time, of high-quality medical education and of patient-centered care, further research on interprofessional rounds models is needed.

Keywords

Ward rounds Critical care Interprofessional relations Medical education-graduate Patient centered care 

Notes

Acknowledgments

This research was funded by the Gordon and Betty Moore Foundation. The authors wish to acknowledge the contributions of Niall Byrne, Ph.D., Simon Kitto, Ph.D., Mandy Pipher, and Scott Reeves, Ph.D.

Compliance with ethical standards

Conflict of interest

None.

References

  1. Accreditation Council for Graduate Medical Education. (2011). Duty hours: Common program requirements. http://www.acgme.org/acgmeweb/Portals/0/PFAssets/ProgramResources/Common_Program_Requirements_07012011%5B1%5D.pdf. Accessed 24 April 2014.
  2. Anspach, R. R. (1988). Notes on the sociology of medical discourse: The language of case presentation. Journal of Health and Social Behavior, 29, 357–375.CrossRefGoogle Scholar
  3. Bosk, C. L., Dixon-Woods, M., Goeschel, C. A., & Pronovost, P. J. (2009). Reality check for checklists. The Lancet, 374(9688), 444–445.CrossRefGoogle Scholar
  4. Bourgeault, I. L., & Mulvale, G. (2006). Collaborative health care teams in Canada and the US: Confronting the structural embeddedness of medical dominance. Health Sociology Review, 15(5), 481–495.CrossRefGoogle Scholar
  5. Brilli, R. J., Spevetz, A., Branson, R. D., Campbell, G. M., Cohen, H., Dasta, J. F., et al. (2001). Critical care delivery in the intensive care unit: Defining clinical roles and the best practice model. Critical Care Medicine, 29(10), 2007–2019.CrossRefGoogle Scholar
  6. Burford, B. (2012). Group processes in medical education: Learning from social identity theory. Medical Education, 46(2), 143–152.CrossRefGoogle Scholar
  7. Busby, A., & Gilchrist, B. (1992). The role of the nurse in the medical ward round. Journal of Advanced Nursing, 17(3), 339–346.CrossRefGoogle Scholar
  8. Coombs, M., & Ersser, S. J. (2004). Medical hegemony in decision making—A barrier to interdisciplinary working in intensive care? Journal of Advanced Nursing, 46(3), 245–252. Retrieved from http://onlinelibrary.wiley.com/doi/10.1111/j.1365-2648.2004.02984.x/abstract.
  9. Curley, C., McEachern, J. E., & Speroff, T. (1998). A firm trial of interdisciplinary rounds on the inpatient medical wards: An intervention designed using continuous quality improvement. Medical Care, 36(8), AS4–AS12.Google Scholar
  10. Danjoux Meth, N., Lawless, B., & Hawryluck, L. (2009). Conflicts in the ICU: Perspectives of administrators and clinicians. Intensive Care Medicine, 35(12), 2068–2077.CrossRefGoogle Scholar
  11. Dixon-Woods, M., & Bosk, C. (2010). Learning through observation: The role of ethnography in improving critical care. Current Opinion in Critical Care, 16(6), 639.CrossRefGoogle Scholar
  12. Durbin, C. G, Jr. (2006). Team model: Advocating for the optimal method of care delivery in the intensive care unit. Critical Care Medicine, 34(3), S12–S17.CrossRefGoogle Scholar
  13. Emerson, R. M., Fretz, R. I., & Shaw, L. L. (1995). Writing ethnographic fieldnotes. Chicago, IL: University of Chicago Press.CrossRefGoogle Scholar
  14. Felten, S., Cady, N., Metzler, M., & Burton, S. (1996). Implementation of collaborative practice through interdisciplinary rounds on a general surgery service. Nursing Case Management Managing the Process of Patient Care, 2(3), 122–126.Google Scholar
  15. Fox, N. J. (1993). Discourse, organisation and the surgical ward round. Sociology of Health and Illness, 15(1), 16–20. doi: 10.1111/1467-9566.ep11343783.CrossRefGoogle Scholar
  16. Glaser, B. G., & Strauss, A. L. (2012 [1967]). The discovery of grounded theory: Strategies for qualitative research. New Brunswick: Aldine Transaction.Google Scholar
  17. Hill, K. (2003). The sound of silence—nurses’ non-verbal interaction within the ward round. Nursing in Critical Care, 8(6), 231–239.CrossRefGoogle Scholar
  18. Hodgkin, P., & Taylor, J. (2013). Power to the people: What will bring about the patient centred revolution? BMJ, 347, f6701. doi: 10.1136/bmj.f6701.CrossRefGoogle Scholar
  19. Iedema, R., Mesman, J., & Carroll, K. (2013). Visualising health CARE practice improvement: Innovation from within. London: Radcliffe.Google Scholar
  20. Kim, M. M., Barnato, A. E., Angus, D. C., Fleisher, L. F., & Kahn, J. M. (2010). The effect of multidisciplinary care teams on intensive care unit mortality. Archives of Internal Medicine, 170(4), 369.CrossRefGoogle Scholar
  21. Kohn, L. T., Corrigan, J. M., & Donaldson, M. S. (1999). To err is human: Building a safer health system. Washington, DC: National Academy Press.Google Scholar
  22. Kopp, B. J., Mrsan, M., Erstad, B. L., & Duby, J. J. (2007). Cost implications of and potential adverse events prevented by interventions of a critical care pharmacist. American Journal of Health-System Pharmacy, 64(23), 2483–2487. doi: 10.2146/ajhp060674.CrossRefGoogle Scholar
  23. Leape, L. L., Cullen, D. J., Clapp, M. D., Burdick, E., Demonaco, H. J., Erickson, J. I., et al. (1999). Pharmacist participation on physician rounds and adverse drug events in the intensive care unit. JAMA, 282(3), 267–270. Retrieved from http://jama.jamanetwork.com/article.aspx?articleid=190687.
  24. Leslie, M., Paradis, E., Gropper, M. A., Reeves, S., & Kitto, S. (2014). Applying ethnography to the study of context in healthcare quality and safety. BMJ Quality and Safety, 23(1), 99–105. doi: 10.1136/bmjqs-2013-002335.CrossRefGoogle Scholar
  25. Lingard, L., Espin, S., Evans, C., & Hawryluck, L. (2004). The rules of the game: Interprofessional collaboration on the intensive care unit team. Critical Care, 8(6), R403–R408.CrossRefGoogle Scholar
  26. Long, D., Forsyth, R., Iedema, R., & Carroll, K. (2006). The (im)possibilities of clinical democracy. Health Sociology Review, 15(5), 506–519.CrossRefGoogle Scholar
  27. Manias, E., & Street, A. (2001). Nurse–doctor interactions during critical care ward rounds. Journal of Clinical Nursing, 10(4), 442–450.CrossRefGoogle Scholar
  28. Miller, M., Johnson, B., Greene, H. L., Baier, M., & Nowlin, S. (1992). An observational study of attending rounds. Journal of General Internal Medicine, 7(6), 646–648.CrossRefGoogle Scholar
  29. Miller, K. L., Reeves, S., Zwarenstein, M., Beales, J. D., Kenaszchuk, C., & Conn, L. G. (2008). Nursing emotion work and interprofessional collaboration in general internal medicine wards: A qualitative study. Journal of Advanced Nursing, 64(4), 332–343.CrossRefGoogle Scholar
  30. Mizrahi, T. (1985). Getting rid of patients: Contradictions in the socialisation of internists to the doctor–patient relationship. Sociology of Health and Illness, 7(2), 214–235.CrossRefGoogle Scholar
  31. Morrison, C., Jones, M., Blackwell, A., & Vuylsteke, A. (2008). Electronic patient record use during ward rounds: A qualitative study of interaction between medical staff. Critical Care, 12, R148.CrossRefGoogle Scholar
  32. Nugus, P., Greenfield, D., Travaglia, J., Westbrook, J., & Braithwaite, J. (2010). How and where clinicians exercise power: Interprofessional relations in health care. Social Science and Medicine, 71(5), 898–909.CrossRefGoogle Scholar
  33. O’Mahony, S., Mazur, E., Charney, P., & Fine, J. (2007). Use of multidisciplinary rounds to simultaneously improve quality outcomes, enhance resident education, and shorten length of stay. Journal of General Internal Medicine, 22(8), 1073–1079.CrossRefGoogle Scholar
  34. O’Leary, K. J., Sehgal, N. L., Terrell, G., & Williams, M. V. (2012). Interdisciplinary teamwork in hospitals: A review and practical recommendations for improvement. Journal of Hospital Medicine, 7(1), 48–54.CrossRefGoogle Scholar
  35. O’Reilly, K. (2012). Ethnographic methods. New York, NY: Routledge.Google Scholar
  36. Paradis, E. (2015). Unanswered questions on access from the margins. Medical Education, 49(2), 145–146. doi: 10.1111/medu.12652.CrossRefGoogle Scholar
  37. Paradis, E., & Reeves, S. (2013). Key trends in interprofessional research: A macrosociological analysis from 1970 to 2010. Journal of Interprofessional Care, 27(2), 113–122. doi: 10.3109/13561820.2012.719943.CrossRefGoogle Scholar
  38. Paradis, E., Reeves, S., Leslie, M., Aboumatar, H., Chesluk, B., Clark, P., et al. (2014). Exploring the nature of interprofessional collaboration and family member involvement in an intensive care context. Journal of Interprofessional Care, 28(1), 74–75. doi: 10.3109/13561820.2013.781141.CrossRefGoogle Scholar
  39. Peters, M., & ten Cate, O. (2014). Bedside teaching in medical education: A literature review. Perspectives on Medical Education, 3, 76–88. doi: 10.1007/s40037-013-0083-y.CrossRefGoogle Scholar
  40. Pope, C. (2005). Conducting ethnography in medical settings. Medical Education, 39(12), 1180–1187.CrossRefGoogle Scholar
  41. Pronovost, P. J., Angus, D. C., Dorman, T., Robinson, K. A., Dremsizov, T. T., & Young, T. L. (2002). Physician staffing patterns and clinical outcomes in critically ill patients: A systematic review. JAMA, 288(17), 2151–2162. doi: 10.1001/jama.288.17.2151.CrossRefGoogle Scholar
  42. Pronovost, P. J., Berenholtz, S., Dorman, T., Lipsett, P. A., Simmonds, T., & Haraden, C. (2003). Improving communication in the ICU using daily goals. Journal of Critical Care, 18(2), 71–75.CrossRefGoogle Scholar
  43. Ramani, S., Orlander, J. D., Strunin, L., & Barber, T. W. (2003). Whither bedside teaching? A focus-group study of clinical teachers. Academic Medicine, 78(4), 384–390.CrossRefGoogle Scholar
  44. Verghese, A. (2008). Culture shock—Patient as icon, icon as patient. New England Journal of Medicine, 359(26), 2748–2751. doi: 10.1056/NEJMp0807461.CrossRefGoogle Scholar
  45. Wachter, R. M. (2015). Chapter 5: Strangers at the bedside. In R. M. Wachter (Ed.), The digital doctor: Hope, hype, and harm at the dawn of medicine’s computer age (pp. 35–46). New York, NY: McGraw Hill.Google Scholar
  46. Ward, D. R., Ghali, W. A., Graham, A., & Lemaire, J. B. (2014). A real-time locating system observes physician time-motion patterns during walk-rounds: A pilot study. BMC Medical Education, 14(1), 37.CrossRefGoogle Scholar
  47. Weaver, S. J., Lubomksi, L. H., Wilson, R. F., Pfoh, E. R., Martinez, K. A., & Dy, S. M. (2013). Promoting a culture of safety as a patient safety strategy: A systematic review. Annals of Internal Medicine, 158, 369–374.CrossRefGoogle Scholar
  48. Weil, M. H. (1973). The society of critical care medicine, its history and its destiny. Critical Care Medicine, 1(1), 1–4.CrossRefGoogle Scholar
  49. Whale, Z. (1993). The participation of hospital nurses in the multidisciplinary ward round on a cancer-therapy ward. Journal of Clinical Nursing, 2(3), 155–163.CrossRefGoogle Scholar
  50. World Health Organization. (2010). Framework for action on interprofessional education and collaborative practice Geneva. Retrieved from: http://www.who.int/hrh/resources/framework_action/en/.
  51. Zwarenstein, M., Goldman, J., & Reeves, S. (2009). Interprofessional collaboration: Effects of practice-based interventions on professional practice and healthcare outcomes. Cochrane Database of Systematic Reviews, 3, CD000072. doi: 10.1002/14651858.CD000072.pub2.Google Scholar
  52. Zwarenstein, M., Rice, K., Gotlib-Conn, L., Kenaszchuk, C., & Reeves, S. (2013). Disengaged: A qualitative study of communication and collaboration between physicians and other professions on general internal medicine wards. BMC Health Services Research, 13, 494.CrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media Dordrecht 2015

Authors and Affiliations

  1. 1.Leslie Dan Faculty of PharmacyUniversity of TorontoTorontoCanada
  2. 2.Department of Anesthesia, Faculty of MedicineUniversity of TorontoTorontoCanada
  3. 3.The Wilson CentreTorontoCanada
  4. 4.Armstrong Institute for Patient Safety and QualityJohns Hopkins MedicineBaltimoreUSA
  5. 5.Department of Anesthesia and Perioperative CareUniversity of California San FranciscoSan FranciscoUSA

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