Interprofessional rhetoric and operational realities: an ethnographic study of rounds in four intensive care units
- 1.4k Downloads
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.
KeywordsWard rounds Critical care Interprofessional relations Medical education-graduate Patient centered care
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
- 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.
- 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.
- 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
- 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
- Glaser, B. G., & Strauss, A. L. (2012 ). The discovery of grounded theory: Strategies for qualitative research. New Brunswick: Aldine Transaction.Google Scholar
- Iedema, R., Mesman, J., & Carroll, K. (2013). Visualising health CARE practice improvement: Innovation from within. London: Radcliffe.Google Scholar
- 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
- 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.
- O’Reilly, K. (2012). Ethnographic methods. New York, NY: Routledge.Google Scholar
- 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
- 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
- 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/.