Exploring The Nature of Interprofessional Communication
Exploring The Nature of Interprofessional Communication
Exploring The Nature of Interprofessional Communication
The data we report here are a subset of a broader ethnographic study of interprofessional collaboration on four ICUs.19 The two locations discussed in this paper implemented the broadest range of HIT of the full sample, and are thus closer to using HIT as envi- sioned by policymakers. We observed HIT use and care team re- lationships on each unit simultaneously, giving the ICUs pseudonyms e Lakeside and Mid Valley e to protect their ano- nymity. The units deployed high-intensity ICU physician staffing, in which dedicated critical care specialists managed or co-managed patients.20 To improve comparability, we purposively recruited units that also matched on medical specialty and bed count.
Our observations began with both authors acting as non- participant observers. These initial impressions were clarified first with informal and then formal interviews with staff. Informal in- terviews were conducted in natural breaks and pauses in the ICU workflowand sought to clarify the social meanings andmotivations that informed clinicians’ uses of HIT. Semi-structured formal in- terviews were recruited opportunistically, and digitally recorded and transcribed for analysis.
2.3. Participants
Over the course of the ethnography 287 unique ICU clinical care teammembers were identified in our fieldnotes at the Lakeside and Mid Valley sites. Lakeside andMid Valley had extensive HIT systems in place. Lakeside’s 12 patient beds were supplemented with 29 fixed computer workstations and 5 mobile workstations. Of these 11 were dedicated to the use of nurses, 10 to the use of doctors, and 13were administrative, or at the bedside. Mid Valley’s 12 beds were supplemented with 32 fixed, and 6 mobile workstations. Of these 12 were dedicated to the use of nurses, 11 to the use of doctors, and 15 were administrative, or at the bedside. Both ICUs ran a broad range of HIT applications on this hardware, using distinct software applications to enter and manage: nursing notes, medical notes, medication prescribing and dispensing, diagnostic results, and intra-hospital communications.
2.4. Data collection
We kept detailed field notes, recording observations and con- versations within minutes of their occurrence, and then writing these up in more detail for future analysis. From December 2012 to December 2013, 369 h of observations were carried out on the two units.
2.5. Ethical considerations
Institutional review boards at both of the hospitals approved the study protocol for this research. Following best practices in the conduct of healthcare ethnography,21 all interviews included checks on emerging interpretations of how HIT work was experi- enced and distributed. In this way the social meanings of HIT work in the ICU presented here emerged from conversations among re- searchers and with research participants, who had the opportunity to refute or refine emerging interpretations.
2.6. Data analysis
We carried out data analysis using the constant comparative method,22,23 with initial themes identified, re-visited, expanded, collapsed and compared across units. Topic identification and coding were facilitated by NVIVO10 software.
2.7. Rigour
Both authors performed the coding, verifying one another’s work and iterating the analysis in collaboration with the study’s participants. Extracts from the coding are presented in the pages that follow to support our interpretation. The passages have been edited to ensure anonymity and clarity, with omissions or sub- stitutions marked in square brackets. Each passage is attributed to a clinical role (e.g. Staff Nurse; Fellow Physician), with those roles expressing relative seniority within a profession.
3. Findings
3.1. The experience of HIT
Participants’ experiences of HIT varied according to their pro- fessional background, with distinct patterns of HIT integration emerging for nurses and physicians. Nurses tended to see HIT work as ancillary to their ‘real’ or core professional work, while physi- cians tended to see HIT work as central to their professional activities.
3.2. Nurses and the ancillary nature of computer work
Nurses experienced HIT work as a documentary or accountability-oriented layer of activity that overlaid the work at the heart of their ‘real’ professional role.
Save all that money [spent on IT and] give us an extra nurse … and guess what? People will get better care. …. My favorite thing, and I’ve told you this before, was the homeless people. I liked it when a homeless person came in. [I could] go in; wash [and] shave them; make them feel like a human being again. Transform them into what they used to be, probably. Do you think people have time to do that now? No. (Lakeside, Staff RN)
Many nurses, and older nurses in particular, contrasted ‘the work’e the reason they had become nurses in the first placeewith ‘the paperwork’ which, with the implementation of HIT, had become computerized. HIT was seen as a substitute platform for previously analog documentary and administrative work, and thus as ancillary rather than central to the ‘real’work of nursing: hands- on patient care.
While there was grumbling at the time required to “tend to the computer,” nurses generally accepted this high volume. Beyond the fact that their employer required them to use HIT, their acceptance hinged in part on their sense that the computers in their work environment were a force for improving care quality. A junior Staff Nurse at Mid Valley noted that the unit’s online charting system made it more likely for nurses “to get their vital [signs] in every hour, and more likely to get their assessments done every four hours.” The pick-lists, forms, and time stamps of the HIT systems made it both easier to enter information, and more obvious when information had not been entered.
Similarly, another Mid Valley Staff Nurse was “reminded, by looking at [her computer] screen, of several items that slipped her mind amongst all the other work she had been doing since her patient’s [emergency] admission.” A senior Staff Nurse at Lakeside described how he hoped that documenting his work on the HIT system would facilitate broader safety and quality improvement efforts:
If [the hospital] can take [this ICU’s] information and shoot it right to [an off-site quality improvement team] for the things that they need to know, that’s wonderful.
