Silos and social identity: the social identity approach as a framework for understanding and overcoming divisions in health care

Learner experiences of identity and global interdependence following engagement with an interprofessional education course

University core curricula and accreditation standards for healthcare profession programs can be challenging to align. Additionally, interprofessional education (IPE) requirements for healthcare professions curricula have been designed to prepare learners for future practice. This paper describes alignment of an introductory IPE course with embedded Interprofessional Education Collaborative core competencies to specific university Core Curriculum attributes. A cross-sectional, mixed methods design was used to examine 117 learners' reflections on the IPE course content and learning outcomes. Learners from seven pre-licensure health professions programs provided responses on aspects of their IPE learning experience through reflections, surveys, written examinations, and optional focus groups. Open-ended responses were interpreted thematically from a constructivist lens. Results revealed positive perceptions of the course with feedback for areas of consideration for future course activities. Learners reported more engagement with the Core Curriculum attribute of Identities in Context than that of Global Interdependence. Additionally, responses indicated a perception of task work versus teamwork within the interprofessional team activities. Outcomes provided data that enabled continuous quality improvement of the course. Educators seeking to align IPE courses with institutional core curricula and accreditation standards may use this work to inform structure, assessment, and delineation of teamwork as compared to task work.

Starting continuous improvement; creating a common understanding of stroke care delivery in a general hospital

BACKGROUND

Continuous improvement is based on fostering practitioners' suggestions to modify their own work processes This improvement strategy is widely applied in healthcare but difficult to maintain. The cross-disciplinary nature of many care processes constitutes an extra impediment.

METHODS

The study had an explorative design with a qualitative single-case approach. The case presents a project to improve the treatment of patients with thrombotic stroke. Data was obtained via hands on involvement, documents, observations, and interviews with participants in a cross-functional improvement group. A thematic analysis method was employed.

RESULTS

Through learning how tasks were carried out in other disciplines, the participants developed a common understanding of why it took so long to provide treatment to stroke patients. These insights were used to implement practical changes, leading to immediate improvements in stroke care delivery. The results were fed back so that successes became visible. Participants' understandings of the local context enabled them to convince peers of the rationale of changes, setting in motion a permanent improvement structure. The participants considered that mapping and then assessing the entire workflow across disciplines were relevant methods for improving the quality of patient care.

CONCLUSION

Starting an improvement project in a cross disciplinary environment requires deep engagement on the part of professionals. A quintessential prerequisite is therefore the realization that the quality of care depends on cross-disciplinary cooperation. A facilitated learning arena needs to (1) create insights into each other's colleagues' tasks and process interdependencies, (2) increase understanding of how the distribution of tasks among specialist units affects the quality of care, and (3) frequently report and provide feedback on results to keep the process going.

It's a jungle out there: Understanding physician payment and its role in group dynamics

Although collaboration between healthcare professionals is essential for the delivery of effective, efficient, and high-quality care, it remains an ongoing and critical challenge across health systems. As a result, many countries are experimenting with innovative payment and employment models. The literature tends to focus on improving collaboration across organizational and sectoral boundaries, and largely ignores potential barriers to collaborative work between members of the same profession within a single organization. Despite intergroup dynamics and professional boundaries having been shown to restrict patient flow and collaboration between specialties, studies have so far tended to overlook the potential effects of differentiated organizational and payment models on physicians' behaviors and intergroup dynamics. In the present study, we seek to unpack the influence of physicians' payment and employment models on their collaborative behaviors and on intergroup dynamics between specialties, adding to the current scholarship on physician payment and employment by considering how physicians' view and act in response to different structural arrangements. The findings suggest that adopting hybrid models, in which physicians are employed or paid differently within the same organization or practice, creates a bifurcation of the profession whereby physicians across different models are perceived to behave differently and have conflicting professional values. These models are perceived to inhibit collaboration between physicians and complicate hospital governance, restricting the ability to move towards new models of care delivery. These findings can be used as a basis for future work that aims to unpack the reality of physician payment and offer important insights for policies surrounding physician employment.

The mobilisation of professional identity: A scoping and lexical review

Interprofessional care obliges different healthcare professions to share decision-making and sometimes, practices. Given established hierarchies, it can be difficult to promote interprofessional care, partly because of the need to reshape professional identities. Despite interest in effective interprofessional care, there is limited research on how professional identity can be mobilised to promote it. A scoping review as well as lexical review of academic publications was conducted to address this void. After searching seven academic databases and screening the identified publications, 22 publications met the inclusion criteria. They collectively reported on 22 interventions, most of which were used in healthcare. The scoping review suggested there is some evidence that professional identities can be mobilised. Yet, of the 22 interventions, only ten explicitly targeted professional identity. The most common intervention was a training or development program, followed by workplace redesign. The need for internal motivation to mobilise professional identity was reported as was the impact of external drivers, like extending the scope of practice. Extending these findings, the lexical review demonstrated that, among the 22 publications, the relationship between professional identity and mobilisation did not feature prominently within the discourse. Furthermore, it seems that geography matters-that is, while all the publications spoke of professional identity, they differed by region on how they did this. Given these findings, concentrated scholarship is needed on the relationship between professional identity and interprofessional care, lest interprofessional care programs have limited, sustained effect. Implications for scholars and practitioners are explicated.

Navigating a maze: Midwives' identity response to the enactment of an abortion law in Chile

BACKGROUND

Chilean midwives have been identified as essential for successfully implementing an abortion law, a practice which could potentially be understood as contradicting their central mission. Nevertheless, to date, there has been no investigation into how Chilean midwives have incorporated induced abortion care provision into their professional identity.

OBJECTIVE

To elucidate how Chilean midwives understand and provide abortion care and how they have (re)defined their professional identity to include induced abortion care. This article reports the findings of the second part of this aim.

METHODS

This study was underpinned by a constructivist grounded theory methodology informed by a reproductive justice and feminist perspective. Midwives from Chile who have cared for women undergoing abortion were invited to participate in the study. After purposive and theoretical sampling, fifteen midwives were recruited.

FINDINGS

Midwives' identity is woman-centred, with high value placed on their role protecting life. These two aspects of midwives' identity are in contradiction when providing abortion care. Midwives' identity results from and informs midwives' practice. Midwifery regulation influences both practice and identity. The model 'Navigating a maze' explains the interaction of these three elements.

CONCLUSION

Midwives' identity response to the enactment of the Chilean abortion law is an example of how professional identity must navigate regulation and practice to make sense of its purpose. In light of this study's findings, the current tension experienced in midwives' identity should be carefully attended to prevent adverse outcomes for midwives and the Chilean population.

Are emergency departments leader identity workspaces? A qualitative study of emergency physicians

OBJECTIVE

Emergency medicine is a discipline with complex leadership demands, which are experienced by junior and senior emergency physicians alike. In this environment, emergency physicians can struggle to work out what it means to be a leader and develop professional identities as leaders, necessitating a leader identity workspace. The aim of the present study is to explore whether emergency physicians view their work environment as leader identity workspaces.

METHODS

An online qualitative survey was used that included open-ended questions about emergency physicians' experience of their workplace as a 'space' to craft their leadership identity. Participants' responses were analysed using reflexive thematic analysis.

RESULTS

Three themes, comprising several subthemes, were identified that related to emergency physicians' ideal leader selves (leader dreams and desired leader selves), their experience of the community of clinicians in hospitals (confrontational sentient communities) and the types of rituals emergency physicians yearn for to support and legitimate their leadership (seeking vital leadership rites of passage).

CONCLUSION

Our results suggest that neither EDs nor hospitals more generally exhibit the properties of, or are experienced by emergency physicians, as leader identity workspaces.

Evidence behind the exhortation? A rapid review of servant leadership's influence and claims in healthcare over the last decade

Servant leadership is an other-oriented approach to leadership with multiple positive outcomes. However, its influence in the context of medicine, particularly on healthcare leaders, is less clear. We conducted a rapid review to examine the impact of servant leadership in healthcare over the last decade. We included a total of 28 articles, 26 of which described beneficial organisational, relational and personal outcomes of servant leadership. However, most of these were either conceptual or opinion-based articles. Moreover, most quantitative studies were cross-sectional, precluding causal inferences. Our review demonstrates that the purported positive association between servant leadership and healthcare outcomes lacks a strong evidence base. We conclude by calling for more rigorous empirical research to examine the effects and potential challenges of implementing servant leadership in healthcare contexts.

"Learning by osmosis": the transformative social identity journey of physiotherapists developing psychologically-informed practice, a reflexive thematic analysis

BACKGROUND

Despite efforts to support physiotherapists in integrating psychosocial aspects of care to biological ones, clinical practice remains dominated by biomechanistic priorities. To facilitate change, attention and actions need to consider not only the individual level of the therapists but also the cultural and structural levels of the profession. How these multi-layered social dynamics shape practice have not previously been investigated. The Social Identity Approach (SIA) provides a relevant framework to this exploration.

AIM

This study aimed to identify the social identity processes involved in the development of psychologically-informed physiotherapy (PIP) to understand how they may influence practice change.

METHODS

Nine semi-structured interviews were conducted with self-identified psychologically-informed physiotherapists. A Reflexive Thematic Analysis informed by SIA principles enabled to consider meaning as the product of social processes.

FINDINGS

The analysis of participants' experiences in moving from a primarily biomechanistic practice toward the integration of psychosocial aspects of health demonstrated: 1) a transformative "mind-blowing" identity journey; 2) a journey that is not made in isolation; and 3) where leadership matters.

CONCLUSION

Changes in clinical practice involve dynamics at the collective level of the practice environment and of the physiotherapy profession itself, rather than solely at the individual level of clinicians. An understanding of these complex social processes at a managerial level could be important to better support leaders and clinicians in implementing PIP in clinical practice.

"Ego massaging that helps": a framework analysis study of internal medicine trainees' interprofessional collaboration approaches

INTRODUCTION

Patient care depends on collaborative practice. Debate remains as to the best approach to providing education for collaboration, with educational interventions often far removed from the realities of the clinical workplace. Understanding the approaches used for collaboration in clinical practice could inform practical strategies for training. For internal medicine trainees, this involves collaboration with other professions but also with other specialties. This study aimed to explore the approaches that internal medicine trainees use for interprofessional collaboration and the ways that these approaches vary when internal medicine trainees interact with different healthcare provider groups.

METHODS

Following ethical approval and participant consent, interprofessional communication workshops between August 2020 and March 2021 were audio recorded and transcribed verbatim. Workshops involved groups of internal medicine trainees discussing collaboration challenges and the approaches they use in clinical practice. This framework analysis study used the interprofessional collaboration framework described by Bainbridge and Regehr (building social capital, perspective taking and negotiating priorities and resources), and cross-referenced the categorised data with the healthcare groups that trainees collaborate with, to look for patterns in the data.

RESULTS

Seventeen workshops, involving 100 trainees, were included. Trainees described relationship building, perspective taking and negotiating priorities and resources. Relationship building was a modification to the original framework domain of building social capital. Themes of power and civility transcended domains with evidence of using hierarchy as leverage when negotiating and employing civility as a tactical approach throughout.

DISCUSSION

This bi-dimensional analysis highlights patterns of perspective taking when collaborating with other specialties and professions, and the approaches to negotiation of courting favour and coercion when interacting with other specialties. This study provides evidence of the strategies currently utilised by internal medicine trainees, with different healthcare groups, and presents a modified framework which could inform the development of training for collaboration.

'Us versus them': A social identity perspective of internal medicine trainees

INTRODUCTION

Silos and group boundaries in the clinical workplace can result in interprofessional conflict which can be a source of anxiety for doctors in training. The social identity perspective (SIP) incorporates theories of social identity and self-categorisation, and may provide a useful lens to understand the socialisation and identity development of doctors. This study aimed to determine if and how the SIP may provide insight into intergroup relations as experienced by internal medicine (IM) trainees in Scotland.

METHODS

Interprofessional communication workshops hosted as part of an IM boot camp between August 2020 and March 2021 were audio recorded and transcribed verbatim. Subsequent individual interviews with consenting trainees further explored social identity and intergroup relations. Data analysis employed template analysis and deductive independent coding with the SIP informing the initial coding template and new codes added inductively.

RESULTS

Seventeen workshops, involving 100 trainees, and ten subsequent individual interviews were included. Trainees related to the social identity of an IM doctor and to stereotypes within the workplace. They described intergroup tensions resulting from a perception of differing priorities. They experienced outgroup derogation and the impact of role modelling those in their social group during their identity development.

DISCUSSION

The SIP provides a useful lens to understand the social phenomena at play for IM trainees. It confirms the expectation of conflict between specialties and negative perceptions of outgroups. There is a need to consider the hidden curriculum of socialisation in the workplace during training and the influence of the learning environment on identity development.

Theory-based evaluation of three research-practice partnerships designed to deliver novel, sustainable collaborations between adult social care research and practice in the UK: a research protocol for a 'layered' contributions analysis and realist evaluation

INTRODUCTION

Research-practice partnerships (RPPs) are long-term collaborations between research and practice that aim to conduct research that can be used to make practice-based improvements. They intentionally bring together diverse experience in decision making and seek to shift power dynamics so that all partners have a say. The Creating Care Partnerships project aims to explore whether the RPP approach developed within the US educational context can be successfully applied to the English care home context. The project involves a programme of codesign, implementation and evaluation within three case study sites. This protocol set outs the aims, research design and governance of the evaluation.

METHODS AND ANALYSIS

The evaluation takes a theory-based approach to explore how, why and in what circumstances RPPs in the care home context contribute to enhancing research and research use in local care homes and informing wider improvement efforts. A mixed-methods design will be used for each case study, including semistructured interviews, observations of RPP events and meetings, an online survey, activity diary and review of local data and documents. Data collection will proceed in waves, with the theory of change (ToC) being continually refined and used to guide further data collection and analysis. Insights will be drawn using Contribution Analysis, Realist Evaluation and systems perspectives to assess the contribution made by the case study sites to achieving outcomes and the influence of contextual factors. Economic consequences will be identified through the ToC, using a narrative economic analysis to assess costs, consequences and value for money.

ETHICS AND DISSEMINATION

The study has undergone ethics review by HRA Research Ethics Committee. It does not pose major ethical issues. A final report will be published and articles will be submitted to international journals.

Exploring the impact of interprofessional simulation on the professional relationships of trainee pharmacists and medical students: a constructivist interview study

Members of clinical teams can hold stereotyped views of one another that can form barriers to interprofessional cohesion and collaboration. Interprofessional education (IPE) is often championed as a way of teaching individuals to be better team players through the adoption of collaborative attitudes and behaviours. However, the potentially detrimental effects of IPE are not well understood. This study used the social identity approach (SIA) as a lens to explore the impact of interprofessional simulation on the identities and professional relationships of trainee pharmacists and medical students.

Across three different locations in Scotland, trainee pharmacists were paired with medical students to participate in immersive simulation scenarios with post-scenario debriefs. Participants were individually interviewed shortly after their simulation session, using a semi-structured interview schedule based on SIA. Transcripts were analysed using template analysis, with sub-categorizations of SIA forming the initial coding template.

Twenty-five interviews were undertaken across both groups. The interprofessional simulation session effectively challenged pre-existing stereotypes. For the trainee pharmacists, the alteration of self-stereotypes influenced motivation through self-enhancement and, in turn, altered group norms via the promotion of genuine collaboration and joint decision-making. However, social comparisons focussed on status remained prominent.

This study has shown that interprofessional simulation can effectively challenge and alter stereotypes (including self-stereotypes), but social comparisons may be less easy to overcome in this context. As it continues to be embedded within healthcare education, the limitations of IPE must be better understood to ensure that the potential value of such opportunities is maximized.

Interprofessional identity in clinicians: A scoping review

Interprofessional collaborative practice (IPCP) has been recognized as invaluable in delivering safe, high-quality patient care with finite resources. However, despite a decade of advances in interprofessional (IP) research, policy, and competency frameworks, IPCP does not always occur in practice. One reason may be the influence of a clinician's identity in an IP context. The purpose of this scoping review was to understand the nature of IP identity in healthcare clinicians. The PRISMA framework was used to support a comprehensive search strategy and screening of 1746 articles. Inclusion criteria included original research, theses, and reviews, a primary focus on IP identity or professional identity (PI) in an IP team, and a focus on health professionals, including students transitioning to practice. Ninety-five papers met the eligibility criteria, though once charted, just four of the 95 papers focused on IP identity in clinicians. Three further papers examined shared team identity, 25 papers referred to, but did not focus on IP identity, and the remaining 63 papers explored PI in an IP team. While limited studies on clinician IP identity restrict conclusive findings, patterns were identified to direct further research on the nature of IP identity in clinicians. These include values and beliefs, individual and personal factors, profession and professional experience, education, socialization, context, leadership, and the process of IP identity development. While identity is undeniably central to being a clinician, the values, beliefs, attributes, and experiences that contribute to clinician IP identity, how clinician IP identity develops, and factors that influence IP identity remain unclear. The results of this review highlight the value of further investigation of the nature of IP identity, the interplay between PI and IP identity, and identity in an IP context.

Commentary on Burns, Nembhard and Shortell, "Integrating network theory into the study of integrated healthcare": Revisiting and extending research on structural and processual factors affecting coordination

Burns et al.'s innovative recommendation to use social network theory to study integration will contribute to our understanding of how healthcare systems can optimally deliver high quality, coordinated, person-centered care. We discuss three enhancements to this approach. (1) In increasing our attention to social network analysis and processual perspectives, we must not "throw out the baby with the bathwater" and abandon research that includes formal organizational structure. Structure remains an important focus for researchers and healthcare managers, who spend considerable resources on reorganizing. Since there is evidence that formal structure affects social processes and coordination, future research should build on that evidence and investigate how coordination is affected by the segmentation of organizations into units and the structures and processes designed to integrate interdependent work across those units. Conducting network analysis in the context of formal structure can help us better understand how formal structure affects both social networks and coordination. (2) Using multi-level, mixed methods, and qualitative research will be critically important to fully understand how and why formal organizational structure, social networks, and processual dynamics contribute to coordination or fragmentation of care. Because the relationships among these constructs occur not only within, but also across multiple levels, multi-level research is necessary to understand their effects on coordination. In considering the individual level, patients can be studied as a role embedded in networks. In addition, however, we must not lose a focus on patients as people at the center of multi-level networks, whose attitudes, values, preferences and goals may directly affect processual dynamics and coordination of care. (3) Finally, our field lacks precision in nomenclature, specification of levels, and the constructs within them, including ambiguity around even what is meant by "structure" and its variations. Furthermore, different authors use "macro", "meso", and "micro", differently, contributing to confusion in the discourse on organizational phenomena. Greater clarity and consistency in terminology is needed to facilitate research and improve communication across the field.

Who's on your team? Specialty identity and inter-physician conflict during admissions

PURPOSE

Despite the implementation of professionalism curricula and standardised communication tools, inter-physician conflict persists. In particular, the interface between emergency medicine (EM) and internal medicine (IM) has long been recognised as a source of conflict. The social nuances of this conflict remain underexplored, limiting educators' ability to comprehensively address these issues in the clinical learning environment. Thus, the authors explored EM and IM physicians' experiences with negotiating hospital admissions to better understand the social dynamics that contribute to inter-physician conflict and provide foundational guidance for communication best practices.

METHODS

Using a constructivist grounded theory (CGT) approach, the authors conducted 18 semi-structured interviews between June and October 2020 with EM and IM physicians involved in conversations regarding admissions (CRAs). They asked participants to describe the social exchanges that influenced these conversations and to reflect on their experiences with inter-physician conflict. Data collection and analysis occurred iteratively. The relationships between the codes were discussed by the research team with the goal of developing conceptual connections between the emergent themes.

RESULTS

Participants described how their approaches to CRAs were shaped by their specialty identity, and how allegiance to members of their group contributed to interpersonal conflict. This conflict was further promoted by a mutual sense of disempowerment within the organisation, misaligned expectations, and a desire to promote their group's prerogatives. Conflict was mitigated when patient care experiences fostered cross-specialty team formation and collaboration that dissolved traditional group boundaries.

CONCLUSIONS

Conflict between EM and IM physicians during CRAs was primed by participants' specialty identities, their power struggles within the broader organisation, and their sense of duty to their own specialty. However, formation of collaborative inter-specialty physician teams and expansion of identity to include colleagues from other specialties can mitigate inter-physician conflict.

Exploring the role of power during debriefing of interprofessional simulations

Interprofessional simulation aims to improve teamwork and patient care by bringing participants from multiple professions together to practice simulated patient care scenarios. Yet, power dynamics may influence interprofessional learning during simulation, which typically occurs during the debriefing. This issue has received limited attention to date but may explain why communication breakdowns and conflicts among healthcare teams persist despite widespread adoption of interprofessional simulation. This study explores the role of power during interprofessional simulation debriefings. We collected data through observations of seven interprofessional simulation sessions and debriefings, four focus groups with simulation participants, and four interviews with simulation facilitators. We identified ways in which power dynamics influenced discussions during debriefing and sometimes limited participants' willingness to share feedback and speak up. We also found that issues related to power that arose during interprofessional simulations often went unacknowledged during the debriefing, leaving healthcare professionals unprepared to navigate power discrepancies with other members of healthcare teams in practice. Given that the goal of interprofessional simulation is to allow professionals to learn together about each other, explicitly addressing power in debriefing after interprofessional simulation may enhance learning.

The power of proximity: Effects of a multidisciplinary fibroid clinic on inter-specialty perceptions and practice patterns

Background

Multidisciplinary collaboration has generally been shown to have positive effects on healthcare but can be difficult to facilitate. This study assessed the effects of a multidisciplinary fibroid clinic on practice patterns and clinician perceptions to better understand drivers of interspecialty collaboration.

Materials and methods

Annual rates of hysterectomies, myomectomies, and uterine fibroid embolizations (UFEs) performed in an urban healthcare system were collected from 2012–2019. Rates of each procedure were compared over time before and after launching a multidisciplinary fibroid clinic at the academic medical center. Referral rates were also compared. The gynecologists and interventional radiologists (IRs) involved in the clinic were interviewed 2 years prior to and after the clinic launch about their approaches to fibroids and perceptions of others who treat this condition. A phenomenological approach was used to identify and compare themes within the interviews by two researchers with excellent inter-rater agreement (κ = 0.80).

Results and discussion

Annual rates of fibroid procedures increased over time (p<0.01) but the relative number of UFEs decreased (p = 0.01). UFE referrals by the clinic gynecologists significantly increased as did the number of combined fibroid procedures (p<0.01). However, the rates of one fibroid procedure relative to others were not different between the clinic and rest of the healthcare system (p = 0.55). Specialty-specific perceptions of fibroid treatments and inter-specialty dynamics did not change. Despite this, clinicians unanimously perceived the clinic and post-clinic practice patterns as positive and distinct from their previous work and relationships between gynecology and IR elsewhere. Limitations of this study included its single clinic design and potential confounder of differences in advertising pre- versus post-clinic.

Conclusion

Creating the right practice environment may be more important for fostering inter-specialty collaboration and work satisfaction than shared mental models or procedural volumes in certain practice settings.

Social Identity in a public hospital: sources, outcomes, and possible resolutions

The comprehensive, twofold goal of this paper is to investigate how social identities in a multilayered social platform of a public hospital are shaped, and to explain the impact of these identities on staff interrelations, patients, and the organization's overall ability to meet challenges. We conducted a qualitative study, collecting data from 30 employees working in a medium-sized public hospital in Israel using a semi-structured interview guide. Using a thematic analysis approach and drawing on social identity theory, we found that departmental identity is the most prominent social identity associated with the hospital staff. This identity was strengthened by strong in-group management, but little influenced by senior out-group management; its importance also caused organizational goals to be overlooked. We discuss these findings and offer recommendations for addressing the adverse impacts of departmental identity on staff, patients, and the organization's ability to meet challenges. This study has clarified sources and impacts of SI in a hospital context. It has also demonstrated the need for a more unified hospital identity to improve the hospital's daily work and achieve the organization's goals in a dynamic, competitive environment. Most literature on social identity has addressed personal- and group-level antecedents of social identity, neglecting the potential participation of in-group and out-group management in shaping these identities, as well as management's contribution to the achievement or nonachievement of organizational goals. By adopting a qualitative approach, the current study provides a deeper understanding of how senior management and direct in-group management can shape social identities-a perspective heretofore missing from the research. Recognizing these identity-shaping forces is essential for understanding the challenges that hospitals face, and the various (at times, life-or-death) consequences of these forces.

SUPPLEMENTARY INFORMATION

The online version contains supplementary material available at 10.1007/s12144-022-02729-4.

'Nurses whisper.' Identities in nurses' patient safety narratives of nurse-trainee doctors' interactions

CONTEXT

Nurses are integral to patient safety, but little is known about their narrative constructions of identity in relation to their dyadic interactions with trainee doctors about patient safety and competence during the trajectory of a medical career.

AIM

We sought to examine how identities are constructed by experienced nurses in their narratives of patient safety encounters with trainee doctors.

METHODS

Our qualitative study gathered narrative data through semi-structured interviews with nurses of different professional standing (n = 20). Purposive sampling was used to recruit the first eight participants, with the remainder recruited through theoretical sampling. Audio recordings were transcribed verbatim and analysed inductively through a social constructionist framework and deductively using a competence framework.

RESULTS

We classified seven identities that participants constructed in their narratives of dyadic interactions with trainee doctors in relation to patient safety: nurses as teacher, guardian of patient wellbeing, provider of emotional support, provider of general support, expert advisor, navigator and team player. These identities related to the two key roles of nurses as educators and as practitioners. As they narrated these dyadic interactions, participants constructed identities that positioned trainee doctors in character tropes, suggesting gaps in professional competence: nurses as provider of general support was commonly narrated in the context of perceived deficits of personal or functional capabilities and nurses as team player was mainly associated with concerns (or reassurances) around ethical capabilities.

DISCUSSION AND CONCLUSION

Our findings are consistent with, and extend the wider literature on the development of professional competence, interprofessional collaboration in health care, and the nature and organisation of nursing work. Nurses' work in ensuring patient safety and support trainee doctors' professional development merits greater formal recognition and legitimation.

A Realist Evaluation of Team Interventions in Acute Hospital Contexts-Use of Two Case Studies to Test Initial Programme Theories

BACKGROUND

Designing and implementing team interventions to improve quality and safety of care in acute hospital contexts is challenging. There is little emphasis in the literature on how contextual conditions impact interventions or how specific active ingredients of interventions impact on team members' reasoning and enact change. This realist evaluation helps to deepen the understanding of the enablers and barriers for effective team interventions in these contexts.

METHODS

Five previously developed initial programme theories were tested using case studies from two diverse hospital contexts. Data were collected from theory driven interviews (n = 19) in an Irish context and from previously conducted evaluative interviews (n = 16) in a US context. Data were explored to unpack the underlying social and psychological drivers that drove both intended and unintended outcomes. Patterns of regularity were identified and synthesised to develop middle-range theories (MRTs).

RESULTS

Eleven MRTs demonstrate how and why intervention resources introduced in specific contextual conditions enact reasoning mechanisms and generate intended and unintended outcomes for patients, team members, the team and organisational leaders. The triggered mechanisms relate to shared mental models; openness, inclusivity and connectedness; leadership and engagement; social identity and intrinsic motivational factors.

CONCLUSIONS

The findings provide valuable information for architects and facilitators of team interventions in acute hospital contexts, as well as help identify avenues for future research. Dataset: The data presented in this study are available on request from the corresponding author. The data are not publicly available due to their sensitive nature and potential identification of participants.

The role of the informal and formal organisation in voice about concerns in healthcare: A qualitative interview study

The importance of employee voice-speaking up and out about concerns-is widely recognised as fundamental to patient safety and quality of care. However, failures of voice continue to occur, often with disastrous consequences. In this article, we argue that the enduring sociological concepts of the informal organisation and formal organisation offer analytical purchase in understanding the causes of such problems and how they can be addressed. We report a qualitative study involving 165 interviews across three healthcare organisations in two high-income countries. Our analysis emphasises the interdependence of the formal and informal organisation. The formal organisation describes codified and formalised elements of structures, procedures and processes for the exercise of voice, but participants often found it frustrating, ambiguous, and poorly designed. The informal organisation-the informal practices, social connections, and methods for making decisions that are key to coordinating organisational activity-could facilitate voice through its capacity to help people to understand complex processes, make sense of their concerns, and frame them in ways likely to prompt an appropriate organisational response. Sometimes the informal organisation compensated for gaps, ambiguities and inconsistencies in formal policies and systems. At the same time, the informal organisation had a dark side, potentially subduing voice by creating informal hierarchies, prioritising social cohesion, and providing opportunities for retaliation. The formal and the informal organisation are not exclusive or independent: they interact with and mutually reinforce each other. Our findings have implications for efforts to improve culture and processes in relation to voice in healthcare organisations, pointing to the need to address deficits in the formal organisation, and to the potential of building on strengths in the informal organisation that are crucial in supporting voice.

A Citizen of Two Worlds: The IR/DR Residency

The integrated interventional radiology (IR) residency accepted its first applicants in 2017. Achieving specialty status represents a significant milestone for IR; recognizing the expanding role of IR as part of an interdisciplinary team. However, this transition has had challenges that were well predicted by Heitkamp and Gunderman in 2014 and are reflected in the history of many specialties. New specialties often have complex relationships with their "parent" specialties, creating debates and tension regarding training, licensure, and scope of practice. Many of these factors have been discussed in opinion pieces by leaders in the field, reflecting upon the transition. There have also been surveys of matched IR/DR residents. However, there are few firsthand accounts of the challenges faced by trainees during such a transition, challenges that often are not well captured by an online survey.

Exploring the barriers and facilitators of psychological safety in primary care teams: a qualitative study

BACKGROUND

Psychological safety is the concept by which individuals feel comfortable expressing themselves in a work environment, without fear of embarrassment or criticism from others. Psychological safety in healthcare is associated with improved patient safety outcomes, enhanced physician engagement and fostering a creative learning environment. Therefore, it is important to establish the key levers which can act as facilitators or barriers to establishing psychological safety. Existing literature on psychological safety in healthcare teams has focused on secondary care, primarily from an individual profession perspective. In light of the increased focus on multidisciplinary work in primary care and the need for team-based studies, given that psychological safety is a team-based construct, this study sought to investigate the facilitators and barriers to psychological safety in primary care multidisciplinary teams.

METHODS

A mono-method qualitative research design was chosen for this study. Healthcare professionals from four primary care teams (n = 20) were recruited using snowball sampling. Data collection was through semi-structured interviews. Thematic analysis was used to generate findings.

RESULTS

Three meta themes surfaced: shared beliefs, facilitators and barriers to psychological safety. The shared beliefs offered insights into the teams' background functioning, providing important context to the facilitators and barriers of psychological safety specific to each team. Four barriers to psychological safety were identified: hierarchy, perceived lack of knowledge, personality and authoritarian leadership. Eight facilitators surfaced: leader and leader inclusiveness, open culture, vocal personality, support in silos, boundary spanner, chairing meetings, strong interpersonal relationships and small groups.

CONCLUSION

This study emphasises that factors influencing psychological safety can be individualistic, team-based or organisational. Although previous literature has largely focused on the role of leaders in promoting psychological safety, safe environments can be created by all team members. Members can facilitate psychological safety in instances where positive leadership behaviours are lacking - for example, strengthening interpersonal relationships, finding support in silos or rotating the chairperson in team meetings. It is anticipated that these findings will encourage practices to reflect on their team dynamics and adopt strategies to ensure every member's voice is heard.

Interprofessional teamwork: the role of professional identity and signature pedagogy - a mixed methods study

PURPOSE

One overlooked determinant of interprofessional teamwork is the mobilisation of professional identity. Taking a health or social care practitioner out of their professional silo and placing them in an interprofessional team setting will challenge their professional identity. The theory of signature pedagogy was used to investigate the challenges and what is needed to support practitioners to mobilise their professional identity to maximise teamwork.

DESIGN/METHODOLOGY/APPROACH

A cross-sectional mixed methods study was undertaken in the form of three focus groups, with members of health and social care teams in Wales, UK. Using nominal group technique, participants explored and ranked the challenges and benefits of mobilising their professional identity within an interprofessional setting.

FINDINGS

Findings on mobilising professional identity were found to be aligned closely with the three signature pedagogy apprenticeships of learning to think and to perform like others in their profession and to act with moral integrity. The biggest challenge facing practitioners was thinking like others in their profession while in an interprofessional team.

RESEARCH LIMITATIONS/IMPLICATIONS

The focus of this study is health and social care teams within Wales, UK, which may limit the results to teams that have a similar representation of professionals.

PRACTICAL IMPLICATIONS

Healthcare leaders should be aware of the opportunities to promote mobilisation of professional identity to maximise teamwork. For example, at induction, by introducing the different roles and shared responsibilities. Such practical implications do have consequences for policy as regards interprofessional team development and organisational commitments to adult learning and evaluation.

ORIGINALITY/VALUE

This is the first study of professional identity of interprofessional healthcare and social professionals using signature pedagogy to gain a better understanding of teamwork.

Managing intergroup silos to improve patient flow

BACKGROUND

Health care managers face the critical challenge of overcoming divisions among the many groups involved in patient care, a problem intensified when patients must flow across multiple settings. Surprisingly, however, the patient flow literature rarely engages with its intergroup dimension.

PURPOSE

This study explored how managers with responsibility for patient flow understand and approach intergroup divisions and "silo-ing" in health care.

METHODOLOGY/APPROACH

We conducted in-depth interviews with 300 purposively sampled senior, middle, and frontline managers across 10 Canadian health jurisdictions. We undertook thematic analysis using sensitizing concepts drawn from the social identity approach.

RESULTS

Silos, at multiple levels, were reported in every jurisdiction. The main strategies for ameliorating silos were provision of formal opportunities for staff collaboration, persuasive messages stressing shared values or responsibilities, and structural reorganization to redraw group boundaries. Participants emphasized the benefits of the first two but described structural change as neither necessary nor sufficient for improved collaboration.

CONCLUSION

Silos, though an unavoidable feature of organizational life, can be managed and mitigated. However, a key challenge in redefining groups is that the easiest place to draw boundaries from a social identity perspective may not be the best place from one of system design. Narrowly defined groups forge strong identities more easily, but broader groups facilitate coordination of care by minimizing the number of boundaries patients must traverse.

PRACTICE IMPLICATIONS

A thoughtfully designed combination of strategies may help to improve intergroup relations and their impact on flow. It may be ideal to foster a "mosaic" identity that affirms group allegiances at multiple levels.

The Role of Power in Health Care Conflict: Recommendations for Shifting Toward Constructive Approaches

PURPOSE

The combination of power and conflict is frequently reported to have a detrimental impact on communication and on patient care, and it is avoided and perceived negatively by health care professionals. In view of recent recommendations to explicitly address power and conflict in health professions education, adopting more constructive approaches toward power and conflict may be helpful. This study examined the role of power in conflicts between health care professionals in different cultural contexts to make recommendations for promoting more constructive approaches.

METHOD

The authors used social bases of power (positional, expert, informational, reward, coercive, referent) identified in the literature to examine the role of power in conflicts between health care professionals in different cultural settings. They drew upon semistructured interviews conducted from 2013 to 2016 with 249 health care professionals working at health centers in the United States, Switzerland, and Hungary, in which participants shared stories of conflict they had experienced with coworkers. The authors used a directed approach to content analysis to analyze the data.

RESULTS

The social bases of power tended to be comparable across sites and included positional, expert, and coercive power. The rigid hierarchies that divide health care professionals, their professions, and their specialties contributed to negative experiences in conflicts. In addition, the presence of an audience, such as supervisors, coworkers, patients, and patients' families, prevented health care professionals from addressing conflicts when they occurred, resulting in conflict escalation.

CONCLUSIONS

These findings suggest that fostering more positive approaches toward power and conflict could be achieved by using social bases of power such as referent power and by addressing conflicts in a more private, backstage, manner.

Factors influencing physician responsiveness to nurse-initiated communication: a qualitative study

BACKGROUND

How quickly physicians respond to communications from bedside nurses is important for the delivery of safe inpatient care. Delays in physician responsiveness can impede care or contribute to patient harm. Understanding contributory factors to physician responsiveness can provide insights to promote timely physician response, possibly improving communication to ensure safe patient care. The purpose of this study was to describe the factors contributing to physician responsiveness to text or numeric pages, telephone calls and face-to-face messages delivered by nurses on adult general care units.

METHODS

Using a qualitative design, we collected data through observation, shadowing, interviews and focus groups of bedside registered nurses and physicians who worked in four hospitals in the Midwest USA. We analysed the data using inductive content analysis.

RESULTS

A total of 155 physicians and nurses participated. Eighty-six nurses and 32 physicians participated in focus groups or individual interviews; we shadowed 37 physicians and nurses across all sites. Two major inter-related themes emerged, message and non-message related factors. Message-related factors included the medium nurses used to convey messages, physician preference for notification via one communication medium over another and the clarity of the message, all of which could cause confusion and thus a delayed response. Non-message related factors included trust and interpersonal relationships, and different perspectives between nurses and physicians on the same clinical issue that affected perceptions of urgency, and contributed to delays in responsiveness.

CONCLUSIONS

Physician responsiveness to communications from bedside nurses depends on a complex combination of factors related to the message itself and non-message related factors. How quickly physicians respond is a multifactorial phenomenon, and strategies to promote a timely response within the context of a given situation must be directed to both groups.

Information sharing challenges in end-of-life care: a qualitative study of patient, family and professional perspectives on the potential of an Electronic Palliative Care Co-ordination System

OBJECTIVES

To explore current challenges in interdisciplinary management of end-of-life care in the community and the potential of an Electronic Palliative Care Co-ordination System (EPaCCS) to facilitate the delivery of care that meets patient preferences.

DESIGN

Qualitative study using interviews and focus groups.

SETTING

Health and Social Care Services in the North of England.

PARTICIPANTS

71 participants, 62 health and social care professionals, 9 patients and family members.

RESULTS

Four key themes were identified: information sharing challenges; information sharing systems; perceived benefits of an EPaCCS and barriers to use and requirements for an EPaCCS. Challenges in sharing information were a source of frustration for health and social care professionals as well as patients, and were suggested to result in inappropriate hospital admissions. Current systems were perceived by participants to not work well-paper advance care planning (ACP) documentation was often unavailable or inaccessible, meaning it could not be used to inform decision-making at the point of care. Participants acknowledged the benefits of an EPaCCS to facilitate information sharing; however, they also raised concerns about confidentiality, and availability of the increased time and resources required to access and maintain such a system.

CONCLUSIONS

EPaCCS offer a potential solution to information sharing challenges in end-of-life care. However, our findings suggest that there are issues in the initiation and documentation of end-of-life discussions that must be addressed through investment in training in order to ensure that there is sufficient information regarding ACP to populate the system. There is a need for further qualitative research evaluating use of an EPaCCS, which explores benefits and challenges, uptake and reasons for disparities in use to better understand the potential utility and implications of such systems.

Male Nurses' Dealing with Tensions and Conflicts with Patients and Physicians: A Theoretically Framed Analysis

Proposes

Delivery of healthcare involves engagements of patients, nurses and other health professionals. The Social Identity Theory (SIT) can provide a lens to investigate intergroup interactions. This study explores how male nurses deal with intergroup tensions and conflicts with patients and physicians when delivering healthcare.

Methods

A collaborative qualitative research study was conducted by two research teams, with one from Mainland China and the other from Macau. Twenty-four male nurses were recruited, with 12 from each of the two regions. A similar guide was used by the two teams to conduct in-depth interviews with the participants. Thematic analysis was used, and SIT guided the data analysis and interpretation of the results.

Results

Four themes identified are related to nurse/patient relationships: respecting patients’ decisions, neglecting minor offenses, defending dignity, taking a dominant position; two themes are related to nurse/physician relationships: rationalizing physicians’ superiority over nurses, establishing relationships with physicians by interpersonal interactions.

Conclusion

Male nurses avoid confrontation with patients in case of disagreements but take on gender- and profession-based dominance in dealing with intense conflicts to maintain healthcare order. They do not challenge the status hierarchy between nurses and physicians but manage to maintain harmonious relationships with physicians by engaging in interpersonal activities with physicians in leisure times.

Implication

Male nurses can take the lead to create inclusive groups to engage patients and physicians in delivering healthcare. The masculine traits of male nurses do not subvert the nurse/physician hierarchy stereotype but strengthen it.

Point your SmartPhone at the code above. If you have a QR code reader the video abstract will appear. Or use:

https://youtu.be/hGgcK1YRVcU

A critical exploration of professional jurisdictions and role boundaries in inter-professional end-of-life care in the community

This article critically examines how professional boundaries and hierarchies influence how end-of-life care is managed and negotiated between health and social care professionals. Our findings suggest there is uncertainty and lack of clarity amongst health and social care professionals regarding whose responsibility it is to engage, and document, the wishes of patients who are dying, which can lead to ambiguity in treatment decisions. We go on to explore the potential role of a new electronic system, designed to facilitate information sharing across professional boundaries, in shaping and bridging professional boundaries in the delivery of end-of-life care. We highlight potential negative impacts that may arise when health and social care groups are permitted varying levels of access to the system, and how this may be seen to reflect the value placed on their role in end-of-life care.

The social network of medical case managers, housing providers, and health department staff in the Ryan White HIV/AIDS Program: A Midwest case study

BACKGROUND

Broad networks of providers in the Ryan White system are essential to end the HIV epidemic. Yet, there is little evidence that has assessed social networks of providers within HIV care networks. The purpose of this study is to provide a cross-sectional analysis of the role medical case managers (MCM), housing providers (HP), and health department staff (HDS), play in a Ryan White-funded area.

METHODS

All MCMs, HPs, and HDS (N = 57) in a Midwest Transitional Grant Area were invited to participate in a social network survey. Social network composition scores, exponential random graph modeling and ANOVA tests were conducted using SPSS and R Studio.

RESULTS

Communication in this network was significantly more likely between SW of the same provider type (e.g. MCMs communicating with other MCMs, β = .87, p<.001). HDS reported larger overall social networks (F(2,54) = 4.59, p = <.01), larger networks with other provider types (F(2,54) = 9.23, p<.001), and higher quality of relationships with other provider types (F(2,54) = 3.90, p<.05) than MCM or HP. HDS were more likely to communicate across the system than MCMs or HPs (β = .75, p<.001).

DISCUSSION

HDS play an important role in communicating across provider types in care delivery for HIV. Our results indicate that health departments represent essential agencies for broad dissemination of resources and knowledge, and may bridge communication barriers for coordination of housing support and HIV care delivery.

Implementing post-discharge care following acute kidney injury in England: a single-centre qualitative evaluation

OBJECTIVES

We sought to understand the factors influencing the implementation of a primary care intervention to improve post-discharge care following acute kidney injury (AKI).

DESIGN

Qualitative study using semi-structured interviews and thematic analysis.

SETTING

General practices in one Clinical Commissioning Group area in England.

PARTICIPANTS

A total of 18 healthcare staff took part in interviews. Participants were practice pharmacists, general practitioners, practice managers and administrators involved in implementing the intervention.

RESULTS

We identified three main factors influencing implementation: differentiation of the new intervention from other practice work; development of skill mix and communication across organisations. Overall, post-AKI processes of care were deemed straightforward to embed into existing practice. However, it was also important to separate the intervention from other work in general practice. Dedicating staff time to proactively identify AKI on discharge summaries and to coordinate the provision of care enabled implementation of the intervention. The post-AKI intervention provided an opportunity for practice pharmacists to expand their primary care role. Working in a new setting also brought challenges; time to develop trusting relationships including an understanding of boundaries of clinical expertise influenced pharmacists' roles. Unclear and inconsistent information on discharge summaries contributed to concerns about additional work in primary care.

CONCLUSIONS

The research highlights challenges around post-discharge management in the primary care context. Coordination and communication were key factors for improving follow-up care following AKI. Further consideration is required to understand patient experiences of the interface between secondary and primary care. The issues pertaining to discharge care following AKI are relevant to practitioners and commissioners as they work to improve transitions of care for vulnerable patient populations.

Organizational Silos: A Scoping Review Informed by a Behavioral Perspective on Systems and Networks

In recent years, several organizations have implemented interventions aimed at integrating work processes and bridging network clusters. These are often permeated by different assumptions regarding clusters in organizational settings. There are concerns about the formation of silos and structural barriers to communication across the formal and informal network structures. Conversely, network clusters are regarded as spaces of local social reinforcement from which innovation ideas may emerge. Although terminologically and functionally different, they share some common features insofar as organizational behavior is concerned and the production of artifacts that fulfill organizational goals. The present scoping review presents an analysis of the literature on organizational silos while investigating attempts to bridge network clusters. Based on the search results, 40 studies were included in the analysis of the findings; of these, 20 were empirical studies and were included in a further quantitative analysis of methods and findings. We identified patterns of definitions of silos and variation in terms of aims, variables, and methods used to evaluate interventions among the heterogeneous studies. Special attention was dedicated to the role of consequences of siloed organizational behavior. We conclude that silos comprise barriers to achieving organizational goals insofar as they pose a threat to internal cooperation.

Factors influencing interprofessional team collaboration when delivering care to community-dwelling seniors: A metasynthesis of Canadian interventions

The rapid growth in the proportion of adults over the age of 65 translates into greater need of complex, highly specialized care. Hence, coupled with other factors, healthcare expenditures in Canada have grown exponentially, creating tension for a high-quality care while managing costs. Interventions with community-based interprofessional teams have been piloted across Canada as a means to provide efficient specialized care. These teams must, however, work collaboratively for a more comprehensive and patient-centered care. This metasynthesis aimed to identify common factors or characteristics found to be essential for a collaborative practice among members of an interdisciplinary team delivering coordinated care to community-dwelling seniors in both rural and urban centers in Canada. Six databases (Medline, CINAHL, Sage, JSTOR, ProQuest, Web of Science) were searched for qualitative peer-reviewed articles on community-based interventions with interprofessional teams in Canada and published between 2005-2018. Six articles were included and appraised using the COREQ guidelines for quality, followed by a thematic analysis for common themes related to team collaboration. Overarching themes related to practices of interprofessional collaboration were trust and respect, communication, and shared vision. Sub-themes included trust in the relationship between health care professional, professional identity and role clarity, interprofessional communication, communication with the client or family, and common goals. Interprofessional teams work collaboratively when trust and respect, communication, and shared vision are valued and present. Agencies coordinating interprofessional teams for community-based care could be pivotal in ensuring an environment conducive to collaboration, such as learning and team building opportunities.

Interventions to minimise doctors’ mental ill-health and its impacts on the workforce and patient care: the Care Under Pressure realist review

Background

The growing incidence of mental ill-health in health professionals, including doctors, is a global concern. Although a large body of literature exists on interventions that offer support, advice and/or treatment to sick doctors, it has not yet been synthesised in a way that takes account of the complexity and heterogeneity of the interventions, and the many dimensions (e.g. individual, organisational, sociocultural) of the problem.

Objectives

Our aim was to improve understanding of how, why and in what contexts mental health services and support interventions can be designed to minimise the incidence of doctors’ mental ill-health. The objectives were to review interventions to tackle doctors’ mental ill-health and its impact on the clinical workforce and patient care, drawing on diverse literature sources and engaging iteratively with diverse stakeholder perspectives to produce actionable theory; and recommendations that support the tailoring, implementation, monitoring and evaluation of contextually sensitive strategies to tackle mental ill-health and its impacts.

Design

Realist literature review consistent with the Realist And Meta-narrative Evidence Syntheses: Evolving Standards quality and reporting standards.

Data sources

Bibliographic database searches were developed and conducted using MEDLINE (1946 to November week 4 2017), MEDLINE In-Process and Other Non-indexed Citations (1946 to 6 December 2017) and PsycINFO (1806 to November week 2 2017) (all via Ovid) and Applied Social Sciences Index and Abstracts (1987 to 6 December 2017) (via ProQuest) on 6 December 2017. Further UK-based studies were identified by forwards and author citation searches, manual backwards citation searching and hand-searching relevant journal websites.

Review methods

We included all studies that focused on mental ill-health; all study designs; all health-care settings; all studies that included medical doctors/medical students; descriptions of interventions or resources that focus on improving mental ill-health and minimising its impacts; all mental health outcome measures, including absenteeism (doctors taking short-/long-term sick leave); presenteeism (doctors working despite being unwell); and workforce retention (doctors leaving the profession temporarily/permanently). Data were extracted from included articles and the data set was subjected to realist analysis to identify context–mechanism–outcome configurations.

Results

A total of 179 out of 3069 records were included. Most were from the USA (45%) and had been published since 2009 (74%). More included articles focused on structural-level interventions (33%) than individual-level interventions (21%), but most articles (46%) considered both levels. Most interventions focused on prevention, rather than treatment/screening, and most studies referred to doctors/physicians in general, rather than to specific specialties or career stages. Nineteen per cent of the included sources provided cost information and none reported a health economic analysis. The 19 context–mechanism–outcome configurations demonstrated that doctors were more likely to experience mental ill-health when they felt isolated or unable to do their job, and when they feared repercussions of help-seeking. Healthy staff were necessary for excellent patient care. Interventions emphasising relationships and belonging were more likely to promote well-being. Interventions creating a people-focused working culture, balancing positive/negative performance and acknowledging positive/negative aspects of a medical career helped doctors to thrive. The way that interventions were implemented seemed critically important. Doctors needed to have confidence in an intervention for the intervention to be effective.

Limitations

Variable quality of included literature; limited UK-based studies.

Future work

Use this evidence synthesis to refine, implement and evaluate interventions.

Study registration

This study is registered as PROSPERO CRD42017069870.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 19. See the NIHR Journals Library website for further project information.

Explicit Dialogue About the Purpose of Hospital Admission Is Essential: How Different Perspectives Affect Teamwork, Trust, and Patient Care

PURPOSE

The authors previously found that attending physicians conceptualize hospital admission purpose according to 3 perspectives: one focused dominantly on discharge, one on monitoring and managing chronic conditions, and one on optimizing overall patient health. Given implications of varying perspectives for patient care and team collaboration, this study explored how purpose of admission is negotiated and enacted within clinical teaching teams.

METHOD

Direct observations and field interviews took place in 2 internal medicine teaching units at 2 teaching hospitals in Ontario, Canada, in summer 2017. A constructivist grounded theory approach was used to inform data collection and analysis.

RESULTS

The 54 participants included attendings, residents, and medical students. Management decisions were identified across 185 patients. Attendings and senior medical residents (second- and third-year residents) were each observed to enact one dominant perspective, while junior trainees (first-year residents and students) appeared less fixed in their perspectives. Teams were not observed discussing purpose of admission explicitly; however, differing perspectives were present and enacted. These differences became most noticeable when at the extremes (discharge focused vs optimization focused) or between senior medical residents and attendings. Attendings implicitly signaled and enforced their perspectives, using authority to shut down and redirect discussion. Trainees' maneuvers for enacting their perspectives ranged from direct advocacy to covert manipulation (passive avoidance/forgetting and delaying until attending changeover).

CONCLUSIONS

Failing to negotiate and explicitly label perspectives on purpose of admission may lead to attendings and senior medical residents working at cross-purposes and to trainees participating in covert maneuvers, potentially affecting trust and professional identify development.

Exploring group boundaries and conflicts: a social identity theory perspective

CONTEXT

In the clinical environment, health care professionals self-categorise into different groups towards which they develop positive attitudes, whereas they view other groups less favourably. Social identity theory purports that these attitudes influence group processes and may foster conflicts that impede collaborative practice, although this relationship is poorly understood. This study used concepts from social identity theory to examine the interplay between group processes and conflicts, as well as the consequences of these conflicts, with the goal of identifying educational strategies to favour teamwork.

METHODS

Semi-structured interviews with 82 randomly selected physicians and nursing professionals working at a Swiss academic medical centre explored participants' experiences of conflicts. Data analysis was informed by social identity theory and focused on interviews where group processes were highlighted by participants. The analysis sought to uncover how group processes were intertwined with conflicts and how they affected health care professionals.

RESULTS

A total of 42 participants out of the initial pool of 82 interviews shared 52 stories of conflicts involving group processes. Most of these stories were shared by physicians and involved groups of physicians at different hierarchical levels. Conflicts and group processes were linked in two ways: (i) through processes of group membership when individuals struggled to join a relevant group, and (ii) through intergroup boundaries, such as when participants perceived that power differentials disadvantaged their own groups. Conflicts could lead to difficult experiences for clinicians who questioned their abilities, became disillusioned with their professional ideals and developed negative perceptions of other groups.

CONCLUSIONS

This study suggests that conflicts involving group processes may lead to stronger intergroup boundaries, challenging current educational efforts to favour teamwork in health care. Taking steps to create more inclusive groups and to encourage perspective taking may help manage intergroup conflict.

Barriers and facilitators for prevention in Danish dental care

Objective: To explore barriers and facilitators to oral disease prevention in Danish dental care from a multi-stakeholder perspective. Methods: Eleven semi-structured focus groups and interviews about Danish oral healthcare were conducted with 27 stakeholders (general public, dental teams, dental policy makers) in Copenhagen. Transcripts were analyzed using deductive thematic analysis independently by KR and HL, supervised by JC and KVC. Results: Seven broad themes were identified, including both barriers and facilitators: Knowledge and attitudes, Education and training, Regulation, Incentivization, Multidisciplinary approach, Access to care and the Dental professional-patient relationship. Whilst all themes were relevant to each group of stakeholders, the salient driver within each theme was different for each group. Conclusions: Stakeholder perspectives on the Danish Oral health care system suggest the following are important features for a preventively focused system: (a) Involving all stakeholders in oral healthcare planning. (b) Securing sufficient and ongoing briefing regarding disease prevention for all stakeholders. (c) Regulatory support and creation of incentives to promote and facilitate implementation of disease prevention. (d) Appropriate prevention for disadvantaged groups within society which may be possible to a higher degree by means of multidisciplinary collaboration. (e) Personal relations between the patient and the professional based on mutual trust.

The stipulation-stimulation spiral: A model of system change

This paper proposes a general model, based on what is known about the nature of (complex) systems, of how systems-in particular, health care systems-respond to attempted change. Inferences are drawn from a critical literature review and reinterpretation of two primary studies. The two fundamental system-change approaches are "stipulation" and "stimulation": stip(ulation) attempts to elicit a specific response from the system; stim(ulation) encourages the system to generate diverse responses. Each has a unique strength: stip's is precision, the ability to directly impact the desired outcome and only that outcome; stim's is resonance, the ability to take advantage of behavior already present within the system. Each approach's inherent strength is its complement's inherent weakness; thus, stip and stim often clash if attempted simultaneously but can reinforce each other if applied in alternation. Opposite patterns (the "stip-stim spiral" vs "stip-stim stalemate") are observed to underpin successful vs failed system change: The crucial difference is whether decision-makers respond to a need for precision/resonance by strengthening the appropriate approach (stipulation/stimulation, respectively), or merely by weakening its complement. With further validation, the model has the potential to yield a more fundamental understanding of why system-change efforts fail and how they can succeed.

Informal Clinical Integration in Medicare Accountable Care Organizations and Mortality Following Coronary Artery Bypass Graft Surgery

BACKGROUND

Accountable care organizations' (ACOs') focus on formal clinical integration to improve outcomes overlooks actual patterns of provider interactions around shared patients.

OBJECTIVE

To determine whether such informal clinical integration relates to a health system's performance in an ACO.

RESEARCH DESIGN

We analyzed national Medicare data (2008-2014), identifying beneficiaries who underwent coronary artery bypass grafting (CABG). After determining which physicians delivered care to them, we aggregated across episodes to construct physician networks for each health system. We used network analysis to measure each system's level of informal clinical integration (defined by cross-specialty ties). We fit regression models to examine the association between a health system's CABG mortality rate and ACO participation, conditional on informal clinical integration.

SUBJECTS

Beneficiaries age 66 and older undergoing CABG.

MEASURES

Ninety-day CABG mortality.

RESULTS

Over the study period, 3385 beneficiaries were treated in 161 ACO-participating health systems. The remaining 49,854 were treated in 875 nonparticipating systems or one of the 161 ACO-participating systems before the ACO start date. ACO systems with higher levels of informal clinical integration had lower CABG mortality rates than nonparticipating ones (2.8% versus 5.5%; P<0.01); however, there was no difference based on ACO participation for health systems with lower to relatively moderate informal clinical integration. Regression results corroborate this finding (coefficient for interaction between ACO participation and informal clinical integration level is -0.25; P=0.01).

CONCLUSIONS

Formal clinical integration through ACO participation may be insufficient to improve outcomes. Health systems with higher informal clinical integration may benefit more from ACO participation.

The growing pains of physician-administration relationships in an academic medical center and the effects on physician engagement

Background

Physician engagement has become a key metric for healthcare leadership and is associated with better healthcare outcomes. However, engagement tends to be low and difficult to measure and improve. This study sought to efficiently characterize the professional cultural dynamics between physicians and administrators at an academic hospital and how those dynamics affect physician engagement.

Materials and methods

A qualitative mixed methods analysis was completed in 6 weeks, consisting of a preliminary analysis of the hospital system’s history that was used to purposefully recruit 20 physicians across specialties and 20 healthcare administrators across management levels for semi-structured interviews and observation. Participation rates of 77% (20/26) and 83% (20/24) were achieved for physicians and administrators, respectively. Cohorts consisted of equal numbers of men and women with experience ranging from 1 to 35 years within the organization. Field notes and transcripts were systematically analyzed using an iterative inductive-deductive approach. Emergent themes were presented and discussed with approximately 400 physicians and administrators within the organization to assess validity and which results were most meaningful.

Results & discussion

This investigation indicated a professional cultural disconnect was undermining efforts to improve physician engagement. This disconnect was further complicated by a minority (10%) not believing an issue existed and conflicting connotations not readily perceived by participants who often offered similar solutions. Physicians and administrators felt these results accurately reflected their realities and used this information as a common language to plan targeted interventions to improve physician engagement. Limitations of the study included its cross-sectional nature with a modest sample size at a single institution.

Conclusions

A qualitative mixed methods analysis efficiently identified professional cultural barriers within an academic hospital to serve as an institution-specific guide to improving physician engagement.

Pushing for partnership: physician engagement and resistance in primary care renewal

PURPOSE

Healthcare policymakers and managers struggle to engage private physicians, who tend to view themselves as independent of the system, in new models of primary care. The purpose of this paper is to examine this issue through a social identity lens.

DESIGN/METHODOLOGY/APPROACH

Through in-depth interviews with 33 decision-makers and 31 fee-for-service family physicians, supplemented by document review and participant observation, the authors studied a Canadian province's early efforts to engage physicians in primary care renewal initiatives.

FINDINGS

Recognizing that the existing physician-system relationship was generally distant, decision-makers invested effort in relationship-building. However, decision-makers' rhetoric, as well as the design of their flagship initiative, evinced an attempt to proceed directly from interpersonal relationship-building to the establishment of formal intergroup partnership, with no intervening phase of supporting physicians' group identity and empowering them to assume equal partnership. The invitation to partnership did not resonate with most physicians: many viewed it as an inauthentic offer from an out-group ("bureaucrats") with discordant values; others interpreted partnership as a mere transactional exchange. Such perceptions posed barriers to physician participation in renewal activities.

PRACTICAL IMPLICATIONS

The pursuit of a premature degree of intergroup closeness can be counterproductive, heightening physician resistance.

ORIGINALITY/VALUE

This study revealed that even a relatively subtle misalignment between a particular social identity management strategy and its intergroup context can have highly problematic ramifications. Findings advance the literature on social identity management and may facilitate the development of more effective engagement strategies.

Practice educators' attitudes and perspectives of interprofessional collaboration and interprofessional practice learning for students: A mixed-methods case study

Interprofessional collaboration (IPC) is important for the delivery of effective integrated health and social care systems. Interprofessional practice learning (IPPL) enables students to learn to work together within a relevant context and prepare for future IPC. While there is some evidence that negative attitudes impact on IPC and interprofessional education, there is a dearth of research on health and social work professionals' attitudes and perspectives of IPC and IPPL opportunities for students. A mixed-methods case study was used to investigate practice educators' attitudes and perspectives of IPC and IPPL for their students. Results showed that attitudes were positive and that mainly meso- and macro-level factors, as opposed to the micro level, impacted on the implementation of IPC and IPPL for students' learning in practice settings. IPC was perceived to be best enabled by effective communication, established teams, IPPL for staff, and shared processes and policies. Close working proximity to other professionals encouraged informal communication and positive interprofessional relationships. Motivation and resources were perceived as enablers of IPPL, but there were often missed opportunities for IPPL. These findings suggest that further work is required to identify systems for improving IPC and to enhance IPPL opportunities for students learning within practice settings.

Image and perception of physicians as barriers to inter-disciplinary cooperation? - the example of German occupational health physicians in the rehabilitation process: a qualitative study

BACKGROUND

In the German rehabilitation system, primary care physicians (PCPs), occupational health physicians (OPs), and rehabilitation physicians (RPs) fulfill different distinct functions and roles. While effective cooperation can improve outcomes of rehabilitation, the cooperation between these groups of stakeholders has been criticized as lacking or insufficient. This article proposes an approach to understand the low levels of cooperation by examining the role of group perception and group identity in intra-professional cooperation as a barrier to cooperation between physicians in different roles. Group perception was evaluated in terms of (1) negative views about another group of medical specialists and (2) differences between the perception of members and non-members of a medical specialty group. To examine this issue, we focused on the role of OPs in the German rehabilitation process.

METHODS

We implemented a qualitative study design with eight focus group discussions with PCPs, OPs, RPs, and patients (two focus group discussions per stakeholder group; 4-10 participants) and qualitative content analysis. We used the Social Identity Approach by Tajfel and Turner as a theoretical underpinning.

RESULTS

While all protagonists reported a positive perception of their own professional group, we found numerous negative perceptions about other groups, especially regarding OPs. Negative perceptions of OPs included 1) apparent conflict of interest between employer and employee, 2) lack of commitment to patient outcomes, 3) lack of useful specialized knowledge which could have a bearing on rehabilitation outcomes, and 4) distrust on the part of their patients. We also found divergent perceptions regarding roles, responsibilities, and capabilities among the specialist groups. Both negative and conflicting perceptions about roles were characterized as barriers to cooperation by study participants.

CONCLUSION

This example of cooperation between RPs, OPs, and PCPs suggests that negative and diverging perceptions about an out-group could create barriers in intra-professional and inter-disciplinary cooperation between physicians. These perspectives might also be useful in explaining problems at intersections between different specialties. We suggest examining the inter-group dimension of perception-based barriers to cooperation in future interventions to overcome problems caused by intra-professional and inter-disciplinary conflicts in addition to other barriers (i.e. organizational hurdles).