Journal of Interprofessional Care
ISSN: 1356-1820 (Print) 1469-9567 (Online) Journal homepage: http://www.tandfonline.com/loi/ijic20
An ethnographic investigation of junior doctors’ capacities to practice interprofessionally in three teaching hospitals Jacqueline Milne, David Greenfield & Jeffrey Braithwaite To cite this article: Jacqueline Milne, David Greenfield & Jeffrey Braithwaite (2015) An ethnographic investigation of junior doctors’ capacities to practice interprofessionally in three teaching hospitals, Journal of Interprofessional Care, 29:4, 347-353 To link to this article: http://dx.doi.org/10.3109/13561820.2015.1004039
Published online: 03 Feb 2015.
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http://informahealthcare.com/jic ISSN: 1356-1820 (print), 1469-9567 (electronic) J Interprof Care, 2015; 29(4): 347–353 ! 2015 Informa UK Ltd. DOI: 10.3109/13561820.2015.1004039
ORIGINAL ARTICLE
An ethnographic investigation of junior doctors’ capacities to practice interprofessionally in three teaching hospitals Jacqueline Milne1, David Greenfield2 and Jeffrey Braithwaite2
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1
Faculty of Medicine, University of New South Wales, Sydney NSW, Australia and 2Australian Institute of Health Innovation, Centre for Healthcare Resilience and Implementation Science, Macquarie University, NSW, Australia Abstract
Keywords
Collaborative practice among early career staff is at the bedrock of interprofessional care. This study investigated factors influencing the enactment of interprofessional practice by using the day-to-day role of six junior doctors in three teaching hospitals as a gateway to understand the various professions’ interactive behaviours. The contextual framework used for the study was Strauss’ theory of negotiated order. Ethnographic techniques were applied to observe the actions and interactions of participants on typical working days in their hospital environments. Field notes were created and thematic analysis was applied to the data. Three themes explored were culture, communication, and collaboration. Issues identified highlight the bounded organisational and professional cultures within which junior doctors work, and systemic problems in interprofessional interaction and communication in the wards of hospitals. There are indications that early career doctors are interprofessional isolates. The constraints of short training terms and pressure from multi-faceted demands on junior doctors can interfere with the establishment of meaningful relationships with nurses and other health professionals. The realisation of sustained interprofessional practice is, therefore, practically and structurally difficult. Enabling factors supporting the sharing of expertise are outweighed by barriers associated with professional and hospital organisational cultures, poor interprofessional communication, and the pressure of competing individual task demands in the course of daily practice.
Communication, complexity, ethnography, interprofessional practice, interprofessional collaboration, professional boundaries, professional cultures
Introduction Hospitals are complex, ever-changing organisations (Braithwaite, Clay-Williams, Nugus, & Plumb, 2013a; Sturmberg & Martin, 2013). They face substantial challenges from mounting operational costs, and increasing patient demands for sophisticated care delivered by highly skilled health professionals (Barraclough & Birch, 2006; Milne, 2012; Wachter, 2004). This complexity is further exacerbated by the intricacies of clinical interventions, necessitating a broad range of hospital-based investigations, procedures, and treatment options for patients (Nardi et al., 2007; Plsek & Greenhalgh, 2001). There are specific challenges across the landscape of teaching hospitals, as junior doctors undertake postgraduate training and education (Gleason, Daly, & Blackham, 2007; Opdam, 2006). Doctors in particular face stresses and competing demands in fulfilling their tasks (Ibrahim, Jeffcott, Davis, & Chadwick, 2013; Newbury-Birch & Kamali, 2001). The multi-faceted aspects of care and the complicated working environments that junior doctors encounter require more than clinical knowledge (Pownall, 2009; Ross et al., 2013). One Correspondence: Dr Jacqueline Milne PhD, Visiting Fellow, Faculty of Medicine, Level 3 Samuels Buidling, University of New South Wales, Sydney NSW 2052 Australia. E-mail: [email protected]
History Received 7 November 2013 Revised 28 October 2014 Accepted 31 December 2014 Published online 3 February 2015
important factor in the transition to being a competent practitioner is how junior doctors relate to and work with their professional colleagues from nursing and other health professions. To be effective, health care is best delivered by interprofessional teams (Ibrahim et al., 2013; Scholes & Vaughan, 2002). The safe delivery of care lies at the heart of interprofessional practice. The goal is to optimise care provided by the clinical team with the patient purposefully as the focus of professionals’ combined skills, expertise, and care (Braithwaite & Travaglia, 2006). The interdependency of health professionals and their relationships are therefore fundamental, and interprofessional cultures, and competence in communication as well as practice, loom as critical characteristics (Blumenthal, 1994; Gittell, Godfrey, & Thistlewaite, 2013). The broader interprofessional literature is consistent in supporting the merits of collaborative interprofessional practice for improving the quality of care and patient safety (Interprofessional Education Collaborative Expert Panel, 2012; Reeves et al., 2010; Rice et al., 2010; World Health Organization Department of Human Resources for Health, 2010). The combination of shared, communicated patient care objectives with joint assessment of patient progress between health professionals is vital to collaborative interprofessional practice (Thistlethwaite, 2008). However, the implementation of interprofessional practice is subject to the different professions’
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capability and willingness to collaborate and cooperate as equal professional partners, combining and valuing their respective skills in delivering patient care (Braithwaite & Travaglia, 2005; Cameron, 2011; MacMillan, 2012). Doctors’ connectedness with health professionals such as nurses, pharmacists, physiotherapists, social workers, and speech pathologists relates to their level of interprofessional practice and competence in the delivery of care during their formative years (Gozu, Kern, & Wright, 2009; Greenfield, Nugus, Travaglia, & Braithwaite, 2011; Interprofessional Education Collaborative Expert Panel, 2011; Piterman, Newton, & Canny, 2010). However, we do not know much about interprofessionalism in this period. There are indications that early career doctors are busy interprofessional isolates (see Westbrook, Ampt, Kearney, & Rob, 2008). This study explored junior doctors’ interprofessional relationships in the multifarious cultures of teaching hospitals where their clinical attitudes and behaviours are forged (Hall, 2005). Our aim was to examine factors influencing the enactment of interprofessional practice in the day-to-day practice of junior doctors through observing their behaviours and relationships with other professionals. We do not seek to privilege medicine, but we sought to examine young doctors’ behaviours as a gateway device, to look at how they enact their roles in relation to their colleagues in nursing and other health professions. Theoretical framing The study was framed using Strauss’ theory of negotiated order (1978) and applied to doctors’ relationships and interactions within the hospital organisational setting, to test their capacity to work interprofessionally. A multi-faceted negotiated order is embedded in the work practices of health professionals and the organisation of hospitals in which they work (Georgiou et al., 2007). Essentially, there are workplace trade-offs, agreements, and bargains struck in a steady stream in busy interactive environments. Professional roles are fluid in the execution of their practice, requiring manifold interactive re-negotiations with other professionals throughout their daily practice in caring for patients (Day & Day, 1977; Strauss, Schatzman, Ehrlich, Bucher, & Sabshin, 1963). We used the negotiated order paradigm to contextualise the study, following Nugus, Greenfield, Travaglia, Westbrook, and Braithwaite (2010). While this approach has been used in other interprofessional studies (see Reeves et al., 2009; Zwarenstein & Reeves, 2002) here we focus on junior doctors and their professional coal-face colleagues.
Methods We used rapid ethnography, an approach suited to gathering rich data within a relatively short time frame (Handwerker, 2001; Millen, 2000).
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Context The field researcher sought to become immersed in participants’ day-to-day world and observe the execution of their tasks, and their professional relationships and responses to everyday events. The researcher conducted constant side-by-side shadowing of participant doctors. Typically, shifts commenced with ward rounds. Then, the scope broadened to observation of other health professionals, as participant doctors moved within and beyond their specialty wards to different clinical and administrative areas. Other professionals observed included senior clinicians, junior doctor counterparts, nurse unit managers, clinical nurse consultants, nurse managers, nurse educators, enrolled nurses, hospital pharmacists, physiotherapists, social workers, dieticians, speech pathologists, radiographers, and occupational therapists. Participants readily adapted to being observed. There was little time to adjust their behaviour in response to being shadowed because of the immediacy of their tasks. Their work was spontaneous and busy at all times. Data collection Fieldwork was conducted during September and October 2011. Preliminary observation of the workplace behaviours and environmental settings at each site was conducted to gather situational data. This enabled the securing of contextual baseline perspectives on the respective hospital environments before commencing the ethnographic observations of the doctors. Situational fieldwork totalled 12 h of observations, and the rapid ethnography involved 51.5 h of observational time. The observations of each doctor presented a unique opportunity to witness the background, scale and scope of their working days and provided a window into their encounters with other doctors, nurses, and health professionals in a range of clinical settings across the respective hospitals. We undertook these in-depth ethnographic observations following established principles (see Bosk, 1985; Denzin & Lincoln, 2002; Mays & Pope, 2000; Miles & Huberman, 1984). The major form of data collection was detailed hand written field notes recording observations in real time, following procedures enunciated by Nugus et al. (2010). Additional material gathered was in the form of situational data specific to each setting (Spradley, 1980; see Table I). This information included the clinical specialisation(s) and physical environment of the ward or unit, the graduate level of doctors, staffing and bed numbers, outlier patients reviewed, and the flow and identity of visiting itinerant professional staff. Outlier patients occupy beds in different wards at a distance from the specialty ward to which they would normally be allocated. Data analysis
Participants Six participants were drawn from a cohort of 32 doctors previously interviewed and surveyed in three Australian teaching hospitals (Milne, 2012). All consented to being observed on-site at their respective hospitals for the entirety of one of their rostered shifts. Doctors’ postgraduate experience ranged from a junior intern to residents and registrars in vocational training. In Australia, all three are collectively known as ‘‘residents’’ or ‘‘junior medical officers’’ (‘‘house officers’’ in the United Kingdom and ‘‘residents’’ in the United States). In Australia, they can be either overseas or locally trained, so one international medical graduate (IMG) and one Australian medical graduate (AMG) from each of the three hospitals was selected. Their working experience in the Australian hospital system ranged from 18 months to 6 years.
QSR NVivo9 software (QSR International, Burlington, MA) was used to manage the data which amounted to 21 480 words of text. Field notes were coded and data were treated as individual narratives (Atkinson, 1992; Polkinghorne, 1995) to convey the sense of reality evoked through the presence of the observer immersed in the domain of the participants. Using the negotiated order frame, data were examined to identify where and how junior doctors performed their role, who they engaged with or avoided and how they displayed their ‘‘doctoring’’ through their activities and behaviours. The data were analysed against themes of culture, communication, and collaboration in the context of negotiated interprofessional interactions and associated behaviours observed. Field notes and themes were discussed by the research team to interpret and make sense of the data sets.
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Table I. Study sites, settings, and participants. Hospitals and shifts observed
Characteristics of settings
Participants
Hospital A 350 beds Day shift
Multiple specialities ward including: renal and vascular medicine, haematology, immunology, medical oncology 34 ward patients. Seven outliers Other patients in ED Nine registered and enrolled nurses One clinical nurse educator One shared pharmacist Medical ward: gastroenterology, colorectal, drug and alcohol 34 ward patients. One outlier Other patients in ED and day-only ward (endoscopy and colonoscopy) Seven registered and enrolled nurses (including agency nurses) One clinical nurse specialist Two nurse educators
Neuroscience ward (medical and surgical beds) 34 patients. No outliers Out of ward: ICU, ED, theatre, radiology Surgical registrar, resident Seven registered and enrolled nurses One nurse educator Emergency Department 12 bed cubicles Three resuscitation beds 16 nurses Admitting officer, two staff specialists, three residents, one registrar
Female resident Australian medical graduate Second year postgraduate training
Colorectal surgery, Upper gastrointestinal surgery 28 patients. Six outliers Out of ward: theatre and outpatients 13 Registered and enrolled nurses One pharmacist
Female resident Australian medical graduate First year postgraduate trainee
Emergency medical unit – morning 10 patients Two registered nurses Emergency outpatients – afternoon Two staff specialists and registered nurses
Male resident International medical graduate Between first and second year postgraduate training
Hours of observation: 8
Hospital A Day shift
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Hours of observation: 9.5
Hospital B 440 beds Day shift Hours of observation: 9 Hospital B Afternoon/evening shift Hours of observation: 8.5 Hospital C 660 beds Day shift Hours of observation: 8.5 Hospital C Day shift Hours of observation: 8
Ethical considerations Ethics approval was granted for the study by the University of New South Wales, Australia (HREC 09211) and a lead Hospital Ethics Committee in New South Wales (HREC/09/SVH/ 137).
Results Ward rounds at the outset of shifts were invariably conducted, typically by registrars, without the presence of other health professionals. As recorded in the field notes: The doctors commence their ward round. Nurses continue to go about their business independently of the round. (Field researcher notes, Hospital A, morning round, gastroenterology, drug and alcohol and clinical pharmacology ward) As a consequence, discussion of patient care was confined to medical perspectives between the doctors on the round. Junior doctors on the medical team were then responsible for the direct transmission and communication of patient orders arising from the ward rounds. Communication was largely one way, from the doctors to the nurses, and conveyed in the imperative reflecting
Female registrar Australian graduate Fourth year postgraduate training Physician trainee
Male senior resident International medical graduate Third year postgraduate training
Female registrar International medical graduate Third year postgraduate training in Australia Emergency medicine trainee
the constraints of time and the expectations under which they work on a daily basis. The ward rounds were the generators of a large part of junior doctors’ activities for the day. Accomplishing orders after the rounds, such as medication orders, tests and investigative procedures, checking results, writing up patient notes, and instigating the processes for discharging patients, were time consuming and somewhat lone tasks. On the surgical wards, registrars conducted early rounds at around 7 am before going to theatre. This left very junior doctors in charge of managing problems arising with surgical patients. An instance of protracted attempts to insert a naso-gastric tube in a postoperative neurosurgical patient with a tracheotomy bore witness to such a situation. As the field notes indicated: The doctor is approached by a nurse to assist with a nasogastric tube insertion. The patient is clearly distressed. The doctor fails to succeed in her attempt. The nurse then reveals that she has had several failed attempts already. The doctor immediately orders a radiology screen to confirm the correct placement of the tube before attempting reinsertion. (Nurse and second year junior doctor, Hospital B, neurosurgical ward)
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Meanwhile, notes from observing a hospital emergency department handover round recorded:
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The round begins around a high bench outside the central working station. Gathered here are ten doctors: two staff specialists, three registrars, a senior resident, four residents and a medical student. A nurse joins the round when we get to cubicle eight and then the nurse’s phone rings so he walks away. (Field researcher notes, Hospital B, afternoon handover round, emergency department) Participant doctors spent limited time on the wards where most of their inpatients were based, with much of their day consumed by tasks away from these locations. When they were on the wards, most of their time was spent engaged in patient-related organisational and administrative tasks mainly executed by telephone or computer screen. This required little interaction with anyone else in the immediate vicinity. There was limited direct face-to-face communication about patients between participant doctors and their professional colleagues on the wards. Pharmacists, physiotherapists, occupational therapists, social workers, and other professionals were usually assigned across several wards making it difficult for our target doctors to liaise with them about shared patient management at mutually convenient times. Those observed on the wards at different times were mostly attending to patients without liaising with the participant doctors. The doctors made no attempt to engage with them, either. In preparing for the discharge of patients, doctors communicated to others by telephone. In one instance where a physiotherapist had determined that a 90-year-old patient was not ready to go home alone, a consultant and a registrar (a junior doctor in specialist training) arrived on the ward to see the patient. Following review and discussion of the medical record, they overrode the concerns of the physiotherapist ordering that the patient should be sent home that day by ambulance. Recurring behaviours and lack of interactions were observed: The geriatrics registrar is aware of the physiotherapist’s assessment of the patient. The physiotherapist is present with the patient. The junior doctor is also present. He follows the registrar’s order and proceeds to prepare the paperwork for the lady’s discharge. The lady does not speak for herself. (Field researcher notes, Hospital C, emergency medical unit) A difficulty encountered at each hospital was distinguishing the role and identity of some professionals and the seniority levels of nurses because of the variety of uniforms they wore. A predilection for staff across hospital sites to wear their identity tags hanging low and out of easy sight, added to this problem of professional identification. Work outside the wards Observing the junior doctors beyond their allocated ward area provided an opportunity to witness multiple activities. They variously attended to patients in the emergency department, outpatient department, day-only surgery unit, intensive care unit, and radiology and imaging departments. One junior doctor was asked by a registrar to negotiate urgent operating theatre time for a patient on a Saturday: The doctor confides that she feels nervous about approaching the theatre nurse in charge because she has a reputation for being difficult. (Second year junior doctor, Hospital B, neurosurgical ward)
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A similar experience occurred with another participant doctor trying unsuccessfully to request a radiology procedure for a patient. In order to escalate a response, the doctor hand delivered the request. She was informed by a medical colleague that: The NUM [Nurse Unit Manager] who controls access to radiology can be obstructive and difficult to get on with. (Third year junior doctor, Hospital B, radiology and imaging unit) Junior doctors frequently reviewed their outlier patients. In one hospital, the time taken to review outliers extended beyond an hour, with outliers occupying beds on different levels and wings of the hospital. When visiting the various wards, there was typically an absence of communication with local nursing staff to inquire about the condition of these patients. On five occasions across the six shifts, shadowed doctors were tracked hand-delivering requests for tests and procedures to expedite their progress in the system. These actions emanated from pressure from senior medical colleagues to ensure that procedures were not delayed or that results were available in time for the following morning rounds. Professional relationships The onward care of geriatrics patients was the subject of discussion amongst an observed interprofessional meeting. In a conference room, there were interactions at play between registrars, nurses, a social worker, and an occupational therapist. They discussed and jointly agreed on management options for a range of patients with varying needs. This illustrated the manner in which timely decisions were made by focusing on the patients through interprofessional discussions. The opportunity for shared learning was also evident as the details of clinical progress and the needs of each patient were discussed. In another hospital where medical and surgical patients occupied the length of a whole floor, the doctors’ office adjoined the nurse’s station, facilitating occasional informal interaction between medical, nursing and other professionals. The surgical resident attached to the ward was observed to be a good communicator. This was demonstrated by engagement and respect when communicating with other health professionals. Interaction was facilitated by these qualities of communication, which in turn were enabling factors for negotiation about patient regimens and treatment requirements as well as discharge planning. There was very limited evidence of positive interprofessional behaviours from other senior medical staff who visited the doctor’s room. In other hospitals, the areas designated for doctors to work in were separated from the nurse’s station. Far less interprofessional interaction, and often none at all, occurred in these settings. Aside from the ward rounds at the commencement of shifts, and these were not guaranteed to be interprofessional, no formal handovers were observed on the wards at the end of shifts. However, in one hospital, a participant doctor was scheduled to work on an evening shift covering several hospital wards. When doing so it was mandatory to attend a formal handover at 4.30 pm in the emergency department. Factors affecting interprofessional relationships and collaboration In one emergency department visited as part of the shadowing, there were voiced interprofessional inadequacies, and disharmony was acknowledged by the nurses. In conversations among them, one nurse went as far as saying she had been on duty for 6 h
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without having to talk to a doctor. Multiple professions were observed working in a communal work station with minimal interaction. On the wards, the lack of communication and interaction between doctors, nurses, and other professionals verged on disrespect at times. Registrars displayed a generalised ‘‘failure to notice’’ professionals other than fellow doctors, despite their proximate presence at times, such as standing side-by-side with nurses and other professionals writing up patient notes. Commonly this was marked by the absence of acknowledging anyone’s presence in any observable manner. Their focus was on completing the task at hand. Doctors seemed intent on fulfilling the demands of their shifts in a way that precluded spending time communicating with other professionals unless it could not be avoided. For example, a doctor who had examined a patient in emergency in the morning returned to review the patient’s condition late in the day. The patient was advised that they could go home with a follow-up appointment. The paper work was completed and left at the bedside. The doctor went to the emergency desk and told a nurse that the patient could go home, that the discharge information was next to the bed and to send the consultant’s letter in the internal mail. The manner of the communication was abrupt and technical, conveying little respect for the nurse. Senior nurses at two hospitals were heard to make comments about this type of ‘‘command’’ behaviour. They discussed the impersonal manner of doctors, who did not make the effort to know who they were. One said: They never introduce themselves and they often don’t thank us. (Nurse Unit Manager, Hospital C, colorectal and upper gastrointestinal surgery ward) Another indicated dissatisfaction with this kind of communication after a rare early morning encounter at the nurse’s station: The one minute they’re asking us [questions] and the next they’re telling us we don’t know anything. (Nurse Manager, Hospital C, colorectal and upper gastrointestinal surgery ward) In making these comments, the nurses displayed a sense of resignation about this attitude from doctors.
Discussion Junior doctors’ roles are constrained by the daily stresses associated with fulfilling their clinical tasks. The negotiated order paradigm used in this study shed light on the extent of the doctors’ interest, efforts, and capacity to practice interprofessionally. The pattern of their work involves spanning intraprofessional and interprofessional boundaries, negotiating and re-negotiating in the process of gaining and transmitting information, and managing within complex clinical and organisational hierarchies. Most interactive negotiations were done tacitly and passively rather than explicitly or actively. There were instances of doctors perceiving nurses as using their power of position to be obstructive (Svensson, 1996). System-related factors such as the fragmentation of tasks and the need to review outlier patients (see Goulding, Adamson, Watt, & Wright, 2012) in different locations, frustrated doctors through placing additional physical demands on their capacity to practise efficiently. Comments from, and about, some nurses were evidence of an undercurrent of disrespect between doctors and nurses at times, an attitude inhibiting the collaborative effort required for practising interprofessionally.
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Junior doctors in this study were busy and focused, highly mobile as they moved around their environments, and chiefly interacted, when they did inter-relate, with their peers. Apart from their participation in ward rounds and bumping into people intermittently in their daily work activities, largely they were isolates, and uniprofessional in nature. Westbrook et al. (2008) found that junior doctors spend a significant amount of time fulfilling tasks alone. The present study provides a narrative to underscore that point. In effect, there were fundamental professional, attitudinal, communication, and work practice barriers to collaborative working relationships. A perceived lack of respect towards other professionals may be a signal of an unconscious lack of sensitivity to interact collaboratively with others because of time constraints. Alternatively it may reflect an attitude associated with status and hierarchy limiting the impetus for boundary spanning and meaningful interaction (Powell & Davies, 2012). The clinical pecking order, with doctors at the top of the hierarchy in a relatively separate silo-like heterarchy, and not needing to relate to other health staff, seemed to be a perennial presence. This research supports extant research about tribal behaviours associated with the discrete cultures of the different health professions in the daily conduct of work (Braithwaite, Iedema, & Jorm, 2007a; Carlisle, Cooper, & Watkins, 2004; Creswick, Westbrook, & Braithwaite, 2009; Hamilton, 2011; Hunter, 1996). Communication was often fleeting, limiting the ability for doctors to meaningfully interact interprofessionally. The challenge this creates is manifested in their delivery of patient care in parallel, rather than in union with other members of the health care team such as nurses, the more constant providers of care on the wards. These ethnographic observations highlighted some of the challenges faced by junior doctors working with other professions and within their own profession. They provide an opportunity to understand the testing nature of the junior doctor role as a conduit for information between more senior medical staff and other health professionals. Notably, unlike their professional colleagues, in particular nurses, junior doctors are not constants on wards because of the peripatetic nature of their work and the rotations required for their training (Ibrahim et al., 2013; Lewin & Reeves, 2011; Reeves & Lewin, 2004). These structural constraints militate against wardbased interprofessional relationships and cross-boundary spanning. The predominant issues relate to the cultures of hospitals and to bounded professional sub-cultures engendering tribal behaviour. There could be more effort from each profession to ameliorate these deficits. However, based on this and other studies (e.g. Braithwaite et al., 2007b, 2013b; Rice et al., 2010; Westbrook et al., 2008), it does not seem feasible to simply call for greater levels of interprofessional effort, although many proponents do. To achieve consistent and sustained interprofessional practice would require fundamental alterations in attitudes and behaviours. This would include greater recognition by doctors that the reach of collaborative practice embraces professionals, beyond doctors working with their medical colleagues (Reeves & Lewin, 2004; Whitehead, 2007). Further limitations to productive interprofessional relationships may arise from the lack of professional cultural diversity which doctors in medical training have experienced. Training doctors in medical faculties with only intermittent exposure to other professional groups constrains doctors’ appreciation of the work and world-views of fellow clinicians. Despite much rhetoric about interprofessionalism, it cannot be assumed that the benefits of interprofessionalism have been inculcated in the medical training of students or the respective professions to which other clinicians belong. In our study, different professional groups involved in the day-to-day care of patients and delivery of health
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services tended to function within the scope of their professional norms and conventions, creating invisible and yet almost palpable boundaries. If the patient is to be the centre of care, as is the rationale for team-oriented, interprofessionally based practice, these sorts of barriers inhibiting relationships between junior doctors and other professionals need to be addressed. Junior doctors face a range of stresses in fulfilling their daily tasks (Ibrahim et al., 2013; Westbrook et al., 2008). Systemrelated barriers to their time include the presence of outlier patients and significant administrative tasks, including, not infrequently, the necessity for hand delivery of investigative requests. These barriers are physically demanding to overcome and constrain their capacity to work interprofessionally. Doctors walked considerable distances between different departments to attend to patients. Such mobility and fragmented work activities interfere with sustained opportunities to relate to other health professionals about the immediate care of their shared patients. Overall, the current system of training junior doctors in teaching hospitals restricts opportunities for promoting interprofessional relationships and, therefore, inhibits the development of collaborative practice. The training system is, by definition, part of the fabric and organisational culture of teaching hospitals. The tradition of bounded professions resides in this longstanding milieu. Thus, the nature of junior doctors’ work in the different hospital settings was frequently unable to satisfy the elements necessary for effective interprofessional practice because of the fractured nature of their work and the professional boundaries of the staff. Despite these barriers and the manifestations of bounded negotiated order, our research detected no suggestion of a lack of caring; work activities were continuously targeted at providing services to patients, and clinicians worked hard, and diligently, doing their best to provide care. Rapid, in-depth ethnographic work of this kind foregrounds a detailed and nuanced narrative of the activities of those enrolled in the study. The attempt here is to create a rich image of junior doctors’ relationships with their professional colleagues. A notable difficulty in each hospital was determining the professional identity of many staff because of the variety of uniforms they wore and poorly displayed personal identification. If a trained ethnographic researcher with a clinical background had difficulty with staff identification, patients and even fellow health professionals would also doubtless find this challenging.
Declaration of interest The authors report no conflicts of interest. The authors alone are responsible for the writing and content of the paper. The study was supported under a National Health and Medical Research Council (NH&MRC) Program Grant number 568612.
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ISSN: 1356-1820 (Print) 1469-9567 (Online) Journal homepage: http://www.tandfonline.com/loi/ijic20
An ethnographic investigation of junior doctors’ capacities to practice interprofessionally in three teaching hospitals Jacqueline Milne, David Greenfield & Jeffrey Braithwaite To cite this article: Jacqueline Milne, David Greenfield & Jeffrey Braithwaite (2015) An ethnographic investigation of junior doctors’ capacities to practice interprofessionally in three teaching hospitals, Journal of Interprofessional Care, 29:4, 347-353 To link to this article: http://dx.doi.org/10.3109/13561820.2015.1004039
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http://informahealthcare.com/jic ISSN: 1356-1820 (print), 1469-9567 (electronic) J Interprof Care, 2015; 29(4): 347–353 ! 2015 Informa UK Ltd. DOI: 10.3109/13561820.2015.1004039
ORIGINAL ARTICLE
An ethnographic investigation of junior doctors’ capacities to practice interprofessionally in three teaching hospitals Jacqueline Milne1, David Greenfield2 and Jeffrey Braithwaite2
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1
Faculty of Medicine, University of New South Wales, Sydney NSW, Australia and 2Australian Institute of Health Innovation, Centre for Healthcare Resilience and Implementation Science, Macquarie University, NSW, Australia Abstract
Keywords
Collaborative practice among early career staff is at the bedrock of interprofessional care. This study investigated factors influencing the enactment of interprofessional practice by using the day-to-day role of six junior doctors in three teaching hospitals as a gateway to understand the various professions’ interactive behaviours. The contextual framework used for the study was Strauss’ theory of negotiated order. Ethnographic techniques were applied to observe the actions and interactions of participants on typical working days in their hospital environments. Field notes were created and thematic analysis was applied to the data. Three themes explored were culture, communication, and collaboration. Issues identified highlight the bounded organisational and professional cultures within which junior doctors work, and systemic problems in interprofessional interaction and communication in the wards of hospitals. There are indications that early career doctors are interprofessional isolates. The constraints of short training terms and pressure from multi-faceted demands on junior doctors can interfere with the establishment of meaningful relationships with nurses and other health professionals. The realisation of sustained interprofessional practice is, therefore, practically and structurally difficult. Enabling factors supporting the sharing of expertise are outweighed by barriers associated with professional and hospital organisational cultures, poor interprofessional communication, and the pressure of competing individual task demands in the course of daily practice.
Communication, complexity, ethnography, interprofessional practice, interprofessional collaboration, professional boundaries, professional cultures
Introduction Hospitals are complex, ever-changing organisations (Braithwaite, Clay-Williams, Nugus, & Plumb, 2013a; Sturmberg & Martin, 2013). They face substantial challenges from mounting operational costs, and increasing patient demands for sophisticated care delivered by highly skilled health professionals (Barraclough & Birch, 2006; Milne, 2012; Wachter, 2004). This complexity is further exacerbated by the intricacies of clinical interventions, necessitating a broad range of hospital-based investigations, procedures, and treatment options for patients (Nardi et al., 2007; Plsek & Greenhalgh, 2001). There are specific challenges across the landscape of teaching hospitals, as junior doctors undertake postgraduate training and education (Gleason, Daly, & Blackham, 2007; Opdam, 2006). Doctors in particular face stresses and competing demands in fulfilling their tasks (Ibrahim, Jeffcott, Davis, & Chadwick, 2013; Newbury-Birch & Kamali, 2001). The multi-faceted aspects of care and the complicated working environments that junior doctors encounter require more than clinical knowledge (Pownall, 2009; Ross et al., 2013). One Correspondence: Dr Jacqueline Milne PhD, Visiting Fellow, Faculty of Medicine, Level 3 Samuels Buidling, University of New South Wales, Sydney NSW 2052 Australia. E-mail: [email protected]
History Received 7 November 2013 Revised 28 October 2014 Accepted 31 December 2014 Published online 3 February 2015
important factor in the transition to being a competent practitioner is how junior doctors relate to and work with their professional colleagues from nursing and other health professions. To be effective, health care is best delivered by interprofessional teams (Ibrahim et al., 2013; Scholes & Vaughan, 2002). The safe delivery of care lies at the heart of interprofessional practice. The goal is to optimise care provided by the clinical team with the patient purposefully as the focus of professionals’ combined skills, expertise, and care (Braithwaite & Travaglia, 2006). The interdependency of health professionals and their relationships are therefore fundamental, and interprofessional cultures, and competence in communication as well as practice, loom as critical characteristics (Blumenthal, 1994; Gittell, Godfrey, & Thistlewaite, 2013). The broader interprofessional literature is consistent in supporting the merits of collaborative interprofessional practice for improving the quality of care and patient safety (Interprofessional Education Collaborative Expert Panel, 2012; Reeves et al., 2010; Rice et al., 2010; World Health Organization Department of Human Resources for Health, 2010). The combination of shared, communicated patient care objectives with joint assessment of patient progress between health professionals is vital to collaborative interprofessional practice (Thistlethwaite, 2008). However, the implementation of interprofessional practice is subject to the different professions’
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capability and willingness to collaborate and cooperate as equal professional partners, combining and valuing their respective skills in delivering patient care (Braithwaite & Travaglia, 2005; Cameron, 2011; MacMillan, 2012). Doctors’ connectedness with health professionals such as nurses, pharmacists, physiotherapists, social workers, and speech pathologists relates to their level of interprofessional practice and competence in the delivery of care during their formative years (Gozu, Kern, & Wright, 2009; Greenfield, Nugus, Travaglia, & Braithwaite, 2011; Interprofessional Education Collaborative Expert Panel, 2011; Piterman, Newton, & Canny, 2010). However, we do not know much about interprofessionalism in this period. There are indications that early career doctors are busy interprofessional isolates (see Westbrook, Ampt, Kearney, & Rob, 2008). This study explored junior doctors’ interprofessional relationships in the multifarious cultures of teaching hospitals where their clinical attitudes and behaviours are forged (Hall, 2005). Our aim was to examine factors influencing the enactment of interprofessional practice in the day-to-day practice of junior doctors through observing their behaviours and relationships with other professionals. We do not seek to privilege medicine, but we sought to examine young doctors’ behaviours as a gateway device, to look at how they enact their roles in relation to their colleagues in nursing and other health professions. Theoretical framing The study was framed using Strauss’ theory of negotiated order (1978) and applied to doctors’ relationships and interactions within the hospital organisational setting, to test their capacity to work interprofessionally. A multi-faceted negotiated order is embedded in the work practices of health professionals and the organisation of hospitals in which they work (Georgiou et al., 2007). Essentially, there are workplace trade-offs, agreements, and bargains struck in a steady stream in busy interactive environments. Professional roles are fluid in the execution of their practice, requiring manifold interactive re-negotiations with other professionals throughout their daily practice in caring for patients (Day & Day, 1977; Strauss, Schatzman, Ehrlich, Bucher, & Sabshin, 1963). We used the negotiated order paradigm to contextualise the study, following Nugus, Greenfield, Travaglia, Westbrook, and Braithwaite (2010). While this approach has been used in other interprofessional studies (see Reeves et al., 2009; Zwarenstein & Reeves, 2002) here we focus on junior doctors and their professional coal-face colleagues.
Methods We used rapid ethnography, an approach suited to gathering rich data within a relatively short time frame (Handwerker, 2001; Millen, 2000).
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Context The field researcher sought to become immersed in participants’ day-to-day world and observe the execution of their tasks, and their professional relationships and responses to everyday events. The researcher conducted constant side-by-side shadowing of participant doctors. Typically, shifts commenced with ward rounds. Then, the scope broadened to observation of other health professionals, as participant doctors moved within and beyond their specialty wards to different clinical and administrative areas. Other professionals observed included senior clinicians, junior doctor counterparts, nurse unit managers, clinical nurse consultants, nurse managers, nurse educators, enrolled nurses, hospital pharmacists, physiotherapists, social workers, dieticians, speech pathologists, radiographers, and occupational therapists. Participants readily adapted to being observed. There was little time to adjust their behaviour in response to being shadowed because of the immediacy of their tasks. Their work was spontaneous and busy at all times. Data collection Fieldwork was conducted during September and October 2011. Preliminary observation of the workplace behaviours and environmental settings at each site was conducted to gather situational data. This enabled the securing of contextual baseline perspectives on the respective hospital environments before commencing the ethnographic observations of the doctors. Situational fieldwork totalled 12 h of observations, and the rapid ethnography involved 51.5 h of observational time. The observations of each doctor presented a unique opportunity to witness the background, scale and scope of their working days and provided a window into their encounters with other doctors, nurses, and health professionals in a range of clinical settings across the respective hospitals. We undertook these in-depth ethnographic observations following established principles (see Bosk, 1985; Denzin & Lincoln, 2002; Mays & Pope, 2000; Miles & Huberman, 1984). The major form of data collection was detailed hand written field notes recording observations in real time, following procedures enunciated by Nugus et al. (2010). Additional material gathered was in the form of situational data specific to each setting (Spradley, 1980; see Table I). This information included the clinical specialisation(s) and physical environment of the ward or unit, the graduate level of doctors, staffing and bed numbers, outlier patients reviewed, and the flow and identity of visiting itinerant professional staff. Outlier patients occupy beds in different wards at a distance from the specialty ward to which they would normally be allocated. Data analysis
Participants Six participants were drawn from a cohort of 32 doctors previously interviewed and surveyed in three Australian teaching hospitals (Milne, 2012). All consented to being observed on-site at their respective hospitals for the entirety of one of their rostered shifts. Doctors’ postgraduate experience ranged from a junior intern to residents and registrars in vocational training. In Australia, all three are collectively known as ‘‘residents’’ or ‘‘junior medical officers’’ (‘‘house officers’’ in the United Kingdom and ‘‘residents’’ in the United States). In Australia, they can be either overseas or locally trained, so one international medical graduate (IMG) and one Australian medical graduate (AMG) from each of the three hospitals was selected. Their working experience in the Australian hospital system ranged from 18 months to 6 years.
QSR NVivo9 software (QSR International, Burlington, MA) was used to manage the data which amounted to 21 480 words of text. Field notes were coded and data were treated as individual narratives (Atkinson, 1992; Polkinghorne, 1995) to convey the sense of reality evoked through the presence of the observer immersed in the domain of the participants. Using the negotiated order frame, data were examined to identify where and how junior doctors performed their role, who they engaged with or avoided and how they displayed their ‘‘doctoring’’ through their activities and behaviours. The data were analysed against themes of culture, communication, and collaboration in the context of negotiated interprofessional interactions and associated behaviours observed. Field notes and themes were discussed by the research team to interpret and make sense of the data sets.
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Table I. Study sites, settings, and participants. Hospitals and shifts observed
Characteristics of settings
Participants
Hospital A 350 beds Day shift
Multiple specialities ward including: renal and vascular medicine, haematology, immunology, medical oncology 34 ward patients. Seven outliers Other patients in ED Nine registered and enrolled nurses One clinical nurse educator One shared pharmacist Medical ward: gastroenterology, colorectal, drug and alcohol 34 ward patients. One outlier Other patients in ED and day-only ward (endoscopy and colonoscopy) Seven registered and enrolled nurses (including agency nurses) One clinical nurse specialist Two nurse educators
Neuroscience ward (medical and surgical beds) 34 patients. No outliers Out of ward: ICU, ED, theatre, radiology Surgical registrar, resident Seven registered and enrolled nurses One nurse educator Emergency Department 12 bed cubicles Three resuscitation beds 16 nurses Admitting officer, two staff specialists, three residents, one registrar
Female resident Australian medical graduate Second year postgraduate training
Colorectal surgery, Upper gastrointestinal surgery 28 patients. Six outliers Out of ward: theatre and outpatients 13 Registered and enrolled nurses One pharmacist
Female resident Australian medical graduate First year postgraduate trainee
Emergency medical unit – morning 10 patients Two registered nurses Emergency outpatients – afternoon Two staff specialists and registered nurses
Male resident International medical graduate Between first and second year postgraduate training
Hours of observation: 8
Hospital A Day shift
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Hours of observation: 9.5
Hospital B 440 beds Day shift Hours of observation: 9 Hospital B Afternoon/evening shift Hours of observation: 8.5 Hospital C 660 beds Day shift Hours of observation: 8.5 Hospital C Day shift Hours of observation: 8
Ethical considerations Ethics approval was granted for the study by the University of New South Wales, Australia (HREC 09211) and a lead Hospital Ethics Committee in New South Wales (HREC/09/SVH/ 137).
Results Ward rounds at the outset of shifts were invariably conducted, typically by registrars, without the presence of other health professionals. As recorded in the field notes: The doctors commence their ward round. Nurses continue to go about their business independently of the round. (Field researcher notes, Hospital A, morning round, gastroenterology, drug and alcohol and clinical pharmacology ward) As a consequence, discussion of patient care was confined to medical perspectives between the doctors on the round. Junior doctors on the medical team were then responsible for the direct transmission and communication of patient orders arising from the ward rounds. Communication was largely one way, from the doctors to the nurses, and conveyed in the imperative reflecting
Female registrar Australian graduate Fourth year postgraduate training Physician trainee
Male senior resident International medical graduate Third year postgraduate training
Female registrar International medical graduate Third year postgraduate training in Australia Emergency medicine trainee
the constraints of time and the expectations under which they work on a daily basis. The ward rounds were the generators of a large part of junior doctors’ activities for the day. Accomplishing orders after the rounds, such as medication orders, tests and investigative procedures, checking results, writing up patient notes, and instigating the processes for discharging patients, were time consuming and somewhat lone tasks. On the surgical wards, registrars conducted early rounds at around 7 am before going to theatre. This left very junior doctors in charge of managing problems arising with surgical patients. An instance of protracted attempts to insert a naso-gastric tube in a postoperative neurosurgical patient with a tracheotomy bore witness to such a situation. As the field notes indicated: The doctor is approached by a nurse to assist with a nasogastric tube insertion. The patient is clearly distressed. The doctor fails to succeed in her attempt. The nurse then reveals that she has had several failed attempts already. The doctor immediately orders a radiology screen to confirm the correct placement of the tube before attempting reinsertion. (Nurse and second year junior doctor, Hospital B, neurosurgical ward)
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Meanwhile, notes from observing a hospital emergency department handover round recorded:
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The round begins around a high bench outside the central working station. Gathered here are ten doctors: two staff specialists, three registrars, a senior resident, four residents and a medical student. A nurse joins the round when we get to cubicle eight and then the nurse’s phone rings so he walks away. (Field researcher notes, Hospital B, afternoon handover round, emergency department) Participant doctors spent limited time on the wards where most of their inpatients were based, with much of their day consumed by tasks away from these locations. When they were on the wards, most of their time was spent engaged in patient-related organisational and administrative tasks mainly executed by telephone or computer screen. This required little interaction with anyone else in the immediate vicinity. There was limited direct face-to-face communication about patients between participant doctors and their professional colleagues on the wards. Pharmacists, physiotherapists, occupational therapists, social workers, and other professionals were usually assigned across several wards making it difficult for our target doctors to liaise with them about shared patient management at mutually convenient times. Those observed on the wards at different times were mostly attending to patients without liaising with the participant doctors. The doctors made no attempt to engage with them, either. In preparing for the discharge of patients, doctors communicated to others by telephone. In one instance where a physiotherapist had determined that a 90-year-old patient was not ready to go home alone, a consultant and a registrar (a junior doctor in specialist training) arrived on the ward to see the patient. Following review and discussion of the medical record, they overrode the concerns of the physiotherapist ordering that the patient should be sent home that day by ambulance. Recurring behaviours and lack of interactions were observed: The geriatrics registrar is aware of the physiotherapist’s assessment of the patient. The physiotherapist is present with the patient. The junior doctor is also present. He follows the registrar’s order and proceeds to prepare the paperwork for the lady’s discharge. The lady does not speak for herself. (Field researcher notes, Hospital C, emergency medical unit) A difficulty encountered at each hospital was distinguishing the role and identity of some professionals and the seniority levels of nurses because of the variety of uniforms they wore. A predilection for staff across hospital sites to wear their identity tags hanging low and out of easy sight, added to this problem of professional identification. Work outside the wards Observing the junior doctors beyond their allocated ward area provided an opportunity to witness multiple activities. They variously attended to patients in the emergency department, outpatient department, day-only surgery unit, intensive care unit, and radiology and imaging departments. One junior doctor was asked by a registrar to negotiate urgent operating theatre time for a patient on a Saturday: The doctor confides that she feels nervous about approaching the theatre nurse in charge because she has a reputation for being difficult. (Second year junior doctor, Hospital B, neurosurgical ward)
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A similar experience occurred with another participant doctor trying unsuccessfully to request a radiology procedure for a patient. In order to escalate a response, the doctor hand delivered the request. She was informed by a medical colleague that: The NUM [Nurse Unit Manager] who controls access to radiology can be obstructive and difficult to get on with. (Third year junior doctor, Hospital B, radiology and imaging unit) Junior doctors frequently reviewed their outlier patients. In one hospital, the time taken to review outliers extended beyond an hour, with outliers occupying beds on different levels and wings of the hospital. When visiting the various wards, there was typically an absence of communication with local nursing staff to inquire about the condition of these patients. On five occasions across the six shifts, shadowed doctors were tracked hand-delivering requests for tests and procedures to expedite their progress in the system. These actions emanated from pressure from senior medical colleagues to ensure that procedures were not delayed or that results were available in time for the following morning rounds. Professional relationships The onward care of geriatrics patients was the subject of discussion amongst an observed interprofessional meeting. In a conference room, there were interactions at play between registrars, nurses, a social worker, and an occupational therapist. They discussed and jointly agreed on management options for a range of patients with varying needs. This illustrated the manner in which timely decisions were made by focusing on the patients through interprofessional discussions. The opportunity for shared learning was also evident as the details of clinical progress and the needs of each patient were discussed. In another hospital where medical and surgical patients occupied the length of a whole floor, the doctors’ office adjoined the nurse’s station, facilitating occasional informal interaction between medical, nursing and other professionals. The surgical resident attached to the ward was observed to be a good communicator. This was demonstrated by engagement and respect when communicating with other health professionals. Interaction was facilitated by these qualities of communication, which in turn were enabling factors for negotiation about patient regimens and treatment requirements as well as discharge planning. There was very limited evidence of positive interprofessional behaviours from other senior medical staff who visited the doctor’s room. In other hospitals, the areas designated for doctors to work in were separated from the nurse’s station. Far less interprofessional interaction, and often none at all, occurred in these settings. Aside from the ward rounds at the commencement of shifts, and these were not guaranteed to be interprofessional, no formal handovers were observed on the wards at the end of shifts. However, in one hospital, a participant doctor was scheduled to work on an evening shift covering several hospital wards. When doing so it was mandatory to attend a formal handover at 4.30 pm in the emergency department. Factors affecting interprofessional relationships and collaboration In one emergency department visited as part of the shadowing, there were voiced interprofessional inadequacies, and disharmony was acknowledged by the nurses. In conversations among them, one nurse went as far as saying she had been on duty for 6 h
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without having to talk to a doctor. Multiple professions were observed working in a communal work station with minimal interaction. On the wards, the lack of communication and interaction between doctors, nurses, and other professionals verged on disrespect at times. Registrars displayed a generalised ‘‘failure to notice’’ professionals other than fellow doctors, despite their proximate presence at times, such as standing side-by-side with nurses and other professionals writing up patient notes. Commonly this was marked by the absence of acknowledging anyone’s presence in any observable manner. Their focus was on completing the task at hand. Doctors seemed intent on fulfilling the demands of their shifts in a way that precluded spending time communicating with other professionals unless it could not be avoided. For example, a doctor who had examined a patient in emergency in the morning returned to review the patient’s condition late in the day. The patient was advised that they could go home with a follow-up appointment. The paper work was completed and left at the bedside. The doctor went to the emergency desk and told a nurse that the patient could go home, that the discharge information was next to the bed and to send the consultant’s letter in the internal mail. The manner of the communication was abrupt and technical, conveying little respect for the nurse. Senior nurses at two hospitals were heard to make comments about this type of ‘‘command’’ behaviour. They discussed the impersonal manner of doctors, who did not make the effort to know who they were. One said: They never introduce themselves and they often don’t thank us. (Nurse Unit Manager, Hospital C, colorectal and upper gastrointestinal surgery ward) Another indicated dissatisfaction with this kind of communication after a rare early morning encounter at the nurse’s station: The one minute they’re asking us [questions] and the next they’re telling us we don’t know anything. (Nurse Manager, Hospital C, colorectal and upper gastrointestinal surgery ward) In making these comments, the nurses displayed a sense of resignation about this attitude from doctors.
Discussion Junior doctors’ roles are constrained by the daily stresses associated with fulfilling their clinical tasks. The negotiated order paradigm used in this study shed light on the extent of the doctors’ interest, efforts, and capacity to practice interprofessionally. The pattern of their work involves spanning intraprofessional and interprofessional boundaries, negotiating and re-negotiating in the process of gaining and transmitting information, and managing within complex clinical and organisational hierarchies. Most interactive negotiations were done tacitly and passively rather than explicitly or actively. There were instances of doctors perceiving nurses as using their power of position to be obstructive (Svensson, 1996). System-related factors such as the fragmentation of tasks and the need to review outlier patients (see Goulding, Adamson, Watt, & Wright, 2012) in different locations, frustrated doctors through placing additional physical demands on their capacity to practise efficiently. Comments from, and about, some nurses were evidence of an undercurrent of disrespect between doctors and nurses at times, an attitude inhibiting the collaborative effort required for practising interprofessionally.
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Junior doctors in this study were busy and focused, highly mobile as they moved around their environments, and chiefly interacted, when they did inter-relate, with their peers. Apart from their participation in ward rounds and bumping into people intermittently in their daily work activities, largely they were isolates, and uniprofessional in nature. Westbrook et al. (2008) found that junior doctors spend a significant amount of time fulfilling tasks alone. The present study provides a narrative to underscore that point. In effect, there were fundamental professional, attitudinal, communication, and work practice barriers to collaborative working relationships. A perceived lack of respect towards other professionals may be a signal of an unconscious lack of sensitivity to interact collaboratively with others because of time constraints. Alternatively it may reflect an attitude associated with status and hierarchy limiting the impetus for boundary spanning and meaningful interaction (Powell & Davies, 2012). The clinical pecking order, with doctors at the top of the hierarchy in a relatively separate silo-like heterarchy, and not needing to relate to other health staff, seemed to be a perennial presence. This research supports extant research about tribal behaviours associated with the discrete cultures of the different health professions in the daily conduct of work (Braithwaite, Iedema, & Jorm, 2007a; Carlisle, Cooper, & Watkins, 2004; Creswick, Westbrook, & Braithwaite, 2009; Hamilton, 2011; Hunter, 1996). Communication was often fleeting, limiting the ability for doctors to meaningfully interact interprofessionally. The challenge this creates is manifested in their delivery of patient care in parallel, rather than in union with other members of the health care team such as nurses, the more constant providers of care on the wards. These ethnographic observations highlighted some of the challenges faced by junior doctors working with other professions and within their own profession. They provide an opportunity to understand the testing nature of the junior doctor role as a conduit for information between more senior medical staff and other health professionals. Notably, unlike their professional colleagues, in particular nurses, junior doctors are not constants on wards because of the peripatetic nature of their work and the rotations required for their training (Ibrahim et al., 2013; Lewin & Reeves, 2011; Reeves & Lewin, 2004). These structural constraints militate against wardbased interprofessional relationships and cross-boundary spanning. The predominant issues relate to the cultures of hospitals and to bounded professional sub-cultures engendering tribal behaviour. There could be more effort from each profession to ameliorate these deficits. However, based on this and other studies (e.g. Braithwaite et al., 2007b, 2013b; Rice et al., 2010; Westbrook et al., 2008), it does not seem feasible to simply call for greater levels of interprofessional effort, although many proponents do. To achieve consistent and sustained interprofessional practice would require fundamental alterations in attitudes and behaviours. This would include greater recognition by doctors that the reach of collaborative practice embraces professionals, beyond doctors working with their medical colleagues (Reeves & Lewin, 2004; Whitehead, 2007). Further limitations to productive interprofessional relationships may arise from the lack of professional cultural diversity which doctors in medical training have experienced. Training doctors in medical faculties with only intermittent exposure to other professional groups constrains doctors’ appreciation of the work and world-views of fellow clinicians. Despite much rhetoric about interprofessionalism, it cannot be assumed that the benefits of interprofessionalism have been inculcated in the medical training of students or the respective professions to which other clinicians belong. In our study, different professional groups involved in the day-to-day care of patients and delivery of health
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services tended to function within the scope of their professional norms and conventions, creating invisible and yet almost palpable boundaries. If the patient is to be the centre of care, as is the rationale for team-oriented, interprofessionally based practice, these sorts of barriers inhibiting relationships between junior doctors and other professionals need to be addressed. Junior doctors face a range of stresses in fulfilling their daily tasks (Ibrahim et al., 2013; Westbrook et al., 2008). Systemrelated barriers to their time include the presence of outlier patients and significant administrative tasks, including, not infrequently, the necessity for hand delivery of investigative requests. These barriers are physically demanding to overcome and constrain their capacity to work interprofessionally. Doctors walked considerable distances between different departments to attend to patients. Such mobility and fragmented work activities interfere with sustained opportunities to relate to other health professionals about the immediate care of their shared patients. Overall, the current system of training junior doctors in teaching hospitals restricts opportunities for promoting interprofessional relationships and, therefore, inhibits the development of collaborative practice. The training system is, by definition, part of the fabric and organisational culture of teaching hospitals. The tradition of bounded professions resides in this longstanding milieu. Thus, the nature of junior doctors’ work in the different hospital settings was frequently unable to satisfy the elements necessary for effective interprofessional practice because of the fractured nature of their work and the professional boundaries of the staff. Despite these barriers and the manifestations of bounded negotiated order, our research detected no suggestion of a lack of caring; work activities were continuously targeted at providing services to patients, and clinicians worked hard, and diligently, doing their best to provide care. Rapid, in-depth ethnographic work of this kind foregrounds a detailed and nuanced narrative of the activities of those enrolled in the study. The attempt here is to create a rich image of junior doctors’ relationships with their professional colleagues. A notable difficulty in each hospital was determining the professional identity of many staff because of the variety of uniforms they wore and poorly displayed personal identification. If a trained ethnographic researcher with a clinical background had difficulty with staff identification, patients and even fellow health professionals would also doubtless find this challenging.
Declaration of interest The authors report no conflicts of interest. The authors alone are responsible for the writing and content of the paper. The study was supported under a National Health and Medical Research Council (NH&MRC) Program Grant number 568612.
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