http://informahealthcare.com/jic ISSN: 1356-1820 (print), 1469-9567 (electronic) J Interprof Care, 2014; 28(4): 331–338 ! 2014 Informa UK Ltd. DOI: 10.3109/13561820.2014.891574

ORIGINAL ARTICLE

Patient safety and professional discourses: implications for interprofessionalism Paula Rowland1,2,3 and Simon Kitto2,4,5 1

Department of Occupational Science and Occupational Therapy, University of Toronto, Toronto, Ontario, Canada, 2Wilson Centre, University of Toronto, Toronto, Ontario, Canada, 3Collaborative Academic Practice, University Health Network, Toronto, Ontario, Canada, 4Department of Surgery, University of Toronto, Toronto, Ontario, Canada, and 5Continuing Professional Development, University of Toronto, Toronto, Ontario, Canada Abstract

Keywords

Patient safety has been presented as a unifying concern across the health professions. This conceptual connection has been accompanied with efforts towards standardized, interprofessional safety competencies, as well as increased attention towards interprofessional education for systems improvement. Despite numerous program initiatives and research endeavors, progress towards improving patient safety in hospitals is viewed as disappointingly slow. This paper adds to a body of literature that suggests patient safety remains a difficult problem to solve because safety is not simply a technical issue, but is a practice embedded in organizational and professional contexts. In this paper, we explore the differences between the professions, as different professional groups intersect with the ways patient safety is thought about, talked about, and known about in an acute care hospital in Canada. We draw on findings from a critical discourse analysis of documents related to patient safety, as well as transcripts from interviews from (a) formal health care leaders and (b) practicing clinicians from medicine, nursing, occupational therapy, physiotherapy, and social work. This analysis suggests implications for the way different professions may or may not work with one another in the service of patient safety.

Critical discourse analysis, interprofessional care, policy, qualitative method, teambased care

Introduction Patient safety has long been a concern within the health professions (Foucault, 1973/1994; Strauss, Fagerhaugh, Suczek, & Wiener, 1985). Currently, the concern with patient safety in the hospital is neatly captured in the phrase hazards of hospitalization (Schimmel, 1964/2003), referring to the occurrence of hospitalinduced complications that are not directly related to the patient’s underlying disease process. This concern is frequently articulated by reference to the influential report, To Err is Human published by the Institute of Medicine (1999) (IOM). In this report, the authors estimated the prevalence of hospital-based deaths related to medical error range from 44 000 (6.6% of admissions) to 98 000 (13.6% of admissions) per year in the United States. The IOM report, and the follow-up document titled Crossing the Quality Chasm (Institute of Medicine, 2001), brought new attention to the problem of patient safety in hospitals. Since the publication of To Err is Human, there has been a sharp increase in the number of publications related to patient safety (Lima, 2006). Indeed, a new field of health care specific safety science has been born (Travaglia & Braithwaite, 2009) making use of the traditions of human factors engineering, cognitive psychology (Perneger, 2005), and insights from high reliability organizations (Weick, Sutcliffe, & Obstfeld, 2008). In this paper, we explore how Correspondence: Paula Rowland, PhD, Collaborative Academic Practice, University Health Network, Toronto, Ontario, Canada. E-mail: [email protected]

History Received 11 July 2013 Revised 4 December 2013 Accepted 3 February 2014 Published online 4 March 2014

this concern with patient safety in hospitals is articulated across five professions: medicine, nursing, occupational therapy, physiotherapy and social work. This paper explores the implications for how professionals engage with hospital patient safety programs and with clinicians from other professions. Connecting interprofessional care and patient safety In recent years, common sense arguments have linked interprofessional care to patient safety (Knox & Simpson, 2004). This has been accompanied with efforts towards standardized, interprofessional safety competencies (Frank & Brien, 2008), as well as increased attention towards interprofessional education for systems improvement (Ladden, Bednash, Stevens, & Moore, 2006). Despite of all of these program initiatives, research endeavors, and resources, patient safety remains a ‘‘tough nut to crack’’ (Leistikow, Kalkman, & Bruijn, 2011, p. 342) with progress viewed as disappointingly slow. Dixon-Woods (2010) suggests that patient safety remains a difficult problem to solve because safety is not simply a technical issue, but is a practice embedded in organizational and professional politics. While there is a growing body of research on the intersections of interprofessionalism and interprofessional education with patient safety (Infante, 2006; Jeffs, Lingard, Berta, & Baker, 2012; Ladden et al., 2006; Sheps, 2006), this paper diverges from mainstream patient safety literature by adopting a critical theory orientation rather than a socio-technical perspective.

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In this paper, we explore differences between the professions, as different professional groups intersect with the ways patient safety is thought about, talked about, and known about in acute care hospitals. The study is critical in the sense that it starts from the premise of questioning the assumptions and implicit arguments that characterize the mainstream patient safety literature. Here, mainstream patient safety literature is defined as the body of work consistent with the core assumptions as outlined in the IOM (1999) report. In this mainstream literature, patient safety is considered to be a socio-technical problem, where human actions are interwoven with systems and infrastructures, being therefore vulnerable to the designs of systems and the errors that these systems inevitably hold (Danholt, 2010). Whereas the mainstream literature on patient safety implicitly argues that the conceptual problem is one of weaving together the technical and the social to improve safety, a critical perspective is concerned with ‘‘what constitutes patient safety in the first place?’’ (Danholt, 2010, p. 33). In regards to the latter, the construction of patient safety is something to be studied empirically. This study started with the assumption that different professions may be engaging with concepts of patient safety differently, resulting in implications for how professions work together in the service of patient safety. This assumption has been explored in different ways in the academic literature. For example, Travaglia and colleagues (2012) used data-mining software to visualize different conceptualizations of quality and safety manifesting in interviews of five different groups of healthcare workers. The conceptual maps produced showed clear differences in the perspectives of professional groups, suggesting variations in the perceptions, and therefore priorities, for quality and safety. Other studies have indicated how different narratives of risk, and therefore safety, can emerge in different professional groups, perhaps even in competition with the official policy or managerial narratives of safety (Currie, Humpreys, Waring, & Rowley, 2009; McDonald, Waring, & Harrison, 2005). Thus, social scientists have begun to explore how patient safety policy and programs are located within wider systems of practice (Currie et al., 2009), specifically systems that are characterized by dynamics of professional hierarchy and interdependence (McDonald, Waring, & Harrison, 2006). The study from which this paper is drawn made use of particular conceptual framing in order to explicitly explore how the professions are wrapped up in these larger systems of meaning related to their professional practice and how they engage with patient safety policies and programs. Specifically, we used Foucault’s (1991a) concepts of discourse and governmentality. Accordingly, this paper addresses three research questions: (1) how is patient safety made visible and constituted as part of the delivery of health care practices? (2) how does patient safety make it possible to think in particular ways about professional practice, and the provision of health care? and (3) how do the strategies and knowledges that have become associated with patient safety create truths about professional practice? In this paper, we specifically explore the different conceptualizations of practice that are made possible as different professions intersect with patient safety discourses.

kinds of identities, or subjectivities (Foucault, 1991a). There are many different discourses operating in a single organization at any given time. Some discourses are afforded more legitimacy than others, therefore being more able to shape what is knowable, sayable, or even thinkable about patient safety and professional practice (Foucault, 1977/1980). Thus, a discourse analysis of patient safety is concerned with issues of power, knowledge and identity as discourses of patient safety operate within a particular organizational setting. We adopted this approach to contribute to a growing body of literature that involves a careful reconsideration of relationships between knowledge, power, and identity as they are assembled through a concern for patient safety.

Methods

The community hospital was chosen specifically because of its reputation as a leader in quality improvement and patient safety initiatives. This was an intentional sampling strategy, ensuring mainstream discourses of safety and quality would be manifesting within the organization. For ethical reasons, the study hospital is simply referred to as Hospital. The Hospital is located in a large city in Ontario with approximately 500 patient beds, providing acute, long term, and ambulatory care. Of those 500 beds, approximately 85 serve

Conceptual underpinning In this study, the term discourse is used to refer to an entire system of meaning (Foucault, 1970/1981) that governs what we consider to be true. Discourses are productive, meaning that they produce certain possibilities for action (Foucault, 1975/1980). Further, as we govern ourselves and others by what we consider to be true (Foucault, 1991b), discourses produces the possibility of certain

Research design The study was designed as a qualitative, single case study (Creswell, 2009). The object of study was the patient safety discourses operating within medical units of a single tertiary hospital. This decision was based on the increasing significance of medical units in the provision of health care services within the Canadian system. The Canadian Institute of Health Information (CIHI, 2005) reported that of the 2 427 251 acute inpatient hospitalizations in Canada (excluding Quebec) in 2004 to 2005, 41.3% of admissions were through a medical service such as internal medicine, cardiology, or respiratory services. This medical patient group accounted for the highest percent of hospital days, with an average length of stay (LOS) of 8.9 days per admission. This is a relatively long length of stay when compared to other services such as surgery, with an average length of stay of 5.4 days. Importantly, patients aged 60 years or older accounted for 60% of all hospital days recorded between 2004 and 2005. In that same time period, only 17% of Canadian citizens were 60 years or older. Based on the discursive construction of adults aged 60 years or older as being at particular risk for hospitalization, the object of interest was further limited to patient safety concerns for adults aged 60 years or older. Limiting the object to these particular safety discourses allowed a focus on the five professions most frequently named in the literature as being involved with care planning for this patient population, namely the professions of medicine, nursing, occupational therapy, physiotherapy, and social work. The study proceeded in two phases: (a) document analysis and (b) interviews. For the document analysis, we were particularly interested in texts that governed professional practice. Therefore, we began by examining legislative documents, accreditation requirements, Hospital strategic documents, and clinical practice guidelines related to professional practice with patients aged 60 years or older in medical units. From this initial analysis, we also included related texts that were referred to in our original text archive. Further, we followed up on any influential texts that were discussed in interviews. We limited the study to texts that were published between 1999 and 2012. Interviews were conducted following study protocol review and approval was obtained from all applicable research ethics boards. This included informed consent protocols, as well as the process and structures put in place to ensure participant confidentiality. Research setting

Patient safety discourses

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Table 1. Abbreviated list of documents analyzed. Title

Date

Source

Building on Values: The Future of Health Care in Canada

2002

Commitment to the Future of Medicare Act Commitment to the Future of Medicare Act: Minister’s Speaking Notes Accountability Agreements in Ontario’s Health System: How Can They Accelerate Quality Improvement and Enhance Public Reporting?

2004 2004

Intended Audience

Excellent Care for All Act Excellent Care for All Act: Strengthening the Focus on Quality, Value, and Evidence Based Care in Ontario Quality Improvement Plan Guidance Document 2011 Quality Improvement Plan: An Analysis for Learning Public Service for Ontarians: A Path to Sustainability and Excellence Patient Rights and Responsibilities Hospital Quality Plan Hospital Safety Plan

2011 2011 2012 2011 2011–2012 2009–2012

Commission on the Future of Health Care in Canada Provincial legislation Ministry of Health and Long Term Care website Ontario Health Quality Council and Ontario Joint Policy and Planning Committee Provincial legislation Ministry of Health and Long Term Care Website Health Quality Ontario Health Quality Ontario Ontario Ministry of Finance Hospital external website Hospital external website Hospital intra-net

Hospital Strategic Plan

2011–2014

Hospital website

2008

2010 2010

admitted patients with acute medical conditions. Typically, the length of stay for acute medical patients is between 3 to 7 days within the unit. The average age of admitted medical patients is 60 years. Sample The document analysis phase involved a text analysis of national, provincial, regional, and hospital documents related to care planning and patient safety for older adults admitted to the acute medical unit of the hospital. This included, but was not limited to, legislation, media briefings related to legislation, hospital strategic plans, hospital reports, hospital policies, and relevant clinical practice guidelines. Table 1 provides a description of a selection of the document analyzed. Documents were accessed through internet, organizational intranet, and hand searches. Documents were stored electronically via the program, HyperResearchÔ (Randolph, MA). The interviews involved two groups. The first group invited to interview was a stratified sample of formal leaders within the Hospital who were responsible for developing, implementing and evaluating patient safety programs within the Hospital. Using this sampling criteria, six participants were eligible to interview. All six agreed to participate. The second group of interviews involved practicing point of care clinicians from five professional groups: medicine (MD), nursing, occupational therapy (OT), physiotherapy (PT), and social work (SW). Of the potential sample of clinicians working within the acute medical unit, nine agreed to participate in an interview. Table 2 provides a brief description of the individuals interviewed. Following the informed consent process, all participants engaged in a one to one, face to face interview with the first author. These interviews were conducted between January and July 2012. All interviews were digitally recorded and later transcribed by the first author. All transcripts were imported into the computer program, HyperResearchÔ. Analysis The analysis made use of the broad strategies of discourse analysis, informed by the work of Fairclough Parker (2003), Potter (1996), and Potter and Wetherall The analysis was further informed by Dean’s

critical (2003), (1987). (2010)

Publically available Publically available Publically available Publically available

Publically available Publically available Publically available Publically available Publically available Publically available Publically available Internally available to hospital staff and physicians Publically available

Table 2. Final Interview Sample.

Organizational Title in Hospital Director 1 Vice President 1 Manager Vice President 2 Director 2 Medical Administrator

Number of Years at Hospital 6 14 16 17 21 23

Professional Role

Number of Years at Hospital

Physician (MD1) Nurse 1 Social Worker (SW1) Nurse 2 Physiotherapist Social Worker (SW2) Nurse 3 Physician (MD2) Occupational Therapist

2.5 4 5 7 8 13 15 20 22

governmentality analytic. Dean’s analytic requires an interrogation of the texts along four pillars: (a) what is made visible, (b) what forms of knowledge are created or used, (c) what technologies are created or used, and (d) what identities are presupposed and/or created. In this analysis, all documents were treated as texts, including the transcripts generated through interviews. All texts were submitted to the same form of analysis. This involved a first read through the text for literal meanings and textual interconnections. The second reading looked for patterns of intertextuality (Fairclough, 2003), examining how concepts were engaged and/or transformed across texts. This reading also included attention to the discursive strategies deployed in the texts, the use of particular kinds of tropes, the translations/transformations of concepts across texts, and the subject positions that were being constructed through the texts. The third reading specifically interrogated the data using Dean’s (2010) governmentality analytic. The computer program, HyperResearch, was used to store and sort data. The theory building capacity of the computer program was not used. The first author led the analysis with regular communication with the second author. To ensure the trustworthiness and credibility (Silverman, 2006) of the study, we were careful to ensure that our conceptual framing, methodological decisions, and analytical strategies were coherent (Carter & Little, 2007).

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We engaged in the analysis in an iterative fashion, including discussion about emerging understandings and opportunities to look for deviant cases that might disrupt the emerging analysis. The first author maintained a reflexive journal, systematically documenting design and analysis decisions throughout the process. Finally, as members of Canadian society, we acknowledge that we are also wrapped up within the discourses that we hoped to analyze. A strong conceptual frame gave us distance from, and analytical leverage into, our phenomenon of interest.

Findings The findings presented here attend to the intersections of patient safety discourses as they engage with the situated knowledge of professionals. This occurs as the professionals consider their professional practice related to patient safety and care planning. In this section, we suggest how the strategies and knowledges associated with patient safety discourses make certain ways of thinking about professional practice possible. Through the analysis of what clinicians say as representatives of their professional discourses, this section provides an analytical description of how discourses of safety may interact, be changed by, and change, professional discourses. Essentially, it is in the intersection of these discourses where the conditions of possibility (Foucault, 1970/1981) for interprofessional interactions to occur are made manifest. We then explore the implications for the way different professions may or may not work with one another. Conceptualizations of practice made possible in intersection with patient safety discourses This section analyzes two different orientations towards professional practice that are possible in intersection with patient safety discourses. The analysis explicates how professions are imbricated within these practices differently, suggesting implications for how the different professions may be able to work with one another in the service of patient safety. Safety practice as preventing the occurrence of (physical) events while in hospital This orientation towards safety was primarily concerned with the prevention of adverse events within the hospital. While not stated explicitly, the concern is primarily centered on physical safety, with a great deal of attention paid to the prevention of forces acting on the patient body (falls, decubitis ulcers) or within the patient body (medication errors, infections). This attention to falls, ulcers, medication errors, and infections is also reflected (and mandated) throughout Hospital strategy texts, clinical practice guidelines, and accreditation requirements. The attention to the prevention of (physical) adverse events was considered to be a standard of practice across all the professions. For example, both social workers highlighted infection control and falls prevention as unifying concern across the interprofessional team: SW1: We talk about safety. And when we talk about safety, we are talking about safety that can be looked at . . . If the patient has (clostridium difficile), we make sure the patient is isolated. And we make sure to respect that. We do whatever we have to do . . . Or other safety measures if a patient as a history of falls . . . The intent is always to work as a team. SW2: Infection control, handwashing. These are things that are part of our . . . standard of care for social work as well. However, despite articulating how the profession of social work supported the patient safety agenda, both social workers also

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indicated that their professional practice remained ‘‘disconnected’’ (SW2) from hospital patient safety programs. For these social workers, and for the participants from other professions, it is primarily the profession of nursing that is at the centre of safety practices related to the prevention of physical adverse events. Each of the following quotes indicates an understanding of safety practices as primarily driven by nursing, with the role of other professions to support this work, primarily by increasing the gaze of nursing: SW1: But, if we go into a room and we are seeing something that doesn’t quite fit with what we’ve been told by other members of the team, we bring it to the nurse’s attention. To say, the patient was getting up. The patient was staggering. MD2: But, if I see a patient on the ward who I know they are climbing out of bed . . . I will probably mention it to the nurse who is directly responsible. PT: Safety huddles. Lately, I haven’t been attending . . . A lot of the stuff that they talk about is medication errors. Stuff that isn’t relevant (to my practice). Like, I never touch medication. So, to stand and listen for 50 minutes of ‘‘oh, be careful because this blue pill resembles that blue pill’’. If I see a blue pill laying around, I just give it to a nurse. Thus, the nursing role is positioned as central to the prevention of physical adverse events. Further, the primary work of nursing in this safety context is preventing adverse events by being vigilant. For example, Nurse 1 describes her profession’s most significant role in safety as ‘‘watching, making sure everything is going smooth(ly)’’. Clinical practice guidelines and hospital texts related to the prevention of injury also deployed this concept of vigilance, requiring nurses to make use of risk screen tools at preappointed times in the patient’s admission. With the primary safety concern being the prevention of physical adverse events within the hospital, this safety orientation is quite conservative and risk intolerant. For example, Nurse 1 describes part of the value of receiving report from Personal Care Aides is to hear about a patient’s mobility status to inform care planning for the shift. Nurse 1: ‘‘And I will ask one of them . . . can this person get to the toilet ok? Can I walk them’’? And they will say, No, no, no leave them in bed because she fell, or she almost fell last time. In a related example, when asked how she would prioritize a need for the patient to progress his or her functional skills set in anticipation of leaving the hospital, Nurse 2 replied: Nurse 2: I guess, it really would depend on what’s going on at the time. Like, if you, if you have the time to let them be independent and use supervision and whatever is suggested, then you are going to do it. But, if you don’t, you are not . . . If there are more acute patients. Or, your workload is very heavy. The reality is, probably not. It is probably not going to happen. The above quotes are made sensible, in a Foucauldian sense, when considering how the profession of nursing is positioned (by themselves and others) as primarily accountable for preventing falls within the hospital setting. This orientation towards safety as the prevention of physical adverse events has the potential to elevate the role of nursing within the hospital. Ironically, even as a strong concern for the physical safety of patients while in hospital may be elevating the role of the nurse, there is a potential that this orientation may also

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be narrowing the breadth of nursing professional practice. As one director commented:

the physiotherapist notes how her work would change in the absence of any risk of falls:

(Clinicians) are . . . primed to see (medication errors, electronics documentation issues, patient injury, falls, decubitus ulcers) as incidents. But when a patient isn’t assessed as frequently as they need to be . . . Or we don’t call in the necessary supports early enough. They don’t see that as an incident.

PT: We would all do wound care. No one gets out of bed. No one climbs stairs. No one uses any gait aids. No walkers, canes, whatever. Right? Safest possible. But, it’s not going to promote any independence. Return to home is going to be a challenge. So, ok, you’ve fixed my kidney failure, but now I can’t walk.

Indeed, in the following excerpt, the nurse answers a general question about safety in a time-delimited way: Researcher: What do you consider to be key safety concerns in your practice? Nurse 2: Right now, it is definitely falls. Yeah. Wound care. Those are the two big ones. When asked further, the nurse offered that last month, the concern was medication incidents, but now ‘‘that’s old news’’ (Nurse 2). This comment reflected the focus of managerial programs over the last year, a focus that was also clearly visible in the review of hospital texts. While the rest of the interview did acknowledge a more expansive view of patient safety, reflecting concern with patient safety as mechanism to prevent medication errors, falls, and wounds, this excerpt suggests the ways in which managerial programs of focus may begin to constitute professional practice around specific domains of concern, potentially to the exclusion of others. Safety practice as being able to assess, predict and manage risk The previous section located a concern with safety as bound within the physical locality of the hospital. In other words, there is an imperative to keep a patient physically safe for the duration of each shift, and this conservative orientation perpetuates across shifts. This implies an orientation to safety that is conservative, relying on a logic of vigilance. The profession of nursing was positioned (by themselves and others) as being the driver of this conservatively oriented thread of activity. Another way of orienting to safety was the consideration of the patient’s safety upon his or her eventual discharge from the hospital setting. This required a different orientation to safety; namely, an orientation that was selectively risk tolerant. By selectively risk tolerant, we mean this orientation required a certain tolerance of risk as a necessary part of clinical practice, with the intention to progress a patient from the hospital setting to a physical locality that has fewer professional and nonprofessional services. This second orientation was directed towards the end of the admission, where rehabilitation therapists and social workers are put in the role (by themselves and others) as being concerned with anticipating and accommodating patient safety concerns upon the patient’s discharge from the hospital. As an example of how social workers were positioned as being concerned with the discharge process, a hospital text described a newly implemented program of weekly meetings between social workers and unit managers. These meetings were designed to explicitly address the problem of discharge from the hospital for those patients who were no longer considered to require the services of an acute care hospital. Throughout the interviews, the prevention of falls was used as an example of the problem of the absence of risk potentially creating harm. Here, the argument is that an overly conservative approach, perpetuated across shifts, creates its own harm in the form of de-conditioning, muscle atrophy, skin breakdown, and (less obviously) psychological distress. In the following excerpt,

In this framing, in order to meet the requirements of care, there needs to be some tolerance for the risk of falls. Further, some tolerance of risk is required in order to assess how much support someone will need in order to return home safely. The nature of assessment is always to take the patient to the limits of his or her capacity, such that a ‘‘durable’’ (SW2) safety plan can be constructed that is sensitive to the limits of a person’s ability. The occupational therapist argues that without the tolerance of some level of risk in assessment, the patient’s limits cannot be determined. This results in the risk being transferred from the physical locality of the hospital to the potentially riskier locality of the patient’s home. This tension is expanded in the following quote from the same occupational therapist. Here, she speaks explicitly to the limits of the logic of incident reporting as a means to design prevention of further incidents. In this example, she speaks to the need to take risks in order to progress a patient’s physical ability. While the introduction of new pieces of equipment may reduce the risk of staff and patient injury, it would interrupt the clinical project of physical progression. OT: A ‘‘no lifts’’ policy says . . . don’t transfer (patients) if they are a two person max assist transfer. Well, how am I ever going to get them to something less than a two-person max assist transfer if I can’t get them started on that process? The above quote illuminates clinical scenarios within the hospital, where therapists engage in form of risk assessment that balances the risks that must be taken now in order to reduce the risks the patient will experience upon leaving hospital. This analysis begins to point to the logic of prediction that is constituted as a necessary part of professional practice as it intersects with patient safety discourses. While this logic of prediction could be deployed to support the safety orientation that was both conservative and vigilant, it was mostly articulated in relationship to the ability to assess, predict, and manage risk such that patients could be ‘‘pushed to the next step in the process’’ (OT) within the hospital setting, while simultaneously creating discharge plans that would avoid patients ‘‘coming back to our emergency room because they have failed’’ (MD2). In the interviews, the task of predicting whether a patient will be safe going home was largely restricted to the concern of occupational therapists and physical therapists, with some conceptual treatment from physicians and social workers. For example, Nurse 1 indicated that the concern of safety at home was ‘‘OT, PT, and I guess, homecare. That would be more in their field’’. In this orientation to safety within the patients’ homes, therapists were plagued with the impossibility of being able to predict someone’s functioning, and therefore their safety, upon return to their home environment. While accountable for the decisions made about someone’s ability to return home, there was very little the therapists could control outside of the hospital walls. Therefore, while there was tendency for therapists to be selectively risk tolerant within the hospital setting, there was also a tendency for their recommendations are conservative outside of the hospital setting so that ‘‘failing at home’’ (PT)

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could be avoided. In making recommendations about safety, the physiotherapist ruefully notes, ‘‘It is beyond your control. Right? The best you can do is make your recommendation. Hope they follow through with it. And hope that there isn’t an acute decline, cognitively or functionally, that would make those recommendations inappropriate’’ (PT). Safety discourses as participating in tensions between the professions These two different orientations to safety practice, the first being oriented to physical safety within hospital walls and the second being oriented to a more expansive understanding of safety beyond the hospital setting, invited predictable tensions between the professions. Some of these tensions are apparent in the following quotes: PT: We are pretty good at coming to consensus. Where we might have difficulty is not necessarily between OT and PT. But, maybe between allied and nursing . . . It is more of a tension between what you think is appropriate and what a family might think is appropriate. Or what a nurse might think is appropriate. Or what a doctor (might think) . . . How much risk are we willing to accept and acknowledge? And how can we manage it? MD1: On a subtle level, one person’s risk evaluation is just not registering with another person’s . . . There is a team of nurses and physicians who say, ok, this person can go home. And they physio says, yes, but I am not sure they can really negotiate the stairs at home. So, the hospital team is not really in the process of thinking about the home. Whereas the rehab team is already there in their minds. Sometimes, it does clash. Further, an orientation to safety practices as primarily concerned with the prevention of physical adverse events within the hospital setting rendered invisible different safety practices, with the potential effect of marginalizing the practice of some professions. For example, despite her long, intricate discussion of the ways in which social workers participate in hand hygiene programs, monitor for falls risk, as well as work to reduce oppression, ensure emotional and psychological safety, and address issues of abuse, the social worker in the following quote does not recognize her profession specific practice within the hospital’s patient safety programs: SW1: The safety things . . . the expectation is that the nurse is going to focus on that component. We follow through with whatever decision in regards to safety measures that need to be taken. Social workers do not take a significant role in (those measures) . . . So, I would not say social workers have a major role in safety, patient safety. Taken in context of the interview, this above quote does not indicate that social workers do not participate in hospital safety programs. Indeed, the same social worker also indicated how participation and support of safety programs is part of social work standard practice. However, the above quote suggests that the practices of social work that are embedded in an orientation to safety that is beyond a concern with the prevention of physical adverse events in the hospital setting are not visible in hospital patient safety programs. Further, in a later quote, the same social worker describes how her profession specific safety mechanisms may not be recognizable to other professions: SW1: Some of the (physicians) may be under the impression is that all social workers do is go in and do the (palliative)

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application. We can’t. That’s not our practice. We have to assess. We have to understand their circumstances . . . They need to understand what is happening . . . This is showing the patient respect. These are safety mechanisms. We are not oppressing the patient.

Discussion This study demonstrates a strong discourse of patient safety as concerned with the prevention of adverse events. While not stated explicitly, the specific focus of concern is with physical events. The nursing profession is most strongly aligned with the concern for the patient’s physical safety while in the hospital. In this alignment, nurses are afforded a position of power through the patient safety discourses as they are currently operating in acute hospitals. However, these same nurses may also be experiencing a narrowing of the breadth of their professional concern. In contrast, the constructions of safety work offered by rehabilitation therapists and social workers were largely marginalized by a biomedical model of patient safety. Instead, rehabilitation therapists and social workers mainly represented their involvement in safety through their role in interprofessional assessment. Interprofessional assessment plays two roles in intersection with patient safety discourse. First, such assessment expands the nurses’ gaze (Foucault, 1973/1994), supporting the project of nursing vigilance. Second, interprofessional assessment is used to bolster collective predictive logics as teams attempt to make decisions about discharge planning. With this emphasis on the professional role of therapists as making safe and durable discharge plans, the logic of prediction may be coming to replace previously existing professional logics of diagnosis (Rose, 1999). The emphasis comes to be the classification of patients in terms of their future conduct, their riskiness, and the identification of the steps necessary to manage that conduct (Rose, 1999). Replacing a logic of diagnosis with a logic of prediction has implications for what it means to be a professional (Fournier, 1999), with implications for the kinds of relationships that are possible between clinicians and patients, as well as between clinicians and managers (Castel, 1991). This study also suggests how patient safety discourses are wrapped up in expressions of professional power. Patient safety discourses rooted in biomedical and socio-technical assumptions privilege some forms of practice while marginalizing others. Further, patient safety discourses as primarily a concern with the prevention of adverse physical events presents a limited view of the safety practices of each of the professional groups, rendering invisible the ways in which safety is the careful articulation of many different kinds of cognitive, physical, emotional, and sentimental forms of work, an argument developed in Strauss et al. (1985) ethnographic study of the social organization of clinical work in hospitals. Infante (2006) also cautions against a single conceptualization of safety that privileges biomedical or managerial definition of clinical care, calling for a critical examination of the current paradigm of ‘‘systems’’ that is unable to include all actors of the system. Infante further argues that ‘‘having patient safety as the ultimate goal of team work should not mean subsuming all of the different health professionals’ functions to the biomedical model of care’’ (p. 521). Instead, Infante suggests a sociological model of the patient as a means to bridge the ‘‘systems’’ gap between patient safety and interprofessional care. What this discussion suggests is that the notion of this single, biomedical discourse of patient safety being deployed as a

DOI: 10.3109/13561820.2014.891574

unifying and neutral form of governing the professions is likely problematic. While there are a number of methodological limitations related to this study, it nevertheless adds to the academic and practice conversation that a fruitful line of inquiry may not be to continue to consider the problem of implementation or best practice ‘‘spread’’ across the professions, but to consider how the professions do patient safety differently (Zuiderent-Jerak, Strating, Nieboer, & Bal, 2009).

Concluding comments Our findings indicate the complexity of finding a common language or common goal of patient safety across professions. This is consistent with other studies examining how concepts of teamwork (Cott, 1997, 1998), collaboration (Reeves & Lewin, 2004), and person-centered care (Gachoud, Albert, Kuper, Stroud, & Reeves, 2012) differ across the professions. This study challenges the common sense notion that patient safety will act as unifying mechanism across the professions. Instead, this study articulates the nuances between professions, expanding an argument that different professions do patient safety differently (Zuiderent-Jerak et al., 2009). This study suggests that the way forward in the realm of patient safety is complex. Designers of safety policy and programs might consider how different discourses, such as discourses of patient centered care, interprofessional education, interprofessionalism, quality, and efficiency, are intersecting within their own locale, and to what effect.

Acknowledgements This research was conducted as part of the first author’s doctoral dissertation. The authors would like to acknowledge the contributions of the other members of the doctoral committee to this work. The authors would also like to acknowledge the helpful suggestions from the two anonymous reviewers of an earlier manuscript.

Declaration of interest The authors report no conflicts of interest. The authors are responsible for the writing and content of the paper.

References Carter, S.M., & Little, M. (2007). Justifying knowledge, justifying methods, taking action: Epistemologies, methodologies and methods in qualitative research. Qualitative Health Research, 17, 1316–1328. Castel, R. (1991). From dangerousness to risk. In G. Burchell, C. Gordon & P. Miller (Eds.), The Foucault effect: Studies in govermentality (pp. 281–298). Chicago, IL: University of Chicago Press. CIHI. (2005). Inpatient hospitalizations and average length of stay trends in Canada, 2003–2004 and 2004–2005. Retrieved from Canadian Institute for Health Information. http://secure.cihi.ca/cihiweb/products/ hmdb_analysis_in_brief_e.pdf. Cott, C. (1997). ‘‘We decide, you carry it out’’: A social network analysis of multidisciplinary long-term care teams. Social Science & Medicine, 45, 1411–1421. Cott, C. (1998). Structure and meaning in multidisciplinary teamwork. Sociology of Health & Illness, 20, 848–873. Creswell, J.W. (2009). Research design: Qualitative, quantitative, and mixed methods approaches (3rd ed.). Thousand Oaks, CA: Sage Publications. Currie, G., Humpreys, M., Waring, J., & Rowley, E. (2009). Narratives of professional regulation and patient safety: The case of medical devices in anaesthetics. Health, Risk & Society, 11, 117–135. Danholt, P. (2010). The sociotechnical configuration of the problem of patient safety. In D. Nohr & J. Aarts (Eds.), Information technology in health care: Socio-technical approaches (Vol. 157, pp. 31–37). Lansdale, PA: IOS Press. Dean, M. (2010). Governmentality: Power and rule in modern society (2nd ed.). Los Angeles, CA: SAGE. Dixon-Woods, M. (2010). Why is patient safety so hard? A selective review of ethnographic studies. Journal of Health Services Research & Policy, 15, 11–16.

Patient safety discourses

337

Fairclough, N. (2003). The discourse of new labour: Critical discourse analysis. In M. Wetherell, S. Taylor, & S. Yates (Eds.), Discourse as data: A guide for analysis (pp. 229–266). Thousand Oaks, CA: SAGE. Foucault, M. (1970/1981). The order of discourse. In R. Young (Ed.), Unyting the text: A post-structuralist reader (pp. 51–78). Boston, MA: Routledge. Foucault, M. (1973/1994). The birth of the clinic. New York, NY: Random House. Foucault, M. (1975/1980). Prison talk. In C. Gordon (Ed.), Power/ Knowledge: Selected interviews and other writings 1972–1977 (pp. 37–54). Toronto, ON: Random House. Foucault, M. (1977/1980). Two lectures. In C. Gordon (Ed.), Power/ knowledge: Selected interviews and other writings 1972–1977 (pp. 78–108). Toronto, ON: Random House. Foucault, M. (1991a). Governmentality. In G. Burchell, C. Gordon, & P. Miller (Eds.), The Foucault effect: Studies in governmentality (pp. 87–104). Chicago, IL: University of Chicago Press. Foucault, M. (1991b). Questions of method. In G. Burchell, C. Gordon & P. Miller (Eds.), The Foucault effect: Studies in governmentality (pp. 73–86). Chicago, IL: University of Chicago Press. Fournier, V. (1999). The appeal to ‘‘professionalism’’ as a disciplinary mechanism. The Sociological Review, 47, 280–307. Frank, J., & Brien, S. (Eds.). (2008). The safety competencies: Enhancing patient safety across the health professions. Ottawa, ON: Canadian Patient Safety Institute. Gachoud, D., Albert, M., Kuper, A., Stroud, L., & Reeves, S. (2012). Meanings and perceptions of patient-centeredness in social work, nursing and medicine: A comparative study. Journal of Interprofessional Care, 26, 484–490. Infante, C. (2006). Bridging the systems gap between interprofessional care and patient safety: Sociological insights. Journal of Interprofessional Care, 20, 517–525. Institute of Medicine. (1999). To err is human: Building a safer health care system. Washington, DC: The National Academies Press. Institute of Medicine. (2001). Crossing the quality chasm: A new health system for the 21st century. Washington, DC: The National Academies Press. IOM. (1999). To err is human: Building a safer health care system. Washington, DC: The National Academies Press. Jeffs, L.P., Lingard, L., Berta, W., & Baker, G.R. (2012). Catching and correcting near misses: The collective vigilance and individual accountability trade-off. Journal of Interprofessional Care, 26, 121–126. Knox, G.E., & Simpson, K. (2004). Teamwork: The fundamental building block of high-reliability organizations and patient safety. In B.J. Youngberg & M.J. Hatlie (Eds.), The patient safety handbook (pp. 379–414). Mississauga, Ontario: Jones & Bartlett. Ladden, M.D., Bednash, G., Stevens, D.P., & Moore, G.T. (2006). Educating interprofessional learners for quality, safety and systems improvement. Journal of Interprofessional Care, 20, 497–505. Leistikow, I.P., Kalkman, C.J., & Bruijn, H.D. (2011). Why patient safety is such a tough nut to crack. BMJ, 342, d3447. Retrieved from www.bmj.com/content/342/bmj.d3447. Lima, C. A. (2006). The discourse of patient safety (Doctoral dissertation), University of Hawaii, Waikiki, Hawaii. McDonald, R., Waring, J., & Harrison, S. (2005). ‘‘Balancing risk, that is my life’’: The politics of risk in a hospital operating theatre department. Health, Risk & Society, 7, 397–411. McDonald, R., Waring, J., & Harrison, S. (2006). Rules, safety and the narrativisation of identity: A hospital operating theatre case study. Sociology of Health & Illness, 28, 178–202. Parker, I. (2003). Critical discursive psychology. London, UK: Palgrave Macmillan. Perneger, T. (2005). The Swiss cheese model of safety incidents: Are there holes in the metaphor? BioMed Central Health Services Research, 5, 71. Potter, J. (1996). Representing reality: Discourse, rhetoric and social construction. Thousand Oaks, CA: SAGE. Potter, J., & Wetherell, M. (1987). Discourse and social psychology: Beyond attitudes and behaviour. Thousand Oaks, CA: Sage Publications. Reeves, S., & Lewin, S. (2004). Interprofessional collaboration in hospitals: Strategies and meanings. Journal of Health Service Research and Policy, 9, 218–225.

338

P. Rowland & S. Kitto

Rose, N. (1999). Powers of freedom: Reframing political thought. New York, NY: Cambridge University Press. Schimmel, E.M. (1964/2003). The hazards of hospitalization. Quality & Safety in Health Care, 12, 58–63. Sheps, S. (2006). Reflections on safety and interprofessional care: Some conceptual approaches. Journal of Interprofessional Care, 20, 545–548. Silverman, D. (2006). Interpreting qualitative data: Methods for analyzing talk, text, and interaction (3rd ed.). Los Angeles, CA: SAGE. Strauss, A., Fagerhaugh, S., Suczek, B., & Wiener, C. (1985). The social organization of medical work. Chicago: The University of Chicago Press.

J Interprof Care, 2014; 28(4): 331–338

Travaglia, J., & Braithwaite, J. (2009). Analysing the ‘‘field’’ of patient safety employing Bourdieusian technologies. Journal of Health Organization and Management, 23, 597–609. Travaglia, J., Nugus, P., Greenfield, D., Westbrook, J.I., & Braithwaite, J. (2012). Visualising differences in professionals’ perspectives on quality and safety. BMJ Quality & Safety, 21, 778–783. Weick, K.E., Sutcliffe, K., & Obstfeld, D. (2008). Organizing for high reliability: Processes of collective mindfulness. In A. Boin (Ed.), Crisis management (Vol. 3, pp. 31–66). Los Angeles, CA: Sage. Zuiderent-Jerak, T., Strating, M., Nieboer, A., & Bal, R. (2009). Sociological refigurations of patient safety; ontologies of improvement and ‘‘acting with’’ quality collaborators in healthcare. Social Science & Medicine, 69, 1713–1721.

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Patient safety and professional discourses: implications for interprofessionalism.

Patient safety has been presented as a unifying concern across the health professions. This conceptual connection has been accompanied with efforts to...
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