Interprofessional rhetoric and operational realities: an ethnographic study of rounds in four intensive care units

Abstract

Morning interprofessional rounds (MIRs) are used in critical care medicine to improve team-based care and patient outcomes. Given existing evidence of conflict between and dissatisfaction among rounds participants, this study sought to better understand how the operational realities of care delivery in the intensive care unit (ICU) impact the success of MIRs. We conducted a year-long comparative ethnographic study of interprofessional collaboration and patient and family involvement in four ICUs in tertiary academic hospitals in two American cities. The study included 576 h of observation of team interactions, 47 shadowing sessions and 40 clinician interviews. In line with best practices in ethnographic research, data collection and analysis were done iteratively using the constant comparative method. Member check was conducted regularly throughout the project. MIRs were implemented on all units with the explicit goals of improving team-based and patient-centered care. Operational conditions on the units, despite interprofessional commitment and engagement, appeared to thwart ICU teams from achieving these goals. Specifically, time constraints, struggles over space, and conflicts between MIRs' educational and care-plan-development functions all prevented teams from achieving collaboration and patient-involvement. Moreover, physicians' de facto control of rounds often meant that they resembled medical rounds (their historical predecessors), and sidelined other providers' contributions. This study suggests that the MIRs model, as presently practiced, might not be well suited to the provision of team-based, patient-centered care. In the interest of interprofessional collaboration, of the optimization of clinicians' time, of high-quality medical education and of patient-centered care, further research on interprofessional rounds models is needed.

Perceptions of interdisciplinary rounding practices

“…This study revealed that some interactions in rounding discussions are negative. These findings support similar results by (Paradis et al, ) ethnographic study of IDR in an intensive care unit. They found that physicians often projected a dominance over other staff members that made them feel hesitant to participate as equal partners.…”

Articulating the ideal: 50 years of interprofessional collaboration in Medical Education

“…The use of negation here places ‘doctor’ as the dominant and arguably most legitimate profession, and has the potential to alienate and diminish valuable health care team members. This language reflects the hierarchical nature of health care delivery, which is amplified by care structures that maintain medical dominance despite growing egalitarian beliefs …”

“…Our authorship team is composed of an interdisciplinary group that includes one clinician (a physician with previous training in history [CRW]), two sociologists (EP and JCR), an epidemiologist (CC) and a linguist (MP). Collectively, we are committed to more egalitarian relationships in health care, and four of us (CC, CRW, EP and MP) have published accounts critical of doctors’ dominance . Our structured coding scheme and analytic approach were developed to distance ourselves from our previous beliefs and to allow us to look with empirical detachment at the data excerpted from selected articles.…”

Ethnography in health professions education: Slowing down and thinking deeply

“…This interpretation of triangulation adopts the view that a single truth (or close to it) about the phenomenon can be found and enhanced by studying the phenomenon from multiple perspectives, which is a positivistic claim. By contrast, one of the strengths of ethnography is that it can highlight the nuances and differences that exist around a particular phenomenon from different stakeholders’ perspectives . (p. 183‐4) From this perspective, collecting data from multiple sources helps develop analytical insights between individuals or social groups, which is aligned with the subjective epistemology of ethnography.…”