This section will briefly discuss professional cultures that may hinder teamwork, particularly the culture of physicians, historically seen as team leaders. Also presented are examples of current educational initiatives that promote an environment in which members of interdisciplinary healthcare teams can freely and respectfully question each other's actions and decisions.
It is beyond the scope of this case to discuss these issues in depth, but some discussion is offered as food for thought. The discussion is not meant to be definitive or all inclusive.
Interprofessional collaboration is examined in a BMJ issue (2000 Apr 15) devoted entirely to the roles of physicians and nurses. In one article (Doctors and nurses: doing it differently. The time is ripe for a major reconstruction.) the authors note:
The relationship between doctors and nurses has never been straightforward. The differences of power, perspective, education, pay, status, class, and - perhaps above all - gender have led to tribal warfare as often as peaceful coexistence. Nurses' readiness to be slighted and doctors' reluctance to be challenged create an undercurrent of tension. This may be masked in practice settings by the pressing need to get the work done, but it is there.
For decades we understood the professions as a conventional nuclear family, with doctor-father, nurse-mother, and patient-child. But our hope for total wisdom and protection from father is forlorn, our wish for total comfort and protection from mother unachievable, and the patient has grown up.
In the described nuclear family, perhaps laboratory technologists and other so-called "allied health professionals" are poor country cousins?
If patient safety requires the ability of members of interprofessional healthcare teams to question the actions and decisions of team members, it helps if the culture of each profession welcomes questioning. Below are three articles that examine cultures and autonomy from different perspectives.
Article 1. A case study from the Agency for Healthcare Research and Quality - Morbidity and Mortality Rounds on the Web reports on an intern who ignores a suggestion by a pharmacist on how a particular dose of drugs should be given:
- One dose, 50 pills (No longer online)
The commentary on the case includes these key points:
- This troubling case exposes how the unique culture of residency education, as well as the long-standing tradition of resident autonomy, are often at odds with patient safety.
- Within residencies.....needing and requesting help from colleagues is often seen as failure.
- Many residency programs also have a culture of devaluing input from non-physician professionals.
- Physicians have consistently prized autonomy in clinical decision-making.
- However, if physicians are not following evidence-based medicine or, moreover, are harming patients as they exercise their independence, the autonomy should be curtailed in the name of safety and quality.
The physician providing commentary goes further:
The answer to this seeming conflict of autonomy versus patient safety is in creating a culture where everyone looks critically at clinical outcomes, focuses on best patient care, and actively addresses the priorities of clinical autonomy, clinical judgments, and evidence-based medicine.
We need an environment in which young physicians are comfortable asking for help, are willing to recognize and respond to the expertise of all members of the care team, and see patient safety systems as supporting their goals of providing better patient carenot as hassles in an already over-loaded workday.
Ultimately, the goal must be to create a culture that allows physicians to comfortably ask for help when they are beyond their area of competence while preserving the intense personal sense of commitment and responsibility for the quality of care of their patients.
Article 2. The cultural of physicians is also examined in this news item and associated article in which a neurosurgeon insisted that a trauma patient needed immediate attention and urged staff to skip a 2-hour procedure to sterilize the equipment, which had been borrowed from another hospital. According to the news item, a nurse refused to let the surgeon operate and ultimately police were called when the physician lost control of himself.
- Disruptive Clinician Behavior: A Persistent Threat to Patient Safety (July /August 2006, Patient Safety & Quality Healthcare)
The article examines various factors that contributed to disruptive behavior by health professionals (not just physicians). One factor is that some physicians may have trouble handling questions about their decisions. The authors make these points:
Increasingly, healthcare organizations are devoting efforts to creating a culture of safety, one in which every member of the healthcare team feels safe in voicing opinions and concerns regarding a patient's plan of care and in which the fear commonly associated with reporting errors or disagreeing with those in positions of authority is eliminated.
The complementary concepts of teamwork ...and high reliability organizations... have also gained popularity and further underscore the importance of developing cultures in which all members of the healthcare team work collaboratively and respectfully, monitoring and correcting each other's performance and providing input into the team's work and decisions, regardless of power and rank.
The cultural shift suggested by the patient safety movement from a paternalistic, "captain of the ship" model to a team-based approach with empowerment of and accountability to all team members may itself contribute to perceived loss of autonomy and increase frustration on the part of the more seasoned physicians.
Article 3. Carroll and Quijada examine healhcare cultures and how to facilitate change:
- Carroll JS, Quijada MA. Redirecting traditional professional values to support safety: changing organisational culture in health care. Qual Saf Health Care 2004 Dec;13 Suppl 2:ii16-21.
They note that autonomy (the right for professionals to make their own decisions) is key to medical culture, but not necessarily to all occupational cultures within healthcare, and caution that while autonomy is a strength , it can also be a weakness:
... doctors assume they have to be "iron men" who can do everything themselves, learn everything themselves, and work long hours without sleep. No one, including colleagues, feels comfortable telling a physician how to practice medicine.
The authors stress that cultures are not monolithic:
A hospital, for example,is not a single culture but rather a fragmented collection ofoccupational culturessuch as medicine, nursing, and management(and subcultures within, such as surgery, anaesthesiology, pharmacy,finance, and marketing). Within these occupational groups thereare international cultures, such as Jamaican nurses, Salvadorancleaning crews, and Irish maintenance workers ....
One of the main themes of the paper is that lasting change needs to be consistent with culture and "Rather than oppose the existing culture, it may be more effective to build on existing cultural strengths and gradually shift or tilt the culture." Table 2 from the paper shows desired cultural elements and pairs them with existing cultural strengths that couldbe drawn upon for change. For example, the existing practice of self criticism could be used to help people develop a culture of openly reporting problems.
Table 2 Healthcare cultural resources
As shown by these three articles, perceived loss of autonomy is considered to be a major obstacle to collaboration and open questioning within health teams.
Many aspects of physician culture apply to other health professions. For example, without education and training on how to interact in teams, it is human nature to resist questioning of our views and decisions.
Changing healthcare culture is summarized in this table. Note that all trends lead to loss of autonomy for healthcare professionals.
|Old --> New
Educators have long recognized that teamwork, with understanding of and respect for the roles of diverse health providers, will not just happen when professionals are brought together in teams. Unlike the book/film Field of Dreams, "build it and they will come" unfortunately does not apply.
In Altogether for Health (editorial, Student BMJ), the author notes:
Healthcare students go through a process of "professionalisation", which consists of an adoption of the attitudes and working culture associated with a particular profession as well as acquiring the knowledge and skills essential to its practice. Later on, in the workplace, professionals may have little understanding of the roles of the other healthcare professions and may undervalue the other professions' contribution to care for the patient, making interprofessional teamwork difficult.
In 2000 the BMJ devoted an entire issue on the roles of physicians and nurses, including this editorial:
- Davies C. Getting doctors and nurses to work together BMJ 2000 Apr 15;320:1021-2.
Celia Davies makes these points:
- Working together means acknowledging that all participants bring equally valid knowledge and expertise from their professional and personal experience.
- Affirmations, acknowledgment, and recognition are important, but it is the questions and challenges that arise from the differences that are vital.
- There are good reasons why doctors and nurses are not far along this road. Traditionally the profession of medicine created doctors who were self reliant and independent. It emphasised expertise, autonomy, and responsibility more than interdependence, deliberation, and dialogue.
- Nursing traditions have been different, emphasising hierarchy and bureaucratic rule following. Even if these have diminished, along with deference to doctors, nurses still work "around" others.
- Individually, nurses and doctors may strive to overcome the lingering images of their professions, but there is a weight of tradition, including a tradition of gender thinking, to contend with. Nursing is no more conducive to collaborativeworking than is medicine.
- Both need to change if a collaborativemodel is to work.
The animated discussion of articles in the issue shows the degree of controversy involved:
Accordingly, educators, practitioners, and governments know that training is required. Educational programs and professional associations have developed initiatives.
The Royal College of Physicians and Surgeons of Canada (RCPSC) uses a framework for residency training, as well as for physician continuing education, that includes competencies and roles expected of a medical or surgical specialist, such as professional, communicator and collaborator.
The CanMEDS competencies have been integrated into the Royal College's accreditation standards, objectives of training, final in-training evaluations, exam blueprints, and the Maintenance of Certification program.
Interprofessional teams of student health professionals that treat patients:
- St. George's Medical School, University of London: students from medicine, nursing, occupational therapy, and physiotherapy are put into interprofessional teams that work in shifts to run a rehabilitation ward in a local hospital for five weeks. As well as doing the work appropriate to their own profession, the students meet as a team to handover patients at the changeover of shifts. As a group, they also have reflective time with a facilitator and finish the placement with a group presentation on what they have experienced and learnt. (Source: Altogether for Health)
CLARION curriculum at University of Minnesota:
- The CLARION curriculum: year-long experiential activities culminating in a capstone event - a Case Competition in which interprofessional teams of students present a root cause analysis of a fictitious sentinel event to a panel of senior-level health executives.
Changing professional cultures to facilitate collaboration and questioning among the health professions takes a long time and requires the efforts of educators and practitioners, who should model best practice for their students and colleagues.
The nurse followed a physician's order "to continue transfusion even if it takes all day" without questioning the order, even though it contravened established best practice standards. She did not believe that she had the authority to question the physician's order beyond her initial inquiry about the slow running transfusion since doctors were responsible for specifying rates of transfusion. She did not contact the TS laboratory because the physician had been questioned and had already decided. She was a recent graduate who had worked in a setting where physicians were not questioned.
The incident involved deviations in established practice and standards and could be considered a near miss, in that the blood unit was not contaminated and did not cause a bacteriogenic transfusion reaction.The patient's febrile non-hemolytic reaction was unrelated to the deviations in practice.
However, a preliminary investigation suggested that not questioning orders that compromised patient safety was a systemic problem that went beyond individual physician-nurse interactions. Accordingly, the transfusion service (TS) decided to conduct a root cause analysis. Some of the key questions to be answered included:
- Why did the patient's physician think it was acceptable to "continue the transfusion even if it takes all day"?
- Why did the nurse not question the physician directly about orders that contravened blood safety standards?
- Why did the nurse not contact her nursing manager nor the TS laboratory?
An investigation revealed the following:
Laboratory staff in the TS revealed that in the past they had hesitated to question unusual transfusion requests because sometimes clinicians would get upset and speak harshly or yell at them.
The ability to contact the TS medical director or physician on-call (as specified in their SOP, QCAI.013. Pathologist Consultation Protocol in TraQ TRM) helped alleviate part of the problem. Examples in the SOP of circumstances for calling the TM medical director about atypical blood orders included:
- Inappropriate requests for blood products as described in the blood supplier, e.g., CBS Circular of Information and Clinical Guide to Transfusion
- Request for a special blood product for a patient with no history of special transfusion requirements
- First time requests for special products (e.g., immune globulins, factor concentrates) not ordered by a hematologist or not meeting criteria for indications for use
- Requests for fewer than five or more than eight platelet units for an adult
The laboratory technologists reported:
- Having defined criteria for when to call physicians helped ensure that needless calls were not made while still enhancing patient safety.
- Having a physician knowledgeable about transfusion speak to clinicians helped since they could discuss the clinical issues involved within their scopes of practice.
- As an example, laboratory staff believed that directly telling a physician that the patient had an antibody that could cause a hemolytic transfusion reaction was appropriate, whereas directly telling a physician that his blood order may be inappropriate was better handled by the TM medical director, peer-to-peer.
- However, in essence, TS lab staff were instructed to question unusual orders, but "give them [physicians] what they want".
Part of the analysis involved surveying other nurses on the unit and throughout the hospital anonymously, with no fear of reprisals, about practices, policies, and their comfort level with questioning physician orders/requests.
- Nurses reported that since they work in close proximity with physicians, they have increased opportunities to discuss issues directly.
- However, many reported that they seldom questioned physicians as it was not encouraged.
- Moreover, they felt uncomfortable doing it and feared subtle reprisals by physicians that could make their working relationships "sheer hell".
A few senior nurses said that the nurse in question could have questioned the physician directly on the best practice issue of transfusing over a long time and suggest that he contact the TM medical director. Depending on the response, the nurse could have sought further advice and support from colleagues, for example:
- Depending on available support systems, nurses may take the issue to their clinical practice expert and then the nurse unit manager, who can also speak to the physician.
- If needed, the unit manager can consult the physician's department head, all the way up to the Chief of Staff, something that would seldom happen.
The TS learned that it needed:
- To take a more active role in TM education with clinical staff (nurses and physicians), so that they become more comfortable asking the TS for guidance.
- To increase its educational role with clinicians to make them aware of current transfusion guidelines and blood safety standards.
Facility-wide follow-up. Eventually the regional blood transfusion committee decided to investigate inter-professional responsibilities when interacting as part of a healthcare team, especially when questioning the decisions of other team members was required to maintain patient safety. Some of the issues to be explored included:
- How can members of different professions interact more and learn about each others roles, perspectives, and challenges?
- How can mutual professional respect be fostered?
- What type of environment would facilitate staff asking more questions of supervisors and getting support when needed?
- What would help staff become more comfortable with questioning the decisions of other team members?
- How do we remove barriers to inappropriate team interactions (angry responses, feeling stupid), etc.)?
As an interim measure, ongoing educational sessions were held to discuss the issues involved. All health professionals in the facility were encouraged to attend profession-specific "rap sessions", followed by interdisciplinary "grand rounds" that examined the challenges involved.
- Patient safety requires that professionals question the actions and decisions of other health providers, even if the responsibility is outside their scope of practice.
- Professional cultures may devalue input from other health providers and strongly value professional autonomy
- Interprofessional education that focuses on communication and teamwork can help foster respectful collaboration among members of different professions.
- All professionals can help promote effective collaboration and non-threatening questioning by modelling best practice for students and colleagues.
What of the following have been identified as potential barriers to interprofessional questioning of decisions?
- Culture of devaluing input from others
- Emphasis on professional autonomy
- Emphasis on hierarchies and following rules
- Fear of annoying a professional with more status
- All of the above
What would you do if a health practitioner outside your profession questioned a decision you made?
Indicate whether each statement concerning health professions is True (T) or False (F).
- Cultures of different health professions vary only slightly
- To develop a new culture you should first destroy the old one
- Professional autonomy is both a strength and a weakness
- If a particular competency is outside a profession's scope of practice, practitioners are not responsible for ensuring patient safety related to it
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