- Email: [email protected]
Power and conflict in intensive care clinical decision making
Power and conflict in intensive care clinical decision making Maureen Coombs
It is clear that current government policy places increasing emphasis on the need for flexible team working. This requires a shared understanding of roles and working practices. However, review of the current literature reveals that such a collaborative working environment has not as yet, been fully achieved. Role definitions and power bases based on traditional and historical boundaries continue to exist. This ethnographic study explores decision making between doctors and nurses in the intensive care environment in order to examine contemporary clinical roles in this clinical speciality. Three intensive care units were selected as field sites and data was collected through participant observation, ethnographic interviews and documentation. A key issue arising in this study is that whilst the nursing role in intensive care has changed, this has had little impact on how clinical decisions are made. Both medical and nursing staff identify conflict during patient management discussions. However, it is predominantly nurses who seek to redress this conflict area through developing specific behaviours for this clinical forum. Using this approach to resolve such team issues has grave implications if the government vision of interdisciplinary team working is to be realised. © 2003 Elsevier Science Ltd. All rights reserved. Maureen Coombs RN, PhD, MSc, BSc (Hons), Consultant Nurse Critical Care, Southampton University Hospitals Trust, Senior Lecturer School of Nursing and Midwifery, Intensive Care Unit, Southampton General Hospital, University of Southampton, D Level Centre Block, Tremona Road, Southampton SO16 6YD, UK. Tel: +44 (0) 2380 777222, bleep 9130; E-mail: maureen.coombs@ suht.swest.nhs.uk (Requests for offprints to MC) Manuscript accepted: 31/03/03
KEYWORDS: Intensive care; Ethnography; Decision making; Interdisciplinary team working; Clinical decision making.
Introduction Developments in technology, increased consumer interest in health and illness, together with a continued political interest on health care delivery has impacted on health care in ways that few could have predicted. The resultant workforce and organisational changes have brought developments in nursing practice and role into sharper focus—not least within the area of intensive care (Department of Health (DoH) 2001). However, even though recent strategy documents (DoH, 2000, 2001) have provided a framework for the development of nursing, the increasing importance on the ‘development and leadership of clinical teams providing patient
© 2003 Elsevier Science Ltd. All rights reserved. doi:10.1016/S0964-3397(03)00040-5
care’ is acknowledged (DoH, 2001, p. 1). The nature of contemporary intensive care mandates a team approach. In this context, all practitioners involved in care delivery are challenged to change their practice and develop their roles in order to make the best use of all available resources (DoH, 2000). This paper presents a study that arose from personal reflection on the contemporary nursing role and a re-consideration on the nature of team working in the delivery of intensive care. The purpose of this research was to develop a critical awareness of the contribution of medicine and nursing to one specific area of patient management; that of clinical decision-making.
Intensive and Critical Care Nursing (2 0 0 3) 1 9, 1 2 5–1 3 5 125
Intensive and Critical Care Nursing
Background to the study This section presents an overview of the literature pertinent to the study. The development of the intensive care unit is initially detailed, exploring the profile of clinical teams that work within this environment. Key studies undertaken on team working in health care are discussed. The section concludes with a specific focus on the clinical ward round and how this can assist our understanding of how medical and nursing staff work.
Intensive care and the clinical team The specialist clinical units of intensive care are a relatively recent phenomenon. Whilst often seen as a medical driven clinical speciality, ‘it should be recognised that all members of the multidisciplinary team are crucial to patient care and outcome’ (Smith, 1998, p. 115). Although the importance of a designated area for close observation of acutely ill patients was initially recognised in the nineteenth century (Nightingale, 1863), intensive care medicine has evolved as advances in technology and the ability of medicine to treat and support disease, have occurred. This has led to diverse technical therapies to be located in one designated area and has resulted in the intensive care unit becoming the ‘hospital’s hospital’ (Oh, 1996, p. 12). However, this increase in technology has presented a conflict for intensive care nurses in balancing the science of such technology with the art of nursing (Ashworth, 1990). Noc and Weil (1996) identified the key nursing responsibilities to be aligned with the science of technology through involvement with maintaining patient observations and the responsibility for gathering all non-invasive and invasive laboratory data. Whilst such perspectives have focused on technical functions undertaken by nurses in intensive care; this has rendered the art of nursing invisible and unacknowledged (Fairman, 1992). With such emphasis on nurses delivering medical care the need for nurses to preserve
126
Intensive and Critical Care Nursing
(2 0 0 3) 1 9, 1 2 5–1 3 5
humanity in an age of technology (Mann, 1992) has been emphasised. Woodrow (1997) argues that whilst clinical practice is focused on multiple system failure support, this provides but one challenge for the nurse clinician who chooses to work in the intensive care environment. Intensive care nurses are seen to provide the link between the patient and machine. Therefore, not only is technological competence required, but also compassion and humanity need to be demonstrated (Benner, 1984; Anspach, 1993). Thirty years ago the different practices of medicine and nursing in intensive care were easily identifiable (Roth & Daze, 1984). This distinction was based on the intensive care nurse initiating treatment based on the assessment of the patient’s symptoms; not through making differential medical diagnosis. The contemporary role of the intensive care nurse has since developed with the addition of tasks from medicine (role extension) and the development of nursing (role expansion) through enhanced nursing knowledge (Hunt & Wainwright, 1994). The boundary between contemporary nursing and medicine in intensive care continues to be blurred (Webb, 1996). Anderson and O’Brien (1995) details one unit’s experiences of nursing role changes through the development of a nurse-led patient extubation programme. This allowed nurses to make professional nursing decisions without direct medical consultation. Other highlighted areas of nursing role development within this speciality include new assisted ventilatory modes, sedation administration, and drug and fluid prescription (Royal College of Nursing, 1997; DoH, 2001). Intensive care areas have been identified as highly complex areas with high levels of uncertainty and instability above other hospital care areas (Leatt & Schneck, 1981). Whilst there have undoubtedly been changes in the acuity of all care areas since this observation was made, the intensive care environment continues to be unpredictable and complex. It has therefore been highlighted that the nature of care provided to critically ill patients therefore requires interdependent practice (Hickey et al., 1996). The concept of collaboration is a key underpinning concept to interdependent
© 2003 Elsevier Science Ltd. All rights reserved.
Power and conflict in intensive care clinical decision making
practice. In this, collaboration can be defined as ‘a cop-operative venture. It assumes power based on a knowledge base or expertise as opposed to power shared on role or function’ (Kraus, 1980, p. 12). Patient needs are placed paramount, with collaboration providing a synergistic alliance that optimises the contribution of each discipline (Weiss & Davis, 1985).
Clinical team working The historical empirical evidence details team working but reveals how members have often worked in isolation and with hierarchical relationships. The seminal works of Freidson (1970) and Stein (1967) argue that medicine holds a dominant and unchallenged position in health care by virtue of its knowledge base and societal position. This led to Stein (op. cit.) describing the interplay between medicine and nurses, referred to as playing the game; however, recent empirical studies have challenged this position. In Hughes’ (1988) study of casualty work in a British unit, the complex workload and high medical turnover were identified as key factors that promoted the role of nurses. Further support for nursing’s involvement in decision making was also evident in Porter’s observational study (1991) through the informal decision making processes nurses used to affect patient care decisions. Svensson’s (1996) study, located in Sweden, investigated doctor–nurse interplay using interviews with nurses from 14 wards in five hospitals. Analysis of the transcripts revealed a strong nursing voice. In identifying the social needs of the patient and co-ordinating care, nurses were felt to be in a unique position. However, when discussing patient treatment issues close to the medical treatment domain, there was still some evidence of Stein’s (op. cit.) game being played. Allen (1997) further developed Svensson’s work and demonstrated many examples of contested interprofessional boundaries, but little evidence of inter-occupational conflict and negotiations. The conclusion drawn by Allen was that nurses often manage their working role to minimise any conflict and that this was a taken for granted feature of normal nursing practice.
© 2003 Elsevier Science Ltd. All rights reserved.
The clinical ward round In exploring how patient care decisions are made, the ward round has proved to be an interesting area for study. This is one of the key forums where all key members of the clinical team come together to formulate a patient management plan. The ward round is seen to have several functions including assisting in the continuity of care, information transfer, provide opportunity for learning and enable effective communication and planning within the team (Walsh & Ford, 1989). In recent years, this has become a strong focus for sociological study in order to understand the complex processes involved in health care team working. Whilst key studies are outlined here, there is little empirical work undertaken within the critical care setting. In the United Kingdom, Busby and Gilchrist’s (1992) observed the ward rounds of three consultants with further data collected though interviews with eight of the patients and questionnaires that were sent to 60 staff members. The study findings demonstrated that nurses perceived their main ward round role to be information giving, patient advocacy, and asking questions on behalf of the patients. Although the consultants identified that nurses had a high knowledge of the patients, 76% of the time the consultants asked the junior doctor for details regarding the patient. Analysis of the 2391 observed interactions demonstrated that only 12% of comments were made by, and only 10% of discussion directed at, nurses. Nurses were only asked their opinion four times throughout the duration of the study. The majority of the discussion with nurses (88%) was related to patient symptom and treatment. Interprofessional conflicts between medicine and nursing have been documented since the time of Florence Nightingale (Kalisch & Kalisch, 1977). However, reflecting social change over the past 40 years, the focus of such accounts have moved from an accepted description of the dominant power bases within the health care professions, to a more dynamic process by which power and authority within clinical teams is being challenged. Understanding these conflicts requires an understanding of the historical traditions of the professions; the traditional gender
Intensive and Critical Care Nursing (2 0 0 3) 1 9, 1 2 5–1 3 5 127
Intensive and Critical Care Nursing
relationships; and the hierarchical nature of health care organisations. Nurses as an occupational group are predominantly practice based and female. Nursing remains fundamentally perceived as women’s work, and therefore undervalued (Gamarnikow, 1978; Witz, 1992). Nursing and medicine reflects two different cultures with contradictory visions (Temkin-Greener, 1983). In this, medicine emphasises the status quo of its authority within an inherently hierarchical organisation and function, whilst nursing stresses a more egalitarian vision of power relations with collaboration and peer co-operation as prerequisites for team care provision (Prescott & Bowen, 1985). A more contemporary awareness of how clinical teams work is paramount if further role development and modernisation of health care services is to be achieved.
Research method This section presents the ethnographic approach used in this study. A summary of the method and data collection tools is given together with details of the data analysis model. Due to the focus of this paper, only a brief overview of the method is presented. However, the importance in considering access to the field sites, consent from the study participants, the nature of the fieldworker role, and the ethical and rigour issues when undertaking clinical research cannot be over-emphasised.
Summary of research design As a key objective for the study was to understand medical and nursing staff’s perspective on clinical decision making, ethnography was chosen as the research approach. Through this, the description of the medical and nursing subculture (Holloway & Wheeler, 1996) could be explored to understand each group’s worldview of intensive care. Therefore, a micro ethnographic research design was developed using three intensive care sites. The selection of the sites was purposeful. The sites were chosen for their ability to provide rich information regarding the research focus. The clinical units selected were all intensive care units. The units were a
128
Intensive and Critical Care Nursing
(2 0 0 3) 1 9, 1 2 5–1 3 5
mixture of district general and university teaching hospitals. The bed capacity across the sample varied between 6 and 18 beds. The unit nursing and medical structure was similar in all, although the general management arrangement differed. After access and ethical approval had been gained to the sites, data collection was commenced. The initial data sampling was purposive, with theoretical sampling being used to direct further data collection. A two-phase fieldwork model was developed. Phase 1 of the fieldwork allowed orientation to the field site, key study participants to be highlighted, and prolonged periods in the field for data collection. Any situation or forum that included decisions being made about patient care acted as the focus for the fieldwork. This included observation of interactions at the bedside, in formal ward rounds. Phase 2 of the fieldwork occurred 3 months later. Qualitative data collection methods were employed throughout to allow flexible, unstructured data collection to occur naturally within the field. The key fieldwork approaches of participant observation, in-depth ethnographic interviews and the study of documentation in the field were used during both phases of the fieldwork. Academic literature provided the fourth source of the data. A fieldwork journal was used to collate and organise observational, analytical and methodological notes during the fieldwork experience. The ethnographic nature of this study ensured that data collection and data analysis occurred concurrently. Withdrawal from the field sites marked the conclusion of the fieldwork experience.
Summary of data collection in the field The purpose of data collection in ethnographic work is to perceive how the group under study makes sense of their world (Spradley, 1980). Understanding the cultural realities for that group is therefore a primary focus of ethnographic study and requires the data collection methods to be naturalistic (Hammersley & Atkinson, 1995). The
© 2003 Elsevier Science Ltd. All rights reserved.
Power and conflict in intensive care clinical decision making
fieldwork period, including gaining access to all the sites occurred over a total of 14 months. Over the three sites, a total of 18 ethnographic interviews were obtained, 62 documents collected and used in the data analysis, and over 200 hours of participant observation that required documenting and later coding. The participant observation data also included the brief, opportunistic, informal interviews with medical and nursing staff that occurred in the clinical setting.
Model of data analysis The three-stage model of data analysis used in this study upheld the general analytical principles espoused by Hammersley and Atkinson (1995). In addition, the use of grounded theory offered a systematic framework for data sampling, data analysis and theory generation. The specific analytic techniques of theoretical sensitivity, theoretical sampling, constant comparison in data coding, and the writing of theoretical notes were employed. From the initial in vivo coding, axial coding and finally core categories and propositions were developed. This enabled a substantive theory with explanatory power on the cultures of medicine and nursing in clinical decision making to be developed.
Research findings There were three key categories arising from this study. The first two categories concerned the different types of knowledge and the diverse roles used in clinical decision making. This paper explores the final category to emerge, that of power and conflict in clinical decision making. Field quotes and observations from doctors and nurses are included in italics. This section concludes with strategies used by nurses to address the perceived conflict issues. Power and conflict in clinical decision making Across all three sites, there were examples of mutually satisfying, developed relationships between medicine and nurses: There appears to be a very open relationship between the consultant and the nursing staff. Nurse: what time are you
© 2003 Elsevier Science Ltd. All rights reserved.
doing the ward round? Consultant: 3 minutes. Nurse looks thoughtful. Consultants: 10 minutes OK then? Nurse: Yes that’s fine. Flexible working arrangements were demonstrated, and examples of functioning teams were found. All participants were positive about the general working relationships between medicine and nurses. However, there were areas where the working relationships were not so mutual or satisfying. Strong opinions were held by participants about the relationships between nursing and medicine during clinical decision making. This position is clearly demonstrated in this extract where the senior nurse is describing the nursing role on the unit: the nursing staff have expanded their role tremendously since then and very much been allowed to develop within reason . . . . It is truly a reflection of our relationship with the medical staff. They (the nurses) are truly accountable for their actions and their planning of care; they really look at what they are going to achieve, and how they are going to achieve it.
Only minutes earlier in the interview, the senior nurse had been describing the response of the nursing team to the questioning undertaken by one consultant during the ward round: They are threatened or intimidated by his manner and that is where we need to be supporting our nursing staff. Nurses spoke positively about their role when working with medicine in intensive care. However, nurses did not feel that there were opportunities for total nursing participation in clinical decision making. Nurses ascribed this to the power held by medicine. This gave rise to conflict between medicine and nursing. An enduring observation across the data concerned control and input into the decision making process. Whilst this area was raised by all participants, nursing and medicine gave it different interpretations: Nurse: I would like to see the ward rounds develop. I would like them to be shorter (laughs) and more democratic—to get more involved, especially given the increased amount of responsibility on nurses at present. I would like greater control over the process, over the way it is discussed.
Intensive and Critical Care Nursing (2 0 0 3) 1 9, 1 2 5–1 3 5 129
Intensive and Critical Care Nursing
Nurses were persistent in their belief that clinical decisions were controlled by medicine, leaving little opportunity for influence by nurses. This was contrasted with a powerful belief from doctors about medical power: Doctor: Nursing is very rigid—they are always showing fear, always covering their back. Medicine is a profession—nursing isn’t. Medicine tries controversial procedures, my nurses are constrained within a framework—which are produced in vast arrays of paperwork which really doesn’t have a great deal of relevance to clinical practice.
Medicine did not perceive themselves to be part of the structure that constrained nursing. Doctors did not critically reflect on the role medicine played in placing restrictions on nursing; of reinforcing the rigid framework within which nurses found themselves. Despite the assertion in this quote of ‘my nurses’ with the associated power and gender undertones, medicine did not consider how they shaped the nursing role within the clinical arena. Medical staff placed importance on the bedside nurse having intimate knowledge of the patient, although this knowledge was not frequently used as a source of information. When this nursing knowledge was ignored, or not acknowledged, nurses felt frustrated and devalued. This incident concerns the management of a patient who, in the nurse’s view, had become distressed. The nurse was asking the medical staff permission to administer further sedative drugs. After presenting her case, the consultant asks: ‘What do you think her sedation score is right now?’ Behind the nurse at other side of bed, the senior registrar is attempting to elicit a gag response by tugging at the ETT (endotracheal tube). This action is noted by the round and all giggle. The nurse looks round. Cons says: ‘−2, therefore the answer is no, wean the midazolam off.’ Nurse: ‘but she was agitated before, we’ve just given her sedation for physio.’ Cons: ‘Well, we’re doing a trachy soon, leave the midazolam off as it will defeat the object of the exercise in achieving a quick wean.’ Nurse looks upset and angry and obviously unhappy with the exchange.
In this situation, power in the knowledge used by the doctor is demonstrated through
130
Intensive and Critical Care Nursing
(2 0 0 3) 1 9, 1 2 5–1 3 5
failing to acknowledge the situation as presented by the nurse, leading to inter-professional conflict. The doctor ignored the nurse’s knowledge of the patient at that time. He also failed to acknowledge the nurse’s professional and moral need to provide patient comfort through ordering sedation to be withheld. In ignoring these fundamental principles in the nursing philosophy and knowledge base, the power of medicine’s knowledge over nursing was displayed. Power in medical knowledge was also demonstrated through nurses being largely unquestioning and unchallenging of the medical management plan. The lack of medical consideration for nursing knowledge was also interpreted by nurses as an insult to their clinical skills and professional experiences in intensive care. This incident occurred during the presentation of a patient on a ward round. The doctor stated: The patient then had a query arrest (an unconfirmed arrest). The nurse who had been looking after the patient becomes very defensive and says: ‘She had an asystolic arrest and had no output for 2 minutes. We couldn’t feel a femoral pulse and she was apnoeic—we rescussed her. By the time the team reached us, she was coming back.’ The Consultant says: ‘O.K.’ and the round continues. The nurse is still annoyed afterwards—she comes to talk to me. ‘I know she had an arrest. There were four nurses there for God’s sake. She had no output, she wasn’t breathing. We started CPR and put out a call. There was one nurse doing CPR. One maintaining the airway, one feeling for a pulse—and I have to justify to a doctor that she was asystolic. I just feel like saying, look why am I having to go through this with you—she had an asystolic arrest that responded to Adrenaline. Really, after all my years of training and experience’.
Nurses were educated and trained to manage such situations. The distress demonstrated here was not from dealing with the medical emergency, but having the nursing knowledge of the situation disbelieved by medicine. Such incidents not only served to re-enforce the nursing belief about the power of medical knowledge, but highlight the potential for conflict within the team.
© 2003 Elsevier Science Ltd. All rights reserved.
Power and conflict in intensive care clinical decision making
The power of medicine in decision making frequently caused problems with nurses accessing the ward rounds: The nurse’s position during the ward round was more varied. The more vocal nurses made an effort to join the circle that inevitably formed at the end of the bed. One actually said to me as the team was lining up ‘See how they all gather round now, it’s as if they are sharing a secret.’ At times the joining of this circle actually necessitated a prod from the nurses to open up the circle. Another leaned right over a bedside table at an awkward angle to join the circle. Some said ‘excuse me’ and moved in, at other times medical staff would automatically move aside to make room.
Nurses were often physically located on the peripheries of these forums, and not included, except through being asked if there were any issues at the end of the discussion: Some of them (medical staff) ask us by name, others just turn around and ask us as an afterthought. Another nurse felt strongly that ‘nurses are completely ignored on the round by the doctors—the nurse at the bedside and the nurse in charge are just not valued.’ Medicine controlled the ward rounds. This led at times, to competing agendas as doctors prescribed a plan that did not consider the concerns of the nurses. The discussion regarding the management of a particularly sick young girl illustrates this. My field notes show that this involved a very senior, experienced and assertive nurse. However: suddenly at the end of the discussion he found the medical staff walking away with no discussion or answering of his queries. He said: ‘Excuse me, but what about my queries?’ The Consultant said: ‘We’ll be back later to bronch. her.’ The nurse turned to me, held up his hands and said: ‘And that’s how it goes here, particularly between nurses and doctors’.
The nurse had concerns he wanted to raise there and then, not wait until after the round. This situation did not appear to be recognised by doctors, who left the bedside without further discussion. This left the nurse feeling frustrated that nursing issues could only be raised at a time agreeable to medicine. This power of doctors in the ward rounds was evident in all sites.
© 2003 Elsevier Science Ltd. All rights reserved.
Breaking through the inner circle—nursing strategies for clinical decision making Reflecting on power and conflict within the decision making process, it is clear that nurses were perceived, and perceived themselves to have an insignificant power base within the decision making process. This left nurses feeling that there was little opportunity for them to input into decisions in formal ward rounds. The more experienced nurses reflected on how nurses could behave: I don’t think nurses always make the best of the opportunities to present themselves. In the study, similar approaches to address this were being used across all data sites. The nursing strategies mainly focused on the support of nursing staff, enabling a greater contribution to be made. Through this, it was anticipated that nursing staff could then be more active in the process. Nurses would be able to demonstrate nursing knowledge and role, and work collaboratively with medicine: The challenge is how we are all going to agree. How we are going to work together when we have different agendas . . . . It is just accepted that we work by different rules . . . . We work with a different set of values and agendas. Different mechanisms of how to deal with it—of negotiation, of getting what we say as valued . . . . I think it’s important to look at how we develop our staff.
These strategies were primarily concerned with the personal and interpersonal development of the nursing staff. Such techniques were not concerned with challenging the position of the nursing knowledge base or role with regards to medicine. It was acknowledged across the sample that credible clinical experience was useful to achieve input into decision making. This was used as a source of knowledge and experience to validate the clinical issues raised, and when to raise them: But you need to build yourself up, for example if you want your input into the ward round—you need to time your input, not just necessarily wait for the end—to choose the most appropriate time. To break through that inner circle at the end of the bed. You know, that doctors huddle together in their little circle and it’s like you have to break into that, to have you input into the ward round.
Intensive and Critical Care Nursing (2 0 0 3) 1 9, 1 2 5–1 3 5 131
Intensive and Critical Care Nursing
As a result, part of the knowledge strategies used by nurses in all sites included developing an awareness of the competing agendas: You need to play games with the managers and the doctors—to know what each of them wants. You don’t do anything different, just differently. You need to be more proactive and think how to respond to the different personalities. Through this, subtle covert measures were taken to enable nurses’ knowledge to influence decision making rather than directly challenging the dominant power bases. A further key strategy supported by all experienced nurses concerned the nurse’s behaviour during the ward round: The nurses are always doing distracting things, like emptying urine bags, ferreting under the bed, fiddling with the bed pedals. The novice works in a more structured way—oh the 08.00 obs are due—I must do those. We should work in a more loose way, oh the ward round is here, and I’ll do the obs later. Sometimes everyone’s there and standing with their back to you—I’ll just put my elbows out and say ‘excuse me’ to sometimes, just out of devildry, I’ll stand in the middle of the circle, in front of everyone!! The nurse needs to be clear of the plan for the day, cos you know that you’re not going to find a doctor for hours.
The final strategy suggested was the use of the more experienced nurses as role models. As highlighted by one senior nurse: They (nurses) don’t help themselves, they are very often doing the obs. And have their back to the ward round. I see it as the role of the (nurse) co-ordinator to push the nurse forward. For example if the nurse is doing something, I will go over and take over so that she will get to the round.
The role of the nurse in charge could assist the bedside nurse by undertaking essential care, and therefore allowing the bedside nurse to attend ward rounds. Through drawing on the senior nurses, issues to be raised, could be rehearsed and active support during the ward round could be given. All the doctors interviewed espoused a team approach to care, but resolution of any problems, lay within the domain of nursing.
132
Intensive and Critical Care Nursing
(2 0 0 3) 1 9, 1 2 5–1 3 5
The following excerpt from a consultant interview highlights this issue: I think that our working relationships are very forward—we are all part of the team—if the doctor isn’t there it fails, and if the nurse isn’t there, it fails. . . . I think we (doctors) lead the team by involvement and motivation. We promote, motivate, demonstrate respect, call each other by first names. I think that some of the nurses may feel that there is a hierarchy, but I think that it’s their problem. They’re shit scared of medicine, but that’s their problem. The junior staff (junior doctors) have a rough ride if they don’t know the patient. They are trained by embarrassment. Nursing is different, it’s high on molly coddling. Nurses appreciate handholding.
As the final part of this quote demonstrates, nursing and medicine often presented two contrasting views in this study. However, the importance of understanding each other’s point of view was one that was frequently raised and spoken of as ‘a two way thing’. This was seen as important so that mutual goals and agendas could be set and worked to, otherwise as this nurse commented:—what’s the point? If medicine is running one race, and nursing another—they may as well shut the unit. Both nurses and doctors were aware of the power and conflict within making decisions about patient management. Medicine had ultimate authority and responsibility in the decision making process. However, nurses had reduced power with which to influence and inform clinical issues. Medicine ascribed this to the subordinate position that nurses perceived themselves in, whilst nurses believe that this subordinate position was re-enforced by medicine. In conclusion, intensive care decision making continues to be strongly driven by the medical knowledge base and authority. This shapes the structure and content of the key forums. The key holders of medical knowledge (the medical staff) are therefore maintained in the powerful role of decision-maker. Other sources of knowledge and roles, such as those held by nurses are not as valued, resulting in tension between nursing and medicine. Attempts to address these issues focus on the interpersonal development of the nurse, rather
© 2003 Elsevier Science Ltd. All rights reserved.
Power and conflict in intensive care clinical decision making
than a direct challenge on the current hierarchical model of knowledge and roles in clinical decision making practice.
Discussion of findings This study has demonstrated that the power held by medicine is instrumental in affecting the nursing role in intensive care. Nurses were a marginalised group in decision making and spoke of the need to understand and play the game in this environment. This action obscured the identity and culture of nursing and conformed to the dominant norms of medicine. However, without this manoeuvre, there was minimal opportunity for nursing influence on the decisions made. In appreciating both the nursing and the medical perspective, nurses were socialised to appreciate more than their worldview (Minh-Ha, 1991). However, this was not so of medicine. Throughout the field data, there were few tangible examples of medical staff truly understanding nursing’s worldview, but many of nurses adopting the medical agenda. Street (1992) challenges such behaviour and calls for nurses to move beyond the duplication of medicine in order to resist medical dominance. Traditionally this has occurred by nurses challenging the basis of how clinical decisions are made; this is clearly seen in the example earlier of the nurse discussing sedation for her patient. However, an alternative solution would be to challenge the very process of decision-making in the ward round. This would allow any hierarchies within the team to be openly discussed and the reality of working relationships to be revealed and acknowledged. As Freidson (1970, p. 336) highlighted, there can be agreement that a road is best built by an engineer, ‘but whether it should be built at all, and where it should be located are not wholly esoteric questions’. From the results of this study it is therefore clear that nurses continue to play games as highlighted by Stein et al. (1990) and Stein (1967). As evidenced in the quotes in this paper, there were vociferous statements made by medical and nursing in private spaces, however there were few examples of true open conflict and argument in the field. As highlighted in Allen’s work (1997) potential areas of conflict
© 2003 Elsevier Science Ltd. All rights reserved.
were managed or negotiated, predominantly by the nursing staff. Whilst nurse’s power was used to reduce conflict, this did not directly address the key structural issues causing conflict between doctors and nurses. From this work, it is clear that the historical drive for nurses to achieve professional status has not, to date, been instrumental in achieving nursing visibility within intensive care decision making. It has been argued that the mobilisation of nursing’s collective power, together with the use of a patient centred model of health may enable greater practitioner autonomy (Salvage, 1988) and directly challenge traditional doctor–nurse relationships (Witz, 1992). However, the impact of such approaches, on patients in particular and on the health care workforce in general, has yet to be fully evaluated.
Conclusion As this paper has highlighted, whilst the traditional functions, knowledge and skills of the nurse have evolved, this has not occurred with an associated change in the role of the nurse in the critical care team. The traditional hierarchies within the clinical team remain, and the nursing voice remains constrained by limitations placed by others and by ourselves. It is clear that the next decade will present continued challenges for health care. The need for optimum use of the existing workforce to meet patient needs, together with manpower shortfalls across major health care disciplines has already led to radical discussion documents (British Medical Association, 2002). It is important that all parties engage in such debates, not only to help configure the healthcare workforce of the future, but also to influence how disciplines can move to a truly interdisciplinary model of practice. This will require acknowledgement and respect of all types of knowledge and roles that are required in totality by the critically ill patient. If precisely applied, the clinical governance agenda with its emphasis on clinical partnerships with greater evidence of interdisciplinary working (NHSE, 1999) could provide a vehicle for this. However, trusts will need to make a commitment to move beyond meeting Key Performance Indicators towards
Intensive and Critical Care Nursing (2 0 0 3) 1 9, 1 2 5–1 3 5 133
Intensive and Critical Care Nursing
enabling clinical teams to function as powerful patient focused change agents. In the context of this paper, the future for effective team working lies with medical and nursing staff realising the inherent power through the complementary knowledge and roles held by each group. This philosophy must be extended and shared with other member of the expanded intensive care clinical team. Then we will move from teams that wrestle with ‘breaking through the inner circle’ driven by perceptions of exclusion and invisibility, towards redefining the very shape of intensive care, transformed by a culture of inclusivity and acknowledgement of the contribution of all. Acknowledgements
I would like to express my considerable thanks to all the staff in the sites who participated in this study, for their time, support and interest in this work. References Allen D 1997 The nursing medicine boundary: negotiated order. Sociology of Health and Illness 19(4): 498–520 Anderson J, O’Brien M 1995 Challenges for the future: the nurses role in weaning patients from mechanical ventilation. Intensive and Critical Care Nursing 11(1): 2–5 Anspach RR 1993 Deciding Who Lives: Fateful Choices in the Intensive Care Nursery. University of California Press, Berkley Ashworth P 1990 High technology and humanity for intensive care. Intensive and Critical Care Nursing 6(3): 150–160 Benner P 1984 From Novice to Expert Excellence and Power in Clinical Nursing Practice. Addison Wesley Publishing Company, Menlo Park, CA British Medical Association 2002 The Future Healthcare Workforce—February 2002 HPERU Discussion Paper 9. Web.bma.org.uk/public/pols Busby A, Gilchrist B 1992 The role of the nurse in the medical ward round. Journal of Advanced Nursing 17: 339–346 Department of Health 2000 Comprehensive Critical Care: A Review of Adult Critical Care Services. Department of Health, London Department of Health 2001 The Nursing Contribution to the Provision of Comprehensive Critical Care for Adults: A Strategic Programme of Action. Department of Health, London Fairman J 1992 Watchful vigilance: nursing care, technology and the development of intensive care units. Nursing Research 41(1): 56–59
134
Intensive and Critical Care Nursing
(2 0 0 3) 1 9, 1 2 5–1 3 5
Freidson E 1970 The Profession of Medicine. A Study of the Sociology of Applied Knowledge. University of Chicago Press, Chicago Gamarnikow E 1978 Sexual division of labour: the case of nursing. In: Kuhn A, Holpe E (eds) Feminism and Materialism. Routledge, Kegan Paul, London Hammersley M, Atkinson P 1995 Ethnography: Principles in Practice, 2nd ed. Routledge, London Hickey JV, Ouimette RM, Venegoni I 1996 Advanced Practice Nursing. Lippincott, Philadelphia Holloway I, Wheeler S 1996 Qualitative Research for Nurses. Blackwell Scientific, Oxford Hughes D 1988 When a nurse knows best: some aspects of doctor/nurse interaction in a casualty department. Sociology of Health and Illness 10: 1–22 Hunt G, Wainwright P 1994 Expanding the Role of the Nurse: The Scope of Professional Practice. Blackwell Scientific, Oxford Kalisch BJ, Kalisch PA 1977 An analysis of the sources of physician–nurse conflict. Journal of Nursing Administration 7: 51–57 Kraus WA 1980 Collaboration in Organisations. Human Science Press, New York Leatt P, Schneck R 1981 Nursing and technology: a replication. Administrative Science Quarterly 26: 225–226 Mann RE 1992 Preserving humanity in an age of technology. Intensive and Critical Care Nursing 8: 54–59 Minh-Ha TT 1991 When the Moon Waxes Red. Routledge, New York National Health Service Executive 1999 Clinical Governance. Quality in the New N.H.S. Executive Summary. NHSE, Leeds Nightingale F 1863 Notes on Hospitals. Longmans, Green Noc M, Weil MH 1996 Critical care today. In: Tinker J, Browne D, Sibbald WJ (eds) Critical Care Standard Audit and Ethics. Arnold Press, New York Oh TE 1996 The development, utilisation and cost implications of intensive care medicine: strategies for the future. In: Tinker J, Browne D, Sibbald WJ (eds) Critical Care Standards Audit and Ethics. Arnold Press, New York Porter S 1991 A participant observation study of power relations between nurses and doctors in a general hospital. Journal of Advanced Nursing 16: 728–735 Prescott PA, Bowen SA 1985 Physician nurse relationship. Annals of Internal Medicine 103: 127–133 Roth MD, Daze A-M 1984 Are nurses practising medicine in the intensive care unit? Dimensions of Critical Care Nursing 3(4): 230–237 Royal College of Nursing Critical Care Forum 1997 The Nature of Nursing Work in Intensive Care Results of a Telephone Survey. Royal College of Nursing, London Salvage J 1988 Professionalism or a struggle for survival? A consideration of current proposals for the reform of nursing in the United Kingdom. Journal of Advanced Nursing 13: 515–519 Smith M 1998 Who should run intensive care units? Care of the Critically Ill 14(4): 113–115 Spradley JP 1980 Participant Observation. Holt, Rhinehart and Winston, New York
© 2003 Elsevier Science Ltd. All rights reserved.
Power and conflict in intensive care clinical decision making
Stein L 1967 The doctor nurse game. Archives of General Psychiatry 16: 699–703 Stein LI, Watts DT, Howell T 1990 The doctor nurse game revisited. Nursing Outlook Nov/Dec: 264–268 Street A 1992 Inside Nursing: A Critical Ethnography. State University of New York Press, Albany, NY Svensson R 1996 The interplay between doctors and nurses—a negotiated order perspective. Sociology of Health and Illness 18: 379–398 Temkin-Greener H 1983 Interpersonal perspectives on teamwork in health care: a case study. Milbank Memorial Fund Quarterly 61(4): 641–658
© 2003 Elsevier Science Ltd. All rights reserved.
Walsh M, Ford P 1989 We always do it this way. Nursing Times 85(41): 26–35 Webb AR 1996 Medical staffing and training: the United Kingdom perspective. In: Tinker J, Browne D, Sibbald WJ (eds) Critical Care Standards Audit and Ethics. Arnold Press, New York Weiss SJ, Davis H 1985 Validity and reliability of the collaborative practice scales. Nursing Research 34(4): 299–305 Witz A 1992 Profession and Patriarchy. Routledge, London Woodrow P 1997 Nursing perspectives for intensive care. Intensive and Critical Care Nursing 13: 151–155
Intensive and Critical Care Nursing (2 0 0 3) 1 9, 1 2 5–1 3 5 135
It is clear that current government policy places increasing emphasis on the need for flexible team working. This requires a shared understanding of roles and working practices. However, review of the current literature reveals that such a collaborative working environment has not as yet, been fully achieved. Role definitions and power bases based on traditional and historical boundaries continue to exist. This ethnographic study explores decision making between doctors and nurses in the intensive care environment in order to examine contemporary clinical roles in this clinical speciality. Three intensive care units were selected as field sites and data was collected through participant observation, ethnographic interviews and documentation. A key issue arising in this study is that whilst the nursing role in intensive care has changed, this has had little impact on how clinical decisions are made. Both medical and nursing staff identify conflict during patient management discussions. However, it is predominantly nurses who seek to redress this conflict area through developing specific behaviours for this clinical forum. Using this approach to resolve such team issues has grave implications if the government vision of interdisciplinary team working is to be realised. © 2003 Elsevier Science Ltd. All rights reserved. Maureen Coombs RN, PhD, MSc, BSc (Hons), Consultant Nurse Critical Care, Southampton University Hospitals Trust, Senior Lecturer School of Nursing and Midwifery, Intensive Care Unit, Southampton General Hospital, University of Southampton, D Level Centre Block, Tremona Road, Southampton SO16 6YD, UK. Tel: +44 (0) 2380 777222, bleep 9130; E-mail: maureen.coombs@ suht.swest.nhs.uk (Requests for offprints to MC) Manuscript accepted: 31/03/03
KEYWORDS: Intensive care; Ethnography; Decision making; Interdisciplinary team working; Clinical decision making.
Introduction Developments in technology, increased consumer interest in health and illness, together with a continued political interest on health care delivery has impacted on health care in ways that few could have predicted. The resultant workforce and organisational changes have brought developments in nursing practice and role into sharper focus—not least within the area of intensive care (Department of Health (DoH) 2001). However, even though recent strategy documents (DoH, 2000, 2001) have provided a framework for the development of nursing, the increasing importance on the ‘development and leadership of clinical teams providing patient
© 2003 Elsevier Science Ltd. All rights reserved. doi:10.1016/S0964-3397(03)00040-5
care’ is acknowledged (DoH, 2001, p. 1). The nature of contemporary intensive care mandates a team approach. In this context, all practitioners involved in care delivery are challenged to change their practice and develop their roles in order to make the best use of all available resources (DoH, 2000). This paper presents a study that arose from personal reflection on the contemporary nursing role and a re-consideration on the nature of team working in the delivery of intensive care. The purpose of this research was to develop a critical awareness of the contribution of medicine and nursing to one specific area of patient management; that of clinical decision-making.
Intensive and Critical Care Nursing (2 0 0 3) 1 9, 1 2 5–1 3 5 125
Intensive and Critical Care Nursing
Background to the study This section presents an overview of the literature pertinent to the study. The development of the intensive care unit is initially detailed, exploring the profile of clinical teams that work within this environment. Key studies undertaken on team working in health care are discussed. The section concludes with a specific focus on the clinical ward round and how this can assist our understanding of how medical and nursing staff work.
Intensive care and the clinical team The specialist clinical units of intensive care are a relatively recent phenomenon. Whilst often seen as a medical driven clinical speciality, ‘it should be recognised that all members of the multidisciplinary team are crucial to patient care and outcome’ (Smith, 1998, p. 115). Although the importance of a designated area for close observation of acutely ill patients was initially recognised in the nineteenth century (Nightingale, 1863), intensive care medicine has evolved as advances in technology and the ability of medicine to treat and support disease, have occurred. This has led to diverse technical therapies to be located in one designated area and has resulted in the intensive care unit becoming the ‘hospital’s hospital’ (Oh, 1996, p. 12). However, this increase in technology has presented a conflict for intensive care nurses in balancing the science of such technology with the art of nursing (Ashworth, 1990). Noc and Weil (1996) identified the key nursing responsibilities to be aligned with the science of technology through involvement with maintaining patient observations and the responsibility for gathering all non-invasive and invasive laboratory data. Whilst such perspectives have focused on technical functions undertaken by nurses in intensive care; this has rendered the art of nursing invisible and unacknowledged (Fairman, 1992). With such emphasis on nurses delivering medical care the need for nurses to preserve
126
Intensive and Critical Care Nursing
(2 0 0 3) 1 9, 1 2 5–1 3 5
humanity in an age of technology (Mann, 1992) has been emphasised. Woodrow (1997) argues that whilst clinical practice is focused on multiple system failure support, this provides but one challenge for the nurse clinician who chooses to work in the intensive care environment. Intensive care nurses are seen to provide the link between the patient and machine. Therefore, not only is technological competence required, but also compassion and humanity need to be demonstrated (Benner, 1984; Anspach, 1993). Thirty years ago the different practices of medicine and nursing in intensive care were easily identifiable (Roth & Daze, 1984). This distinction was based on the intensive care nurse initiating treatment based on the assessment of the patient’s symptoms; not through making differential medical diagnosis. The contemporary role of the intensive care nurse has since developed with the addition of tasks from medicine (role extension) and the development of nursing (role expansion) through enhanced nursing knowledge (Hunt & Wainwright, 1994). The boundary between contemporary nursing and medicine in intensive care continues to be blurred (Webb, 1996). Anderson and O’Brien (1995) details one unit’s experiences of nursing role changes through the development of a nurse-led patient extubation programme. This allowed nurses to make professional nursing decisions without direct medical consultation. Other highlighted areas of nursing role development within this speciality include new assisted ventilatory modes, sedation administration, and drug and fluid prescription (Royal College of Nursing, 1997; DoH, 2001). Intensive care areas have been identified as highly complex areas with high levels of uncertainty and instability above other hospital care areas (Leatt & Schneck, 1981). Whilst there have undoubtedly been changes in the acuity of all care areas since this observation was made, the intensive care environment continues to be unpredictable and complex. It has therefore been highlighted that the nature of care provided to critically ill patients therefore requires interdependent practice (Hickey et al., 1996). The concept of collaboration is a key underpinning concept to interdependent
© 2003 Elsevier Science Ltd. All rights reserved.
Power and conflict in intensive care clinical decision making
practice. In this, collaboration can be defined as ‘a cop-operative venture. It assumes power based on a knowledge base or expertise as opposed to power shared on role or function’ (Kraus, 1980, p. 12). Patient needs are placed paramount, with collaboration providing a synergistic alliance that optimises the contribution of each discipline (Weiss & Davis, 1985).
Clinical team working The historical empirical evidence details team working but reveals how members have often worked in isolation and with hierarchical relationships. The seminal works of Freidson (1970) and Stein (1967) argue that medicine holds a dominant and unchallenged position in health care by virtue of its knowledge base and societal position. This led to Stein (op. cit.) describing the interplay between medicine and nurses, referred to as playing the game; however, recent empirical studies have challenged this position. In Hughes’ (1988) study of casualty work in a British unit, the complex workload and high medical turnover were identified as key factors that promoted the role of nurses. Further support for nursing’s involvement in decision making was also evident in Porter’s observational study (1991) through the informal decision making processes nurses used to affect patient care decisions. Svensson’s (1996) study, located in Sweden, investigated doctor–nurse interplay using interviews with nurses from 14 wards in five hospitals. Analysis of the transcripts revealed a strong nursing voice. In identifying the social needs of the patient and co-ordinating care, nurses were felt to be in a unique position. However, when discussing patient treatment issues close to the medical treatment domain, there was still some evidence of Stein’s (op. cit.) game being played. Allen (1997) further developed Svensson’s work and demonstrated many examples of contested interprofessional boundaries, but little evidence of inter-occupational conflict and negotiations. The conclusion drawn by Allen was that nurses often manage their working role to minimise any conflict and that this was a taken for granted feature of normal nursing practice.
© 2003 Elsevier Science Ltd. All rights reserved.
The clinical ward round In exploring how patient care decisions are made, the ward round has proved to be an interesting area for study. This is one of the key forums where all key members of the clinical team come together to formulate a patient management plan. The ward round is seen to have several functions including assisting in the continuity of care, information transfer, provide opportunity for learning and enable effective communication and planning within the team (Walsh & Ford, 1989). In recent years, this has become a strong focus for sociological study in order to understand the complex processes involved in health care team working. Whilst key studies are outlined here, there is little empirical work undertaken within the critical care setting. In the United Kingdom, Busby and Gilchrist’s (1992) observed the ward rounds of three consultants with further data collected though interviews with eight of the patients and questionnaires that were sent to 60 staff members. The study findings demonstrated that nurses perceived their main ward round role to be information giving, patient advocacy, and asking questions on behalf of the patients. Although the consultants identified that nurses had a high knowledge of the patients, 76% of the time the consultants asked the junior doctor for details regarding the patient. Analysis of the 2391 observed interactions demonstrated that only 12% of comments were made by, and only 10% of discussion directed at, nurses. Nurses were only asked their opinion four times throughout the duration of the study. The majority of the discussion with nurses (88%) was related to patient symptom and treatment. Interprofessional conflicts between medicine and nursing have been documented since the time of Florence Nightingale (Kalisch & Kalisch, 1977). However, reflecting social change over the past 40 years, the focus of such accounts have moved from an accepted description of the dominant power bases within the health care professions, to a more dynamic process by which power and authority within clinical teams is being challenged. Understanding these conflicts requires an understanding of the historical traditions of the professions; the traditional gender
Intensive and Critical Care Nursing (2 0 0 3) 1 9, 1 2 5–1 3 5 127
Intensive and Critical Care Nursing
relationships; and the hierarchical nature of health care organisations. Nurses as an occupational group are predominantly practice based and female. Nursing remains fundamentally perceived as women’s work, and therefore undervalued (Gamarnikow, 1978; Witz, 1992). Nursing and medicine reflects two different cultures with contradictory visions (Temkin-Greener, 1983). In this, medicine emphasises the status quo of its authority within an inherently hierarchical organisation and function, whilst nursing stresses a more egalitarian vision of power relations with collaboration and peer co-operation as prerequisites for team care provision (Prescott & Bowen, 1985). A more contemporary awareness of how clinical teams work is paramount if further role development and modernisation of health care services is to be achieved.
Research method This section presents the ethnographic approach used in this study. A summary of the method and data collection tools is given together with details of the data analysis model. Due to the focus of this paper, only a brief overview of the method is presented. However, the importance in considering access to the field sites, consent from the study participants, the nature of the fieldworker role, and the ethical and rigour issues when undertaking clinical research cannot be over-emphasised.
Summary of research design As a key objective for the study was to understand medical and nursing staff’s perspective on clinical decision making, ethnography was chosen as the research approach. Through this, the description of the medical and nursing subculture (Holloway & Wheeler, 1996) could be explored to understand each group’s worldview of intensive care. Therefore, a micro ethnographic research design was developed using three intensive care sites. The selection of the sites was purposeful. The sites were chosen for their ability to provide rich information regarding the research focus. The clinical units selected were all intensive care units. The units were a
128
Intensive and Critical Care Nursing
(2 0 0 3) 1 9, 1 2 5–1 3 5
mixture of district general and university teaching hospitals. The bed capacity across the sample varied between 6 and 18 beds. The unit nursing and medical structure was similar in all, although the general management arrangement differed. After access and ethical approval had been gained to the sites, data collection was commenced. The initial data sampling was purposive, with theoretical sampling being used to direct further data collection. A two-phase fieldwork model was developed. Phase 1 of the fieldwork allowed orientation to the field site, key study participants to be highlighted, and prolonged periods in the field for data collection. Any situation or forum that included decisions being made about patient care acted as the focus for the fieldwork. This included observation of interactions at the bedside, in formal ward rounds. Phase 2 of the fieldwork occurred 3 months later. Qualitative data collection methods were employed throughout to allow flexible, unstructured data collection to occur naturally within the field. The key fieldwork approaches of participant observation, in-depth ethnographic interviews and the study of documentation in the field were used during both phases of the fieldwork. Academic literature provided the fourth source of the data. A fieldwork journal was used to collate and organise observational, analytical and methodological notes during the fieldwork experience. The ethnographic nature of this study ensured that data collection and data analysis occurred concurrently. Withdrawal from the field sites marked the conclusion of the fieldwork experience.
Summary of data collection in the field The purpose of data collection in ethnographic work is to perceive how the group under study makes sense of their world (Spradley, 1980). Understanding the cultural realities for that group is therefore a primary focus of ethnographic study and requires the data collection methods to be naturalistic (Hammersley & Atkinson, 1995). The
© 2003 Elsevier Science Ltd. All rights reserved.
Power and conflict in intensive care clinical decision making
fieldwork period, including gaining access to all the sites occurred over a total of 14 months. Over the three sites, a total of 18 ethnographic interviews were obtained, 62 documents collected and used in the data analysis, and over 200 hours of participant observation that required documenting and later coding. The participant observation data also included the brief, opportunistic, informal interviews with medical and nursing staff that occurred in the clinical setting.
Model of data analysis The three-stage model of data analysis used in this study upheld the general analytical principles espoused by Hammersley and Atkinson (1995). In addition, the use of grounded theory offered a systematic framework for data sampling, data analysis and theory generation. The specific analytic techniques of theoretical sensitivity, theoretical sampling, constant comparison in data coding, and the writing of theoretical notes were employed. From the initial in vivo coding, axial coding and finally core categories and propositions were developed. This enabled a substantive theory with explanatory power on the cultures of medicine and nursing in clinical decision making to be developed.
Research findings There were three key categories arising from this study. The first two categories concerned the different types of knowledge and the diverse roles used in clinical decision making. This paper explores the final category to emerge, that of power and conflict in clinical decision making. Field quotes and observations from doctors and nurses are included in italics. This section concludes with strategies used by nurses to address the perceived conflict issues. Power and conflict in clinical decision making Across all three sites, there were examples of mutually satisfying, developed relationships between medicine and nurses: There appears to be a very open relationship between the consultant and the nursing staff. Nurse: what time are you
© 2003 Elsevier Science Ltd. All rights reserved.
doing the ward round? Consultant: 3 minutes. Nurse looks thoughtful. Consultants: 10 minutes OK then? Nurse: Yes that’s fine. Flexible working arrangements were demonstrated, and examples of functioning teams were found. All participants were positive about the general working relationships between medicine and nurses. However, there were areas where the working relationships were not so mutual or satisfying. Strong opinions were held by participants about the relationships between nursing and medicine during clinical decision making. This position is clearly demonstrated in this extract where the senior nurse is describing the nursing role on the unit: the nursing staff have expanded their role tremendously since then and very much been allowed to develop within reason . . . . It is truly a reflection of our relationship with the medical staff. They (the nurses) are truly accountable for their actions and their planning of care; they really look at what they are going to achieve, and how they are going to achieve it.
Only minutes earlier in the interview, the senior nurse had been describing the response of the nursing team to the questioning undertaken by one consultant during the ward round: They are threatened or intimidated by his manner and that is where we need to be supporting our nursing staff. Nurses spoke positively about their role when working with medicine in intensive care. However, nurses did not feel that there were opportunities for total nursing participation in clinical decision making. Nurses ascribed this to the power held by medicine. This gave rise to conflict between medicine and nursing. An enduring observation across the data concerned control and input into the decision making process. Whilst this area was raised by all participants, nursing and medicine gave it different interpretations: Nurse: I would like to see the ward rounds develop. I would like them to be shorter (laughs) and more democratic—to get more involved, especially given the increased amount of responsibility on nurses at present. I would like greater control over the process, over the way it is discussed.
Intensive and Critical Care Nursing (2 0 0 3) 1 9, 1 2 5–1 3 5 129
Intensive and Critical Care Nursing
Nurses were persistent in their belief that clinical decisions were controlled by medicine, leaving little opportunity for influence by nurses. This was contrasted with a powerful belief from doctors about medical power: Doctor: Nursing is very rigid—they are always showing fear, always covering their back. Medicine is a profession—nursing isn’t. Medicine tries controversial procedures, my nurses are constrained within a framework—which are produced in vast arrays of paperwork which really doesn’t have a great deal of relevance to clinical practice.
Medicine did not perceive themselves to be part of the structure that constrained nursing. Doctors did not critically reflect on the role medicine played in placing restrictions on nursing; of reinforcing the rigid framework within which nurses found themselves. Despite the assertion in this quote of ‘my nurses’ with the associated power and gender undertones, medicine did not consider how they shaped the nursing role within the clinical arena. Medical staff placed importance on the bedside nurse having intimate knowledge of the patient, although this knowledge was not frequently used as a source of information. When this nursing knowledge was ignored, or not acknowledged, nurses felt frustrated and devalued. This incident concerns the management of a patient who, in the nurse’s view, had become distressed. The nurse was asking the medical staff permission to administer further sedative drugs. After presenting her case, the consultant asks: ‘What do you think her sedation score is right now?’ Behind the nurse at other side of bed, the senior registrar is attempting to elicit a gag response by tugging at the ETT (endotracheal tube). This action is noted by the round and all giggle. The nurse looks round. Cons says: ‘−2, therefore the answer is no, wean the midazolam off.’ Nurse: ‘but she was agitated before, we’ve just given her sedation for physio.’ Cons: ‘Well, we’re doing a trachy soon, leave the midazolam off as it will defeat the object of the exercise in achieving a quick wean.’ Nurse looks upset and angry and obviously unhappy with the exchange.
In this situation, power in the knowledge used by the doctor is demonstrated through
130
Intensive and Critical Care Nursing
(2 0 0 3) 1 9, 1 2 5–1 3 5
failing to acknowledge the situation as presented by the nurse, leading to inter-professional conflict. The doctor ignored the nurse’s knowledge of the patient at that time. He also failed to acknowledge the nurse’s professional and moral need to provide patient comfort through ordering sedation to be withheld. In ignoring these fundamental principles in the nursing philosophy and knowledge base, the power of medicine’s knowledge over nursing was displayed. Power in medical knowledge was also demonstrated through nurses being largely unquestioning and unchallenging of the medical management plan. The lack of medical consideration for nursing knowledge was also interpreted by nurses as an insult to their clinical skills and professional experiences in intensive care. This incident occurred during the presentation of a patient on a ward round. The doctor stated: The patient then had a query arrest (an unconfirmed arrest). The nurse who had been looking after the patient becomes very defensive and says: ‘She had an asystolic arrest and had no output for 2 minutes. We couldn’t feel a femoral pulse and she was apnoeic—we rescussed her. By the time the team reached us, she was coming back.’ The Consultant says: ‘O.K.’ and the round continues. The nurse is still annoyed afterwards—she comes to talk to me. ‘I know she had an arrest. There were four nurses there for God’s sake. She had no output, she wasn’t breathing. We started CPR and put out a call. There was one nurse doing CPR. One maintaining the airway, one feeling for a pulse—and I have to justify to a doctor that she was asystolic. I just feel like saying, look why am I having to go through this with you—she had an asystolic arrest that responded to Adrenaline. Really, after all my years of training and experience’.
Nurses were educated and trained to manage such situations. The distress demonstrated here was not from dealing with the medical emergency, but having the nursing knowledge of the situation disbelieved by medicine. Such incidents not only served to re-enforce the nursing belief about the power of medical knowledge, but highlight the potential for conflict within the team.
© 2003 Elsevier Science Ltd. All rights reserved.
Power and conflict in intensive care clinical decision making
The power of medicine in decision making frequently caused problems with nurses accessing the ward rounds: The nurse’s position during the ward round was more varied. The more vocal nurses made an effort to join the circle that inevitably formed at the end of the bed. One actually said to me as the team was lining up ‘See how they all gather round now, it’s as if they are sharing a secret.’ At times the joining of this circle actually necessitated a prod from the nurses to open up the circle. Another leaned right over a bedside table at an awkward angle to join the circle. Some said ‘excuse me’ and moved in, at other times medical staff would automatically move aside to make room.
Nurses were often physically located on the peripheries of these forums, and not included, except through being asked if there were any issues at the end of the discussion: Some of them (medical staff) ask us by name, others just turn around and ask us as an afterthought. Another nurse felt strongly that ‘nurses are completely ignored on the round by the doctors—the nurse at the bedside and the nurse in charge are just not valued.’ Medicine controlled the ward rounds. This led at times, to competing agendas as doctors prescribed a plan that did not consider the concerns of the nurses. The discussion regarding the management of a particularly sick young girl illustrates this. My field notes show that this involved a very senior, experienced and assertive nurse. However: suddenly at the end of the discussion he found the medical staff walking away with no discussion or answering of his queries. He said: ‘Excuse me, but what about my queries?’ The Consultant said: ‘We’ll be back later to bronch. her.’ The nurse turned to me, held up his hands and said: ‘And that’s how it goes here, particularly between nurses and doctors’.
The nurse had concerns he wanted to raise there and then, not wait until after the round. This situation did not appear to be recognised by doctors, who left the bedside without further discussion. This left the nurse feeling frustrated that nursing issues could only be raised at a time agreeable to medicine. This power of doctors in the ward rounds was evident in all sites.
© 2003 Elsevier Science Ltd. All rights reserved.
Breaking through the inner circle—nursing strategies for clinical decision making Reflecting on power and conflict within the decision making process, it is clear that nurses were perceived, and perceived themselves to have an insignificant power base within the decision making process. This left nurses feeling that there was little opportunity for them to input into decisions in formal ward rounds. The more experienced nurses reflected on how nurses could behave: I don’t think nurses always make the best of the opportunities to present themselves. In the study, similar approaches to address this were being used across all data sites. The nursing strategies mainly focused on the support of nursing staff, enabling a greater contribution to be made. Through this, it was anticipated that nursing staff could then be more active in the process. Nurses would be able to demonstrate nursing knowledge and role, and work collaboratively with medicine: The challenge is how we are all going to agree. How we are going to work together when we have different agendas . . . . It is just accepted that we work by different rules . . . . We work with a different set of values and agendas. Different mechanisms of how to deal with it—of negotiation, of getting what we say as valued . . . . I think it’s important to look at how we develop our staff.
These strategies were primarily concerned with the personal and interpersonal development of the nursing staff. Such techniques were not concerned with challenging the position of the nursing knowledge base or role with regards to medicine. It was acknowledged across the sample that credible clinical experience was useful to achieve input into decision making. This was used as a source of knowledge and experience to validate the clinical issues raised, and when to raise them: But you need to build yourself up, for example if you want your input into the ward round—you need to time your input, not just necessarily wait for the end—to choose the most appropriate time. To break through that inner circle at the end of the bed. You know, that doctors huddle together in their little circle and it’s like you have to break into that, to have you input into the ward round.
Intensive and Critical Care Nursing (2 0 0 3) 1 9, 1 2 5–1 3 5 131
Intensive and Critical Care Nursing
As a result, part of the knowledge strategies used by nurses in all sites included developing an awareness of the competing agendas: You need to play games with the managers and the doctors—to know what each of them wants. You don’t do anything different, just differently. You need to be more proactive and think how to respond to the different personalities. Through this, subtle covert measures were taken to enable nurses’ knowledge to influence decision making rather than directly challenging the dominant power bases. A further key strategy supported by all experienced nurses concerned the nurse’s behaviour during the ward round: The nurses are always doing distracting things, like emptying urine bags, ferreting under the bed, fiddling with the bed pedals. The novice works in a more structured way—oh the 08.00 obs are due—I must do those. We should work in a more loose way, oh the ward round is here, and I’ll do the obs later. Sometimes everyone’s there and standing with their back to you—I’ll just put my elbows out and say ‘excuse me’ to sometimes, just out of devildry, I’ll stand in the middle of the circle, in front of everyone!! The nurse needs to be clear of the plan for the day, cos you know that you’re not going to find a doctor for hours.
The final strategy suggested was the use of the more experienced nurses as role models. As highlighted by one senior nurse: They (nurses) don’t help themselves, they are very often doing the obs. And have their back to the ward round. I see it as the role of the (nurse) co-ordinator to push the nurse forward. For example if the nurse is doing something, I will go over and take over so that she will get to the round.
The role of the nurse in charge could assist the bedside nurse by undertaking essential care, and therefore allowing the bedside nurse to attend ward rounds. Through drawing on the senior nurses, issues to be raised, could be rehearsed and active support during the ward round could be given. All the doctors interviewed espoused a team approach to care, but resolution of any problems, lay within the domain of nursing.
132
Intensive and Critical Care Nursing
(2 0 0 3) 1 9, 1 2 5–1 3 5
The following excerpt from a consultant interview highlights this issue: I think that our working relationships are very forward—we are all part of the team—if the doctor isn’t there it fails, and if the nurse isn’t there, it fails. . . . I think we (doctors) lead the team by involvement and motivation. We promote, motivate, demonstrate respect, call each other by first names. I think that some of the nurses may feel that there is a hierarchy, but I think that it’s their problem. They’re shit scared of medicine, but that’s their problem. The junior staff (junior doctors) have a rough ride if they don’t know the patient. They are trained by embarrassment. Nursing is different, it’s high on molly coddling. Nurses appreciate handholding.
As the final part of this quote demonstrates, nursing and medicine often presented two contrasting views in this study. However, the importance of understanding each other’s point of view was one that was frequently raised and spoken of as ‘a two way thing’. This was seen as important so that mutual goals and agendas could be set and worked to, otherwise as this nurse commented:—what’s the point? If medicine is running one race, and nursing another—they may as well shut the unit. Both nurses and doctors were aware of the power and conflict within making decisions about patient management. Medicine had ultimate authority and responsibility in the decision making process. However, nurses had reduced power with which to influence and inform clinical issues. Medicine ascribed this to the subordinate position that nurses perceived themselves in, whilst nurses believe that this subordinate position was re-enforced by medicine. In conclusion, intensive care decision making continues to be strongly driven by the medical knowledge base and authority. This shapes the structure and content of the key forums. The key holders of medical knowledge (the medical staff) are therefore maintained in the powerful role of decision-maker. Other sources of knowledge and roles, such as those held by nurses are not as valued, resulting in tension between nursing and medicine. Attempts to address these issues focus on the interpersonal development of the nurse, rather
© 2003 Elsevier Science Ltd. All rights reserved.
Power and conflict in intensive care clinical decision making
than a direct challenge on the current hierarchical model of knowledge and roles in clinical decision making practice.
Discussion of findings This study has demonstrated that the power held by medicine is instrumental in affecting the nursing role in intensive care. Nurses were a marginalised group in decision making and spoke of the need to understand and play the game in this environment. This action obscured the identity and culture of nursing and conformed to the dominant norms of medicine. However, without this manoeuvre, there was minimal opportunity for nursing influence on the decisions made. In appreciating both the nursing and the medical perspective, nurses were socialised to appreciate more than their worldview (Minh-Ha, 1991). However, this was not so of medicine. Throughout the field data, there were few tangible examples of medical staff truly understanding nursing’s worldview, but many of nurses adopting the medical agenda. Street (1992) challenges such behaviour and calls for nurses to move beyond the duplication of medicine in order to resist medical dominance. Traditionally this has occurred by nurses challenging the basis of how clinical decisions are made; this is clearly seen in the example earlier of the nurse discussing sedation for her patient. However, an alternative solution would be to challenge the very process of decision-making in the ward round. This would allow any hierarchies within the team to be openly discussed and the reality of working relationships to be revealed and acknowledged. As Freidson (1970, p. 336) highlighted, there can be agreement that a road is best built by an engineer, ‘but whether it should be built at all, and where it should be located are not wholly esoteric questions’. From the results of this study it is therefore clear that nurses continue to play games as highlighted by Stein et al. (1990) and Stein (1967). As evidenced in the quotes in this paper, there were vociferous statements made by medical and nursing in private spaces, however there were few examples of true open conflict and argument in the field. As highlighted in Allen’s work (1997) potential areas of conflict
© 2003 Elsevier Science Ltd. All rights reserved.
were managed or negotiated, predominantly by the nursing staff. Whilst nurse’s power was used to reduce conflict, this did not directly address the key structural issues causing conflict between doctors and nurses. From this work, it is clear that the historical drive for nurses to achieve professional status has not, to date, been instrumental in achieving nursing visibility within intensive care decision making. It has been argued that the mobilisation of nursing’s collective power, together with the use of a patient centred model of health may enable greater practitioner autonomy (Salvage, 1988) and directly challenge traditional doctor–nurse relationships (Witz, 1992). However, the impact of such approaches, on patients in particular and on the health care workforce in general, has yet to be fully evaluated.
Conclusion As this paper has highlighted, whilst the traditional functions, knowledge and skills of the nurse have evolved, this has not occurred with an associated change in the role of the nurse in the critical care team. The traditional hierarchies within the clinical team remain, and the nursing voice remains constrained by limitations placed by others and by ourselves. It is clear that the next decade will present continued challenges for health care. The need for optimum use of the existing workforce to meet patient needs, together with manpower shortfalls across major health care disciplines has already led to radical discussion documents (British Medical Association, 2002). It is important that all parties engage in such debates, not only to help configure the healthcare workforce of the future, but also to influence how disciplines can move to a truly interdisciplinary model of practice. This will require acknowledgement and respect of all types of knowledge and roles that are required in totality by the critically ill patient. If precisely applied, the clinical governance agenda with its emphasis on clinical partnerships with greater evidence of interdisciplinary working (NHSE, 1999) could provide a vehicle for this. However, trusts will need to make a commitment to move beyond meeting Key Performance Indicators towards
Intensive and Critical Care Nursing (2 0 0 3) 1 9, 1 2 5–1 3 5 133
Intensive and Critical Care Nursing
enabling clinical teams to function as powerful patient focused change agents. In the context of this paper, the future for effective team working lies with medical and nursing staff realising the inherent power through the complementary knowledge and roles held by each group. This philosophy must be extended and shared with other member of the expanded intensive care clinical team. Then we will move from teams that wrestle with ‘breaking through the inner circle’ driven by perceptions of exclusion and invisibility, towards redefining the very shape of intensive care, transformed by a culture of inclusivity and acknowledgement of the contribution of all. Acknowledgements
I would like to express my considerable thanks to all the staff in the sites who participated in this study, for their time, support and interest in this work. References Allen D 1997 The nursing medicine boundary: negotiated order. Sociology of Health and Illness 19(4): 498–520 Anderson J, O’Brien M 1995 Challenges for the future: the nurses role in weaning patients from mechanical ventilation. Intensive and Critical Care Nursing 11(1): 2–5 Anspach RR 1993 Deciding Who Lives: Fateful Choices in the Intensive Care Nursery. University of California Press, Berkley Ashworth P 1990 High technology and humanity for intensive care. Intensive and Critical Care Nursing 6(3): 150–160 Benner P 1984 From Novice to Expert Excellence and Power in Clinical Nursing Practice. Addison Wesley Publishing Company, Menlo Park, CA British Medical Association 2002 The Future Healthcare Workforce—February 2002 HPERU Discussion Paper 9. Web.bma.org.uk/public/pols Busby A, Gilchrist B 1992 The role of the nurse in the medical ward round. Journal of Advanced Nursing 17: 339–346 Department of Health 2000 Comprehensive Critical Care: A Review of Adult Critical Care Services. Department of Health, London Department of Health 2001 The Nursing Contribution to the Provision of Comprehensive Critical Care for Adults: A Strategic Programme of Action. Department of Health, London Fairman J 1992 Watchful vigilance: nursing care, technology and the development of intensive care units. Nursing Research 41(1): 56–59
134
Intensive and Critical Care Nursing
(2 0 0 3) 1 9, 1 2 5–1 3 5
Freidson E 1970 The Profession of Medicine. A Study of the Sociology of Applied Knowledge. University of Chicago Press, Chicago Gamarnikow E 1978 Sexual division of labour: the case of nursing. In: Kuhn A, Holpe E (eds) Feminism and Materialism. Routledge, Kegan Paul, London Hammersley M, Atkinson P 1995 Ethnography: Principles in Practice, 2nd ed. Routledge, London Hickey JV, Ouimette RM, Venegoni I 1996 Advanced Practice Nursing. Lippincott, Philadelphia Holloway I, Wheeler S 1996 Qualitative Research for Nurses. Blackwell Scientific, Oxford Hughes D 1988 When a nurse knows best: some aspects of doctor/nurse interaction in a casualty department. Sociology of Health and Illness 10: 1–22 Hunt G, Wainwright P 1994 Expanding the Role of the Nurse: The Scope of Professional Practice. Blackwell Scientific, Oxford Kalisch BJ, Kalisch PA 1977 An analysis of the sources of physician–nurse conflict. Journal of Nursing Administration 7: 51–57 Kraus WA 1980 Collaboration in Organisations. Human Science Press, New York Leatt P, Schneck R 1981 Nursing and technology: a replication. Administrative Science Quarterly 26: 225–226 Mann RE 1992 Preserving humanity in an age of technology. Intensive and Critical Care Nursing 8: 54–59 Minh-Ha TT 1991 When the Moon Waxes Red. Routledge, New York National Health Service Executive 1999 Clinical Governance. Quality in the New N.H.S. Executive Summary. NHSE, Leeds Nightingale F 1863 Notes on Hospitals. Longmans, Green Noc M, Weil MH 1996 Critical care today. In: Tinker J, Browne D, Sibbald WJ (eds) Critical Care Standard Audit and Ethics. Arnold Press, New York Oh TE 1996 The development, utilisation and cost implications of intensive care medicine: strategies for the future. In: Tinker J, Browne D, Sibbald WJ (eds) Critical Care Standards Audit and Ethics. Arnold Press, New York Porter S 1991 A participant observation study of power relations between nurses and doctors in a general hospital. Journal of Advanced Nursing 16: 728–735 Prescott PA, Bowen SA 1985 Physician nurse relationship. Annals of Internal Medicine 103: 127–133 Roth MD, Daze A-M 1984 Are nurses practising medicine in the intensive care unit? Dimensions of Critical Care Nursing 3(4): 230–237 Royal College of Nursing Critical Care Forum 1997 The Nature of Nursing Work in Intensive Care Results of a Telephone Survey. Royal College of Nursing, London Salvage J 1988 Professionalism or a struggle for survival? A consideration of current proposals for the reform of nursing in the United Kingdom. Journal of Advanced Nursing 13: 515–519 Smith M 1998 Who should run intensive care units? Care of the Critically Ill 14(4): 113–115 Spradley JP 1980 Participant Observation. Holt, Rhinehart and Winston, New York
© 2003 Elsevier Science Ltd. All rights reserved.
Power and conflict in intensive care clinical decision making
Stein L 1967 The doctor nurse game. Archives of General Psychiatry 16: 699–703 Stein LI, Watts DT, Howell T 1990 The doctor nurse game revisited. Nursing Outlook Nov/Dec: 264–268 Street A 1992 Inside Nursing: A Critical Ethnography. State University of New York Press, Albany, NY Svensson R 1996 The interplay between doctors and nurses—a negotiated order perspective. Sociology of Health and Illness 18: 379–398 Temkin-Greener H 1983 Interpersonal perspectives on teamwork in health care: a case study. Milbank Memorial Fund Quarterly 61(4): 641–658
© 2003 Elsevier Science Ltd. All rights reserved.
Walsh M, Ford P 1989 We always do it this way. Nursing Times 85(41): 26–35 Webb AR 1996 Medical staffing and training: the United Kingdom perspective. In: Tinker J, Browne D, Sibbald WJ (eds) Critical Care Standards Audit and Ethics. Arnold Press, New York Weiss SJ, Davis H 1985 Validity and reliability of the collaborative practice scales. Nursing Research 34(4): 299–305 Witz A 1992 Profession and Patriarchy. Routledge, London Woodrow P 1997 Nursing perspectives for intensive care. Intensive and Critical Care Nursing 13: 151–155
Intensive and Critical Care Nursing (2 0 0 3) 1 9, 1 2 5–1 3 5 135