Julie Apker

Communicating Professional Identity in Medical Socialization: Considering the Ideological Discourse of Morning Report

In this study, the authors investigate how medical ideology and physician professional identity are socially constructed during morning report, a formal teaching conference considered to be a cornerstone of medical education. Analysis of transcripts from 20 meetings reveals physician identity is developed through ideological discourse that produces and reproduces systems of domination that privilege scientific medicine and marginalize humanistic approaches. Findings indicate how, in a socialization context uniquely focused on discourse, communication functions to construct a professional identity grounded in the principles of the biomedical model. Although medical residents deviate from traditional ideology by articulating the voice of the lifeworld, faculty physicians counter these moves by asserting the voice of medicine. The authors draw conclusions regarding identity formation and the socialization practices of medical education.

Meeting the Complex Needs of the Health Care Team: Identification of Nurse—Team Communication Practices Perceived to Enhance Patient Outcomes

Nurses occupy a central position in today’s increasingly collaborative health care teams that place a premium on quality patient care. In this study we examined critical team processes and identified specific nurse—team communication practices that were perceived by team members to enhance patient outcomes. Fifty patient-care team members were interviewed to uncover forms of nurse communication perceived to improve team performance. Using a grounded theory approach and constant comparative analysis, study findings reveal two critical processes nurses contribute to as the most central and consistent members of the health care team: ensuring quality decisions and promoting a synergistic team. Moreover, the findings reveal 15 specific nurse—team communication practices that comprise these processes, and thereby are theorized to improve patient outcomes.

Exploring emergency physician-hospitalist handoff interactions: development of the Handoff Communication Assessment.

STUDY OBJECTIVE We develop and evaluate the Handoff Communication Assessment, using actual handoffs of patient transfers from emergency department to inpatient care. METHODS This was an observational qualitative study. We derived a Handoff Communication Assessment tool, using categories from discourse coding described in physician-patient communication, previous handoff research in medicine, health communication, and health systems engineering and pilot data from 3 physician-hospitalist handoffs. The resulting tool consists of 2 typologies, content and language form. We applied the tool to a convenience sample of 15 emergency physician-to-hospitalist handoffs occurring at a community teaching hospital. Using discourse analysis, we assigned utterances into categories and determined the frequency of utterances in each category and by physician role. RESULTS The tool contains 11 content categories reflecting topics of patient presentation, assessment, and professional environment and 11 language form categories representing information-seeking, information-giving, and information-verifying behaviors. The Handoff Communication Assessment showed good interrater reliability for content (kappa=0.71) and language form (kappa=0.84). We analyzed 742 utterances, which provided the following preliminary findings: emergency physicians talked more during handoffs (67.7% of all utterances) compared with hospitalists (32.3% of all utterances). Content focused on patient presentation (43.6%), professional environment (36%), and assessment (20.3%). Form was mostly information-giving (90.7%) with periodic information-seeking utterances (8.8%) and rarely information-verifying utterances (0.4%). Questions accounted for less than 10% of all utterances. CONCLUSION We were able to develop and use the Handoff Communication Assessment to analyze content and structure of handoff communication between emergency physicians and hospitalists at a single center. In this preliminary application of the tool, we found that emergency physician-to-hospitalist handoffs primarily consist of information giving and are not geared toward question-and-answer events. This critical exchange may benefit from ongoing analysis and reformulation.

Strategic ambiguity in the role development process

Abstract Todays turbulent business and social environment often compels organizations to adopt internal programs that will help them cope with complexity. One organizational sector in which this is particularly true is the health care industry, as managed care programs and competitive forces have changed the way hospitals and clinics operate. This study looks at a specific organizational program designed to cope with these industry changes and considers the impact of the program on the nurses involved. Drawing on theory and research on role development and strategic ambiguity, this case analysis looks at a hospital system in which the nursing role of “care coordinator”; was defined in a strategically ambiguous way. After analyzing interviews with 19 care coordinators, conclusions are drawn regarding affective reactions to strategic role ambiguity, behavioral adaptation to strategic role ambiguity, and the importance of conceptualizing role ambiguity as a systemic process.

Improving Interunit Transitions of Care Between Emergency Physicians and Hospital Medicine Physicians: A Conceptual Approach

Patient care transitions across specialties involve more complexity than those within the same specialty, yet the unique social and technical features remain underexplored. Further, little consensus exists among researchers and practitioners about strategies to improve interspecialty communication. This concept article addresses these gaps by focusing on the hand-off process between emergency and hospital medicine physicians. Sensitivity to cultural and operational differences and a common set of expectations pertaining to hand-off content will more effectively prepare the next provider to act safely and efficiently when caring for the patient. Through a consensus decision-making process of experienced and published authorities in health care transitions, including physicians in both specialties as well as in communication studies, the authors propose content and style principles clinicians may use to improve transition communication. With representation from both community and academic settings, similarities and differences between emergency medicine and internal medicine are highlighted to heighten appreciation of the values, attitudes, and goals of each specialty, particularly pertaining to communication. The authors also examine different communication media, social and cultural behaviors, and tools that practitioners use to share patient care information. Quality measures are proposed within the structure, process, and outcome framework for institutions seeking to evaluate and monitor improvement strategies in hand-off performance. Validation studies to determine if these suggested improvements in transition communication will result in improved patient outcomes will be necessary. By exploring the dynamics of transition communication between specialties and suggesting best practices, the authors hope to strengthen hand-off skills and contribute to improved continuity of care.

Sensemaking of change in the managed care era: a case of hospital‐based nurses

This study explores how nurses working in a large, metropolitan hospital make sense of the managed care change. Findings from 24 nurse interviews suggest that nurse sensemaking has generated interpretations of managed care change that are grounded in the caregiving role. Study results show that nurses view managed care with ambiguity. Nurses understand managed care change as instrumental in encouraging collaboration and affecting patient care quality. Implications are drawn regarding the importance of identity construction to the sensemaking process and illustrate the paradox of change in the managed care era. Although nurses view collaboration and professional empowerment as positive outcomes of managed care, further analysis reveals that these values function ideologically, promoting managed care concerns over worker interests. Concertive control – a team‐based process which shifts organizational control from management to employees – is explored as a way that workers act in accordance with management decisions and uphold traditional power structures.

Strategies for improving communication in the emergency department: Mediums and messages in a noisy environment

Alarge body of research provides strong evidence that hospitals are loud environments with noise levels far exceeding those recommended by the World Health Organization (WHO). WHO guidelines specify 35 decibels (dB) for continuous background noise in patient rooms, with nighttime peaks not to exceed 40 dB. Hospital background noise exceeds those levels, and peaks frequently exceed 90 dB. Staff voices and medical equipment typically produce noise at 70–75 dB levels. Other sources of noise include alarms, bedrails, telephones, ice machines, paging systems, and pneumatic tube systems. The noise from portable x-ray machines can exceed 90 dB, analogous to walking next to a highway when a large truck passes. 39) Noise is good for neither patients nor health care providers. High levels of ambient noise in patient care areas have been associated with increases in blood pressure and heart rate and poor sleep patterns. Noise in nurseries has been associated with higher oxygen-support therapy needs. Hagerman et al. reported an increase in readmissions at a coronary care unit following discharge for patients who had poor room acoustics and noisy hospital stays. The emergency department (ED) can be a particularly noisy environment—and noise elevates stress in patients. Weiland et al. found that ED patients listening to a digital audio recording of nature sounds, a soothing beat, or acoustical music demonstrated less anxiety than control subjects listening to a recording of ED noise. The prospects for health care workers in terms of health and hearing loss are just as grim. Work in settings with high levels of ambient noise has been associated with hypertension and coronary artery disease. Noise-induced stress has been identified as a predictor of burnout in critical care nurses. In the ED, noise levels have been identified as stressful and interfering with communication and teaching. High noise levels in a hospital setting have been associated with hearing loss. In the last two decades, there has been much interest in improving communication, including a substantial review of research on communication during patient handoffs in hospitals. Yet little attention has been given to the potential opportunities and challenges associated with technology-based communication, particularly with respect to its use in environments with high levels of ambient noise, such as the ED. Nevertheless, Lund et al. reported that text messaging was a “practical and feasible tool” in mass casualty events, during which background ambient noise levels are inordinately high. 2) In this article, we (1) review the effects of noise on patients and providers; (2) analyze the modes, mediums, and affordances of the prevalent communication mechanisms in the ED; and (3) suggest strategies to reduce ambient noise and improve communication in the ED and ways to evaluate the impact of these strategies.

Conflict and Stress in Hospital Nursing: Improving Communicative Responses to Enduring Professional Challenges

ABSTRACT Nurses function as central figures of health teams, coordinating direct care and communication between team members, patients, and their families. The importance of nurses to health care cannot be understated, but neither can the environmental struggles nurses routinely encounter in their jobs. Organizational communication and nursing scholarship show conflict and stress as two visible and ongoing challenges. This case study aims to (a) explore the ways conflict communication and communicative stress are experienced and endure in nursing and (b) understand how nurses discursively (mis)manage conflict and stress. Open-ended survey comments from nurses (N = 135) employed at a large teaching and research hospital were qualitatively analyzed. Weick’s model of organizing, specifically his notion of communication cycles, emerged as a conceptual lens helpful for understanding cyclical conflict and stress. Results show that exclusionary communication, specifically nonparticipatory and unsupportive messages, contribute to nurse conflict and stress. Nurses tend to (mis)manage conflict and stress using respectful and disrespectful discourse. These communication patterns can facilitate or prohibit positive change. Metaphorically, nurse communicative conflict and stress can be depicted as fire. Relationships can go up in flames due to out-of-control fires in the form of destructive conflict. However, conflict and stress, like fire, can be harnessed for positive ends such as organizational decision making and innovation. Findings suggest conveying respect may help nurses manage and even avoid flames of conflict and stress. Solutions are offered to mitigate the effects of conflict and stress while developing respectful organizational cultures.

HANDOFF COMMUNICATION AND ELECTRONIC HEALTH RECORDS: EXPLORING TRANSITIONS IN CARE BETWEEN EMERGENCY PHYSICIANS AND INTERNAL MEDICINE/HOSPITALIST PHYSICIANS

When transferring patient care responsibilities across the healthcare continuum, clinicians strive to communicate safely and effectively, but communication failures exist that threaten patient safety. Although researchers are making great strides in understanding and solving intraservice handoff problems, inter-service transition communication remains underexplored. Further, electronic health records (EHRs) figure prominently in healthcare delivery, but less is known about how EHRs contribute to inter-service handoffs. This descriptive, qualitative study uses Sensemaking Theory to explore EHR-facilitated, inter-service handoffs occurring between emergency medicine and internal/hospitalist medicine physicians. The researchers conducted six focus groups with 16 attending physicians and medical residents at a major Midwestern academic hospital. Findings suggest clinicians hold varied expectations for information content and relational communication/style. Their expectations contribute to making sense of uncertain handoff situations and communication best practices. Participants generally perceive EHRs as tools that, when used appropriately, can enhance handoffs and patient care continuity. Ideas for practical applications are offered based on study results.

Exploring role dialectics in inter-service admission handoffs: a qualitative analysis of physician communication

ABSTRACT Admission handoffs between emergency physicians (EPs) and internal medicine/hospitalist physicians (IMHPs), a frequently occurring form of patient transfer, remain understudied despite their importance to care continuity. Handoffs function as more than simple information transfer; they require a repertoire of interpersonal skills to accomplish tasks and develop professional relationships. Relational Dialectics Theory (RDT), a perspective that asserts social life consists of oppositional and unified discourses present in personal relationships, frames the current study. We use role dialectics to more fully understand the contradictions that emerge from the competing discourses of physician roles. Data were collected from six focus groups consisting of residents and attending physicians working at a large, urban, academic medical center in the Midwest United States. Using a grounded, constant-comparative approach, analysis of transcripts reveals that these physicians encounter two key role dialectics during handoffs: autonomy–collaboration and uncertainty–certainty. Interventions for physicians and hospital decision-makers are recommended.