Short reportOvercoming gendered and professional hierarchies in order to facilitate escalation of care in emergency situations: The role of standardised communication protocols
Introduction
UK patient safety policy documents acknowledge that managing escalation of care at a professional and organisational level is a key issue in distributed care systems (NCEPOD, 2005, NICE, 2007). Changes in physiological vital signs (notably respiration, pulse, blood pressure, oxygenation, and mental function) often occur in the period six to 24 h before patients clinically deteriorate on general wards (Hillman et al., 2002). However, these changes in clinical signs are often ‘missed, misinterpreted or mismanaged’ (McQuillan et al., 1998, Hodgetts et al., 2002) resulting in the concept ‘failure to rescue’ (FTR). Delays in treatment or deficient care of these patients can result in unanticipated admissions to intensive care units (ICU). These unanticipated admissions are twice as likely to develop cardiac arrest and are associated with an increased ICU and hospital mortality (McGloin et al., 1999, McQuillan et al., 1998).
UK policy response to FTR has been to focus on individuals’ knowledge, attitudes and skills (e.g. improving recording of observations, skills of recognition and patterns of communication). A recurring theme noted amongst FTR cases is inter and intra-professional difficulties in speaking out and asking for help; this has been linked with power relations underpinning medical discourse (Allen, 2004). Currently, a nurse alerted to a patient whose condition is rapidly deteriorating will refer the patient to a junior doctor who in turn may then need to call for help from a medical superior thus increasing delay. The contribution of occupational and hierarchical boundaries, a culture of secrecy, fear and autocratic leadership to failure to articulate and listen to concerns has been documented (Healthcare Commission, 2007, National Patient Safety Agency, 2007).
In this paper we examine the social development and utilisation of these communication protocols. We conceptualise their potential role in overcoming gendered and professional hierarchies. We suggest that the standardised communication protocol could be considered as a ‘boundary object’, structuring relations between nursing and medical staff. We examine this construct and aim to generate new insights into the potential for standardised narratives to maintain coherence across intersecting social worlds.
Section snippets
The problem – gendered and professional hierarchies
Relations at work in healthcare settings intersect at the crossroad of gender, profession and hierarchy (Davies, 2003). Unequal relationships exist in healthcare work, the everyday practice of ‘doing dominance and doing deference have been part and parcel of how nursing and medicine were historically constructed in relation to one another’ (Davies, 2003, p. 728). A problem long recognised within sociological understandings of patient safety is that those in subordinate positions are often
The solution – the communication protocol as a boundary object
Standardising the referral process has been offered as a solution to this problem (JCICPS, 2006). Standardised communication protocols are constructed as a useful mnemonic for nurses in emergency situations to help them to articulate their concerns to the medical staff (who are often not co-located on the same ward). They are constructed as situational briefing protocols, designed to ‘eliminate excessive language’ and ‘convey, in less than a minute, vital information needed by the doctor or
An example – SBAR
One protocol, ‘SBAR’, uses the terms ‘situation’, ‘background’, ‘assessment’ and ‘recommendation’. In identifying the ‘Situation’, the nurse is prompted to foreground the purpose of her call; ‘I am calling because…’. Next the nurse provides a ‘Background’ to the patient’s condition illustrating this with physiological parameters such as vital signs. For the ‘Assessment’, the nurse is required to state what is suspected to be going on with the patient. Lastly, the nurse is prompted to make a
Discussion
Inter-occupational interaction in healthcare work is characterised by issues of legitimacy, power and conflict. Existing hierarchical working practices have ‘emerged under the influence of organisational, technical, economic and political constraints to “end up” as relatively stable organisational structures and cultures’ (Tjora & Scambler, 2009, p. 5). However, the hospital’s professional hierarchical structure is not necessarily a deterministic one; there are opportunities for actors to
Acknowledgement
This report/article presents independent research commissioned by the National Institute for Health Research (NIHR). The views expressed in this publication are those of the author(s) and not necessarily those of the NHS, the NIHR or the Department of Health.
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