Elsevier

Social Science & Medicine

Volume 71, Issue 9, November 2010, Pages 1683-1686
Social Science & Medicine

Short report
Overcoming gendered and professional hierarchies in order to facilitate escalation of care in emergency situations: The role of standardised communication protocols

https://doi.org/10.1016/j.socscimed.2010.07.037Get rights and content

Abstract

It has been suggested that as many as 23,000 in-hospital cardiac arrests in the UK could be prevented with earlier detection and intervention (Hodgetts et al., 2002). Cases of ‘failure to rescue’ are often linked with difficulties relaying and interpreting information across occupational and professional boundaries. Standardised communication protocols have been recommended as a means of enabling the transmission of concise, salient information, licensing and empowering the individual to overcome established hierarchies in speaking out and asking for help. This paper critically examines the current discourse around such protocols. We find that there is a paucity of evidence regarding the complex relationship between social contexts, individual applications of these protocols and short- and long-term impact on safety and ‘failure to rescue’ rates. The paper highlights the complexities of the underlying power dynamics that are located within gendered and occupational hierarchies and explores the role of standardised communication protocols as a potential boundary object. The paper discusses the potential for these protocols to inter-relate and act as a mediating boundary object between nursing and medical staff, enabling understanding and sharing of cultural context.

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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