A sociological exploration of the tensions related to interprofessional collaboration in acute-care discharge planning

Abstract

Patient discharge is a key concern in hospitals, particularly in acute care given the multifaceted and challenging nature of patients' health care needs. Policies on discharge have identified the importance of interprofessional collaboration, yet research has described its limitations in this clinical context. This study aimed to extend our understanding of interprofessional interactions related to discharge in a general internal medicine setting by using sociological theories to illuminate the existence of, and interplay between, structural factors and micro-level practices. An ethnographic approach was employed to obtain an in-depth insight into health care providers' perspectives, 2 of healthcare labour in patient discharge with opportunities for some interprofessional negotiations; the role of organizational routines in facilitating and challenging interprofessional negotiations in patient discharge; and tensions in organizational priorities that impact an interprofessional approach to discharge. The findings provide insight into the various levels at which interventions can be targeted to improve interprofessional collaboration in discharge while recognizing the organizational tensions that challenge an interprofessional approach.

Examining the implementation of collaborative competencies in a critical care setting: Key challenges for enacting competency-based education

“…In relation to the wider literature, in a survey of over 600 clinical teams (Dixon-Woods et al, 2014) it was found that in addition to effort and skills of team members and good processes, organizational resources made available to teams including adequate staffing levels, were critical to their success. Top-down targets such as those related to admission and discharge, can result in healthcare providers focusing on throughput rather than interprofessional collaboration and quality of care (Allard & Bleakley, 2016;Goldman et al, 2016). Given the resource pressures in healthcare systems, it is important to be conscious of both the messages of interprofessional collaboration targeted at the individual level and the organizational resources being invested to enables these ideals.…”

Occupational therapy on the margins

“…The role of occupational therapists (amongst others) is connected with their professional power which involves working within the interests of their employers, such as state or corporate healthcare systems which, as dominant players in the organisation of services, are able to determine how needs are met. Examples of this may be working within the need for corporate safety and limited liability in clinical decision making (Durocher, Gibson, & Rappolt, 2016), or organisational communication and efficiency priorities (Goldman et al 2016). These principles become margins within which people with disabilities and people with experiences of mental distress may be contained by groups of professional workers such as occupational therapists.…”

Bedside nurses’ roles in discharge collaboration in general internal medicine: Disconnected, disempowered and devalued?

“…This approach is affecting the range of professional groups in GIM, and healthcare more broadly, as they defend or adapt their professional boundaries and roles to these demands (Correia, 2013;Harvey, Thompson, Pearson, Willis, & Toffoli, 2017;Henderson, Willis, Toffoli, Hamilton, & Blackman, 2016;Newman & Lawler, 2009;Reeves, Nelson, & Zwarenstein, 2008;Shannon & French, 2005). For example, social workers, pharmacists, occupational therapists and physiotherapists in GIM units have experienced changes in their roles in the healthcare division of labour with greater emphasis on discharge-related responsibilities (Galati, Wong, Morra, & Wu, 2011;Goldman et al, 2016;Neeman et al, 2017). Physicians in these settings have pressures to prioritize their decision-making around patient flow with an increasing emphasis on the value of teaching residents about safe discharge (Greysen, Schiliro, Horwitz, Curry, & Bradley, 2012;Schoenborn & Christmas, 2013).…”

“…New discharge professional roles have been created to facilitate admissions and discharge in acute care medical units (Okoniewska et al, 2015). Nurses in managerial roles across a range of hospitals units have engaged in 'organizing work' that entails sophisticated technical, organizational and social skills (Allen, 2014); this has also been reported in the GIM context (Goldman et al, 2016). Challenging questions remain about the professional role of the nurse bedside carer in current healthcare systems (Allen, 2014(Allen, , 2015Heartfield, 2005).…”

“…For example, physicians' needs to prioritize patient flow can lead to tensions in their interactions with nurses and other healthcare professionals around discharge. Social workers, physiotherapists and occupational therapists' expertise in discharge planning can increase their involvement in discharge decisionmaking (Goldman et al, 2016). Interprofessional interactions concerning discharge in GIM occur amidst longer-standing challenges with collaboration, in particular physician-nurse interactions (Lewin & Reeves, 2011;Liu, Manias, & Gerdtz, 2014;O'Leary, Ritter, et al, 2010;Reeves & Lewin, 2004;Reeves et al, 2008Reeves et al, , 2009Wu et al, 2013).…”