1 Exploring power relations embedded in medication

Exploring power relations embedded in medication communication processes on general medical wards LIU, W., MANIAS, E. & GERDTZ, M. (2014) Exploring power relations embedded in medication communication processes on general medical wards. Qualitative Research Journal, 14(2), 161-178

Introduction and background This paper reports on findings of an ethnographic study investigating communication processes for medication management in two general medical wards of an acute care hospital. In the paper, we explore power relations embedded in medication communication processes and their effects on social relations and clinical outcomes. For the purpose of this paper, medication communication was defined as verbal interactions and non-verbal cues about medication management among nurses, doctors, pharmacists and patients in their situated environments. The study was theoretically informed by the work of Norman Fairclough. Fairclough’s (1992) conceptualisation of language is concerned with overt and covert relationships of dominance, power and resistance manifested in dialogue, text and action. For Fairclough, text relates to not only verbal and written transcripts, but also to any symbolic expressions such as visual images and body gestures. Language varies according to the social identities and subject positions that people take up within their local environments (Boutain, 1999). Fairclough (1992) explains that people often draw upon ideological “common sense” without thinking in their daily activities and conversations (p. 84, emphasis in the original). In healthcare, common sense treats “authority and hierarchy as natural – the doctors knows about medicine and the patient doesn’t” (Fairclough, 1992, p.92). However, this common sense approach is problematic as it not only sustains unequal doctor-patient relationships, but it also neglects complex power struggles 1

operating between doctors and patients in specific clinical environments. In applying Fairclough’s account of language to this study, we intended to disrupt the ideological common sense approach in hospital environments by unveiling hidden power relations embedded in medication communication processes and engaging clinicians to think about their daily practice in different ways. Previous studies have identified tensions inherent in doctor-patient (Spinewine et al., 2005), nurse-patient (Bolster and Manias, 2010) and pharmacist-patient relationships (Pilnick, 2003) during medication communication processes. In acute care hospital settings, a paternalistic doctor-patient relationship where doctors made treatment decisions and patient received the treatment prevailed in medication management among elderly patients (Spinewine et al., 2005). Similarly, nurses’ interactions with patients during medication activities were largely centred on nurses’ understanding of what was important for patients, and that interactions were generally initiated and dominated by nurses (Bolster and Manias, 2010). In a hospital paediatric outpatient clinic, pharmacist-patient interactions were also characterised by a relationship between information-givers and information-recipients (Pilnick, 2003). Power struggles also exist between doctors and nurses when communicating about medication information. Due to the professional hierarchy between medicine and nursing, nurses are historically known to be good at using a covert style of communication in which they make medication recommendations in such a way that their suggestions appear to be initiated by doctors (Stein, 1967). Stein called this form of communication, the doctor-nurse game. Previous studies (Churchman and Doherty, 2010; Lawton et al., 2012) highlight nurses’ avoidance of disturbing the asymmetric doctor-nurse power relationship when communicating with doctors 2

about patient management. Riley and colleagues (2007) also noticed this covert style of communication in their investigation of the role of whiteboards in interdisciplinary communication. On the oncology wards, whiteboards were used unofficially by nurses to communicate with doctors about specific medication decisions to avoid direct challenges to interdisciplinary relationships. The overt display of messages on whiteboards, noting incorrect medication orders by doctors, demonstrated nurses’ knowledge of medication use and their resistance to the medical dominance (Riley et al., 2007). Although pharmacists play an important role in medication management, existing literature has placed little emphasis on interdisciplinary relationships between the nurse and pharmacist and between the doctor and pharmacist. In addition, previous studies on clinician-patient relationships (Bolster and Manias, 2010; Pilnick, 2003; Spinewine et al., 2005) have mainly focused on two-way interactions between patients and doctors, between patients and nurses or between patients and pharmacists. There is a lack of investigation into the multi-way information exchanges among patients and clinicians of different disciplines. Furthermore, there is limited research on patients’ resistance to dominant clinical practices in hospital settings or clinicians’ resistance to organisational dominance in their daily work. This paper explores how power is exercised in verbal and non-verbal medication communication processes that involved patients and clinicians from the disciplines of nursing, medicine and pharmacy. Specifically, we explore how clinicians and patients are affected by clinician-patient relationships when communicating about medication management, how clinicians of different disciplines exercise power in discussing treatment options as a team, what discourses are embodied in medication communication processes, and how those discourses impact on clinical 3

practices and social relationships. In addressing complex power relations embedded in medication communication processes, it is possible to expand our understandings of medication safety practices. Methodology A critical ethnographic approach was used in the study to capture medication communication processes as they unfolded in practice. Critical ethnography involves an examination of culture for the purpose of thinking about aspects in different ways (Madison, 2005). It aims to challenge taken-for-granted political assumptions and dominant powers of society (Schwandt, 2007). In the study, we strive to find out whose voice is represented in daily communication activities and how forms of power affect the ways in which participants communicate with each other. Ethnographic field work was undertaken between January and November, 2010. Multiple data collection methods including participant observations, field interviews, video-recordings and video reflexive focus groups were employed to enrich data sources and establish rigour of the findings. This paper focuses on the use of video-recorded data to uncover the verbal and nonverbal, taken-for-granted, habitual activities that informed clinical interactions about medication management. Video-recorded data captured the complexities and dynamics of clinical interactions within contextualised environments and provided us with opportunities to examine power relations from different aspects of clinical work. A hand-held Sony-digital video camera (DCR-TRV 19E) was used to record clinical interactions and focus group activities. A Sony microphone (ECM-MSD1) was attached to the video camera to minimise surrounding noises and maximise clarity of interactions. The first author, who also worked as an emergency department nurse of the participating hospital, conducted the video-

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recording and focus group activities. The study took place in two general medical wards of a major teaching hospital in Melbourne, Australia. Use of video methods A combination method of video-recording observations and video reflexive focus groups was employed. Prior to the commencement of video-recordings, the first author undertook participant observations and field interviews for a period of one to two months in each ward. These activities not only generated ideas leading to the production of video-recordings, but also facilitated the build-up of trust and ensured mutual understanding between clinicians and the first author. Video-recordings were scheduled between 07:00am and 21:00pm at different time blocks and on different days of the week to coincide with the ward routines for holding medication-related activities, such as nursing handovers, medical ward rounds, multidisciplinary meetings and informal medication interactions among nurses, doctors, pharmacists and patients. All videorecordings were conducted in collaboration with participants. For example, if clinicians had experienced a particularly busy shift, video-recordings were often cancelled as requested by clinicians. Raw video-recorded data were available for review after the recording, and on request of the video-recorded participants, it would be erased if they considered that inappropriate or items of a liable nature were recorded. No participants in the study expressed concerns about the appropriateness or liability of video-recorded data. Video reflexive focus groups were organised in each ward after the completion of raw video data collection. A reflexive DVD was produced from the raw video data to stimulate group discussions about medication communication and to challenge clinicians about how they 5

interacted with each other and how power relations were played out. Focus groups were videorecorded by placing the camera on a stationary tripod with its lens focused on the first author who facilitated group discussions. Ethical considerations The study was approved by the Human Research Ethics Committees at the participating hospital. All video-recordings were performed with the knowledge of and with written consent from the individuals who appeared within the frame of filming. Those who did not consent to be recorded were not captured in the frame of the video, and the camera was paused when they spoke. Written consent for video-recordings was obtained from 72 nurses, 30 doctors, one pharmacist, two physiotherapists and 23 patients. Verbal consent was sought from all health professionals and family members who showed up unexpectedly during the video-recording. All participants’ identifiable features in the video-recorded outputs were removed using pixelisation techniques. Analysing video data Data presented in this paper are derived from 34 hours of video-recordings and five video reflexive focus groups. Data analysis began with the first author’s verbatim transcription of interactions on the video-recordings. All authors independently interpreted the transcripts and visual images to develop understandings of the meanings that verbal and non-verbal communication conveyed. On the completion of transcription, all video and written data were imported into NVivo 8 (QRS International). Data were analysed using Fairclough’s (1992) three-level critical discourse analytic framework. Critical discourse analysis aims to reveal the role of language in the creation and reproduction of unequal power relations between social groups, with the ultimate goal of contributing to social 6

changes along the lines of more equal power relations in society (Jørgensen and Phillips, 2002). Questions developed were informed by the theoretical basis of the study. Level one of the analysis aimed to examine the structure and content of the text. Questions asked included “What words and body language are used by participants? Who is speaking? Who is silent? What aspects of patient’s care are prioritised? To what extent are competing interests of clinicians, patients and the organisation addressed?” Level two of the analysis aimed to explore the strategic use of the text and spoken word. Questions asked included “What power relations are relevant to the construction of the conversation? What identities, roles or positions of people are relevant to the conversation? Where are people positioned when speaking in the conversation? What are the situated meanings and values to people, time and places relevant to the conversation?” Level three of the analysis aimed to evaluate the clinical and social consequences of the text. Questions asked included “Does the conversation strengthen or challenge the status quo in clinical practice? Have the traditional power relations been threatened, thereby contributing to positive social changes?” Uncovering power relations in medication communication processes Medication communication in the medical wards represented a combination of formal (structured ward rounds, handovers and multidisciplinary meetings) and informal (ad hoc, opportunistic interactions at any space and any time of the day) interactions involving patients and clinicians of different disciplines. In what follows, video-recorded data are used to reveal four different forms of power relations between clinicians and patients, between nurses and doctors, between clinicians and the organisation, as well as between clinicians of multidisciplinary teams. To encompass diverse practices, we present video excerpts that featured different participants in different interactions. 7

Power relations between clinicians and patients – Clinical practices prioritised over patient care activities In the medical wards, clinical practices such as medication history-taking and medication administration were given a higher priority by doctors and nurses, compared with patient care activities such as personal hygiene and nutritional needs. Sometimes, patients had to subordinate their concerns when there was a disjunction between clinical practices and patient care activities. The following excerpt was transcribed from a video-recoded observation of a nurse giving an iron transfusion to a patient with gastroenteritis. The excerpt was marked with times to show the sequence of activities, illustrating the amount of time the patient had to wait to receive an iron transfusion:

14:30pm

The iron infusion bag was retrieved from the hospital blood bank. The nurse was reading the iron transfusion protocol. According to the protocol, a medical doctor needed to stay at the bedside when a testing dose of iron was being administered.

15:15pm

The nurse paged the doctor in the gastroenterology ward.

16:00pm

The nurse paged the doctor again.

17:00pm

Dinner was served to the patient at the bedside.

17:05pm

Before the patient started to eat her dinner, the gastroenterology doctor came to the ward. The nurse and the nurse coordinator double-checked the

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patient, the iron transfusion bag and the transfusion protocol. The patient’s baseline vital signs were recorded. 17:15pm

A testing dose of iron was given by the nurse. The doctor was on the phone discussing about another patient.

17:30pm

The nurse recorded the patient’s vital signs. The doctor left the ward.

17:45pm

The nurse rechecked the patient’s vital signs and started the iron transfusion. The nurse checked the patient’s vital signs every 15-30 minutes until the transfusion was completed.

[Insert Figure 1 here]

In this scenario, the iron transfusion finished around 19:00pm, and after waiting for two hours after receiving her meal, the patient still had not eaten her dinner. The patient was interrupted from eating during administration of the iron transfusion because the nurse had to frequently check her vital signs such as pulse and blood pressure every 15-30 minutes during the transfusion. The patient’s meal was left cold sitting on the table in front of her (Figure 1). This scenario demonstrated the competing discourses of clinical safety and patient sustenance. In order to maintain the safety discourse, the nurse had to wait for the gastroenterology doctor to come to the ward before starting the iron transfusion. The discourse of patient sustenance was subordinated to clinical activities that were undertaken to maintain the safety discourse. During 9

the observation, the patient showed her disappointment to the camera lens a few times by making a grimacing face and shaking her head. After the testing dose of iron was administered, the nurse asked the patient if she had any unusual feelings. The patient said loudly to the camera in laughter, “No, just hungry.” The nurse responded that, “Hungry and cross, fair enough.” In this specific context, the patient positioned herself as an object to the video camera, while at the same time as a subject actively involved in the video-recording process. This scenario also showed that nursing time was subordinate to medical time. Although the iron transfusion bag was retrieved from the blood bank at 14:30, the nurse could not start the transfusion until 17:05 when the gastroenterology doctor arrived on the ward. The nurse had to work with the doctor’s schedule while trying to meet the patient’s immediate needs at the bedside. The nurse’s response to the patient’s statement of feeling hungry might be perceived as an open expression of her internal conflict. The gastroenterology doctor also had to face constant struggles in trying to balance her workload and patient safety. The gastroenterology doctor was not based in the medical ward. She had to move from the gastroenterology ward to review the patient in the medical ward. While moving between different ward spaces, the doctor relied on her pager and mobile phone to communicate with other clinicians to ensure that patient safety was maintained. The doctor positioned herself as a multitasking professional and managed her practice beyond the confined ward space. On the other hand, the nurse’s movements largely remained at the bedside areas for the provision of continuous patient care.

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The power struggle between clinicians and patients was also demonstrated through negotiation over discharge time from the hospital. In the following video excerpt, a medical registrar was discussing the discharge plan with a patient who was admitted to the ward with back pain:

Medical registrar:

Hopefully we can get you home to your wife today. How does that sound?

Patient:

When?

Medical registrar:

When you feel up to it.

Patient:

But I still have pain.

Medical registrar:

I know that you’ve got pain. The pain doctors are happy with the pain tablets you are on at the moment. Unfortunately, we cannot make the pain go away completely. I don’t think you need to stay in hospital until the pain is gone completely . . . What I would like the physiotherapist to do for you is to give you a few little exercises, keep you mobile, just until we can get you move enough to be safe at home. OK?

Patient:

Do you think I can stay here tonight?

Medical registrar:

Um. I hope not. It would be nice for you at home. We’ll see what the physiotherapist says.

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To start with the conversation, the medical registrar presented the organisational efficiency discourse in a social norm. It was the social ideology that most patients would expect an early discharge from the hospital. The medical registrar assumed that the patient would be happy to go back home. The patient disagreed with the discharge plan by asserting an immediate concern about his pain management. The medical registrar acknowledged the patient’s concern, but the patient’s view was overridden by the pain specialists’ opinion. The medical registrar normalised the pain symptoms by indicating that they “cannot go away completely.” The patient proceeded with another question to negotiate the discharge time. Despite the patient’s negotiation, the conversation continued as if the patient had no say in the control of discharge time and pain treatment. It appeared that the patient’s legitimacy in occupying the hospital space was completely determined by the medical registrar. The medical registrar’s response to the patient was persuasive and worked to invite the patient’s consensus. The medical registrar constructed her language by initially expressing her personal opinion, then deferring the decision about discharge time to the physiotherapist. The use of hesitance through “um” and politeness “it would be nice” revealed the medical registrar’s struggle to address the patient’s concern about pain management and the organisational concern about working efficiency at the same time. Power relations between nurses and doctors – Nurses’ assertion of professional autonomy During observations, nurses with different levels of experience asserted professional autonomy when communicating with doctors, particularly inexperienced medical residents, about medication management by offering specific advice on medical prescribing and challenging medication decisions. Nurses’ assertion of autonomy was linked to power of professional 12

knowledge and structural changes in the healthcare system, as illustrated in the following excerpt extracted from a video-recorded observation. In this scenario, a patient who had just been transferred from the emergency department became physically aggressive. An enrolled nurse from the emergency department, who worked under the supervision of a registered nurse, escorted the patient to the medical ward. The nurse coordinator was called upon to see the patient because of his challenging behaviour. The conversation was about initiating medication treatment to manage the patient’s agitation:

[Outside patient room] Enrolled nurse:

The doctor [indicating the admission medical registrar] said he had written some haloperidol [an anti-psychotic]. If you can give him some of that, it might settle him down.

Nurse coordinator:

[Checking the medication chart] But he doesn’t have haloperidol charted. I’ll get [name the medical resident] to have a look of the patient.

[Staff station] Nurse coordinator:

He [the patient] comes in with increased confusion. He is really getting very aggressive [passing the medication chart to the medical resident].

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Medical resident:

Is he normally aggressive? He’s got temazapam [a tranquiliser] [pointing to the medication chart].

Nurse coordinator:

It’s too early to give temazapam now [it was 16:50pm]. Just chart haloperidol. I think that’s what the [medical] registrar is going to chart.

Medical resident:

I am charting now. I just need to find the frequency here [checking online medication references]. It said two hourly.

Nurse coordinator:

It sounds a bit too much for me. But he [the patient] is a big man.

Medical resident:

Let’s leave him on two-hourly. It said here to titrate to clinical effects. Do you think we could try something else?

Nurse coordinator:

I don’t know which one is more appropriate for him at the moment. But he really needs something now.

[The medical resident charted a PRN (orders given as required) haloperidol order]

[Insert Figure 2 here]

In this scenario, the nurse coordinator’s advice led to the prescribing of haloperidol. The nurse coordinator gleaned first-hand information about the patient’s condition and medication needs at the bedside. Then, she moved to the staff station where the medical resident was located. Being 14

away from the bedside, the medical resident passively received clinical information provided by the nurse coordinator. The video footage vividly displayed the nurse coordinator’s geographic movement from the patient’s bedside to the staff station and her use of assertive language (“really getting,” “very aggressive”) and non-verbal language (passing the medication chart to the medical resident) to influence medication decision-making (Figure 2). The medical resident raised a question about the patient’s normal psychological status, but he did not wait for an answer. The medical resident appeared to be reluctant to initiate a new medication order without reviewing the patient. He suggested the use of temazapam that had been prescribed on the medication chart. The suggestion was overtly objected by the nurse coordinator. The nurse coordinator’s language was unmitigated and concise, “just chart haloperidol.” She then used an explicit subjectivity term, “I think,” when justifying her request for the haloperidol order. The nurse coordinator preempted what the medical registrar was likely to prescribe based on the information provided by the enrolled nurse from the emergency department. Haloperidol prescribing was often used by the medical registrar in agitated patients admitted to the ward. It was unusual for a medical resident to prescribe against his senior registrar’s opinion. The nurse coordinator’s responses to the medical resident’s statement about the haloperidol frequency and his request for an alternative treatment were strategic. The nurse coordinator demonstrated her medication knowledge by relating the haloperidol frequency to the patient’s physical build. She deferred the final medication decision to the medical resident, but she rearticulated that there was no time for tossing ideas around because of the patient’s immediate medication needs. 15

Nurses’ assertion of autonomy in decision-making was exercised not only by those with institutional status like nurse coordinators, but also by bedside nurses. During observations, bedside nurses were seen using their medication knowledge and knowledge of individual patients to confront doctors’ medication decisions when they perceived medication orders as inappropriate. Nurses’ power struggles for professional autonomy were sometimes hidden from face-to-face interactions with doctors. To handle disagreements about medication-related issues, nurses were observed incorporating pharmacists for arbitration on the appropriateness of prescribing dose, route or frequency. Nevertheless, nurses often spoke about their avoidance of challenging medical decisions because of the traditional disciplinary hierarchies. After watching the video clips demonstrating nurses’ involvement in medication decision-making during a focus group, nurses related their thoughts in different ways:

Staff nurse 1:

We are doctors’ eyes and hands. We check every single [medication] order to make sure everything is correct. But we don’t get credit for that.

Staff nurse 2:

I think we need to speak out. Nurses should go to doctors’ [ward] rounds and voice our opinions.

Through the process of video-recording and reflexivity, nurses openly acknowledged their scrutinisation of medication orders for accuracy and appropriateness. Nurses were able to reveal various subject positions they appropriated involving proactivity and surveillance to ensure 16

medication safety was addressed from their perspective. Proactive approaches enabled nurses to question medication decisions made by doctors. Nurses tended to engage in surveillance of doctors to ensure safe prescribing and to exercise their influence in decision-making processes. In addition, nurses raised their critical awareness of existing doctor-nurse power relations and made recommendations for practice change. The existing doctor-nurse power relations strengthened doctors’ authority in prescribing medication orders and nurses’ responsibility of medication administration. Power relations between clinicians and the organisation – Contesting the patient allocation structure The structure for allocating patients to different wards was based on diagnosis, which was jointly carried out by the medical registrar and hospital bed manager. The medical wards were responsible for admitting patients who experienced acute exacerbations of their chronic medical illnesses such as diabetes or airway disease. Patients in the medical wards often required multidisciplinary input and discussions about treatment options. In actual situations, the structure of patient allocation was not always clear-cut. Patients who required specialty treatment were often admitted to medical wards when there was a bed shortage in specialty wards, as demonstrated in the following video excerpt taken from a ward round observation. The discussion was about the appropriateness of treating a young patient with back pain in the medical ward:

Medical registrar:

He is a 30-year-old man with back pain and decreased mobility. Neurology [team] knows about him. 17

Medical consultant:

So what’s he here for?

Medical registrar:

Back pain and couldn’t mobilise.

Medical consultant:

So this is not a general medical issue, is it?

Medical registrar:

Um [pause].

Medical consultant:

OK. So it ends up as a general medical issue. OK, as long as he is comfortable, no neurological deficits? He’s got no reflexes? He fell, did he?

Medical registrar:

No. I cannot remember what the reason is.

Medical consultant:

I must say I have a real philosophic objection to admit a 30year old man with back pain under a general medical unit.

Medical resident:

Look, the only, sorry, the only reason it was done is that he outstayed his short stay [unit] time and he had to go somewhere [to a ward].

Medical consultant:

Well, I am a nephrologist and a physician. What am I going to do with back pain? It’s actually counter-intuitive to what these guys [hospital administrators] were trying to do. It’s stupid [raised tone]. What we are doing is just because the hospital is running out of hours and the ordinary muscularskeleton unit [beds]. It doesn’t make sense . . . I’ve got this recorded on the tape [pointing to the camera]. (Figure 3) 18

[Insert Figure 3 here]

To start with, the relationship between the medical consultant and the medical registrar in this scenario was an unequal one, with the medical consultant firmly in control of how the conversation developed. This relationship was marked by the types of questions initiated by the medical consultant and the types of answers provided by the medical registrar. The medical registrar presented the case to the medical consultant and emphasised that the neurology team had been notified about the patient’s presence in the medical ward. It was conventional practice for medical registrars to know patients’ medical histories and make referrals to relevant specialty teams. The ward round also represented an education forum where relatively inexperienced doctors presented patient information to experienced consultants who then provided education about treatment options. Following the case presentation, the medical consultant asked why the patient was admitted to the medical ward. This question appeared to be obvious − the patient was admitted for back pain and decreased mobility. This obvious question might have had another implicit meaning that the patient was not supposed to be “here” in the medical ward, as articulated in the medical consultant’s later comments. The medical registrar might have not noticed this implicit meaning at this stage. He repeated the patient’s presenting problems. The medical consultant responded with a negative question, challenging the appropriateness of managing the patient and his medications in the medical ward. The medical consultant’s question might be also seen as a challenge to the medical registrar’s performance. The power relationship was covertly expressed

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in the medical registrar’s hesitant pause and the medical consultant’s repetitive questions about the patient’s neurological status. Being familiar with the patient’s hospital trajectory, the medical resident provided an explanation to the medical consultant’s inquiry about the patient’s allocation to the ward. The language that the medical consultant and the medical resident used in the exchange is worth noting. The medical consultant’s language was blunt, using words like “must say” and “real philosophic objection.” The medical consultant precisely declared his ideological interest by making assertive claims. Conversely, the medical resident’s language was polite and defensive, using words like “sorry” and “the only reason.” The medical resident’s politeness was based on her recognition of power difference and social distance with the medical consultant. The medical resident’s explanation was a turning point where local resistance to organisational structures became evident. The doctors in the medical ward were resistant to the organisational structure for patient allocation. The medical consultant’s statement about the inappropriateness of admitting the patient to the medical ward sounded curt, dismissing the organisational power in allocating patients across hospital wards. Although the medical consultant queried about how to treat the patient, the question actually functioned as a declaration. The medical consultant spoke of himself as “a nephrologist,” which had two meanings in this context. First, the medical consultant took up a specialist position to reinforce his professional status and authority in organisational spaces. Second, the medical consultant believed that the patient would have received more appropriate medication management if he was allocated to the neurology specialty ward rather than the medical ward. The medical consultant protested against the institutional

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authority of allocating patients according to hospital demands instead of individual patients’ needs. Directly facing the camera lens, the medical consultant overtly expressed his contestation to organisational structures through his combined use of formal (“philosophic,” “counter-intuitive”) and slang (“stupid”) language. His body gesture of pointing to the camera further demonstrated his resistance to the organisational power. Taking this one step further, the medical consultant’s body language might be interpreted as his exercise of power in shaping the research process. Although the doctors’ interactions and activities were under the gaze of the camera that was controlled by the first author, the medical consultant actually took the control of the filming process by assuming a subjective position and utilising the camera to complain about his work. The medical consultant’s communication practice acted against ideological conventions on the ward where clinical practices were shaped by organisational structures. In this clinical context, the hospital resource constraint led to the admission of a patient who required neurology specialty treatment to the medical ward. Although the hospital structure was applied to all clinicians, the medical consultant was able to challenge the structure and patient treatment in a more valiant way than the registrar and the resident. This conversation occurred in a corridor space about 15 feet away from the patient’s bedside, so it was difficult for the patient to hear the doctors’ conversation. During the whole conversation, the patient was spoken about as a clinical object with no say in his hospital trajectory and treatment. The patient was positioned as an object ‘being owned’ by different teams in the hospital.

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Power relations between clinicians of multidisciplinary teams – Collaborative decision-making Multidisciplinary meetings on the medical wards were convened with clinicians from the disciplines of medicine, nursing, pharmacy and allied health to discuss and plan patient care. During the meetings, the ward consultant directed medical residents to speak about each patient, which was followed by contributions from the pharmacist, nurse coordinator and allied health clinicians. The following video-recorded excerpt was extracted from an afternoon multidisciplinary meeting. The discussion was about adjusting the analgesic dosage for a patient who had chronic back pain:

Medical resident:

[Name patient] can go home tomorrow morning. There’s a question with the local pharmacist. I wrote down the [telephone] number of the [local] pharmacy.

Ward consultant:

[Turning over to the registered pharmacist].

Registered pharmacist:

I’ve already spoken to the [local] pharmacy. Do you want us to dispense tramadol [an opioid analgesic]? She’s only had one dose [on the ward], that’s [the order] in the PRN section. Is it an ongoing plan?

Medical resident:

Yeah, she’s only had one dose so far. I don’t know what you [indicating the ward consultant] think about that?

Ward consultant:

Has she got anything else charted for PRN?

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Medical resident:

No, that’s it.

Registered pharmacist:

She is on regular paracetamol [an analgesic and antipyretic] and oxycontin [an opioid analgesic], tramadol makes them [patients] crazy. But she had it this morning.

Senior physiotherapist:

She’s got dementia.

Nurse coordinator:

If she only had one [tablet], how much does she need then?

Registered pharmacist:

The thing is if your [indicating the physiotherapist] assessment indicates she needs it. I am not sure how useful the PRN will be. Nurses said they gave it [the PRN dose] to her, an hour later, she still complained 10 out 10 pain [a numerical rating scale from 0 to 10 in which 0 means ‘no pain’ and 10 means ‘worst possible pain’].

Senior physiotherapist:

From our point of view, she will always say that. She was lying there telling me she would have 10 out 10 pain with breakthrough [of analgesics]. We got her out of bed and walked,

and

had

breakfast.

So

there

are

some

[psychological] elements of that. Ward consultant:

Alright. How about we make it 50mg [tramadol] once a day? Apparently she’s had 100mg today and she is alright. Let’s give her 50mg once a day [regularly].

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[Insert Figure 4 here]

A prominent feature of this excerpt was the ways in which clinicians engaged in medication communication and worked interchangeably with clinicians of other disciplines. Communication was organised around a case presentation by the medical resident, who subsequently raised a question about the patient’s “local pharmacist.” The medical resident did not specify what the question was, but he indicated that the ward pharmacist needed to contact the patient’s local pharmacy. The ward consultant embodied a physical gesture to coordinate team discussions by turning his head towards the pharmacist (Figure 4). The medical resident assumed that the doctors and pharmacist had already known about the case being discussed. This selective impartation of information might have denied other clinicians’ access to certain knowledge about the patient. The pharmacist disagreed about discharging the patient on tramadol. Her starting point was a direct question (“do you want . . .”), which was followed by three supporting premises − the patient only had one tramadol dose on the ward; the tramadol order was written in the PRN section; and there was a concern about the patient’s ongoing pain management. The pharmacist provided reasons to support her argument for not sending the patient home on PRN tramadol. The medical resident acknowledged the pharmacist’s reasoning by repeating her premise about the patient’s use of analgesics in the ward. He proceeded with an overt question for the ward consultant, seeking out his opinion. The ward consultant then took control of further questioning. The pharmacist responded to the ward consultant’s question about the patient’s PRN medication

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regimen with a two-part answer. First, the pharmacist’s medication knowledge about “tramadol making them crazy” worked to strengthen her argument for not discharging the patient on PRN tramadol. Second, the pharmacist’s objective knowledge about the patient (“she had it this morning”) constituted contradictory aspects to her argument. Comments made by the senior physiotherapist and the nurse coordinator supported the pharmacist’s argument. However, the nurse coordinator’s input was minimal because of her limited knowledge about the patient. The nurse coordinator participating in the meeting had just started her afternoon shift. Compared with other clinicians who had already had clinical encounters with the patient in the morning, the afternoon nurse coordinator was at a disadvantage in contributing to the medication discussion. Instead, the pharmacist represented nurses’ voices by speaking about bedside nurses’ assessments of the patient’s pain score. The senior physiotherapist’s input cannot be overlooked with her self-initiated talk about the patient’s pain level. She reconfirmed the nursing assessment of the patient’s pain score and suggested a possible cause of the patient’s pain. The ward consultant exercised his controlling role by making a final medication decision with all the information gathered. Although the decision was made by the ward consultant without seeking further advice from other clinicians up to that point, it was a joint contribution of medical, pharmacy, physiotherapy and nursing disciplines. Discussion and conclusion In this paper, we have explored the complex power relations and struggles embedded in medication communication processes using ethnographic video-recorded data. An investigation

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of social relationships within the clinical context has enhanced our understanding of power relations in medication safety practices. Although the traditional clinician-patient hierarchy persisted in medication communication processes, our observations revealed instances where patients showed resistance to power structures by speaking to the video camera and nurses about the issues of particular concerns to them within specific contextualised environments. The presence of the camera enabled patients to express their feelings and challenge existing power inequalities in the healthcare system. Patients positioned themselves as active participants, not merely passive objects of the videoing process. Fairclough’s (2006) critical approach provided a process for looking at power and resistance in a dialectic relationship – where there is power; there is resistance in overt or covert forms. Nevertheless, the patients’ voice was largely missing from decision-making processes. When patients challenged medical authority in controlling discharge time, doctors ensured the continuation of dominant power through communication practices, such as the normalisation of patient experiences and use of persuasive language. Organisational commitment should be made to involve patients in medication communication forums such as ward rounds. A structured ward round format can encourage participation of patients because they can prepare themselves with questions to discuss with doctors. Ward rounds should also involve clinicians of different disciplines to create opportunities for multi-way information exchange at the patient bedside. Previous studies highlight nurses’ engagement in the doctor-nurse game when communicating with doctors about medication management, emphasising nurses’ avoidance of disturbing the asymmetric doctor-nurse power relationship (Riley et al., 2007; Stein, 1967). However, nurses in the current study adopted assertive language and a commanding tone when requesting 26

medication orders from inexperienced doctors. When disagreements about medication decisions arose between individual nurses and doctors, nurses strategically involved a third party such as pharmacists for arbitration, challenging the cardinal rule of the doctor-nurse game where nurses had to accommodate doctors’ opinions to “avoid disagreements at all costs” (Stein, 1967, p.699). Our findings also revealed the way in which power was exercised in patient allocation. The medical consultant’s exclamation of “I’ve got this recorded on the tape” was an open manifestation of his ventilation of emotions. The videoing allowed him to display his resistance to dominant organisational power through verbal accounts and non-verbal gestures, which he might have never done before. The video had an empowering effect on clinicians. Due to the presence of the camera, clinicians were able to articulate their impromptu emotions and concerns during the actual communication encounter. Being videoed offered participants a space within which they could enact their work and articulate feelings about their work (Iedema et al., 2007). While the medical consultant could overtly resist the organisational structure of patient allocation, the patient’s physical location in the hospital remained fully determined by organisational structures. Multidisciplinary meetings exhibited a form of “collaborative power” (Nugus et al., 2007, p.901) to achieve the common goal of patient discharge and organisational efficiency. Pharmacists’ contribution to multidisciplinary meetings focused on the organisation of discharge medications. Clinicians of allied health contributed when they could add to the discussion of a particular patient. They determined the timing of talking through self-initiated turns. Nevertheless, the ward consultant exercised institutional power and professional authority by finalising treatment decisions. 27

Overall, we found that the video was a powerful research tool to uncover the complex dynamics of clinical work. Critical scholars believe that people make choices about their words to construct social identities, social relationships and beliefs (Boutain, 1999; Fairclough, 1992). The use of video techniques allowed us to pause a moment of action and analyse participants’ choices of words in great detail, looking for relationships between texts and exploring previously unnoticed features in the interactions. Video-recorded data enabled clinicians to reflect on daily clinical events, to contribute to a critical analysis of social relations and practices, and to uncover dominant and submissive forms of communication. In addition, video-recorded data validated diverse accounts gathered from other channels such as field interviews and focus groups. Video reflexivity enabled clinicians to challenge their previously taken-for-granted assumptions and power relations. By way of example, after watching video clips of their own practice, nurses recognised their active role in shaping medication decisions. Nurses’ critical examination of their contribution to medication decision-making threatened traditional medical dominance and opened up possibilities for enhanced interdisciplinary collaboration. Although we adopted Fairclough’s (1992) critical approach while interpreting language, our ultimate goal was to raise clinicians’ awareness of existing social relations embedded in medication communication processes and to challenge clinicians to think about their own practices in different ways. From the perspective of the first author, the video method provided her with upmost closeness to the clinicians and gave her an opportunity to share the process of knowledge discovery with clinicians at the same time. The use of video in capturing communication activities and enhancing clinicians’ understanding of clinical complexity through reflexivity has been well documented (Carroll et al., 2008; Iedema et al., 2007). Prior to the actual video-recording, the first author spent considerable amount of time in each ward becoming familiar with the 28

clinicians, facilitating the build-up of trust and ensuring mutual understanding. As claimed by Pink (2001), there is never any single “right moment” to start using a video camera. To get video-recording started, a key element lies in the relationship between the researcher and the researched. During video observations, the first author maintained close collaboration with clinicians to decide when and what should be recorded. Beyond the formal ethical restrictions, the first author defined her own guiding ethics of practices through seven years of clinical nursing experience. The video approach also complemented the theoretical basis of the study. Fairclough’s discourse analysis placed great emphasis on the details of the text. The video method captured most detailed data from various dimensions including verbal and non-verbal language as well as contextual environments. Thanks to the technical capacity of the video camera, we were able to seize particular moments of action and explore the meanings conveyed through the visual images. Despite Fairclough’s (1992) concerns about social inequalities, he believes that people have the capacity to resist existing social situations by challenging their ideological thinking. The video-recorded data demonstrated how participants were able to take up different subject positions during the research process to challenge the inequalities associated with clinicianpatient, doctor-nurse, clinician-organisation, multidisciplinary clinicians and researcherparticipant relationships. The study has some limitations. Despite our efforts to examine different professional groups’ perspectives on medication communication, we did not succeed in organising focus groups with doctors or pharmacists due to the rotating nature of medical and pharmacy staff on the wards.

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Nevertheless, we gathered doctors’ and pharmacists’ opinions from individual interviews, and the findings have been reported elsewhere (xxxx, 2013a, 2013b).

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