Communication Between Doctors and the Quality of Patient Care: An Intergroup Perspective

Hewett, David George (2010). Communication Between Doctors and the Quality of Patient Care: An Intergroup Perspective PhD Thesis, School of Medicine, The University of Queensland.

       
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Author Hewett, David George
Thesis Title Communication Between Doctors and the Quality of Patient Care: An Intergroup Perspective
School, Centre or Institute School of Medicine
Institution The University of Queensland
Publication date 2010-08
Thesis type PhD Thesis
Supervisor Professor Barbara A. Leggett
Professor Cindy Gallois
Dr Bernadette M. Watson
Professor Michael Ward
Total pages 155
Total colour pages 14
Total black and white pages 141
Subjects 11 Medical and Health Sciences
Abstract/Summary In this thesis I examined communication between hospital doctors and the influence of their communication on the quality of patient care. Communication failures in the complex, socio-technical environment of hospital care are widely considered to affect the quality of care and the occurrence of inadvertent patient harm. Research indicates the importance of social identity and intergroup relationships articulated through power, control, status and competition. This research adopted a language and social psychology theoretical framework to understand the intergroup dynamics in large health care organisations. The underlying theoretical premise for this inquiry was that communication between doctors is an intergroup process. The first study evaluated whether communication between doctors predicts the quality of care for hospital patients. I conducted a retrospective observational study of all patients hospitalised with upper gastrointestinal bleeding in a large teaching hospital. The study measures were process and outcome indicators of the quality of care, including time taken to perform upper endoscopy, and measures of interspecialty communication derived from medical record review. I used multiple logistic regression to assess the impact of interspecialty communication behaviours and clinical features on the quality of care. Early endoscopy (within 24 hours of admission) was predicted by communication between doctors from the emergency department or admitting unit and a gastroenterologist (OR 21.4, p < .001), admission within the gastroenterology unit (OR 22.7, p < .01), and admission on weekdays (OR 3.72, p = .01). The Blatchford clinical severity score was not a significant predictor of early endoscopy. Interspecialty communication strongly predicted the quality of care for patients with upper gastrointestinal bleeding, and was more important than traditional clinical variables. These findings implicate the interface between specialty units as a source of variation in the quality of patient care, and suggest a potential target for quality improvement interventions. The second study focused on interspecialty communication among doctors, for patients requiring the involvement of multiple specialist departments. I conducted an interview study, framed by social identity and communication accommodation theories, of doctors’ experiences of managing such patients, to explore the impact of communication. Interviews were analysed using Leximancer (text-mining software) and interpretation of major themes. Findings indicated that intergroup conflict is a central influence on communication. Contested responsibilities emerged from a model of care driven by single-specialty ownership of the patient, with doctors allowed to evade responsibility for patients over whom they had no sense of ownership. Counter-accommodative communication, particularly involving interpersonal control, appeared as important for reinforcing social identity and winning conflicts. The third study investigated doctors’ written communication using a sample of medical records, specifically doctors’ progress notes, and the frameworks of social identity and communication accommodation theories. These records include standardised and stylised language, and are intended to record assessment and treatment of patients according to known guidelines for practice. An interpretive analysis of the language and discourse in these records revealed that doctors used medical record entries both to express their specialty identity and to negotiate intergroup conflict. Non-accommodation and interspecialty conflict sometimes took precedence over facilitation of patient treatment and management. The final study employed survey methods to triangulate findings from the earlier studies. One hundred and forty-seven doctors from several specialties completed a questionnaire on their perceptions of responsibility for patient care, perceptions of their own and other specialties, and beliefs about hospital policies; they also interpreted medical record entries by members of their own or other specialties. Results indicated disagreements over which doctor should take responsibility for multiple aspects of patient care, with differences predicted by group memberships. Doctors believed that patient care was best handled by doctors with an interpersonal connection or at the same level of seniority. In interpreting written communication, participants were more proficient when the record was written by a member of their ingroup, as the charts contained ingroup language and concepts. Together, these studies explored the impact of intergroup communication on the quality of patient care in hospitals. Specialty identity and intergroup conflict were invoked over ambiguous and contested responsibilities for patient care. Patient care was a commodity over which identities were negotiated and conflict enacted. Intergroup behaviour allowed clinicians to evade responsibility for patient care; blame between specialty departments was prevalent and intergroup communication, including strong negative statements about members of other specialties, was the norm. The findings implicate the structural organisation of patient care in the genesis of an intergroup climate, and indicate a central and pervasive influence of identity on communication between doctors and intergroup conflict on patient care. These findings have clear implications for future research, where there is a need to investigate strategies to resolve intergroup conflict and to develop health care improvement strategies that consider the intergroup context of health care delivery. To be effective, interventions must focus on the structural aspects of hospitals as organisations, ambiguities in which currently perpetuate intergroup disharmony. Interventions to increase the interpersonal salience of interactions may moderate the impact of intergroup factors, but this strategy alone will not solve the problem. Hospitals are intergroup organisations, and the quality of patient care must be addressed through intergroup means.
Keyword Intergroup Communication
Social identity theory
Communication Accommodation Theory
Health
upper gastrointestinal bleeding
medical records
Patient safety
Australia
Additional Notes Colour: 4, 5, 63, 145-155 A3: nil Landscape: 49, 106

 
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Created: Fri, 12 Nov 2010, 06:01:56 EST by Dr David Hewett on behalf of School of Medicine