Everyday practices at the medical ward: a 16-month ethnographic field study

Axel Wolf 0 1 Inger Ekman 0 1 Lisen Dellenborg 1 2 0 Centre for Person-Centred Care (GPCC), University of Gothenburg , Gothenburg , Sweden 1 Institute of Health and Care Sciences, Sahlgrenska Academy, University of Gothenburg , Gothenburg , Sweden 2 Vardalinstitutet - The Swedish Institute for Health Science , Lund , Sweden Background: Modern hospital care should ostensibly be multi-professional and person-centred, yet it still seems to be driven primarily by a hegemonic, positivistic, biomedical agenda. This study aimed to describe the everyday practices of professionals and patients in a coronary care unit, and analyse how the routines, structures and physical design of the care environment influenced their actions and relationships. Methods: Ethnographic fieldwork was conducted over a 16-month period (between 2009 and 2011) by two researchers working in parallel in a Swedish coronary care unit. Observations, informal talks and formal interviews took place with registered nurses, assistant nurses, physicians and patients in the coronary care unit. The formal interviews were conducted with six registered nurses (five female, one male) including the chief nurse manager, three assistant nurses (all female), two cardiologists and three patients (one female, two male). Results: We identified the structures that either promoted or counteracted the various actions and relationships of patients and healthcare professionals. The care environment, with its minimalistic design, strong focus on routines and modest capacity for dialogue, restricted the choices available to both patients and healthcare professionals. This resulted in feelings of guilt, predominantly on the part of the registered nurses. Conclusions: The care environment restricted the choices available to both patients and healthcare professionals. This may result in increased moral stress among those in multi-professional teams who work in the grey area between biomedical and person-centred care. - Background In the contemporary care environment, the need for strong person orientation rather than disease-centeredness is considered both important and self-evident. However, healthcare professionals still tend to focus on the disease within the person rather than the person with the disease [1]. Ethnographic studies suggest that biomedical knowledge takes precedence in multi-professional dialogue, and that even when physicians are not present, other professionals such as nurses act as deputies for medicine [2]. It appears that the shift from traditional, disease-centred care towards more person-centred, multi-professional care is complicated and slow, and that a variety of challenges such as care fragmentation, time restraints and performance/ target-driven organisations are slowing this shift [3,4]. Michel Foucault argues that modern healthcare and its organisation are based on the historical ideal of the medical discourse as a positivistic tradition built around objectivity [5]. In line with this thought, modern healthcare has adopted a routine-based method of organising care, reducing a unique, living person to a two-dimensional text entry in a lab test form or medical journal [6]. Patients are seen as generalizable, pathological processes rather than individual people in a particular context [7-9], and little scope is available for more subjective interpretations, e.g. a hermeneutical approach [10] or person-centred care (PCC). The patient-healthcare professional interaction of today is somewhat standardised, regardless of whether it involves inserting a catheter or listening to the patients story [11]. This approach tends to transform the patient into a source of information rather than a partner in personcentred care [1]. Such a narrow, biomedical perspective may generate feelings of invisibility and inferiority in patients [12-14], and cause healthcare professionals to objectify patients [15]. PCC highlights the importance of both knowing the unique person that is the patient [16], and engaging with the patient as an active partner in the therapeutic alliance, sharing both power and responsibility [17]. The modern healthcare agenda is increasingly emphasising the importance of partnership between patients and healthcare professionals [17-20]. According to Long el al., understanding the hospital context is becoming increasingly important [21]. However, most clinical studies have only been concerned with specific practices or a certain profession [22]. These studies reduce the clinical setting to a series of isolated interactions or professions, commonly disregarding the complexity of the care environment [23]. The modern clinic is a social world comprising patients, nurses, physicians and other care providers who work at the clinic [10]; as well as a physical context [24-26]. By reducing the clinical world to a series of isolated situations, several studies investigating PCC have targeted specific areas of care, or the patient-physician/patient-nurse relationships [17,27,28]. The dynamics of a clinical setting and its resistance to transition also need to be understood in relation to the complex social world in which the setting exists [29]. Few ethnographic studies have targeted the everyday spectrum of relationships between different kinds of professionals and the patient within the hospital setting [21]. We lack knowledge of how the routines and values of the care environment influence patients and healthcare professionals in everyday hospital practice [22,30]. We aimed to describe the everyday practices of professionals and patients at an internal medical ward in order to analyse how the specific care environment, with its routines, structures and physical environment, influences the purposes, actions and relationships of both patients and healthcare professionals. Methods Study design and study site This study is based on data collected during a 16-month fieldwork period (between 2009 and 2011) in a Swedish coronary care unit. One male and one female researcher (the first and third authors) conducted the fieldwork. The main methods used to collect data were participant observation, informal talks and formal interviews. During the fieldwork, the discrepancy between what people say and what they do was explored. This is invaluable in the study of complex, multi-professional settings such as a hospital clinic. Ethnography involves thick descriptions [31] of social phenomena focusing on a participants way of understanding a situation [10]. Besides acting as a set of techniques for observing social phenomena, ethnography is a particular way of seeing. It is a reflective process in which the researcher strives to see beyond what is taken for granted by themselves and the participants [32]. The fieldwork was carried out in a coronary care unit at a Swedish university hospital with a conceivable catchment area of over 250,000 residents. The ward comprises an intensive care unit (six single rooms) a (...truncated)