This case study will be looking at how the features of a Multi-disciplinary team on a neuroscience ward as part of an organisation culture and how this impacts on how they work and function as a team. Davies et al (2000) suggested that Organisational culture is an emergent property of that organisation’s constituent parts but nevertheless the characteristics of that culture may be described and assessed in terms of the functionality of the organisation. Organisation culture is said to emerge from things which is shared among the staff of that organisation, for example sharing beliefs, attitudes, norms of behaviour and values. Similarly it can be seen as the things that are done within an organisation; this allows the employees to make sense of the organisation allowing people to be able to work together. Some cultures may emerge from a small section of the organisation; this could be associated with power or influence for example the medical or nursing culture.
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The team on the neuroscience ward consisted of three specialist areas which are neurology, neurosurgery and neuro-oncology. The neurological conditions that are treated ranges such as hydrocephalus, spina bifida, epilepsy, encephalitis and major head injuries. The staff consisted of nurses, doctors, neurologist, physiotherapist, and specialist nurses such as epilepsy nurse. During my time on the ward I got a chance to go on daily ward rounds with the doctors and some nurses and there was also a weekly neuro ward round with the neuro-surgeon, nurses, physiotherapist and doctors to discuss the children conditions, any new admission and implementation and evaluation of each child’s care plan. The nurses also carried out assessment such as neurological observations which is the Glasgow Coma Score (GCS), this done to assess if the patient is conscious. GCS is a vital tool in assessing whether the patients’ condition is improving, remaining static or deteriorating.
The organisational culture that will be used to describe the Multi-Disciplinary team is the doctor-nurse relationship. There have been several researches that have looked into the doctor-nurse relationship; this has changed over the past years. Sweet and Norman (1995) suggested that to understand the doctor-nurse relationship we need to understand the relationship between men and women in the society. The relationship between the doctors and nurses can be a very complex as it could be to be hierarchical between nursing and medicine. Much of the research on the relationship between nurses and doctors has been based or comes from the assumption that health care organisation rests upon a hierarchical system of authority in which the doctors are at the highest position. The development of rules and norms, decision-making, control and authority are viewed as processes operating downward in the organisation, while influence from lower levels which is seen as very limited. Unlikely most researcher which suggest that the relationship between doctors and nurses is hierarchical as outlined in the doctor-nurse game, but studies by Hughes and Snelgrove (2000) and Svensson (1996) suggests that the hierarchical stereotypes has been broken down as boundaries for nurses is changing due to the changing knowledge of nursing and nurses have a stronger job role and responsibilities.
Doctor-nurse relationship is based on division of knowledge, power and authority of both nurses and doctors due to stereotypes. Nurses were seen as caring, kind and mostly females, similarly Stein (1967) describes nurses as having initiative, being bold, and were seen as being responsible for important recommendations but they seemed submissive to doctors instructions/power. Nursing was seen as an occupation not as profession like medicine, this created the sexual division of labour. The sexual division of labour is based on unequal power relations between nursing and medicine, so nurses have a different role as doctors due to the power/authority. Nursing is directed by the more powerful occupation (medicine) due to the hierarchy of power, authority and status of medicine which is sometimes expressed as an open/hidden conflict.
Doctors and nurses are said to have a degree of mutual cooperation as their relationship can fit into a game model; Stein (1967) describes the relationship as a game which allows the nurses to inform and advise the doctor without challenging their position. Doctors tend to have total responsibility for making decisions regarding the patient but to help with decision-making are nurses. The doctor-nurse game was developed in the 60’s to help explain stereotypic and hierarchical way of interacting with the doctors. The rule of the game is that open disagreement between
the players must be avoided at all costs, but the nurse must communicate her recommendations without appearing to be making a recommendation statement and the physician(doctor) must not appear to request any recommendation from the nurse( Stein, 1967). This allows the both professions to keep their position and power as the hierarchy suggests so open disagreement is prevented and direct communication is avoided.
The game is scored using a reward-consequence method as is shared by both players, so if the game is played poorly they both suffer the consequences but if they played successfully they both enjoy the reward of a more effective communication and an efficient team. The success of the game creates respect between the doctor and nurse which gives the nurse a sense of value for her role and the doctor gains confident in the nursing staff, therefore providing good services to patient.
The doctor-nurse game was later revisited in 1990, due to changes in the society and the old stereotypes view of hierarchical power between doctor and nurses.
Stein (1990) stated that the number of female doctors increased in the 90’s but the medical training was the same for both male and female doctors. Although medical students go through the same training whether male or female, female doctor did not reflect the stereotypical roles of male power and this brought about the increase of male nurses. Research shows that medical profession has been male dominated while nursing has been regarded as a typical female career, but although medicine is still male dominated, there has been an increase of females into medicine and also an increase of male entry into nursing (Gjerberg and Kjolsrod, 2001).
The image of nursing has also changed as it seems that nurses are gaining more respect, power and autonomy but they might never have the same power that doctors have. Nurses have more specialist roles and duties as they are being trained and educated to specialist in some clinical areas such as intensive care units. This new roles gives nurses more responsibility for their patients as they have more knowledge of certain conditions. Nurses would like nursing to become autonomous profession which has clearly defined roles and expertises. Nowadays nurses have a strong position as they have more important role on the ward for example nurse have a better knowledge of patients and their conditions, as they provide continuity and individual care to patients. Nurses are mostly based on the wards compared to doctors who spend very little time on the wards, so the nurse gets to know and manage the patients care. The knowledge nurses have of their patients gives them a unique position, as nurses will know what the patient can do alone or with help, therefore this makes doctors more dependent on the nurse knowledge. In the study by Svensson (1996) it is evident that there is a good relationship between the doctors, nurses and also the non-specialist nurses as it is mutual and direct. Svensson (1996) stated the nurse relationship with both the doctor and patient has changed as it was previously divided among personnel on the ward, but now with fewer patients the relationship is deeper and the knowledge of the patient is not via the ward sister but directly with the doctor. This therefore reinforces the nurse’s role and allows more direct relationship with doctors.
Stein (1990) found out that nurses decided to stop playing the doctor-nurse game but are focusing on changing nursing and how nurses relate to other professionals. In conclusion, the relationship between doctors and nurse could be both negative and positive but more open communication between doctors and nurses could improve the patient care, but some doctors are reacting badly of the changes but alternatively nurses are happy for the freedom of nursing as an autonomous professional. Hughes and Snelgrove (2000) and Stein (1990) both suggested that nurses are fighting for freedom and recognition to make the nursing profession autonomous, but concurrently nurses roles are extended therefore they have more responsibility for their patients.
The doctor-nurse game by stein (1967) is a very old research but it most of the research can still be applied to doctor-nurse relationship. The game promote good communication between doctors and nurses only if the game is played properly as it requires open and direct communication, this will help the team operate effectively. It also encourage leadership structure of any organisation especially those on top of the hierarchy, as lack of structure creates stress and anxiety. The game is based on the nature of the doctors and nurses training which shaped the attitudes necessary for the game. Nursing training is very different from medical training as nurses learn to play the game throughout their training, they are taught how to relate to doctors and that they have more knowledge and should be shown respect, whilst doctors learn the game after medical school, they learn so much that they believe their life depends on it which cause fear of making a mistake.
The doctor-nurse game does not allow nurses or doctors to fully express their views especially if their recommendation does not match with the doctor’s decision making. The rule of the game does not allow open disagreement, so the nurse can only communicate her recommendation without making any complaints. If the game is played this way it will be played successfully and it will create agreement between doctors and nurses, so they both have to come to a compromise despite their opinions or beliefs. This research used observational study to describe the behaviour of nurses and doctors whilst their communicating in their natural environment (hospital).
From my experience it is evident that the Gender-related power issue still exist on the wards especially the older doctors as they still see themselves as being in full control and nurses as inferior as described in the doctor-nurse game.
Another explanation of doctor-nurse relationship is negotiated order, Svensson (1996) and Allen (1997) both carried out studies looking at doctor-nurse negotiation order. Svensson suggested that the negotiated order perspective is more appropriate way of understanding the doctor-nurse relationship compared to the doctor -nurse game by Stein (1967). The study interviewed 45 nursing staff at 5 hospitals in Sweden to understand how doctor and nurse interact and to develop further idea on how negotiated order works on the ward. From his finding it can be suggested that the negotiation order has changed dramatically but it fits in with the old negotiated order. The nurses interviewed were satisfied with their relationship with the doctors; as their communication is straightforward and open, and they are able to convey their ideas and opinions to the doctor, who listens and takes account of their views, but very few nurses expressed frustration or limitation when communicating with doctors, this does not mean that problems or conflicts do not exist in the relationship with doctors. Research has shown that the negotiation between professionals have changed since the past, as this is evident in the Svensson (1996) study as the nurses interviewed were able to give a full insight into their relationship with the doctors.
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The findings from the study by Svensson (1996) was carried out in Sweden so the results may not be generalised to other countries but the theory of negotiated order of doctor-nurse relationship can be apply to any hospital in any country. The sample size was small as only 45 staff nurses’ ad ward sisters from 14 wards were interviewed; it could be difficult to generalise to different ward and hospitals in Sweden.
Allen (1997) carried out an ethnographic study from data generated from a medical and surgical ward in England, looking at how doctors and nurses work in a hospital environment and what hinders negotiation between both occupation that has resulted in division of labour but the aim of the study was to build on Svensson study. Allen (1997) observed all the staff on the ward and was also a participant depending on the situation then interviewed 11 nurses, 5 auxiliaries, 3 healthcare assistants and 11 clinical managers using semi- structured interview. Finding from this study suggests that nursing, medical and support staff’s take on their roles and duties with minimum negotiation with each other which reduces occupational disagreement. Allen (1997) concluded that the expectation of the research was not met as the interviews carried out the ward staff didn’t reflect the observation on the ward.
All the research looked at had all used ethnographic methods to collect data regarding the doctor-nurse relationship. Ethnography research is done to make sense of people’s actions and behaviours that occurs within teams, groups and organisation by observing them in their environment (Hodges et al, 2008). Hodges et al (2008) stated that the aim of ethnography is to provide rich, holistic insights into people’s views and actions as well as the nature of the location they inhabit, through the collection of detailed observations and date pg 512. Advantage of ethnography is that participant observation will enable researcher to immerse themselves in a setting, therefore providing rich data as to why people behave the way they do within their setting (Hodges et al, 2008). For example in all the studies the researchers were able to observe and understand how doctors and nurses on the ward work together.
One limitation of conducting an ethnography study is the ‘Hawthorne effect’ which may occur when people are been observed as they may change their behaviour (Roberts, 2009). Chiesa and Hobbs (2008) defines Hawthorne effect as an influence that can occur in experiments when subjects know they are being studied and change their behaviour as a result. Another limitation is that it can be difficult for the researcher not to become to engrossed in the study that the results may be subjective/bias.
Whilst on placement I got the opportunity to observe the relationship of doctors and nurses and how they interact with other professionals on the ward as a student nurse. From my observations doctor-nurse relationship on the ward can be explained using the doctor-nurse game (Stein, 1967), non-negotiated order and negotiated order (Svensson, 1996 and Allen, 1997), as it depends on the circumstances and job task. An example of doctor-nurse game is during any decisions regarding a patient’s treatment, i.e. a nurse recommending to a doctor that a patient needs a change of medication or need a particular medication prescribing.
An example of negotiated order is daily ward round that is done to check on patient’s progress, feedback on care, chance for patients to ask about their conditions, it also consists of consultants, doctors, junior doctors, nurses, students and other relevant health professional. Ward round helps to enhance patient care, sharing information and improve communication between each member of the multi-disciplinary team. Whilst on ward round the nurses take note of each patients plan of care or treatment, then after ward round the information is passed on to other nurses.
An example of non-negotiated order is social conversations between doctors and nurses.
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