Our findings illustrate a remarkable contrast in the quantity and quality of interprofessional relationships and work when comparing the communication styles and strategies of hospitalist and consultant physicians in this study. We found that both scheduled and unscheduled face-to-face communication with hospitalists was experienced by staff at all sites to be of an overwhelmingly higher frequency and caliber than that with consultants who some staff did not communicate with in person at all. He continuous presence of hospitalists on the inpatient ward and the perceived and expressed interest of hospitalists to interact in a collegial way with nurses and allied health care providers led to more frequent and effective collaborations in patient assessment and discharge planning. Other health care providers experienced this positively for job satisfaction and morale. Hospitalists themselves promoted the strength of their relationships with other health care providers and believed themselves to be fortunate for having them.
By comparison, nurses and allied health care providers in this study reported a lack of participation and a perceived general lack of interest on the part of consultants in both professional and interpersonal relations reporting poor or non-existent face-to-face communication with them. By and large, consultants were not found to be easily accessible or readily approachable to engage in interprofessional communication. Some health care providers even avoided using real-time communication and relied on charts to convey patient information, a strategy that was recognized as occasionally sub-optimal. Surprisingly, this finding was echoed by consultants interviewed for the research, some of whom were themselves frustrated with the nature of interprofessional communication but felt unable to change the structurally embedded and fragmented way that it happened in their settings. The one-way, task-oriented asynchronous communication described here by a consultant as doctors writing the orders and staff carrying it out resonates with findings from a study of interprofessional rehabilitation units where communication was constrained by hierarchical relations between team members
. In this study, junior nurses and support staff were perceived to occupy a lower and less autonomous status than senior nurses, allied health care practitioners, and physicians which impacted the way that others communicated information to them. Our findings suggest that in the GIM settings where consultants primarily work, nurses and allied health care providers work in a silo running parallel to the physician, which can lend to their perception of not being valued in the physicians’ decision making processes.
Sociological research on interprofessional interactions and relations informs us that ward structure and team design can certainly influence the culture of communication and health care providers’ experiences with the quality and effectiveness of interprofessional work
[35–39]. Most significant for this study is the interactionist approach, a sociological theory that holds individuals’ interactions with others construct their social world
. This provides a useful conceptual framework for understanding how team members’ interactions and communication in their every day work on the unit impact their perceived interprofessional relationships. For instance, research by Ellingson
, drawing upon Goffman’s backstage-frontstage framework, examines communication on an interprofessional geriatric oncology team. Ellingson conceptualizes the clinic backstage as the space away from patients where providers discuss their assessments, while the clinic frontstage is for patient-provider interactions. Findings from her study highlight the importance of provider information exchange and interactions that happen exclusively in the clinical backstage in order to enact effective teamwork everywhere. In our study in GIM, the hospitalist model of care also helped to establish a cohesive “backstage” clinical environment in which physician involvement in ad hoc, social, interprofessional communication, as well as dialogue about patient care, allowed for the development of collegial relationships with other health care providers and unit members. Indeed hospitalists in this study believed themselves to be fortunate to be able to participate in the health care team in this way. While consultants were perceived by colleagues to be caring and competent doctors, their “frontstage” work alone was viewed to be insufficient for effective team-based care.
Findings from this study also echo previous research about the advantages of health care professionals’ co-location for establishing a sense of “boundedness” suggesting that the closer in proximity providers work to one another, the greater the opportunity and outcome for interprofessional care
[42–44]. Hospitalists in our study were perceived to be highly accessible for opportunistic face-to-face communication with other health care providers and also approached others more often for their clinical opinions. In addition, hospitalists’ availability to attend rounds and social-type unit gatherings as a result of not having to leave the ward regularly allowed for more timely and collaborative decision-making regarding patient care, potentially including joint visits to the patient. Baggs and Schmitt’s study
 of perceptions of collaboration among ICU nurses and resident-physicians similarly found that both availability for and receptivity to collaboration were needed for effective working relationships to occur. This included such traits as openness, respect and trust among colleagues, dimensions of interprofessional interaction that were perceived to be lacking within some consultant-staffed units in our study.
Poor interprofessional communication and relationships in such specialties as surgery and intensive care have been previously attributed to the hierarchical relations that persist between the health care professions
[45–47]. Historically, negotiations among health care professionals, especially nurses and physicians, around decision-making, autonomy, and role enactment have been found to result from the hierarchical structure of the medical system which places physicians in a dominant position
[38, 47–49]. The sometimes-implicit, sometimes-explicit dominance of physicians as compared to other professions in the acute hospital setting has been argued to impede the establishment of collegial communication strategies and relationships between physicians and others
; to inhibit some professionals from speaking up even in settings designed for interprofessional interaction
; and to reinforce negative interprofessional behavior among junior physicians
. While the former findings of poor collegiality and staff inhibition appeared to persist in participants’ experiences on consultant-staffed wards in this study, the latter issue of reinforcing negative interprofessional relations could be changing. The suggestion by some participants in this study that junior consultants communicated differently with their nursing colleagues is indicative of this. The junior consultant-nurse relationship may be making incremental changes responsive to the more complex needs of patients and the system at large. This may be reflective of a redefinition of professionalism in the health care fields with the inclusion of an interprofessional approach
. Continuing education in interprofessional collaboration and teamwork skills among physicians of all levels of experience may lead to improved communication in the interprofessional setting. Future research might explore the evolving attitudes and behaviors of this particular group of physicians and its significance for the effectiveness of health care team communication for achieving high quality patient and provider outcomes.
This study has taken a novel approach to understanding potential transformations in the culture of communication in GIM units by comparing the communication styles and strategies of hospitalist and consultant physicians, as well as the experiences of the health care providers working with them. The study is limited however, first methodologically, and secondly in scope. Methodologically, the study is limited by the empirical generalizability of our findings to GIM units that are structured differently and composed of markedly different health care providers or those with different levels of training and experience. The small sample size is also limited. Our criterion sampling technique aimed to capture a broad range of perspectives and experiences rather than a depth of experience from each category of health care provider. While this was achieved, there remains a gap in our findings about profession-specific understandings and use of communication strategies and techniques in the provision of optimal interprofessional patient care. A longer period of more sustained observations would also help to capture this richer data. In addition, due to the nature of GIM health care providers’ busy schedules, half of our interviews were conducted over the telephone at times that were most convenient for participants and ensured confidentiality, e.g., from home, or off hospital property. A limitation of telephone interviews is the inability to capture non-verbal cues from participants, and perhaps, lack of opportunity to establish a similar rapport between researcher and participant. Future research that consists of all face to face interviews, as well as prolonged observation and additional profession-specific interviewing can address these limitations to further enhance our exploration and understanding of this area.
In terms of the scope of this research, additional interview questions that explore the advantages and disadvantages of physician-staffing models from the patient’s perspective and for communication with health care providers outside of the hospital setting are important perspectives that could not be captured in the present study.