Values at work

Comparing affirming and challenging narratives of nurses and physicians in a large health system

Authors

  • Richard M. Frankel Indiana University School of Medicine
  • Thomas S. Inui Indiana University School of Medicine
  • Orit Karnieli-Miller Tel-Aviv University

DOI:

https://doi.org/10.1558/cam.35227

Keywords:

communication, interprofessional relationships, language, professional education, social values

Abstract

Tensions between nurses and physicians have been linked to differences in power, hierarchy, education, compensation and gender. Less attention has been paid to the underlying values on which these differences are predicated. Likewise, little is known about how frequently values conflicts are resolved, and the threats to patient safety unresolved conflicts pose. Our aim was to compare the values embedded in affirming and challenging narratives elicited from nurses and physicians from a large health system. We used thematic analysis and descriptive statistics to assess goodness-of-fit of observed differences in themes. Narratives were coded into eight values categories. Nurses felt affirmed by emotional investment, altruism, humanism, and being of service; for physicians, it was humanism and teamwork. Nurse challenges involved respect, altruism/kindness and emotional investment. For physicians it was also respect and, in addition, professionalism, being of service, humanism and teamwork. Some values affirming narratives, e.g., humanism, were indistinguishable, while for some values challenging narratives e.g., respect, there was virtually no overlap. Participant narratives provide important insights into work-life satisfaction and tensions arising from differences in the underlying values of close working professional groups. Unresolved values conflicts are a potential threat to quality, safety and effective relationships.

Author Biographies

Richard M. Frankel, Indiana University School of Medicine

Richard Frankel is professor of medicine and geriatrics at Indiana University School of Medicine and currently the director of the ASPIRE (Advanced Scholars Program for Internists in Research and Education) Fellowship. He is also a senior health services research scientist at the Regenstrief Institute and a staff member in the Education Institute at the Cleveland Clinic, where he co-leads the Civility, Professionalism and Resilience program. He has published more than 275 scientific articles and authored or edited seven books.

Thomas S. Inui, Indiana University School of Medicine

Thomas S. Inui received his MD from Johns Hopkins School of Medicine. A retired academic physician and active community service volunteer, his emphasis in teaching and research has included physician–patient communication, chronic disease management, health promotion and disease prevention, the social context of medicine and medical humanities. He has published more than 335 peer-reviewed articles and authored or edited eight monographs and books.

Orit Karnieli-Miller, Tel-Aviv University

Orit Karnieli-Miller has a PhD in social work from the University of Haifa, focused on communication in healthcare. She is currently Associate Professor at the Sackler School of Medicine at Tel Aviv University.Her emphasis in teaching and research is on physician–patient communication, breaking bad news, shared decision making, triadic (doctor–patient– companion) communication and professionalism.

References

Agency for Healthcare Research and Quality (2016) The six domains of healthcare quality. Retrieved from: http://www.ahrq.gov/professionals/quality-patient-safety/talkingquality/create/sixdomains.htm

Aiken, Tonia D. and Joseph T. Catalano (1994) Legal, Ethical and Political Issues in Nursing. Philidelphia, PA: Davis.

Arford, Patricia H. (2005) Nurse-physician communication: An organizational accountability. Nursing Economics 23 (2): 72-77.

Attridge, Mark (2009) Measuring and mangaging employee work engagement: A review of the research and business literature. Journal of Workplace Behavioral Health 24 (4): 383-398. https://doi.org/10.1080/15555240903188398

Batalden, Paul B., Eugene C. Nelson, William H. Edwards, Marjorie M. Godfrey and Julie J. Mohr (2003) Microsystems in health care: Part 9. Developing small clinical units to attain peak performance. Joint Commission Journal on Quality and Safety 29 (11): 575-585. https://doi.org/10.1016/S1549-3741(03)29068-7

Bobiak, Sarah N., Stephen J. Zyzanski, Mary C. Ruhe, Caroline A. Carter, Brian Ragan, Susan A. Flocke, David G. Litaker and Kurt C. Stange (2009) Measuring practice capacity for change: A tool for guiding quality improvement in primary care settings. Quality Management in Healthcare 18 (4): 278-284. https://doi.org/10.1097/QMH.0b013e3181bee2f5

Borkan, Jeffrey (1999) Immersion/crystallization. In Benjamin F. Crabtree and William L. Miller (eds) Doing Qualitative Research (2nd edition), 179-194. Thousand Oaks, CA: Sage.

Braddock, Clarence III, Pamela Lynn Hudak, Jacob J Feldman, Sylvia Bereknyei, Richard Frankel and Wendy Levinson (2008) ‘Surgery is certainly one good option’: Quality and time-efficiency of informed decision-making in surgery. Journal of Bone and Joint Surgery 90 (9): 1830-1838. https://doi.org/10.2106/JBJS.G.00840

Branch, Willian T. and Anthony Suchman (1990) Meaningful experiences in medicine. American Journal of Medicine 88 (1): 56-59. https://doi.org/10.1016/0002-9343(90)90128-Z

Carter, Caroline A., Mary C. Ruhe, Sharon Weyer, David Litaker, Ronald E. Fry and Kurt C. Stange (2007) An appreciative inquiry approach to practice improvement and transformative change in health care settings. Quality Management in Healthcare 16 (3): 194-204. https://doi.org/10.1097/01.QMH.0000281055.15177.79

Charmaz, Kathy (1995) Grounded theory. In Jonathan A Smith, Rom Harré and Luk Van Langenhove (eds) Rethinking Methods in Psychology, 27-49. London: Sage. https://doi.org/10.4135/9781446221792.n3

Clancy, Carolyn M. (2007) TeamSTEPPS: Optimizing teamwork in the perioperative setting. Association of periOperative Registered Nurses 86 (1): 18-22. https://doi.org/10.1016/j.aorn.2007.06.008

Cooperrider, David L. (ed.) (2001) Appreciative Inquiry: An Emerging Direction of Organization Development. Champaign, IL: Stipes.

Cooperrider, David L. and Diana Whitney (2005) Appreciative Inquiry: A Positive Revolution in Change. San Francisco: Berrett-Koehler.

Cresswell, John W. and Dana L. Miller (2000) Determining validity in qualitative inquiry. Theory into Practice 39 (3): 124-130. https://doi.org/10.1207/s15430421tip3903_2

Curtis, Kate, Alex Tzannes and Trudy Rudge (2011) How to talk to doctors: A guide for effective communication. International Nursing Review 58 (1): 13-20. https://doi.org/10.1111/j.1466-7657.2010.00847.x

De Meester, Koen, Martijn Verspuy, Koenraad G. Monsieurs and Peter Van Bogaert (2013) SBAR improves nurse-physician communication and reduces unexpected death: A pre and post intervention study. Resuscitation 84 (9): 1192-1196. https://doi.org/10.1016/j.resuscitation.2013.03.016

Flanagan, John C. (1954) The critical incident technique. Psychological Bulletin 51 (4): 327-358. https://doi.org/10.1037/h0061470

Frankel, Richard M. (2000) ‘Captain, I was trying earlier to tell you that you made a mistake’: Deference and demeanor at 30,000 Feet. In Joy K. Peyton, Peg Griffin, Walt Wolfram and Ralph Fasold (eds) Language in Action: New Studies of Language in Society, 289-299. Kresskill, NJ: Hampton Press.

Gittell, Jody H., Kathleen M. Fairfield, Benjamin Bierbaum, William Head, Robert Jackson, Michael Kelly, Richard Laskin, Stephen Lipson, John Siliski, Thomas Thornhill and Joseph Zuckerman (2000) Impact of relational coordination on quality of care, postoperative pain and functioning, and length of stay: A nine-hospital study of surgical patients. Medical Care 38 (8): 807-819. https://doi.org/10.1097/00005650-200008000-00005

Haig, Kathleen M., Staci Sutton and John Whittington (2006) SBAR: A shared mental model for improving communication between clinicians. Joint Commission Journal on Quality and Patient Safety 32 (3): 167-175. https://doi.org/10.1016/S1553-7250(06)32022-3

Havens, Donna S., Joe Vasey, Jody H. Gittell and Wei-Ting Lin (2010) Relational coordination among nurses and other providers: Impact on the quality of patient care. Journal of Nursing Management 18 (8): 926-937. https://doi.org/10.1111/j.1365-2834.2010.01138.x

Hojat, Mohammadreza, Salvatore Mangione,Thomas J. Nasca, Joseph S. Gonnella and Mike Magee (2005) Empathy scores in medical school and ratings of empathic behavior in residency training 3 years later. Journal of Social Psychology 145 (6): 663-672. https://doi.org/10.3200/SOCP.145.6.663-672

Joint Commission Resources (2009) The Joint Commission Guide to Improving Staff Communication (2nd edition). Oakbrook Terrace, IL: Joint Commission on Accreditation of Healthcare Organizations.

Karnieli-Miller, Orit, Amanda C. Taylor, Thomas S. Inui, Steven S. Ivy and Richard M. Frankel (2011) Understanding values in a large health care organization through work-life narratives of high-performing employees. Rambam Maimonides Medical Journal 2 (4): Art. e0062. https://doi.org/10.5041/RMMJ.10062

Leonard, Michael, Suzanne Graham and Doug Bonacum (2004) The human factor: The critical importance of effective teamwork and communication in providing safe care. Quality and Safety in Health Care 13 (Suppl. 1): i85-i90. https://doi.org/10.1136/qshc.2004.010033

Leners, Debra W., Carol J. Roehrs and Adam Piccone (2006) Tracking the development of professional values in undergraduate nursing students. Journal of Nursing Education 45 (12): 504-511. https://doi.org/10.3928/01484834-20061201-06

Militello, Laura G. (1998) Learning to think like a user: Using cognitive task analysis to meet today’s health care design challenges. Biomedical Instrumentation & Technology 32 (5): 535-540.

Mitchell, Pamela, Matthew Wynia, Robyn Golden, Bob McNellis, Sally Okun, C. Edwin Webb, Valerie Rohrbach and Isabelle Von Kohor (2012) Core principles & values of effective team-based health care. Discussion Paper, Institute of Medicine, Washington, DC. https://doi.org/10.31478/201210c

Morgan, David L. (2008) Snowball sampling. In Lisa M. Given (ed.) The Sage Encyclopedia of Qualitative Research Methods, 816-817. Thousand Oaks, CA: Sage.

O’Leary, Kevin J., Jason A. Thompson, Matthew P. Landler, Nita Kulkarni, Corinne Haviley, Katherine J. Hahn, Jiyeon Jeon, Diane B. Wayne, David W. Baker and Mark V. Williams (2010) Patterns of nurse-physician communication and agreement on the plan of care. Quality and Safety in Health Care 19 (3): 195-199. https://doi.org/10.1136/qshc.2008.030221

Reichers, Arnon E. and Benjamin Schneider (1990) Climate and culture: An evolution of constructs. In Benjamin Schneider (ed.) Organizational Climate and Culture, 5-39. San Francisco: Jossey-Bass.

Schaufeli, W. B., Arnold B. Bakker and Marisa Salanova (2006) The measurement of work engagement with a short questionnaire: A cross-national study. Educational and Psychological Measurement 66 (4): 701-716. https://doi.org/10.1177/0013164405282471

Stacey, Ralph D. (1996) Complexity and Creativity in Organizations. San Francisco: Berrett-Koehler.

Starfield, Barbara, Donald Steinwachs, Ira Morris, George Bause, Stephen Siebert and Craig Westin (1979) Patient-doctor agreement about problems needing follow-up visit. Journal of the American Medical Association 242 (4): 344-346. https://doi.org/10.1001/jama.1979.03300040030019

Suchman, Anthony L. and Dale A. Matthews (1988) What makes the patient-doctor relationship therapeutic? Exploring the connexional dimension of medical care. Annals of Internal Medicine 108 (1): 125-130. https://doi.org/10.7326/0003-4819-108-1-125

Tannen, Deborah (1990) You Just Don’t Understand: Women and Men in Conversation. New York: William Morrow.

Taylor, Amanda C., Orit Karnieli-Miller, Thomas S. Inui, Steven S. Ivy and Richard M. Frankel (2011) Appreciating the power of narratives in healthcare: A tool for understanding organizational complexity and values. In Christopher N. Candlin and Srikant Sarangi (eds) Handbook of Communication in Organisations and Professions, 457-480. New York: Mouton. https://doi.org/10.1515/9783110214222.457

Thomas, William I. (1928) The Child in America: Behavior Problems and Programs. New York: Alfred P. Knopf.

Wang, Ya-Ya, Qiao-Qin Wan, Frances Lin, Wei-Jiao Zhou and Shao-Mei Shang (2018) Interventions to improve communication between nurses and physicians in the intensive care unit: An integrative literature review. International Journal of Nursing Sciences 5 (1): 81-88. https://doi.org/10.1016/j.ijnss.2017.09.007

Wengstrom, Yvonne and Marieanne Ekedahl (2006) The art of professional development and caring in cancer nursing. Nursing & Health Sciences 8 (1): 20-26. https://doi.org/10.1111/j.1442-2018.2006.00263.x

Zelek, Barbara and Susan P. Phillips (2003) Gender and power: Nurses and doctors in Canada. International Journal for Equity in Health 2 (1): 1-5. https://doi.org/10.1186/1475-9276-2-1

Published

2020-05-15

How to Cite

Frankel, R. M., Inui, T. S., & Karnieli-Miller, O. (2020). Values at work: Comparing affirming and challenging narratives of nurses and physicians in a large health system. Communication and Medicine, 15(3), 268–281. https://doi.org/10.1558/cam.35227

Issue

Section

Articles