Medication communication during ward rounds on medical wards: Power relations and spatial practices

Medication communication during wards rounds

Medication communication during ward rounds on medical wards: Power

relations and spatial practices

LIU, W., MANIAS, E. & GERDTZ, M. (2013) Medication communication during ward

rounds on medical wards: Power relations and spatial practices. Health, 17(2): pp. 113-34

Abstract Communication plays a crucial role in the management of medications. Ward

rounds are sites where health professionals from different disciplines and patients come

together to exchange medication information and make treatment decisions. This article

examines power relations and spatial practices surrounding medication communication

between patients and health professionals including doctors, nurses and pharmacists

during ward rounds. Data were collected in two medical wards of a metropolitan teaching

hospital in Melbourne, Australia. Data collection methods involved participant

observations, field interviews, video-recordings, together with individual and group

reflexive interviews. A critical discourse analysis was undertaken to identify the location

sites where power relations were reproduced or challenged in ward rounds. Findings

demonstrated that traditional medical hierarchies constructed the ways in which doctors

communicated about medications during ward rounds. Nurses and pharmacists ventured

into the ward round space by using the discourse of preparation and occupying a

peripheral physical position. Doctors privileged the discourse of medication

rationalisation in their ward round discussions, competing with the discourse of inquiry

taken up by patients and families. Ward rounds need to be restructured to provide

opportunities for nurses and pharmacists to speak at dedicated times and in strategic

locations. By critically reflecting upon the complex process of medication

communication during ward rounds, greater opportunities exist for enhanced team

communication among health professionals.

Keywords medication communication, power, space, ward rounds

Introduction and background

The ward round is a routine practice within hospital settings, which provides

opportunities for health professionals from different disciplines and patients to come

together to exchange information and plan treatment (Busby and Gilchrist, 1992). Ward

rounds are the sites where key decisions are made about initiating, continuing, altering, or

ceasing medications. Australia’s National Medicines Policy advocates a partnership

approach in medication management and encourages doctors, pharmacists, nurses and

patients to take a shared responsibility in achieving safe medication use (Australian

Pharmaceutical Advisory Council, 2005). Although collaborative practice has been

shown to be beneficial in the management of patients, ward rounds are historically

dominated by medical staff (Grant, 2008). The ward round is known as a space where

professional hierarchy and power are sustained through the organisation of discourses

(Fox,1993).

Nurses’ passivity and patients’ silence during ward rounds have been reported

across different clinical environments such as internal medicine (Weber et al., 2007),

general surgery (Fox, 1993), and cancer care (Whale, 1993). Despite the extensive body

of literature examining participation in ward round activities, there has been limited work

on participants’ medication information exchanges during ward rounds. Relevant

literature has focused on medication information exchanges during informal

conversations between nurses and doctors (Manias et al., 2005), or between pharmacists

and doctors (Morrison et al., 2008).

Studies investigating spatial aspects of ward rounds have identified that doctors

often make treatment decisions in a private room before moving to the patient bedside in

a critical care environment (Manias and Street, 2001). Nurses primarily conduct their

work on the ‘open-floor’ in public spaces (Spain, 1992: 206). The spatial distance

between doctors’ closed rooms and nurses’ open-floor makes it difficult for nurses to

influence medical decision-making. More recently, Lewin and Reeves (2011: 1599)

metaphorised ward rounds as ‘front-stage shows’ presented for patient audiences.

Morrison et al. (2008) examined the micro-spatial practices of body orientation and

posture of doctors during ward rounds, before and after the use of electronic patient

records. O’Hare (2008: 309) reviewed the ‘anatomy’ of ward rounds, supporting the

tradition of doctors discussing patient care at the bedside but examining sensitive issues

away from the bedside.

Although various studies provide insights into power relations and spatial

elements embedded in ward round practices (Fox, 1993; Manias and Street, 2001), there

are a number of gaps. Investigators have mainly focused on general communication

encounters instead of medication interactions during ward rounds. They have not

examined interactions among health professionals of different disciplines, patients and

families in ward rounds. In addition, past investigators have not explored how medication

interactions are organised in the spatial context of ward rounds. As a result, we know

little about how medication decisions are made across different ward spaces, and how

spaces are associated with social and political power in the decision-making process.

This article aims to examine how power relations are embedded in ward round

practices, and how space and mobility affect medication communication processes during

ward rounds. We define medication communication as discussions about treatment

regimens among doctors, nurses, pharmacists, patients and family members. Specifically,

we explore: what medication information is communicated by whom during ward rounds;

where information is communicated about medications during ward rounds; what

discourses are embodied in medication communication during ward rounds; and who

regulates spatial access to ward rounds.

Methods

Methodological approach

The methodological approach selected for this study was critical ethnography.

Critical ethnography challenges the status quo and the dominant influences of society

(Hammersley, 1992). It enables researchers to investigate power relations situated within

specific clinical contexts (Manias and Street, 2001). This approach was selected to unveil

the power tensions and political struggles among participants in the ward round context.

Critical ethnography encourages participants to engage in the reflexive process of

challenging their ideas and actions (Manias and Street, 2001). In this study, participants

used research data to reflect on their own practices and challenge dominant social

ideologies. As participants were involved in viewing their daily practices on video-

recordings, they were better able to understand the complexities of medication

communication processes and recognise their individual role in contributing to

medication decisions, which opened up possibilities for practice development.

Research sites and participants

This study was undertaken in two medical wards of a metropolitan teaching

hospital in Melbourne, Australia. Two medical wards were selected to encompass diverse

practices and maximise transferability of the findings.

In the General Medical Ward, four medical residents were employed in the ward.

These residents were responsible for patients situated in the ward, as well as medical

patients admitted to other wards across the hospital. As a result, they were only present

for limited periods in the ward. In the Medical Assessment Ward, two medical residents

were employed in the ward. These residents were physically present on the ward most of

the time as their responsibilities involved patients admitted to the ward. Both wards had

one or two medical registrars who supervised the residents’ clinical practices. However,

the registrars were required to move frequently across different wards in the hospital to

admit new patients or coordinate patient transfers. Medical consultants were assigned to

the wards at certain times for the purpose of leading ward rounds.

The ward nurse manager, together with nurse coordinators on each shift, guided

the overall nursing activities and coordinated patient flow on the wards. Clinical nurse

specialists were regarded as nurses with specialised knowledge in general medicine, and

were also given a patient load. Staff nurses were mainly involved in the delivery of

patient care at the bedside. A registered pharmacist was present on each ward on

weekdays. Additionally, an intern pharmacist was employed on the Medical Assessment

Ward to assist with the rapid patient turn-over.

All doctors, nurses and pharmacists who worked on the wards at the time of the

study (from January to November 2010) were eligible for inclusion. Patients were

eligible for participation if they were able to communicate with staff relating to

medication management. Inclusion criteria for patients were that they had to speak

English; to be medically stable and not confused; and to be prescribed at least one

medication for their inpatient treatment.

In-service meetings were organised with staff members in each ward to introduce

the study and to invite them to participate. Information sheets and consent forms were

distributed at the end of each meeting. After obtaining consent from staff members, the

first author approached patients who were allocated to the staff under observation and

provided them with information about the study at the bedside. All participants were

informed that their identity would not be disclosed in any way in all outputs arising from

the study. Written consent was obtained from 31 doctors, 76 nurses, 1 pharmacist and 27

patients participating. Verbal consent was obtained from all other individuals who

happened to be present at the time of observation. This study was approved by the

hospital and university ethics committees.

Data collection

Data collection methods included participant observations, field interviews, and

video recordings, along with individual and group video reflexive interviews. A flow

chart illustrating the data collection process is presented in Table 1. This article draws on

data from 290 hours of participant observations, 72 field interviews, 34 hours of video-

recordings, 1 individual reflexive interview and 5 group reflexive interviews. The first

author of this article collected the research data.

[Figure 1 should appear about here]

Data analysis

Audio tracks of the recordings were transcribed verbatim and entered into

computerised files by the first author. All authors independently interpreted the audio and

video recordings with their understandings of the meanings conveyed. A database was set

up using NVivo 8 (QSR International). Written, spoken and visual data were guided by

Fairclough’s (1992) three-level critical discourse analysis (Table 1).

[Table 1 should appear about here]

Additionally, video-recorded data were quantified to understand the power

relations between health professionals and patients in ward rounds (Nugus et al., 2010).

Video-recorded data enabled manual counting of turn-taking and frequency calculation of

time spent talking by various participants on the medication management topic during

ward rounds. The distribution of time at different locations during ward rounds was also

approximated. The first author conducted the manual counting and calculation as

meticulously as possible.

Rigour

Four methods were used to establish rigour of the study: prolonged encounters,

triangulation, thick description and member checking (Polit and Beck, 2006). Details of

methods used to establish rigour are included in Table 2.

[Table 2 should appear about here]

Results

Medication communication during ward rounds demonstrated complex power

relations tied to different spatial settings and positions. While ward rounds were used as

forums to discuss patient care and treatment decisions, they were often conducted at

locations away from the patient’s bedside such as the staff station and corridors.

Medication decisions were rationalised according to patients’ clinical manifestations and

test results. Participation in ward rounds was determined by the value placed by

consultants of participants’ contributions to medical decisions. Power struggles

embedded in ward rounds were displayed by participants’ turn-taking and time spent

talking at different locations.

On both wards, ward rounds were haphazard in nature, occurring either in the

morning or in the afternoon. Participants in ward rounds included a medical consultant, a

medical registrar, and two or three medical residents assigned to one medical team.

Patients were involved if ward rounds were conducted at the bedside. Family members’

presence during ward rounds was opportunistic. Nurses were rarely present. Pharmacists’

participation in ward rounds was also rare.

Geographic movement across spaces

The spatial structure of ward rounds included a three-stage process. Firstly,

doctors selectively discussed one or two patients in the staff station, which was the

‘private’ space for the ward rounds. Secondly, individual patients were reviewed at the

bedside, which was the ‘public’ space for the ward rounds. Thirdly, doctors finalised

treatment plans and raised issues for clarification in the corridor or back in the staff

station where the next patient consultation started. The corridor was the ‘semi-public’

space for the ward rounds because it was shared by staff, patients and family members

located on the ward, while at the same time, it was set up as an invisible spatial boundary

by doctors during corridor conversations.

In the following video excerpt, doctors displayed how they negotiated spatial

practices in ward rounds. No nurses, pharmacists or family members participated in this

ward round. The patient discussed in this scenario presented with urinary sepsis and

ischemic heart disease. The excerpt was marked with the time span and spatial locations:

[00:00-05:30 Staff station]

Resident 1: [Giving a detailed presentation of the patient’s medical history,

current treatment and test results].

Consultant: She looks just a bit dry [looking at blood results on the computer].

What’s she on frusemide [a diuretic] for?

Resident 1: She’s got ischemic heart disease and aortic valve replacement.

Consultant: Sometimes elderly people can get dehydrated on frusemide and

hypotensive [looking at the medication chart]. She is on verapamil

[an anti-hypertensive]. Well, leave her off verapamil if she is

hypotensive. Let’s see if she needs frusemide. I am going to stop

her frusemide.

[05:30-07:50 Corridor]

Consultant: Have you got an ECG [electrocardiogram] for her? Just show me

her ECG . . . I think her strawberry looks good. You know what the

strawberry is?

Resident 2: It’s the heart [laughs].

Consultant: It’s a heart, pumping well. You got to convince me why she needs

frusemide.

[07:50-12:10 Bedside]

Consultant: She’s got varicose edema. Her JVP [jugular venous pressure, a

clinical sign of body fluid retention] is up . . . Maybe I am wrong.

Maybe she has more significant left ventricular hypertrophy [LVH].

Let’s leave the frusemide. Let’s have a listen [of her heart]. Let’s

go and have a look at her chest X-ray.

[13:10-15:50 Staff station]

Consultant: Yeah, all these things I think this lady probably got LVH [looking

at the chest X-ray on the computer] . . . We have to learn all of

those things on chest X-rays, clinical signs, JVP, heart size. OK, I

would leave her on frusemide for leg oedema and JVP.

This excerpt illustrated how medication decisions were made across different

spaces during the ward round. Initially in the staff station, the resident gave a detailed

case presentation of the patient. The resident brought up the patient’s test results on the

clinical computerised database system for the group discussion. The staff station provided

a private space for the resident to demonstrate to the consultant her clinical skills and

interpretation of patient observations, excluding nurses’ contribution to the process. The

consultant presented his clinical judgment by saying the patient ‘looks just a bit dry.’ He

hesitated because information about the patient’s dry state was drawn from blood test

results, and the patient had not yet been physically examined. The consultant’s decision

to stop the verapamil was made in the staff station as, according to the consultant, the

patient’s medical records and observational charts provided enough clinical details to

cease verapamil. However, more bedside evidence from the patient was required to

confirm the consultant’s view to stop frusemide.

After discussing the patient’s medical records and test results in the staff station,

the doctors decided to move to the patient’s bedside. The doctors walked across the

corridor in a sequence where the consultant led the team, and the residents walked behind

carrying the patient’s medical records. The doctors’ spatial positioning in the team

vividly displayed their hierarchical social status, which was structurally maintained by

the consultant and followed by the residents. The analysis of the patient’s ECG report

occurred opportunistically in the corridor when the consultant decided to glean more

objective information about the patient. The consultant wished to prepare himself with

adequate clinical information before approaching the public space at the bedside. The

consultant inserted a discourse of humor into the seemly very serious medical discussion.

His metaphor of a ‘strawberry’ applied to the heart led to an immediate relief of the

atmosphere, which was manifested by the resident’s laughs. During observations, only

consultants used humor in ward round consultations. Residents did not normally initiate

jokes but responded warmly to consultants’ humor.

Although corridor activities were visible to all people in the public space, other

staff members walking across the corridor did not seem to be interested in the

conversation. Sometimes, doctors formed a circle while discussing sensitive issues,

which created an invisible spatial barrier for others (Figure 2). Doctors often lowered

their voices during corridor conversations, making the conversations difficult to be heard

by others. Not only were doctors discreet with their talk in the corridor, but people

passing by, such as families and visitors, often consciously avoided disturbing the talk by

speeding up their pace and walking along the corridor wall. By staging practices in the

corridor, doctors creatively transformed a public space into a semi-public one where only

selected people were included in discussions. The physical circle created by doctors and

their tone of voices during corridor conversations excluded other staff and patients from

participation.

The ward round moved to the bedside when sufficient objective information was

gathered in the staff station and the corridor. It was always the consultant who initiated

this move. Consultation at the bedside focused on collecting assessment data from

patients. In this ward round excerpt, the patient’s involvement was minimal. The patient

only spoke in response to the doctors’ questions, occupying the subject position of an

information-provider. The patient’s responses were reduced to simple words like ‘alright’

and ‘no pain.’ Even though she was physically present at the bedside, the patient was

addressed as a third person ‘she’ when the consultant spoke to other doctors, distancing

the patient from participating in the discussion. The patient was positioned as a clinical

subject for medical education. The patient’s individual concerns about her illness were

not elicited during bedside consultations.

The ultimate decision for continuing diuretic treatment for the patient was made

back in the staff station after necessary patient assessments were completed at the

bedside. This information was exclusively accessible to the doctors since the patient was

not informed of the final treatment decision. The consultant used ‘I’ when announcing the

final treatment decision, confirming his authority and expertise in making the decision.

The consultant adopted a collective voice and used ‘we’ when educating other doctors.

The use of ‘we’ functioned to build strong cohesion amongst the doctors. The discourse

of education amongst the doctors, which began at the bedside, continued in the staff

station.

Rationalisation of medications

A goal of ward rounds was to rationalise patients’ medication orders and consider

alternative treatment options as a team. Patients’ medication orders were reviewed by

doctors and unnecessary long-term orders were ceased. Doctors mainly used medico-

scientific knowledge in applying logic and reasoning to their medication decisions. They

often discussed patient progress with each other and made treatment decisions in the staff

station based on clinical records and test results. Sometimes, the discourse of medication

rationalisation was constructed at the bedside, as shown in the following video excerpt.

The patient was an older man from a non-English-speaking-background. He was

admitted on the ward with a syncoped collapse. In this scenario, the patient, the patient’s

son and wife, the intern pharmacist, the consultant, the registrar and residents were

present during the ward round and all participated in discussions, which was an unusual

occurrence. The family members asked many questions during the consultation. The

intern pharmacist was present in this particular ward round by accident because she was

in the middle of collecting a medication admission history from the patient when the

medical team approached the bedside. The intern pharmacist positioned herself in the

outer circle of the ward round group (Figure 3). Before moving to the bedside, the

patient’s medical history was presented by the resident in the corridor. Again, the doctors

had to prepare themselves well before entering the patient’s room:

Consultant: So he is not on anything causing his blood pressure drop and fall?

Resident: Frusemide, metoprolol [a β-blocker] 12.5[mg] BD [twice a day].

Consultant: Hello [talking to the patient], Dr. [name himself] is here. How are

you? How is Mr. [name patient] today [sat on the patient’s bed

while the patient was sitting in a chair]?

Son: He seems back to normal.

Patient: I fell asleep and I didn’t know myself yesterday [the patient

recalled his feeling at the time of his collapse].

Consultant: [Turning to the doctors] how long has he been under the

observation?

Registrar: He came in last night about five o’clock.

Consultant: So 18 hours now. I guess the only thing, I reckon, I just wonder

12.5mg BD metoprolol . . . If you put him on 1.25[mg] bisoprolol

[a β-blocker] at night, it would be similar or a bit less than what he

is on now. It will be once a day. So why don’t you do that?

[The resident changed the order on the medication chart]

Consultant: [Turning to the son] so we are just gonna make one minor change

to his medication that might make things a bit simpler.

Son: Sure.

Consultant: Alright.

Son: What is it you are going to change? Or you are not sure?

Consultant: Um. He is on a tablet, a quarter of a tablet twice a day, one of the

heart tablets. We are going to put him on a whole tablet, so that

makes it easy.

Son: Is that the metoprolol?

Consultant: Yeah. But you can take this one [indicating bisoprolol] once a day.

It will be a bit easier [the team walking out the room].

This conversation was about titrating down the patient’s anti-hypertensive therapy

based on his symptoms. The patient’s experience of the illness at the time was required to

guide decision-making. Although the patient was sitting in the room, he remained silent

for most of the consultation. Initially the patient was addressed in the first person by the

consultant; then he was referred in the third person as ‘Mr.’ The polite title Mr. and the

patient’s surname set up a scene for a formal consultation. The son acted as an advocate

responding directly to the consultant’s question. The patient only took one turn during the

conversation by explaining how he felt at the time of his collapse. A possible factor

contributing to the patient’s minimal participation was that the patient spoke English as a

second language, whereas his son spoke fluent English.

During the conversation, the consultant sat on the bed in close proximity to the

patient (Figure 4). He leaned his body forward, aligning himself at the patient’s eye level.

The consultant’s sitting position was conducive to enhancing communication with the

patient. By placing himself at the same level as the patient, the consultant attempted to

interact within close proximity. Although the consultant occupied the same geographic

space as the patient, he never directed any questions about medications to the patient.

Compared with other doctors and family members who stood around the bedside, the

consultant had the privilege of taking control of this space.

The registrar only spoke to answer the consultant’s inquiry about the patient’s

hospital trajectory. The consultant used medical terms while discussing about

medications with other doctors. The consultant’s use of language was adapted to

everyday conversation when he explained the medication change from metoprolol to

bisoprolol to the son. The medication was referred as ‘a heart tablet.’ The consultant did

not volunteer extensive information about the medication change. After selectively

imparting the information about the ‘minor change,’ the consultant completed the turn

with a closed answer ‘alright.’ The son initiated a turn using the discourse of inquiry to

seek out further information about the medication change, challenging the consultant’s

decision-making. The son demonstrated his medication knowledge by referring to the

medication’s generic name ‘metoprolol.’ Overall, there were multiple discourses

embedded in this consultation − the professional discourse of medication rationalisation

and social discourse of interpersonal relationships appropriated by the consultant, and the

discourse of inquiry demonstrated by the family.

The medical team was about to move away after making the decision about the

anti-hypertensive medication. The doctors mainly focused their discussion on how the

anti-hypertensive medication may have contributed to the patient’s hospital admission of

a syncoped collapse. As the medical team was about to move away, the son and wife

sought clarification about the patient’s other medications:

Son: Excuse me, just about his insulin intake.

Wife: The hospital gave him insulin 70 [units] in the morning,

two [units] at night.

Consultant: Two [demonstrating with two fingers]? Two or 20?

Wife: Two, two. But you know what I do? I give 60 [units] in the

morning, six and zero, then 12 [units] at night, make

exactly the dose [the wife had disregarded the previous

hospital orders and gave different insulin doses at home].

Consultant: Why?

Wife: Because [pause].

Consultant: Was he having low sugars or high sugars at home?

Wife: Sometimes low sugar at night.

Consultant: So it’s better to give less at night, not more.

Wife: Less? Sugar sometimes high, sometimes low.

Consultant: How high?

Wife: Sometimes nine.

Consultant: Nine is OK.

Wife: OK?

Consultant: It’s different in different people. In his situation, we’ll be

much worried about very low sugar.

Son: So what should be the dose?

Consultant: It sounds like he might not need anything at night because

you only give him two [units], it’s almost like nothing. OK?

Wife: Alright, if you like this, we’ll leave it like this.

Intern pharmacist: The medical team just dosed 70 [units] in the morning and

two [units] at night.

Consultant: Two [units] at night. It’s not worth giving. [The resident

ceased the night insulin dose].

Intern pharmacist: Yeah, I agree.

The discussion about the insulin dose started when the patient’s family asked for

information as the doctors were about to leave the room. The patient’s wife contributed to

the discussion with her personal knowledge about the patient. She positioned herself as

an active agent in seeking out medication information. Initially, the patient’s wife

enthusiastically presented her reasoning about self-modification of insulin doses at home,

which was questioned by the consultant. The patient’s wife paused following her

utterance of the word ‘because.’ This hesitation can be taken as a sign of giving up the

floor. The patient’s wife appeared to be embarrassed from her facial expression after

exposing her layperson knowledge to the ‘experts.’ The wife’s final consent to the

medical treatment appeared to contradict her initial stance where she attempted to

contribute to decision-making. The wife’s response to the proposed medication change ‘if

you like this’ may have implied active resistance and avoidance of accepting the

consultant’s stance. The consultant’s questions for the wife were reduced to words like

‘why’ and minimal phrases like ‘how high.’ The family members also appeared to be

intimidated by the questions. The doctors’ possible oversight of reviewing the insulin

dosage did not seem to change the conventional question-answer discourse in their

consultations.

The consultant answered the son’s question with low-modality characters

(‘sounds like,’ ‘might,’ ‘almost like’). The consultant selected those words because he

did not want to create emotional distress for the family members by doing the wrong

thing. The consultant’s use of low-modality characters was rhetorically persuasive. The

consultant justified his decision to cease the patient’s night insulin dose with a three-part

list − the patient had ‘low sugar at night;’ the doctors were ‘much more concerned’ about

the patient’s low sugar than high sugar; and two units of insulin was ‘almost like

nothing.’ The discourses of questioning and inviting consensus taken up by the consultant

demonstrated power struggles where the consultant attempted to defend his position.

The intern pharmacist invited herself into the discussion towards the end of the

consultation: yet, her involvement was minimal. She only started to speak when concerns

regarding medications were raised. The intern pharmacist introduced an external agent

‘the medical team’ into her statement, in supporting the family’s concerns. The

introduction of the external agent reduced the likelihood of the intern pharmacist being

challenged on the accuracy of her statement. However, the intern pharmacist only

restated the insulin dose that the patient was ordered, and she did not comment about the

merits and issues relating to the dose given.

Spatial regulation

The nurses’ voice in ward rounds was largely missing. For nurses, their

participation in ward rounds was regulated by doctors, particularly consultants, and

nurses’ physical visibility in the space was determined by doctors’ needs. They were

called to the bedside when doctors sought out certain information that was not recorded

in patients’ documents. At an interview, a consultant speculated nurses’ absence in ward

rounds in terms of spatial constraints, ‘If we are standing in a round with the consultant,

registrar, three residents, ideally the primary nurse, there will be six people. This

physically is just not enough room.’ The consultant perceived inclusion of the nurse in

ward rounds would lead to loss of physical space at the bedside. The consultant believed

that only doctors were legitimated in accessing limited bedside space during ward rounds.

Nurses revealed their contestation for spaces in ward rounds during video

reflexive activities. While watching video excerpts of ward rounds in a focus group, a

nurse reflected on her need to participate in the ward round space, ‘I was chatting away

once because I knew why the medication was withheld. The consultant looked at me as if

I was an alien that just dropped in.’ This nurse provided her interpretation of patient

observations and rationale for withholding certain medications at the bedside, but she felt

that her contribution was undervalued by the doctors. This nurse had worked overseas in

the UK for quite a long time before she started to work on the ward. During her past

nursing experience in the UK, she presented patients’ details in ward rounds and

collaborated with doctors to make decisions. She employed the metaphor of an ‘alien’ to

describe her position of being unexpected in the privileged ward round space. In that

context, the nurse attempted to ‘invade’ the monopoly of doctors during ward rounds by

taking up the resident’s role for case interpretation. Her actions astonished the consultant

who had traditionally regulated ward rounds in terms who spoke at what time.

Nurses adopted strategies showing resistance to the dominant medical practice. At

an interview, a nurse explained how she shifted between invisibility and visibility by

adopting a discourse of preparation:

I’ve seen so many horrible doctor-nurse interactions. So I just stand there [in ward

rounds] and try not to talk. But if I need something [prescriptions], I make sure I

know everything that they [indicating doctors] could possibly ask me. I have all

the charts ready so that if they ask me something, I can find it quickly.

This nurse opposed doctors’ unilateral regulation of ward round spaces. She

constructed her own practice through the discourse of preparation. Normally, she

positioned herself in ward rounds by standing behind doctors (Figure 5). Her physical

visibility was limited to doctors at that stage. When patients’ medication needs arose

from her assessment, this nurse acted as a patient advocate and became functionally

visible to doctors. This nurse prioritised patients’ needs above her own personal desire to

avoid direct interactions with doctors. Her proactive approach also prompted her to learn

more about patients because she was expected to answer a set of medical questions. By

doing so, this nurse moved beyond the traditional listener position to demonstrate her

knowledge during ward rounds.

Before ward rounds, if nurses required particular medication tasks to be

completed, they took time to prepare for what was required during their anticipated

interactions with doctors. When there were no specific medication concerns, nurses did

not always prepare for participating in ward round discussions. Normally, nurses adopted

the position of a docile or submissive nurse during ward rounds as they feared possible

repercussions if they encountered an unpleasant confrontation with doctors. However, if

nurses wanted to take a stand on a particular medication task, they used the discourse of

preparation to enable them to have the necessary knowledge about the medication, while

at the same time, not appearing threatening or provoking in their stance. Their approach

meant that nurses succeeded in having doctors complete a particular medication task

while at the same time ensuring that medical authority in decision-making remained

intact.

Pharmacists were also generally absent from ward rounds. While watching a

reflexive video of doctor-pharmacist interactions to clarify medication orders during ward

rounds, a pharmacist related her thoughts about ward round participation, ‘If we were

there, we would have reviewed and made changes to drug charts, rather than having a

decision made by doctors in the round, then you question them later on.’ The pharmacist

admitted the difficulty in balancing organisational time and participation in ward rounds.

However, medication clarification processes also involved a time commitment. The

pharmacist’s contentment to approach doctors later on and seek clarifications about

medication orders may indicate her level of comfort in approaching residents rather than

communicating with a group of doctors during ward rounds.

Doctors were occasionally absent from ward round spaces, but this only occurred

with junior doctors. Consultants were the people initiating the talk and walk in ward

rounds. When residents were caught up in another ward and were subsequently late, ward

rounds often continued without waiting for them. This situation was not reversible. If

consultants were late or unavailable, ward rounds could not move forward. Residents

either waited in the staff station for the consultant’s arrival or dispersed across spaces to

carry on with other activities. Ward rounds privileged consultants’ availability,

positioning residents as subordinate in controlling clinical time. Doctors’ participation in

ward rounds was also regulated by organisational structures. Since each resident was

assigned to two medical teams on the Medical Assessment Ward, it was common for

residents to be absent from one round when two consultants arrived on the ward at the

same time to conduct two separate ward rounds.

Display of power relationships and geographic movements

Video-recording ward rounds enabled analysis of turn-taking and time spent

talking by participants as a particular group, rather than by individual persons. Using

video-recording, the time that doctors spent at different locations during ward rounds was

also determined. Altogether, 12 ward rounds were video-recorded in this study. The

duration of ward rounds varied between 30 minutes to 90 minutes. In this article, we

randomly selected three ward rounds for the purpose of quantifying medication

interactions. The decision for a random selection of ward rounds for quantitative analysis

was made because the participant structure and discursive features identified in the three

ward rounds were consistent with ward round practices in general. The three ward rounds

involved doctors, patients and families. No nurses and pharmacists participated in these

ward rounds. Figures 6 and 7 show the relative distribution of turn-taking and time of

talking surround medication management in the three ward rounds. Figure 8 shows the

time distribution across different spaces accommodated in the three ward rounds.

The consultants took most of their turns in medication communication during

ward rounds. The registrars and residents shared a similar number of turns in medication

communication. Patients’ involvement in medication communication was minimal. The

patients often played a passive role in turn-taking by responding to questions from the

doctors. Occasionally, the family members took turns, voicing medication concerns on

behalf of patients.

The consultants spoke the longest among participants, accounting for 64% of the

total time spent on medication discussions. They not only initiated most of the turns, but

also spent significant amounts of time educating other doctors and analysing treatment

options. The registrars and residents spoke mostly to present patient clinical concerns,

current treatment regimens and the latest test results. The total time that participants spent

in medication communication was 75.8 minutes, taking up 41% of the total time in three

ward rounds (T=183 minutes).

The doctors spent most of their time at the patient bedside. Corridor conversation

was an indispensible part of ward round practices. The doctors also spent significant

amounts of time checking test results in the staff station and discussing the case outside

the patient room before meeting the patient.

Discussion

This study demonstrated that consultants regulated medication communication

and movements during ward rounds. The spatial positioning taken up by individual

doctors demonstrated their status distinctions (Street, 1995). Although doctors had to

move across spaces consulting their patients, their prestigious status was reflected by the

private staff station to which they could withdraw for group discussion (Spain, 1992).

Doctors approached the public bedside space when they needed to speak about patients.

They moved away from this space when patients’ presence was not required. Patients had

little spatial control while being confined to a designated hospital bed and surrounded by

a ‘parade’ of doctors, strengthening unequal doctor-patient relations (O'Hare, 2008: 309).

These power relations were self-reproducing because participants in ward rounds rarely

discussed or challenged each other’s subject and physical positioning (Fairclough, 1992).

Our findings suggested that establishment of private spaces during ward rounds

did not require reinforcement of walls or doors. Doctors’ physical positioning on the

ward conveyed the message of differential power. Communal spaces like the corridor

were only accessible to doctors at certain times, supporting Spain’s (1992) notion of

exclusive access to spaces by individuals with higher status in the workplace. Although

the corridor was originally designed for public use, it was changed to a venue for medical

conversation during ward rounds.

During medication communication, doctors used the discourse of medication

rationalisation, which did not necessarily involve patients at the public bedside.

Medication decisions were often made in the private staff station after consulting

patients’ test results. The medication rationalisation discourse depended upon medico-

scientific knowledge, and this discourse was mediated by complex power relationships.

Compared with consultants who only came to the ward capturing snapshots of patients’

clinical pictures, residents were positioned favorably in knowing individual patients’

trajectory. Nevertheless, this favorable positioning only enabled residents to give patient

presentations based on patients’ medical histories and test results. It was the consultants

who made treatment decisions. The discourse of preparation was pivotal in ward rounds

for doctors in different rankings. Residents had to prepare for ward rounds to prove their

competency to consultants by carefully reading patient medical histories and memorising

test results prior to ward rounds. Consultants prepared for ward rounds by collecting

sufficient patient information in the staff station and the corridor before approaching the

bedside area. Consultants sought to maintain their authority and prestige in front of

patients by making prompt assessments at the bedside. By doing so, consultants

demonstrated their knowledge and efficiency at the public bedside space.

When ward rounds moved to the bedside, patients’ presence did not always

facilitate participation on their part. Patients had remained silent for most of the time in

ward rounds unless they were asked. This unequal doctor-patient relationship was

sustained in that patients usually kept silent. However, participants also demonstrated

capacity to manipulate situations to fulfill their own intentions (Fairclough, 2006). When

doctors constructed ward round discussions with a pre-set agenda on topics at the

institutional level, families sometimes became ‘aberrant’ (Fox, 1993: 36) by introducing

additional medication concerns (e.g. in the case of discussing the insulin dose). There was

a tension arising from doctors’ attempts to move the consultation towards closure and

from families’ efforts to bring doctors back to the consultation to address their individual

concerns. The typical ‘interactional control feature’ in medical communication was

challenged by families in the local ward round context (Fairclough, 1992: 139). In the

mean time, consultants developed strategies, such as reduced questioning and inviting

consensus, to counter local resistance and maintain the hegemony in ward rounds

(Robertson et al., 2011).

Our data showed a lack of multidisciplinary involvement in ward rounds. The

ward round space was strategically regulated by consultants with a lack of active

involvement from nurses and pharmacists. However, their lack of involvement in ward

rounds did not indicate disinterest. The findings demonstrated occasions where nurses

and pharmacists resisted the dominance of medicine by occupying a peripheral physical

position during ward rounds (Hill, 2003).

When nurses ventured into the ward round space at the bedside and tried to

influence decision-making processes, nursing knowledge was not always appreciated by

doctors. This finding differs from Manias and Street’s (2001) report on consultants’

invitation for nurses’ contribution in the room component of the critical care ward round.

It appeared that nursing knowledge also had a structural hierarchy. Nursing knowledge

obtained in the general medical environment did not appear to be valued as important.

Another possible reason for the different findings is that nurses in this study took a

proactive approach by encroaching on the bedside space of the ward round, which was

historically constructed as the province of doctors (Busby and Gilchrist, 1992). Nurses in

Manias and Street’s (2001) study exhibited their knowledge to doctors in a private room,

without threatening the medical dominance at the public bedside.

Pharmacists seemed to comply with a gap-filler role. Although doctors and

pharmacists needed to collaborate in decision-making, they seemed to have different

responsibilities in aspects of medication management. It was doctors who had the

legitimate authority to write prescriptions, regardless of how much advice was offered by

pharmacists. Pharmacists’ offer of advice for medical prescribing often occurred at the

staff station without patient presence. During observations, pharmacists rarely resisted

this medical practice.

The difficulty in making collaborative medication decisions during ward rounds

also related to organisational time constraints. Nurses, residents and pharmacists worked

within fixed schedules of shift work where they had to accomplish specific medication

tasks within particular time limits. For example, nurses needed to administer medications

according to individual patients’ time regimens. Residents needed to prioritise the

ordering of admission and discharge prescriptions, and making changes to prescriptions

based on patients’ clinical assessments. Pharmacists had to ensure that the wards had

adequate supplies of medications on the shift. In contrast, consultants were afforded more

authority in regulating their working time as demonstrated by unstructured ward round

practices. Consultants only came to the wards at haphazard times of the day to lead ward

rounds. If other health professionals intended to participate in ward rounds, they took on

a submissive stance by fitting within in consultants’ availability of time, which meant that

other activities they were undertaking at the time were either disregarded or delayed in

their completion. Consultants’ exemption from organisational time constraints was a

reflection of their hierarchical status in the system.

Mobility can be used to communicate power and authority, and discourses can be

analysed in the ways in which people move (Halford and Leonard, 2003). Nurses spent

most of their time at the patients’ bedside, and their mobility was confined to the local

bedside to meet patients’ immediate care needs. On the other hand, doctors had the

freedom of movement across ward and hospital spaces. The institution set up the

structure for doctors being responsible for patients located on different wards. There was

no structured opportunity for nurses to offer autonomous assessments and discuss clinical

judgement with doctors in ward rounds (Sorensen and Iedema, 2007). The lack of

mobility and flexibility in nursing work not only contributed to nurses’ social status, but

also limited opportunities for the transfer of bedside knowledge from nurses to doctors

(Spain, 1992).

Furthermore, nursing voices were marginalised when competing with the

institutional discourse of medical education. Although ward rounds were supposed to

function as a communication forum for care decision-making (Hill, 2003), their focus

shifted from discussing patient care to addressing educational needs of junior doctors.

Ward rounds were places where residents presented patient information to consultants,

who then provided education to residents regarding treatment options.

This study has some limitations. Due to the potentially intrusive nature of video-

recording, the first author encountered skepticism and resistance from staff members at

the initial stage of the study. In order to film ward rounds, the first author adopted a

strategy by seeking consent from the team consultant first. Consultants’ public show of

consent often assisted the introduction of video recording other participants in ward

rounds.

Conclusion

Our findings highlighted power struggles operating within the spatial context of

ward round practices. Although traditional medical hierarchies dominated medication

communication in ward rounds at the institutional level, nurses, pharmacists, patients and

family members resisted the dominance at the local ward level. Given that nurses and

pharmacists play a significant role in medication management using their distinctive

knowledge about individual patients and medications, greater attention should be directed

towards their participation in ward rounds to improve patient care and to provide

interdisciplinary shared education. A shift towards involving nurses and pharmacists in

decision-making about medications rather than information-giving may allow for

expression of alternate discourses to the dominant medication rationalisation discourse.

Increased patient and family involvement in ward rounds could also facilitate

incorporation of alternate modes of thinking about how medications are managed in

practice. There needs to be an organisational commitment to formally involve nurses and

pharmacists in ward rounds. Opportunities can be created for nurses and pharmacists to

speak at dedicated times and in strategic locations. For example, nurses can be involved

during the case discussion stage at the bedside. A structured ward round format can

encourage active participation of nurses because they are better prepared to discuss

clinical concerns with doctors.

However, it is worth being cautious not to ‘tack’ nurses and pharmacists on to the

medico-scientific pedagogy dominating ward rounds. It is important for nurses and

pharmacists to recognise their own work processes in contributing to medication

decisions. Nurses and pharmacists should be encouraged to effectively integrate

communication processes into their daily medication management practices. For example,

nurses should involve patients in medication information exchange during bedside

handovers. Pharmacists can liaise with general practitioners, community pharmacists,

nurses and family members during patient counseling sessions at admission and

discharge. Furthermore, a critical approach to identify and reflect upon the complex

process of medication communication is useful in communication skills training among

interdisciplinary health professionals. Given that medication communication was a big

component of ward round discussions, the ward round context is an important focal point

for future medication safety research.

Acknowledgements

The authors would like to thank the staff members and patients who volunteered

their time to participate in this study. We are grateful to the anonymous reviewers for

their critical comments on an earlier version of the manuscript.

Funding

This article is based on a study that was funded by an Australian Research

Council Discovery Grant [grant number DP0879002].

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