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Collaborative care capacity: developing culture, power relationships and leadership support for team care in a hospital

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Collaborative care capacity: developing culture, power relationships and leadership support for team care in a hospital

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Content Running head: COLLABORATIVE CARE CAPACITY 1

Collaborative Care Capacity: Developing Culture, Power Relationships and Leadership Support
for Team Care in a Hospital
Allison L. Noyes

University of Southern California

MA, University of Southern California, 2012
BA, Mount Holyoke College, 2005

Dissertation Submitted in Partial Fulfillment
of the Requirements for the Degree of
Doctor of Philosophy
Communication

University of Southern California
December 2014
COLLABORATIVE CARE CAPACITY 2
Abstract
The primary goal of this project was to expand the definition of communication in health care
collaboration research and to empirically examine the relationship between this expanded
definition of communication and the development of collaborative care capacity in a hospital.
Using research on organizational collaborative capacity as a guide, the empirical studies
examined how communication patterns reproduce structures that either support or inhibit
collaboration in the patient care process. The qualitative study identified communication patterns
around elements of organizational culture, power relationships, and leadership that support and
inhibit collaborative care. Key findings indicate that even when staff and care providers express
a felt need to collaborate, other elements of organizational and team cultures, power
relationships, and leadership structures may work against a hospital’s ability to provide
collaborative care. After piloting an adapted survey instrument to assess collaborative care
capacity quantitatively, analysis suggests a need to develop a new instrument designed
specifically to assess collaborative capacity within the context of a health care organization.
Recommendations for instrument development are provided.
Keywords: communication, collaboration, health care, structuration
COLLABORATIVE CARE CAPACITY 3
Dedication
I dedicate this dissertation project to my parents, David and Beth Noyes, who have
empowered me with more love and support throughout my years on this earth than I ever thought
was humanly possible.

COLLABORATIVE CARE CAPACITY 4
Acknowledgements

I am proud of this achievement but humbled by the incredible support I have had
throughout my years as a student to prepare me for this endeavor. I am forever indebted to these
important people, including: Professor Lee Bowie who casually planted the seed in my mind
during an informal college graduation reception that I should consider doing a Ph.D.; Mr. Hatch
and Mr. Weigandt for teaching me through tennis and music that nothing worthwhile is ever easy
but that hard work is extremely satisfying and pays off in the long run; Miss Kroll for quite
literally teaching me how to think; Mrs. Reger and Mrs. Trylsa for teaching me how to write;
Richard Hunt for mentoring me as a young professional; Kristine Quinio for convincing me to
give LA a shot; the wonderful friends and colleagues I have made during my time at
Annenberg—especially the fearsome foursome including Laurel Felt, Lori Lopez, and Beth
Boser, which grew to include Evan Brody and Katrina Pareira—for all the laughs and so much
support throughout these six years; Dr. Rebecca Weintraub, Dr. Gail Thomas, and Dr. Lori
Marshall for their mentorship, support, and friendship; my dissertation committee members, Dr.
Janet Fulk and Dr. Howard Greenwald, for all their advice and support; my committee chair, Dr.
Patti Riley, who is as kind and caring as she is brilliant and has helped me through graduate
school in more ways than I can possibly describe here; Robin Boden for her friendship and
fantastic editing skills; my mother, father, sister, and brother-in-law for their endless support and
understanding through the good times and the challenges; and especially Paul Soeller, my
amazing fiancé, who has believed in my ability to do this since the day we met and has tirelessly
supported me in achieving this goal; and of course our dog, Ender, who has kept me company
through long days of analysis and writing and has always reminded me that even when life is at
its most chaotic, we can find peace and joy in taking a long walk and stopping to smell the roses.
COLLABORATIVE CARE CAPACITY 5
Table of Contents
Page
List of Tables …………………………………………………………………………………. 12
Chapter 1—Communication and the Need for Collaborative Care …………………………... 13
A Complex System ……………………………………………………………………….. 13
The Need for Collaborative Care …………………………………………………………. 15
Preventable Medical Error ……………………………………………………………. 16
Quality and Efficiency ……………………………………………………………. 16
Patient Safety …………………………………………………………………. 17
Collaboration …………………………………………………………………. 17
Communication ………………………………………………………………. 18
Collaborative Care Capacity ……………………………………………………………… 21
A Communication Perspective ……………………………………………………….. 22
Chapter Summaries ………………………………………………………………………. 23
Chapter 2—Structuring Collaborative Care ………………………………………………….. 24
Structuring Hospitals ……………………………………………………………………... 25
Agency and Reflexivity ………………………………………………………………. 26
The Duality of Structure ……………………………………………………………… 27
Praxis and Time/Space Distanciation ………………………………………………… 30
Social/System Integration and Institutional Reproduction …………………………… 32
Structuration Theory in Health Care Organization Research ………………………… 34
Studying Communication and Collaboration …………………………………….. 36
Collaborative Care Capacity ……………………………………………………………… 37
COLLABORATIVE CARE CAPACITY 6
A Focus on Capacity ………………………………………………………………….. 38
Elements of Collaborative Capacity …………………………………………………. 38
Diverse, Open, Participatory Cultures …………………………………………… 39
Felt Need …………………………………………………………………….. 40
Participation …………………………………………………………………. 40
Openness and Sharing ……………………………………………………...... 41
Appreciation of Diversity ……………………………………………………. 41
Dispersed, Balanced Power ……………………………………………………… 42
Authority and Empowerment ………………………………………………... 43
Flexible, Bridging Leadership …………………………………………………… 44
Leadership Support ………………………………………………………….. 44
Structuring Collaborative Care Capacity ……………………………………………. 45
Hospital Culture …………………………………………………………………. 45
Hospital Power Relationships …………………………………………………… 47
Collaborative Care Leadership ………………………………………………….. 49
Communication-based Change ……………………………………………………... 50
Chapter 3—The Case ………………………………………………………………………... 53
Research Site ……………………………………………………………………………. 53
Research Access to SCCH ………………………………………………………….. 53
Participants ………………………………………………………………………….. 54
Units and Team …………………………………………………………………. 54
Individuals ………………………………………………………………………. 55
Collaborative Organizational Trends in Health Care …………………………………… 56
COLLABORATIVE CARE CAPACITY 7
Policy Change ………………………………………………………………………. 56
Integrated Care …………………………………………………………………….... 57
Medical Home Model ……………………………………………………………….. 57
Collaboration at SCCH ……………………………………………………………… 58
Language Access ………………………………………………………………... 58
Consultant Interventions ………………………………………………………… 59
Research Design ………………………………………………………………………… 59
Communication and Collaborative Care Capacity ………………………………….. 59
Overview of Data Collection ………………………………………………………... 60
Chapter 4—Discourse and Interaction Constitute Collaborative Care ……………………… 61
Literature Review ……………………………………………………………………….. 62
Collaborative Care Capacity on Health Care Teams ………………………………... 63
Collaborative Cultures …………………………………………………………... 63
Health Care Team Cultures …………………………………………………. 64
Collaborative Power Relationships ……………………………………………... 67
Health Care Team Power Relationships ……………………………………. 67
Collaborative Leadership ……………………………………………………….. 72
Health Care Team Leadership ………………………………………………. 73
Information and Communication Technologies ……………………………….... 75
ICTs and Collaboration in the Health Care Context ………………………… 76
Method ………………………………………………………………………………….. 79
Observation …………………………………………………………………………. 79
Observation Procedures ………………………………………………………… 79
COLLABORATIVE CARE CAPACITY 8
Interviews …………………………………………………………………………... 81
Interview Procedures …………………………………………………………… 81
Data Analysis ………………………………………………………………………. 84
Field Notes and Interview Transcripts …………………………………………. 84
Findings ………………………………………………………………………………… 86
Felt Need …………………………………………………………………………… 87
Teamwork and Collaboration …………………………………………………... 87
For the Kids ……………………………………………………………….... 89
Key Players ……………………………………………………………………... 90
Personal Issues ………………………………………………………………….. 92
Lack of Felt Need ……………………………………………………………….. 93
Cultural Differences ………………………………………………………………… 96
Openness and Sharing …………………………………………………………... 96
Open Communication ………………………………………………………. 97
Communication Problems ……………………………………………........... 99
Team Participation ……………………………………………………………… 101
Pediatric Intensive Care Unit ……………………………………………….. 101
Cardiovascular Acute ……………………………………………………….. 102
5A …………………………………………………………………………… 103
Hematology and Oncology …………………………………………………. 105
Bone Marrow Transplant …………………………………………………… 106
General Pediatric Surgery Team …………………………………………..... 107
Appreciation of Diverse Perspectives …………………………………………... 108
COLLABORATIVE CARE CAPACITY 9
Staff/Care Providers ………………………………………………………… 109
Patients/Families ……………………………………………………………. 111
Time …………………………………………………………………………….. 115
Space ……………………………………………………………………………. 120
Decision-making, Planning and Problem Solving ………………………………….. 125
Decision-making ………………………………………………………………... 126
Problem Solving ……………………………………………………………….... 127
Collaborative Leadership Support …………………………………………………... 132
Leadership Support ……………………………………………………………… 132
Bridging …………………………………………………………………………. 133
ICT Use and Collaboration ………………………………………………………….. 141
Face-to-face ……………………………………………………………………… 142
ICT Use ………………………………………………………………………….. 144
Discussion ……………………………………………………………………………….. 146
Values, Goals, and the Need for Collaboration ……………………………………… 146
Openness, Participation, and Diversity ……………………………………………… 148
Openness ………………………………………………………………………… 148
Participation ……………………………………………………………………... 149
Diversity …………………………………………………………………………. 151
Time and Space ……………………………………………………………………… 153
Power Relationships in Decision-making and Problem Solving ……………………. 153
Leadership for Collaboration ………………………………………………………... 155
Using Information and Communication Technologies ……………………………… 155
COLLABORATIVE CARE CAPACITY 10
Summary …………………………………………………………………………….. 156
Limitations ………………………………………………………………………….. 158
Future Research …………………………………………………………………….. 159
Conclusion ………………………………………………………………………….. 160
Chapter 5—Measuring Collaborative Care Capacity Care ………………………………… 161
Literature Review ………………………………………………………………………. 163
Culture ……………………………………………………………………………… 163
Diversity ………………………………………………………………………... 163
Structuring Diversity Relationally ……………………………………………... 165
Power Relationships ………………………………………………………………... 166
Structuring Shared Power ………………………………………………………. 166
Leadership Support …………………………………………………………………. 167
Bridging Relationships ………………………………………………………….. 167
Method ………………………………………………………………………………….. 169
Pilot Survey Procedures …………………………………………………………….. 169
Measuring Collaborative Capacity ……………………………………………… 169
Survey Data …………………………………………………………………………. 170
Pilot Survey Measures …………………………………………………………... 172
Factor Analysis ……………………………………………………………… 172
Demographics ………………………………………………………………. 177
Survey Analysis ……………………………………………………………………... 177
Possible Future Findings ………………………………………………………………… 177
Discussion ……………………………………………………………………………….. 178
COLLABORATIVE CARE CAPACITY 11
Perceptions of Collaborative Capacity ………………………………………………. 178
Limitations …………………………………………………………………………... 180
Future Research ……………………………………………………………………... 180
Chapter 6: Developing Collaborative Care Capacity ………………………………………... 182
Developing a Tool for Measurement ……….…………………………………………… 184
Summary Findings …………………………………………………………………... 184
Developing a New Instrument ………………………………………………………. 188
Collaborative Culture ……………………………………………………………. 189
Collaborative Power Relationships ……………………………………………… 190
Collaborative Leadership ………………………………………………………... 191
Collaborative ICT Use …………………………………………………………... 191
Collaborative Capacity Development …………………………………………………… 191
Organizational Change ……………………………………………………………… 192
Challenges ………………………………………………………………………. 192
Interventions …………………………………………………………………….. 194
Work Patterns and Relationships ……………………………………………. 194
Leadership …………………………………………………………………… 195
High Reliability Team Training ……………………………………………... 196
Education ……………………………………………………………………. 197
Strategic Communication ……………………………………………………….. 197
Conclusion ………………………………………………………………………………. 198
References …………………………………………………………………………………... 200
Appendix ………………………………………………………………………………......... 222
COLLABORATIVE CARE CAPACITY 12
List of Tables
Page
Table 3.1: Overview of Units and Teams …………………………………………………… 55
Table
4.1:
Number of Observation Sessions for Each Unit or Team ………………………. 80
Table
4.2:
Number of Staff and Care Providers Interviewed by Discipline ………………... 82
Table
4.3:
Number of Staff and Care Providers Interviewed by Team …………………….. 83
Table
4.4:
Field Note and Interview Analysis Codebook …………………………………... 84
Table
5.1:
Pilot Survey Respondent Information …………………………………………... 171
Table 5.2: Factor Loadings and Communalities from Principal Axis Factor Analysis with
Varimax Rotation for Nine Collaborative Capacity Items ………………………………….. 175
Table 5.3: Descriptive Statistics for EFFORT and the Log Transformed Composite
VALUES_RLg10 …………………………………………………………………………… 177

COLLABORATIVE CARE CAPACITY 13
Chapter 1: Communication and the Need for Collaborative Care
Communication plays an increasingly central role in the process of delivering safe,
efficient health care as complex diseases and treatments often require large teams of health care
providers to work together with patients and families over an extended period of time. Research
has demonstrated a relationship between good communication and successful collaboration, and
has linked collaboration to safe patient care. However, there is little consistency in how these
concepts are defined in empirical research. If they are defined at all, they tend to be
underspecified; teamwork and collaboration are used interchangeably and communication
typically refers to little more than the exchange of information between two or more people.
Without clearly defined variables, relationships are often hard to discern and research may be
limited by restrictive assumptions.
In this dissertation project, I expand the definition of communication to include the
system of discourse and interaction that shapes the social structure of an organization. This
definition encompasses communication as basic information exchange but also accounts for
communication as the medium through which the social norms, power relationships, and
organizational cultures that create a context for information exchange are established and
institutionalized over time (Giddens, 1979). Using this broader definition of communication, I
explore how discursive patterns play a role in developing the collaborative capacities that are
necessary for a hospital to deliver quality patient care in a complex organizational environment.
Then I test a survey instrument for assessing these capacities.
A Complex System
Over the last century, health care in the United States has evolved from playing a
relatively limited and private role in the lives of individuals into a massive, complicated system
COLLABORATIVE CARE CAPACITY 14
that is intricately woven into the political, social, and economic fabric of daily life. A perfect
storm of external change and internal evolution has created a complex institution comprised of
many different kinds of individuals and organizations that only partially resemble their early
antecedents. Perhaps one of the most notable characteristics of the health care system today is its
complexity (Burns, 2001; Plsek & Greenhalgh, 2001).
Improvements in medical research have yielded more—and better quality—knowledge
about disease and treatment. Enhanced knowledge has increased specialization within both
physician and non-physician groups (Gage, 1997) and led to the development of new health care
disciplines (e.g., Kelley, 1999). Globalization and new information and communication
technologies (ICTs) have enabled the spread of medical knowledge and techniques across
borders (Deaton, 2004). These changes bear partial responsibility for people’s shifting
expectations about life and death and the role of health care in their lives. A few decades ago,
diagnoses like leukemia and AIDS likely came with a death sentence (Greenwald, 2010, sec.
327). Today, people often either recover from or successfully manage these diseases and go on to
live relatively normal lives.
There are more health care professionals from a wider variety of disciplines working in
the United States today than ever before; knowledge of how to treat an extensive range of
ailments continues to grow; and Americans, more than people in other parts of the world, have
come to expect longer lives enabled by modern medicine (Washington Post Staff, 2010, p. 67).
The health care sector has adapted over time to greater demand and better knowledge resources,
resulting in a functional—though expensive, inefficient, and error-prone—system that seems to
be all at once on the brink of necessary change and yet deeply rooted in the past. This study
COLLABORATIVE CARE CAPACITY 15
investigates this tension between what has worked historically and what must change in the
future to ensure the survival of a central component of the U.S. health care system—the hospital.
The Need for Collaborative Care
Collaborative care has been defined broadly in terms of the “multifaceted organizational
intervention[s]” that support team-based patient care, which include drawing new roles into the
care process, encouraging different disciplines to work together, and encouraging information
sharing (Bower et al., 2006, p. 485). Just as managed or integrated care models have developed
at the inter-organizational level to improve coordination and simplify complexity between
different kinds of health care organizations, collaborative care models have become popular
within hospitals as a means of increasing efficiency while also improving patient outcomes.
In hospitals today, “care is delivered by large teams of nurses, doctors, and technicians
from a wide range of disciplines” (Pronovost & Vohr, 2010, sec. 525). Besides a specialized
attending physician or hospitalist who may be primarily responsible for decisions about the
patient’s care, there may also be a team of surgeons, other consulting specialists, and, in a
teaching hospital, fellows or residents who visit the patient. Some combination of support
services—including therapy, social work, case management, nutrition, pain management,
discharge services, and clinical care coordination—will also visit the patient multiple times
throughout a hospitalization and there will be a group of nurses who provide bedside care in
shifts. One reason for this fragmentation of care is the growing number of complicated medical
conditions that can be treated only with a multifaceted approach that often involves an entire
team of highly specialized medical professionals (Gage, 1997). As the number of staff and
providers responsible for caring for a single patient has expanded to include a more diverse range
COLLABORATIVE CARE CAPACITY 16
of disciplines, the need for collaboration among care providers has become increasingly more
apparent.
Preventable Medical Error
An important development in the late 1990s turned the attention of hospital
administrators to the critical role of collaboration in providing quality patient care. The Institute
of Medicine (IOM) issued a report estimating that between 44,000 and 98,000 deaths occur in
U.S. hospitals each year as a result of preventable medical errors (Kohn, Corrigan, & Donaldson,
1999), including delayed treatment, administration of the wrong dose or type of medication,
hospital acquired infections, or wrong-patient/wrong-site/wrong-procedure mistakes (Office of
Quality Monitoring, 2013). This influential report quantified for the first time the magnitude and
pervasiveness of medical error on a national scale and accelerated a paradigm shift that had
begun in the 1970s and 1980s when standardized business indicators related to quality and
efficiency became the dominant forces shaping the evolution of health care (Scott, Ruef, Mendel,
& Caronna, 2000, p. 175).
Quality and efficiency. Management-driven logic and market-based values entered
health policy discourse in the 1970s and by the 1980s began to overshadow the emphasis on
open and equal access to health care popularized in the 1960s with the passage of Medicare and
Medicaid (Scott et al., 2000, p. 217). The rapidly rising cost of health care—in a policy-driven
industry with few market-based incentives—became one of the primary driving forces behind the
shift. As the process of providing and paying for health care became more complex, many of the
organizational systems necessary to coordinate this complexity failed to adapt, resulting in
enormously expensive and inefficient administrative processes (Woolhandler, Campbell, &
Himmelstein, 2003). Economists and management scholars turned their attention to the health
COLLABORATIVE CARE CAPACITY 17
care sector in an effort to reframe thinking and reform processes around the principles of quality
and efficiency. This new perspective encouraged scholar-practitioners within the field to shift the
focus of their research as well.
Patient safety. As the role of “patients” has transformed into that of health care
“consumers,” the concept of quality in health care has become synonymous with patient safety.
No other high-risk industry (e.g., aviation or nuclear energy) can accept an error margin like the
one reported by the IOM without serious repercussions, and people have started questioning why
health care should be an exception. New research has developed around the issue of reducing
medical error and improving patient safety. Findings from this research generally support the
main conclusion from the 1999 IOM report:
that the majority of medical errors do not result from individual recklessness or the
actions of a particular group . . . [but are more commonly] caused by faulty systems,
processes, and conditions that lead people to make mistakes or fail to prevent them
(Institute of Medicine, 1999, p. 2).
These early findings have turned attention away from “blaming and shaming” the individuals
who commit errors and more toward identifying the features of an organizational system that
may have caused, or failed to prevent, errors. Two of the most common variables identified in
organizational systems research on medical error are collaboration and communication
(Catchpole et al., 2007; Hoff, Jameson, Hannan, & Flink, 2004; Leonard, Graham, & Bonacum,
2004; Manser, 2008; Spellbring & Gannon, 1986).
Collaboration. The treatment of complex conditions typically requires a team of
individuals with different backgrounds and knowledge (Medves et al., 2010, p. 86), but as more
staff and providers become responsible for different aspects of a patient case, collaboration
COLLABORATIVE CARE CAPACITY 18
becomes increasingly important for ensuring safe, quality care (Manser, 2008). Research has
established a relationship between successful teamwork and a range of positive organizational
and clinical outcomes, including: better problem solving, higher employee morale, decreased
length of patient stay, and fewer medication errors (Horak, Guarino, Knight, & Kweder, 1991;
Shortell et al., 1994; Sim & Joyner, 2002).
A review of the existing literature on organizational variables and their relationship to
medical error and patient safety identified teams as the most common variable studied (Hoff et
al., 2004, p. 14). Another review of survey instruments measuring patient safety culture found
that teamwork was one of the common dimensions used to assess patient safety culture on
approximately 70 percent of reviewed survey instruments (Singla, Kitch, Weissman, &
Campbell, 2006). Existing research clearly identifies a relationship between collaboration,
patient safety, and hospital quality improvements; however, research also suggests that
communication often determines the success or failure of collaborative efforts.
Communication. According to the Joint Commission on the Accreditation of Hospital
Organizations (JCAHO), communication was the most commonly identified root cause of
medical error (after human factors like fatigue and distraction) in U.S. hospitals in the first six
months of 2013 (Office of Quality Monitoring, 2013, p. 8). Communication is typically found
within the top three reported causes of medical error in any given year. Although rarely explicitly
defined in patient safety research, the Joint Commission describes communication as: “oral,
written, electronic, among staff, with/among physicians, with administration, with patient or
family” (Office of Quality Monitoring, 2013, p. 5).
Researchers have recognized the need to better understand this variable and its impact on
quality patient care. Studies have primarily examined: hand-off communication (Amato-Vealey,
COLLABORATIVE CARE CAPACITY 19
Barba, & Vealey, 2008; Apker, Mallak, & Gibson, 2007; Arora, Johnson, Lovinger, Humphrey,
& Meltzer, 2005); interdisciplinary communication—especially between nurses and physicians
(Simpson, James, & Knox, 2006; Tjia et al., 2009); communication in high risk settings like the
emergency department, operating room, or intensive care unit (Eisenberg et al., 2005; Eisenberg,
Baglia, & Pynes, 2006; Greenberg et al., 2007; Lingard et al., 2004; Mills, Neily, Dunn, &
others, 2008); communication disruptions or failures (Arora et al., 2005; Awad et al., 2005;
Catchpole et al., 2007; Greenberg et al., 2007; Lingard et al., 2004; Rosenstein & O’Daniel,
2008; Sutcliffe, Lewton, & Rosenthal, 2004); and the role of language and culture in patient-
provider communication (Divi, Koss, Schmaltz, & Loeb, 2007; Johnstone & Kanitsaki, 2006,
2009; Karliner, Napoles-Springer, Schillinger, Bibbins-Domingo, & Pérez-Stable, 2008; Walker,
Cromarty, Kelly, & St Pierre-Hansen, 2009).
Evaluation-based research has also included communication among the elements of
patient safety climate/culture (Colla, Bracken, Kinney, & Weeks, 2005; Singla et al., 2006),
while research on interventions that facilitate collaborative communication has focused primarily
on adaptations of the SBAR (Situation, Background, Assessment, Recommendations) method,
originally developed for use in aviation (Beckett & Kipnis, 2009; Dunsford, 2009; Haig, Sutton,
& Whittington, 2006; Hohenhaus, Powell, & Hohenhaus, 2006; Shendell-Falik, Feinson, &
Mohr, 2007). Much of this research on communication and patient care quality assumes a narrow
definition of communication as a process of information exchange between different individuals
or groups. However, there are important exceptions to this assumed definition.
Eisenberg and colleagues (2005) studied effective communication in the “dynamic,
uncertain environment” of a hospital’s Emergency Department (ED) (p. 392). They explain that
the message transmission approach to communication adopted by the JCAHO “leaves out much
COLLABORATIVE CARE CAPACITY 20
of what is most important (and most challenging) about health communication practice” and
suggest looking more broadly at “communication environments” (Eisenberg et al., 2005, p. 393).
The latter approach takes the focus off the information itself and those directly involved in
sharing it and shifts attention to the social context in which information exchange takes place,
thus broadening the range of variables that might impact any particular instance of information
“transfer.”
Sutcliffe and colleagues (2004) studied communication failures and the role they play in
medical errors. They discovered that poor communication was rarely a result of simply forgetting
to share information, but actually involved intentional withholding related to “hierarchical
differences, concerns with upward influence, conflicting roles and role ambiguity, and
interpersonal power and conflict” (Sutcliffe et al., 2004, p. 186). Their initial focus on
communication as information exchange evolved based on the key finding that information
sharing is embedded in a social context characterized by hierarchical leadership and unequal
power relationships—a social context that is constructed through communication.
These studies exemplify the use of a broader definition of communication in health care
quality research—one that is commonly used by scholars in the field of organizational
communication but remains less common in health care management and administration
research. In spite of the recent emphasis on the role of organizational systems in improving
quality and efficiency in hospitals, only a small number of empirical studies examine
communication as a systemic variable. Defining communication as the system of discourse and
relationships that shapes the social structure of an organization broadens the role that
communication plays in the collaborative organizing process. Communication is more than
information exchange; it is a constitutive process (Putnam & Nicotera, 2009). As the medium
COLLABORATIVE CARE CAPACITY 21
through which organizations are created and sustained, through which organizing actually
occurs, communication plays a central role in maintaining a social environment that supports and
encourages collaborative care.
Collaborative Care Capacity
Because this research examines the context in which collaboration occurs, I emphasize
the capacities that enable collaborative care rather than the process of collaboration itself.
Although these two facets of collaboration are heavily intertwined, the analytical distinction is
important. An understanding of the process of collaboration will be of little use in practice
without an understanding of the capacities that must be nurtured and developed in order to
enable the process to succeed. By some accounts, the popular SBAR intervention—which uses a
checklist process for standardizing hand-off communication between units and shifts—
sometimes fails to improve long-term collaborative outcomes for exactly this reason; it attempts
to improve the process without addressing the systemic capacities that enable the process or
prevent it from succeeding over time (Barbour, 2010).
Research on inter-organizational collaboration between government agencies defines
collaborative capacity as “the ability of organizations to enter into, develop, and sustain
interorganizational systems in pursuit of collective outcomes” (Hocevar, Thomas, & Jansen,
2006, p. 256). Adapting this definition for the internal context within a hospital, I define
collaborative care capacity as: the ability of individuals, teams, and units in a hospital to enter
into, develop, and sustain organizational systems that enable quality patient care outcomes.
Although very few health care collaboration studies explicitly refer to capacity building, many
do identify factors that impact the collaborative process. Research on organizational
collaborative capacity identifies range of different factors that affect collaboration and impact
COLLABORATIVE CARE CAPACITY 22
outcomes. A review of this research, which will be discussed more in Chapter Two, reveals three
key themes or areas for collaborative capacity development: 1) organizational culture, 2) power
relationships, and 3) leadership support.
A Communication Perspective
Collaboration is driven by a process of communication and information exchange
between individuals or groups working toward a shared goal. However, collaboration differs
from other processes of communication and information exchange—such as coordination and
cooperation—in one particularly important way. Synergistic collaboration produces an outcome
that could not be accomplished by any one of the collaborators alone (Kerfoot, Rapala, Ebright,
& Rogers, 2006, p. 586). Whereas coordination implies organization among multiple parts and
cooperation implies a willingness to work together, collaboration implies both of these things as
well as the creation of a novel outcome based on interdependencies that extend beyond shared
work.
The term collaborative care recognizes the interdependencies among different kinds of
care providers that produce patient outcomes, which would not be possible from any of the
collaborators working alone. The key areas of organizational capacity that enable collaborative
care—culture, power relationships, and leadership—are embedded in the social environment of a
hospital, which is constructed and sustained via communication. This project investigates the
ways in which communication discursively and interactively structures these key areas of
capacity through social relationships to create and perpetuate an environment that both enables
and constrains collaborative care.

COLLABORATIVE CARE CAPACITY 23
Chapter Summaries
This field research project involved the collection and analysis of two different types of
qualitative data and the testing of an instrument to measure collaborative capacity within a health
care organization. Chapter Two develops the theoretical framework that foregrounds the
empirical research. I use Giddens’ (1979) theory of structuration to explain how communication
creates and maintains the social structures within a hospital. These structures simultaneously
support and inhibit the development of collaborative care capacity. The structuration perspective
applied to the organizational context in a hospital provides a robust, systems-based framework
that expands the role of communication in developing collaborative care capacity. Chapter Three
provides a description of—and detailed background information about—the hospital where all
data were collected. Chapter Four examines how discourse and interaction around the key
collaborative care capacity variables—organizational culture, power, and leadership—structure
the capacity to collaborate. Chapter Five pilots an instrument for measuring collaborative
capacity. An adapted version of an existing instrument is created and tested within a health care
context. Chapter Six makes recommendations for further development of a tool for measurement
and considers potential interventions for developing collaborative capacity in light of findings
from the qualitative study and from piloting the adapted survey instrument.

COLLABORATIVE CARE CAPACITY 24
Chapter 2: Structuring Collaborative Care
An expanded definition of communication and its role in developing collaborative care
capacity in hospitals begins with a reconsideration of how to think about hospitals as
organizations. While Greenwald (2010) acknowledges that health care organizations serve as
venues for the actual delivery of care, he defines organizations not in terms of physical location
or services rendered but as “systems of human relationships that are designed through
recognizable rules, assignments, and procedures to achieve identifiable objectives and goals”
(sec. 3262). Based on this definition, he argues that the delivery of quality health care depends
largely on features of the organization like structure and leadership (Greenwald, 2010, sec.
3262). This way of thinking about a hospital and the level of care provided in terms of social
systems requires organizational communication scholars to examine how such a system-as-
organization develops and sustains itself. One significant way this question can be analyzed lies
in a communication perspective called Communication Constitutes Organization (CCO).
As a coherent perspective, CCO can be traced back to the 1980s when researchers began
questioning the common assumption that the existence and continuity of organizations can be
taken for granted (Putnam, Nicotera, & McPhee, 2008, p. 7). Influenced by the linguistic turn in
the social sciences and by Weick’s (1979) focus on organizing as opposed to the organization,
organizational communication scholars began to view organizations as “systems of interacting
individuals who were actively creating and recreating social orders” (Putnam et al., 2008, p. 6)
through verbal, nonverbal, and symbolic communication. The CCO perspective suggests
hospitals as organizations develop and sustain themselves through constitutive communication.
In their study of mishaps in hospital Emergency Departments (EDs), Eisenberg, Murphy,
and Sutcliffe (2005) employ a CCO perspective to study EDs as “communication
COLLABORATIVE CARE CAPACITY 25
environments”—an approach that challenges the dominant conception of communication as
information transfer (p. 393). In thinking of EDs as communication environments, they utilize a
an “information behavior approach,” which “conceives of communication as constitutive of
meaning” (Deetz, 1994 as cited in Eisenberg et al., 2005, p. 393). In this chapter, I build on the
CCO perspective utilized by Eisenberg and colleagues in their hospital ED study to develop a
theoretical framework that combines the notion of constitutive communication with research on
collaborative capacity. I primarily use Giddens’ (1979) theory of structuration—one of the
critical ontological and epistemological scaffolds for a CCO approach—to help explain how
hospital organizations are socially structured in ways that both support and inhibit collaborative
care. An emphasis on capacity building orients the discussion around communication-based
change.
Structuring Hospitals
Structuration theory (Giddens, 1979) provides a framework for studying hospitals as
“systems of human relationships” (Greenwald, 2010, sec. 3263) embedded in an institutional
context. Giddens (1979) proposed the theory of structuration to acknowledge the role of both
human agency and social structure in the constitution of social systems. Institutional norms,
power relationships, and meanings that are reproduced through structuring processes both enable
and constrain collaborative care in different ways. Banks and Riley (1993) identify and discuss
elements of the theory that may be particularly useful in communication research, including:
agency and reflexivity; the duality of structure; praxis and time/space distanciation; and
social/system integration and institutional reproduction. In this section, these core theoretical
concepts are used to identify and discuss the structuring processes that create and sustain the
COLLABORATIVE CARE CAPACITY 26
social system of a hospital organization. This explication offers an expanded definition of
communication and its role in a hospital system.
Agency and Reflexivity
Agency, according to structuration theory, derives from agents’ ability to rationalize, and
knowledge of, their motivation for their own actions (Banks & Riley, 1993, p. 171). People self-
monitor their actions in social interactions by drawing “from stocks of more or less mutual
knowledge derived from past experience and explicitly learned norms” (Banks & Riley, 1993, p.
171). This reflexive process necessitates agents’ continuous understanding of the basis for their
own actions in any given situation (Giddens, 1984, p. 5).
Agency comes not from unconstrained action but from participants’ “capability to do
otherwise” suggesting that agency implies power (Giddens & Pierson, 1998, p. 84). Actors have
varying degrees of knowledge about the social structures they reproduce through interaction.
When an actor has a high level of discursive consciousness in a particular social context, she is
said to have discursive penetration of the social system that she plays a role in constituting
(Giddens, 1979, p. 5). Discursive penetration enables actors to transform structures, but
reproduction of existing structures via routines remains the norm in day-to-day interaction. It is
important to recognize that agents have the ability to act intentionally even “in circumstances
that include unintended consequences and unacknowledged preconditions” (Giddens, 1984, p.
285 as cited in Banks & Riley, 1993).
In a hospital organization, agency derives from: actors’ knowledge of health, disease, and
treatment; understanding of the health care process; familiarity with the local system of
relationships and artifacts; as well as a more basic understanding of conventions of interaction.
Care providers and hospital administrators have varying levels of critical knowledge,
COLLABORATIVE CARE CAPACITY 27
understanding, and familiarity within this system. However, the vast majority of organizational
members share knowledge of the norms that sustains the hospital as a coherent “organization”
from one day to the next.
Agents in a hospital rely on mutual knowledge to make interaction possible in the course
of providing patient care but the distribution of knowledge is patchy and uneven. When
communicating a change in a patient’s medication to a bedside nurse, for example, a physician
relies on shared knowledge and understanding about the efficacy of medication and proper
administration as well as the implementation of correct protocols for carrying out this process.
However, the physician may have unique knowledge of disease and treatment anomalies that
(some) nurses may not have and the nurse likely has a unique understanding of the patient’s
history and current condition based on more regular, hands-on contact with the patient. Both care
providers understand “how to go on” (Giddens, 1979, p. 171) in this interaction, and most of the
time, these interactions will play out according to a similar routine, yet both actors retain the
capacity to break from this routine, which gives them agency even in a highly directed, legally-
bound institution.
The Duality of Structure
Agency is the mobilizing force in our social world, yet we are able to go through our
daily lives with a systematic understanding (to varying degrees) of our own actions and the
actions of others around us (Banks & Riley, 1993, p. 173). Giddens (1979) explains how this is
possible through a concept he calls the duality of structure:
By the duality of structure, I mean the essential recursiveness of social life, as constituted
in social practices: structure is both medium and outcome of the reproduction of practices
COLLABORATIVE CARE CAPACITY 28
. . . Structure enters simultaneously into the constitution of the agent and social practices,
and ‘exists’ in the generating moments of this constitution (p. 5).
To say that structure is the medium through which social practices are reproduced is to
acknowledge that structure provides people with rules and resources to use in social interaction;
to say that structure is also the outcome of this reproduction is to acknowledge that structure does
not exist independently of the social practices it constitutes, so it is only through their application
that structures have ontological status (Riley, 1983, p. 415). Structures, then, are the ‘rules and
resources’ that agents can draw upon in interaction. Rules refer to practical knowledge while
resources refer to an agent’s ability “to generate command over other persons’ social conditions
(called authoritative resources) and to generate command over material entities (allocative
resources)” (Banks & Riley, 1993, p. 173).
Structuration theory provides a framework for thinking about organizational structure that
departs in multiple ways from common assumptions or past theoretical assumptions. First, the
term “structure” is used to describe a social—not a physical—phenomenon. Structures include
the social rules and resources that actors use when interacting with others.
Second, structure has a kind of dual nature in social interaction. It enables interaction by
providing those stocks of mutual knowledge but its existence is also perpetuated in and from the
very same interaction it enables. Third, this dual nature of structure is expressed through three
dimensions that encapsulate relations between individual action and interaction in the present
and enduring institutions—many of which are embedded historically in language and routines
and will continue to be reproduced into the future. These dimensions—all of which are
implicated in any instance of social action—include communication (referred to as signification
at the institutional level), power (or domination), and sanction (or legitimation) (Giddens, 1984).
COLLABORATIVE CARE CAPACITY 29
Finally, structuration resolves a problem found in early precursors to CCO theory, such as the
social constructionist perspective, that assume communicative resources are constructed or
generated almost from scratch in discrete interactions. Structuration theory explains that these
resources are not often generated anew but are instead simply maintained by their latest usage
and sometimes transformed through interaction (McPhee & Iverson, 2008).
In a hospital organization, the dual nature of structure provides a framework and a
vocabulary for examining how interaction among care providers, patients, families, and
administrators is enabled by and reflected in the “systems of deeply layered structures,” which
“explain the ‘framework’ of the organization” (Riley, 1983, p. 415) as it is embedded in the
institution of health care. In the example of a physician changing a patient’s medication, the
physician and nurse share a similar understanding of what this means, how to do it, and what
each of their roles will be because of their own experiences with this process but also from a
historical understanding of how this process has worked in the past (long before either of them
became a doctor or nurse or any other related role). In order to carry out this “medication
change” interaction, the doctor and the nurse rely on “rules and resources” that empower and
enable them to make this decision and to carry out the necessary role-based actions that are
involved in switching medications successfully. At the same time, the very existence of the
structures that enable the “medication change” interaction are made real only as they are “applied
and acknowledged” in the moment of interaction because “they have no reality independent of
the social practices they constitute” (Giddens, 1979 as cited in Riley, 1983, p. 415). In this way,
the structures drawn upon to enable this particular medication change interaction are part of the
patterning of communication and these structures are thus reproduced and become resources for
the future by this interaction. The creation of “complex institutional patterns”—of organizations
COLLABORATIVE CARE CAPACITY 30
like hospitals—results from the interpenetration of multiple overlapping structures from
exponentially large numbers of interactions in this context and other related environments across
space and over time.
Praxis and Time/Space Distanciation
Although structures provide what some call “recipes” for action, rules do not serve as
“prescribed formulations” for how to act (Banks & Riley, 1993, p. 173). The notion of praxis—
or “regularized acts as situated practices”—unifies theories of action and structure in that it
assumes agent “‘intervention’ in a potentially malleable object-world” (Giddens, 1979, p. 56).
Banks and Riley (1993) explain that:
the entire project [of structuration theory] rests crucially on theorizing the relation
between action in the here and now and the reproduction of institutional contexts,
practices, and expectations that stretch out across potentially (and increasingly) vast
distances and time spans (p. 175).
The concepts of agency and structure and their relationship as illustrated in the duality of
structure focus on co-present interaction, but these concepts alone do not explain the persistence
of social systems “across time-space” (Giddens, 1984, p. 110).
The concept of locale refers to the chronically patterned use of space across time by
agents in contextualized action. “Locales may range from a room in a house, a street corner, the
shop floor of a factory, towns and cities, to the territorially demarcated areas occupied by nation-
states,” but locales are regionalized or zoned within “time-space in relation to routinized social
practices” (Giddens, 1984, pp. 118–119). Time is not conceived of as a punctuated moment any
more than space is conceived of as a specific physical location. Social interaction then takes
place within a regionalized locale that shapes (though does not determine) action across time-
COLLABORATIVE CARE CAPACITY 31
space, which establishes “orders of institutional relationships [that] are formed, codified,
memorialized, and concretized as contextual features in the structuration of social life” (Banks &
Riley, 1993, p. 176).
A hospital is a locale regionalized largely by buildings, floors, units, and departments and
by monthly, weekly, and daily (or nightly) shifts punctuated by weekends (Zerubavel, 1979).
Time-space is a contextual feature of action that enables the presence-availability of different
care providers, administrators, patients, and family members who work or receive care across
different zones within the locale of a hospital. The importance of time-space distanciation
becomes clearer in the concrete example of the physician-nurse interaction involved in changing
a patient’s medication. This pattern of action would be very different if the attending physician
initiated the process during morning rounds when the whole team, including the day nurse who
would administer the new medication, was present than if a night nurse attempted to initiated this
process at two o’clock in the morning when there was no attending physician working and the
resident physician was unfamiliar with the medication.
The former context facilitates physical co-presence of key actors whereas the latter
context prevents physical co-presence of key actors (since the attending physician is likely at
home sleeping) and requires a different form of action (perhaps waiting to make the medication
change until the morning or having the resident physician page the sleeping attending physician
to clarify if the medication change is acceptable). These contextualized patterns of interaction
tend to endure across regionalized locales so that in a year, a different physician and a different
nurse might draw from similar contextually based rules and resources to have an almost identical
medication-change conversation during morning rounds. “Thus,” as Riley (1983) explains,
COLLABORATIVE CARE CAPACITY 32
“structuration is grounded in individual interactions that, over time/space, constitute institutions”
(p. 416).
Social/System Integration and Institutional Reproduction
Institutions—or the “practices which have the greatest time-space extension within
[societal] totalities”—are perpetuated by social and system integration (Giddens, 1984, p. 17).
Social integration refers to “systemness on the level of face-to-face interaction” while system
integration refers to “connections with those who are physically absent in time or space”
(Giddens, 1984, p. 29). Actors’ shared knowledge enables the repetition of contextualized
interactive routines that are sequenced throughout daily life. Individuals coordinate their
interaction with other individuals by drawing from shared knowledge of the rules and resources,
or structures, available to each of them and reflexively monitoring their actions accordingly. This
“systemness” that enables co-present actors to successfully engage in contextualized interaction
is essential to, though not the same as, system integration (Giddens, 1984). The reproduction of
practices across diachronic time-space contexts implies system integration. These practices are
enabled in part by information and communication technologies “that unbind time and space and
then rebind them in subsequent, distant instances of social reproduction” (Banks & Riley, 1993,
p. 176).
Social and system integration are essential to the endurance of institutions, which are
chronically reproduced relationship patterns extending across time-space but made real via
praxis. Institutions are characterized by interactions among all three structural principles—
signification, domination, and legitimation—though they can be classified according to the
analytical primacy of each principle. Signification is prominent in modes of discourse;
domination via authoritative resources is prominent in political institutions while domination via
COLLABORATIVE CARE CAPACITY 33
allocative resources is prominent in economic institutions; and legitimation is prominent in legal
institutions or modes of sanction (Giddens, 1979, p. 107). All institutions, regardless of their
classification, are reproduced primarily via routine or tradition. “Routine action . . . is strongly
saturated by the ‘taken for granted’” and is most impactful when it arises out of tradition
(Giddens, 1979, pp. 218–219). And yet agents retain the ability to rationalize even their “taken
for granted” actions creating the potential for agent-driven change (however infrequently
utilized) by way of de-routinization or contrary influence (Giddens, 1979, p. 220).
Hospitals are foundational locales where agents reproduce the interpenetrating structures
that characterize the institution of health care in the United States. In the medication change
example, the physician-nurse interaction during morning rounds exemplifies social integration
while the nurse-physician interaction initiated at two o’clock in the morning that extends across
time until later in the morning and spans across space from the hospital to the attending
physician’s home exemplifies system integration. Both scenarios demonstrate one of thousands
of contextualized, “taken for granted” relationship patterns that perpetuate the institution of
health care. Riley (1983) explains that in any given organizational context:
the stores of knowledge each individual has about interaction in general (a language,
grammar rules, social norms to guide conversations, etc.), combined with knowledge of a
specific organization (standard operating procedures, the organizational chart, available
resources, etc.) can be drawn upon strategically by individuals to achieve their own goals.
At the same time, there is a bias for ‘what has come before,’ since structures that have
been previously drawn upon become part of the stores of knowledge available and are
themselves reproduced (p. 415).
COLLABORATIVE CARE CAPACITY 34
Structuration theory provides a socio-communicative perspective on organizing as an ongoing
process—a continuous achievement rather than a given (“an organization”). Hospitals as
regionalized locales contextualize action that draws from overlapping structural patterns to
reproduce the institution of health care across time-space. To say that hospitals are constituted by
communication is to acknowledge that hospitals, like all organizations, are social
accomplishments achieved through structuration processes and that communication broadly
defined provides the foundation for social interaction.
Structuration Theory in Health Care Organization Research
Structuration theory offers a useful framework for studying health care organizations—
both for selecting and setting up interesting problems to study and for explaining research
findings (Banks & Riley, 1993). Scott, Ruef, Mendel, and Caronna (2000) studied institutional
eras in health care in the United States from a historical perspective, but a rudimentary
application of structural properties allows for rough institutional classification and could be used
to examine further transitional periods of institutional change.
Physicians, via professional associations like the American Medical Association (AMA),
provided the primary form of governance during the era of professional dominance that lasted
roughly from 1945-1965. The primary guiding logic during this era, the quality of care, was
shaped by physician values. This institutional order can be classified as legitimation-domination-
sanction and is characteristic of legal institutions or modes of sanction. The U.S. government
provided the primary form of governance during the era of federal involvement that lasted from
1966-1982 after the passage of Medicare and Medicaid legislation. The primary guiding logic
during this era was equity of access, which people viewed as a political rights issue tied to
citizenship. This institutional order can be classified as domination (authoritative)-signification-
COLLABORATIVE CARE CAPACITY 35
legitimation and is characteristic of political institutions. In the current era that began in 1983, a
new guiding logic based on cost control, efficiency and private, market-based forms of
governance has taken precedence. This institutional order can be classified as domination
(allocative)-signification-legitimation and is characteristic of economic institutions that remain at
the forefront of health care practice today (Geist-Martin, Sharf, & Ray, 2003; Giddens, 1984, p.
33; Scott et al., 2000).
The study of health care organization has primarily taken place within the current
institutional era, which has oriented much of this work around management and efficiency (in
tandem with the legacy logic of care quality). Structuration theory has been used to study
information management via health information systems (HIS). This research has examined HIS
implementation, adaptation, and outcomes (Ghosh, 2007; Goh, Gao, & Agarwal, 2011;
Greenhalgh & Stones, 2010; Kouroubali, 2002; Triche, Cao, & Song, 2011). Structurational
analysis has also been used to study patient empowerment (Greener, 2008) and patient safety
culture (Groves, Meisenbach, & Scott-Cawiezell, 2011). Nicotera, Mahon, and Zhao (2010) used
the concept of structurational divergence to study how actors deal with structural conflicts in a
health care setting. Dopson, Fitzgerald, and Ferlie (2008) used structuration to study
contextualized change and innovation in a health care organization. Perhaps most relevant to this
project is the structuration-based research that examined the integration of health care at the
institutional level (Demers, Arseneault, & Couturier, 2010) and care coordination and
collaboration at the local level (Beringer, Fletcher, & Taket, 2006; D’Amour, Goulet, Labadie,
Martín-Rodriguez, & Pineault, 2008; Tellioğlu & Wagner, 2001).
Berginger and colleagues (2006) studied the care coordination process in two children’s
hospitals to learn more about how this process works, how people think it should work, and to
COLLABORATIVE CARE CAPACITY 36
identify the structures—the rules and resources—staff use to coordinate care. Their findings
indicate that communication was critically important for successful coordination but that
providers relied on verbal communication in the actual process of coordinating far more than
written records. They found that personal relationships were a key ‘resource’ that coordinators
used, while ‘rules’ for care coordination hinged largely on a flexible, in-the-moment negotiation
of responsibility for coordination coupled with a paradoxically clear understanding that final care
decisions are made by doctors. D’Amour and colleagues (2008) based their structuration model
of interprofessional collaboration on the notion of duality of structure in that it “takes issues of
structure into account but focuses on relationships between individuals and the interaction
between the relationships and the organizational dimensions” (p. 188). The four dimensions of
the model—shared goals and vision, internalization, formalization, and governance—reflect this
relationship and are used to develop an assessment of collective action readiness in health care
organizations. Tellioğlu and Wagner (2001) used structuration to study collaboration among staff
and care providers in a hospital radiology department from a spatial perspective. The concept of
regionalization enabled them to differentiate between the different spaces in which people work
in the course of different activities—and to demonstrate how most of these “spaces” include both
a physical and electronic element.
Studying communication and collaboration. Structuration theory has been used in
many different ways as a framework for research on health care organization—and health care
collaboration in particular. However, the opportunity remains to utilize structuration in
developing a distinctly communication-based approach to the study of collaborative care in a
hospital. In their call for more structuration-based research within the field of communication,
Banks and Riley (1993) explain “that communication figures prominently in the repertoire of
COLLABORATIVE CARE CAPACITY 37
ideas and vocabulary of structuration theory” (p. 169). Giddens (1984) himself describes
communication “as a general element of interaction” (p. 29), which he uses most explicitly in
relating the interactive level of action to structures of signification at the institutional level. Signs
or structures of signification exist only “as the medium and outcome of communicative processes
in interaction” and must be understood as inextricably tied to structures of domination and
legitimation, which exist only through interaction in the form of power and sanction (Giddens,
1984, p. 31).
The grounding of structuration theory in human interaction makes it a useful framework
for studying the relationship between communication-in-action and collaborative organizational
structures at the institutional level in a hospital. Barbour (2010) implicitly recognizes the duality
of structure in explaining that the schemas for “routine and ritualized conversations in health care
. . . come in part from institutions” (p. 451) and yet health care professionals “appropriate
institutions to their own ends” (p. 450). A systematic examination of communication as a
constitutive element of organizing in a hospital will provide a broader and more comprehensive
understanding of the role communication plays in creating and maintaining organizational
structures that enable collaborative care. Next, I use structuration theory and existing research on
organizational collaborative capacity to further develop the notion of collaborative care capacity
in a hospital and explain how it is grounded in organizational communication.
Collaborative Care Capacity
I adapted Hocevar and colleagues’ (2006) definition of inter-organizational collaborative
capacity to define collaborative care capacity as the ability of individuals, teams, and units in a
hospital to enter into, develop, and sustain organizational systems that enable quality patient care
outcomes. This definition assumes organization among multiple parts (coordination) and implies
COLLABORATIVE CARE CAPACITY 38
a willingness to work together (cooperation) as well as a novel outcome—a level of care quality
that would not be possible for individuals to provide when working alone. It is in this sense that
collaborative care extends beyond the traditional notion of ‘teamwork’ in which each teammate
contributes a unique part of the care process. The popular notion of teamwork does not account
for the interdependencies among staff and providers that make the outcome of truly collaborative
care greater than the sum of its parts.
A Focus on Capacity
I focus specifically on the organizational capacities that enable collaborative care instead
of the process itself. This distinction is a subtle but important one. While it is critical to
understand the process of collaborative care, this understanding alone will be insufficient for a
hospital to systematically improve its ability to provide this kind of care unless it has developed
organizational structures and systems that support this process. The difference between the ad
hoc structures and systems that care providers often rely on when working with others to provide
care and the structures and systems that are built on a strong foundation of collaborative capacity
is that the latter are highly reliable and sustainable. In short, “a capacity for collaboration
enhances the probability of mission completion” (Hocevar et al., 2006, p. 257). In the next
section, I review collaboration research that identifies key organizational “preconditions” (Gray
& Wood, 1991, p. 14) or capacities for collaboration, and then I use structuration theory to
explain how actors in a hospital organization might utilize and reproduce structures that develop
or restrict these capacities.
Elements of Collaborative Capacity
A range of studies from different fields and different organizational contexts—primarily
public administration and health care management—was reviewed in order to create a list of
COLLABORATIVE CARE CAPACITY 39
preconditions or capacities that enable collaboration. In an effort to make sense of this list, I
looked for commonalities among the capacities, and then categorized them in three groups:
organizational culture, power relationships, and leadership support. These categories captured—
either directly or indirectly—most of the capacities identified in the reviewed collaboration
research.
Diverse, open, participatory cultures. Organizational culture comprises one important
sphere for collaborative capacity development. I use Eisenberg and Riley’s (2001)
“communicative view of organizational culture,” which “sees communication as constitutive of
culture” (p. 294). This perspective rejects the notion that organizations have one defined
corporate culture (e.g., ‘IBM has a culture of service’) and instead recognizes that
“organizational culture consists solely of patterns of human action and its recursive behaviors . . .
and meaning” (Eisenberg & Riley, 2001, p. 294). Organizational culture is evident in practice
through verbal (formal and information conversation), nonverbal (organizational texts and
nonverbal behaviors), and symbolic (department layouts and team design) communication.
Culture is not a static entity but is instead produced and reproduced through dynamic
processes; it is also not singular in that most organizations have multiple subcultures—or
“competing systems of meaning”—that may create tensions (Riley, 1983, p. 415). The analytical
focus when studying organizational cultures begins with symbolic orders or modes of
discourse—what Giddens (1979) calls structures of signification—while acknowledging the
ways in which these structures are interwoven with those of domination and legitimation (p.
107). Sewell (1992) argues that it is actors’ knowledge of rules that enables them to act, and the
long-established “social scientific term for 'what people know,’” is “‘culture’” (p. 7). Based on
this view of culture, it should be apparent that there is not a single extant ‘culture’ that enables
COLLABORATIVE CARE CAPACITY 40
collaboration but rather intersecting patterns of human action, and meanings that accompany this
action, that reflect elements of collaborative culture.
Felt need. Research suggests that collaborative organizational culture must reflect the
need for collaboration. While this may seem obvious, it cannot be taken for granted. One
research team found that in building community health alliances, the first major capacity-
building challenge is actually the deceptively simple decision to develop collaborative
organizational structures instead of relying on existing structures to govern the alliance. Beyond
the structural changes enabled by this decision is the equally or even more important collective
identity building that it enables (Alexander, Christianson, Hearld, Hurley, & Scanlon, 2010, p.
651). Hocevar and colleagues (2006) call this a “felt need” to collaborate and emphasize that this
is often driven by “common goals and recognition of interdependence” that give individual
actors a shared sense of purpose (p. 272). Thomson, Perry, and Miller (2007) call this mutuality,
which they describe as “mutually beneficial interdependencies” that are tied to interests and are
often based either “on homogeneity or an appreciation and passion for an issue” (p. 5).
Specifically in service-based work, Thomson (1999) found that sharing a commitment to a
similar population of people was critically important in sustaining collaboration (as cited in
Thomson et al., 2007, p. 6).
Participation. Another element that research has found in collaborative organizational
cultures is an awareness of the important role that active participation plays in supporting
collaborative work, accompanied by the values that prompt this awareness. Participation may
seem like another obvious component of collaboration; however, it is possible for culture to
reflect a felt need to collaborate without reflecting full participation in collaborative work.
Alexander and colleagues (2010) explain that as a central component of collaboration,
COLLABORATIVE CARE CAPACITY 41
participation depends on “recognition of why some individuals or organizations may be reluctant
to participate” (p. 659). Reciprocity and trust take time to develop and are strongest when
personal relationships develop alongside formal working relationships as a substitute for formal
collaborative structures. When these values are reflected in the culture, collaborative work will
be more sustainable over time (Thomson et al., 2007, p. 6). Citing Galbraith’s STAR model,
Hocevar and colleagues (2006) include the important values of commitment and motivation that
provide a foundation for active participation in collaborative work processes. Commitment to,
and motivation for, collaboration present a unique challenge in hospitals where time is a valuable
resource and care providers must balance “between decision-making efficiency and inclusiveness
in participation” (Alexander et al., 2010, p. 652).
Openness and sharing. A related though distinct element reflected in collaborative
organizational culture is openness and sharing of the resources essential to accomplish the
collective mission or goal. For example, in organizations that engage in some kind of knowledge
work (which is most organizations today), it is essential for people to share knowledge and
information for collaboration to be successful. In hospitals, the safety of patients depends to
some degree on the openness of the communication environment to ensure that all of the
different care providers responsible for the same patient have all the information they need to
contribute to the best, most informed care decisions (Singla et al., 2006). Hocevar and colleagues
(2006) also found that “timely dissemination” and “free flow of information,” as well as
communication systems that facilitate this free flow, are essential enablers of collaboration (p.
261).
Appreciation of diversity. The final common element of collaborative culture identified
in research is an appreciation of diversity. This factor is particularly important to the outcome of
COLLABORATIVE CARE CAPACITY 42
collaborative work. “The active involvement of a diverse network of community members
enables potentially disparate interests to take collective action” (Hays, Hays, DeVille, & Mulhall,
2000). Without the element of diversity, the novel, greater-than-sum-of-parts outcomes that are
characteristic of collaborative work will not be realized. Hocevar and colleagues (2006) refer to
this element as an appreciation of others’ perspectives, implicitly recognizing that diversity in an
organization can come in many forms: age, gender, race or ethnicity, department, professional or
educational background, or position within the organizational hierarchy.
Dispersed, balanced power. Organizational power relationships provide another
opportunity for collaborative capacity development. Lukes’ (1974) third-dimension of power—
the management of meaning—is critical here. “Power, conceived as the ability to ‘act otherwise’
in the context of the dialectic of control,” can be studied “by focusing on how social actors draw
on communication resources to privilege a structurational process that favors their interests”
(Mumby, 2001, p. 602). This view of positive power is rooted in Foucault’s (1982) notion of
governing as a process of structuring “the possible field of action of others” (p. 221). Like
culture, power relationships are not static entities but are instead dynamic features of interaction.
Power relationships are features of all institutions—produced and reproduced by actors in their
patterned use and reproduction of rules and resources. Yet power is also the critical element that
enables actors to initiate change. The analytical focus when studying organizational power starts
with political and economic institutions—what Giddens (1979) calls structures of domination—
while acknowledging the ways in which these structures are interwoven with those of
signification and legitimation (p. 107). Political institutions are reproduced by actors’ patterned
mobilization of authoritative resources, while economic institutions are reproduced by actors’
patterned mobilization of allocative resources. In knowledge-intensive industries, knowledge
COLLABORATIVE CARE CAPACITY 43
and information serve as critically important resources that actors use to reproduce entrenched
political and economic institutions. Research on collaboration suggests that power relationships
are an important component of organizational collaborative capacity developments.
Authority and empowerment. Alexander and colleagues (2010) examined collaborative
organizations and found that successful ones “embraced a norm of equality among members” (p.
652). Other research suggests that sufficient authority and autonomy to engage in the
collaborative endeavor are most important (Hocevar et al., 2006; Huxham, 1996, p.5 as cited in
Thomson et al., 2007, p. 5). Experimental research at the group level confirms the importance of
equality to collaborative information sharing specifically. In an information suppression
experiment, mixed-status groups were primed with different hierarchical roles while equal-status
groups were primed with non-hierarchical roles. Individuals in both groups were given different
pieces of information, which they had to use as a group to make a decision. Mixed-status groups
were less likely to reference important information in their discussions and made worse decisions
than the equal-status groups (Hollingshead, 1996, p. 193). Equality, authority, and autonomy all
relate to power, which Gray (1985) defines in terms of “control over critical resources for
solving problems” (p. 926). She complicates the notion of power balance explaining that power
imbalance is actually the natural state of our social world. However, “there is considerable
evidence to suggest that effective collaboration cannot take place unless key stakeholders possess
roughly equal capability to influence domain development” (Gray, 1985, p. 927). She resolves
this tension by breaking collaborative endeavors into multiple phases. During the problem-
setting and direction-setting phases, power balance is critical because it provides a foundation for
trust, which enables collaborators to speak freely (Walton, 1969, p. 3 as cited in Gray, 1985, p.
COLLABORATIVE CARE CAPACITY 44
927). Then during the structuring phase, power can be redistributed to restore natural imbalance
in such a way that enables successful implementation.
Flexible, bridging leadership. Leadership encompasses the final key domain identified
in collaborative capacity research. I adopt Fairhurst’s (2007) discursive view of leadership as
something that is “‘exercised when ideas expressed in talk or action are recognized by others as
capable of progressing tasks or problems which are important to them’” (Robinson, 2001, p. 93,
as cited in Fairhurst, 2008, p. 511). This definition acknowledges the processual nature of
leadership “as [goal-oriented] influence and meaning management” and recognizes that it is not
limited in practice to individuals who occupy formal “leadership” roles in an organization but
can be practiced by different people at different times (Fairhurst, 2008, p. 511). The analytical
focus when studying organizational leadership as a structuring phenomenon starts with modes of
sanction—what Giddens (1979) calls structures of legitimation—while acknowledging the ways
in which these structures are interwoven with those of domination and signification (p. 107).
Discursive leadership research focuses on interactions between people in which leadership
processes occur as opposed to other domains of leaderships research that focus on unique
individuals as leaders.
Leadership support. Research suggests that leadership support is critically important to
the success of a collaborative endeavor. From a discursive leadership perspective, this notion of
leadership support encompasses two different processes. First, it involves formal leaders within
the hierarchical structure of the organization “managing meaning” in such a way as to encourage
and enable collaboration. Second, it involves all organizational members engaging in influence
and meaning management processes that support collaborative work. Research suggests that
leadership is crucial to achieving collaborative goals (Hays et al., 2000, p. 375) but also that it is
COLLABORATIVE CARE CAPACITY 45
critical for leaders to represent diverse interests and groups (Alexander et al., 2010, p. 654),
which is why it remains important for leadership to be a flexible process. Collaborative work
often relies on voluntary participation, creating an “inherent tension between self and collective
interests” (Thomson et al., 2007, p. 4). Leaders—whether embedded in the formal hierarchy of
the organization or not—manage this tension through influence processes and through their
direct or indirect ability to support the normalization of collaborative work processes. Social
capital, or the ability to bridge social and communicative divides across the organization, plays
an important role in collaborative leadership (Hocevar et al., 2006). Individuals in any role at any
level of the organization who use their influence to encourage and enable participation among
diverse individuals and groups play a collaborative leadership role (Hays et al., 2000, p. 377).
Structuring Collaborative Care Capacity
Research identifies three critical areas for collaborative capacity development:
organizational culture, power relationships, and leadership support. In this section I utilize the
foundational elements and bracketing processes of structuration theory to further develop the
concept of collaborative care capacity. I focus in particular on the foundational role
communication plays in developing and sustaining the collaborative organizational structures
and systems in a hospital that constitute this capacity.
Hospital culture. Staff and care providers who work in hospitals share a great deal of
knowledge of rules that enable them to act (Sewell, 1992); they share a cultural system driven by
the value of human life and a basic understanding of disease and treatment that provides a
foundation of shared meaning. Hospitals are also comprised of a complex web of competing
subcultures, or systems of meaning, driven by competing knowledge and values. The major
disciplines of nursing, medicine, and surgery exhibit different subcultures, as do different
COLLABORATIVE CARE CAPACITY 46
specialties within (or sometimes extending across) the disciplines—including emergency care,
cancer care, or critical care. The disciplines often referred to as “ancillary”—including therapy,
social work, care coordination, pharmacy, spiritual care, and nutrition—also exhibit unique
subcultures. An administrative team comprised of some individuals with a clinical care
background and some with a background in business or administration typically handles the
management of hospitals; these administrative teams exhibit a unique subculture that sometimes
conflicts with the shared elements of culture that unite clinical care providers. Even clinical
leaders—nursing unit managers and physician division chiefs—who accrue more administrative
responsibilities over time will reproduce elements of both administrative and their own clinical
subcultures as they attempt to balance competing cultural meanings and influences.
Cultural rules or shared systems of meaning are used and exhibited by groups of people
across time and space. Nurses learn elements of nursing culture as part of the practice of nursing.
Medical doctors learn medical culture as part of the practice of doctoring. Elements of culture are
embedded in the educational and apprenticeship programs that are common to most health care
disciplines. New nurses observe experienced nurses using and reproducing a particular system of
meaning in professional interactions that enables them to do their part in providing patient care.
As these new nurses begin to practice patient care themselves, they will draw from, and
reproduce, many of these discipline-specific cultural rules as they coordinate their interactions
with patients and other care providers. A similar process of cultural production and reproduction
occurs across different disciplines, groups, and teams as well as across the hospital; individuals
reproduce different systems of meaning in different contexts. A surgical nurse will likely draw
from and reproduce elements of surgical culture when he is working in the Operating Room
(OR) but may draw from and reproduce elements of nursing culture when he is at the morning
COLLABORATIVE CARE CAPACITY 47
nursing “huddle” where nurse representatives from all the different nursing teams gather to
discuss plans and staffing needs for the day.
The cultural elements identified in collaborative capacity research—felt need to
collaborate, active participation, openness and sharing, and appreciation of diversity—are likely
present in the espoused corporate “culture” of most hospitals. However, espoused organizational
culture and enacted organizational culture(s) are often dramatically different—in part because
large, complex organizations have so many competing sub-cultural systems. Physicians may
value team-based care less than other disciplines, like nursing or social work, and this may be
reflected in practice by how physicians provide care to their patients (Leipzig et al., 2002, p.
1144). Some units and teams might equate participation with merely physical presence during
team rounds while others assume that participation involves voiced opinions. A nursing unit may
value and reward the open sharing of advice, information, mistakes, feelings, etc., while the
social workers who see patients on the unit value information security and tend to share only
what is absolutely necessary. Medical doctors on the oncology team might appreciate the diverse
opinions of other care disciplines and of patients or family members with different belief systems
while the surgeons they work with who remove cancerous tumors feel like an understanding of
diverse opinions is inefficient and unnecessary given their expertise. These competing
subcultures in a hospital make it challenging to develop shared practices around the elements of
collaborative culture.
Hospital power relationships. Staff and care providers in hospitals are powerful agents
capable of intervening to “‘make a difference’” in the care process (Giddens, 1984, p. 14);
however, institutional structures empower individuals to differing degrees. Power is not
COLLABORATIVE CARE CAPACITY 48
something an individual has but rather something an individual uses in contextualized
interaction. Barbour (2010) explains that:
Health care professionals . . . shepherd, appropriate, and suffer knowledge-intensive
discourses in their conversations, and these individuals draw their legitimacy in
organizing—their power to create and judge these discourses—from their attachments to
institutions (p. 450).
Knowledge and information are two of the most important resources available to care providers
because hospitals tend to privilege scientific rationality and evidence-based medicine. All care
providers have some knowledge of the disease and treatment process to draw from as a
communicative resource, but knowledge that is attained through education and sanctioned by
certification is typically privileged. Physicians tend to have more education-based knowledge
than any other discipline, and although this has changed to some degree over time, physicians
clearly remain at the top of the deeply entrenched clinical hierarchy. Power is a characteristic of
all action, and the reproduction of hospital systems over time and across space “presumes
regularized relations of autonomy and dependence between actors” (Giddens, 1984, p. 16).
The subordination of all other disciplines to physicians creates a clear system of
accountability in hospitals and allows for efficient decision-making, but collaborative capacity
research suggests that severe power imbalances can inhibit collaborative processes by
undermining trust and participation around problem solving. While power imbalances are natural
features of stable health care institutions that are reproduced continuously across time-space,
they may also strip collaborators of the necessary authority to fully contribute to team-based care
processes. The reproduction of patient care structures across time-spaces contexts that privilege
COLLABORATIVE CARE CAPACITY 49
certain groups over others and highlights their superiority makes it challenging to develop
collaborative power relationships.
Collaborative care leadership. Staff and care providers across all levels of a hospital
engage in leadership by expressing ideas that others find compelling for their ability to progress
the care process and solve important problems (Robinson, 2001, p. 93 as cited in Fairhurst, 2008,
p. 511). Formal leaders entrenched in the top levels of a hospital’s hierarchy may be uniquely
and favorably positioned to engage in discursive leadership as the management of meaning
aimed at attaining a goal (Fairhurst, 2008, p. 511). This view of leadership presumes power—
though not necessarily “positional power” or the inherent power that accompanies a formal
leadership position. The ability to manage meaning (Lukes, 1974) involves access to
communicative resources, though these may be articulated symbolically as well as
verbally/nonverbally.
Research suggests that the development of collaborative care capacity requires leadership
support to normalize collaborative work processes. This normalization process requires the
bridging of communicative gaps through talk and action in ways that others recognize as
progressive in terms of work processes and problem solving. Collaborative leaders then are not
only those who hold formal leadership positions in the hospital’s hierarchy and support
collaborative care, but are also individuals with social capital who create opportunities for
collaborating in the care process and manage meaning around these opportunities in a persuasive
way that works to normalize collaborative care. This flexible network-oriented leadership can be
difficult to develop in organizations with strong formal leadership structures like hospitals,
which may support and normalize siloed work processes that run counter to the practice of
collaborative care.
COLLABORATIVE CARE CAPACITY 50
Communication-based Change
Few hospitals exhibit a strong, developed capacity for collaboration across all three areas
identified in research, and in fact many hospitals exhibit entrenched practices that inhibit these
capacities. Many hospitals now claim to embrace elements of collaborative culture in their vision
and mission. But competing sub-cultural systems rooted in history and tradition—and
perpetuated in the patterned use and reproduction of structures in interaction—often inhibit the
development of collaborative elements of culture in practice. One study in a hospital that was
working to create a more open information culture where employees would feel comfortable
talking about and sharing information about errors and accidents found that in spite of changes in
organizational policy, which emphasized that this information would be used for learning—not
for blaming—new nurses were using the phrase “‘writing someone up’” to describe safety
incident reports (Groves et al., 2011, p. 1849). The policy change alone failed to reframe
people’s understanding of what it meant to submit a safety incident report. Nurses with a long
tenure at the hospital continued to reproduce the culture of blame by framing this process as
‘writing people up’ and thus new nurses learned this meaning in practice.
Some hospitals are beginning to acknowledge the deleterious effects of extremely
imbalanced power relationships on quality of care. But the extremely high value placed on
physicians’ large corpus of education-based knowledge, and the hierarchical system built around
this value, remains firmly intact in most health care organizations. Although the imbalance is
natural and beneficial for assigning responsibility, it is problematic in the brainstorming and
problem-solving phases of the patient care process. For example, “ancillary” care providers like
social workers tend to seek approval of physicians in determining care protocols, but physicians
do not reciprocate by seeking the approval of social workers (Abramson & Mizrahi, 1996). The
COLLABORATIVE CARE CAPACITY 51
implicit assumption here is either that physicians’ knowledge encompasses that of social workers
making it unnecessary to seek social workers’ input or that the unique knowledge of social
workers is non-essential to physicians in their decision-making.
Many hospitals are recognizing the need for new forms of leadership better suited to the
complex, networked form of these organizations. But network leadership is more of a discursive
process of persuasion and meaning management than an administrative process of coordination
and people management, and this can be a challenging difference to understand. Network leaders
already exist across all levels of the formal hierarchy in hospitals. They use their social capital to
bridge across different disciplinary and departmental divides, and they normalize collaboration
as an essential component of the care process and a way to solve problems. However, their
unique form of leadership often goes unnoticed within the formal reward system of the
organization, and they may even find their behavior stifled by the siloed work practices of
leaders in the formal hierarchy of the hospital.
For most hospitals, change will be an essential component of collaborative care capacity
development, which involves capacity building in all three areas: organizational culture, power
relationships, and leadership. Distinctions between the elements of collaborative capacity can
only be made analytically to facilitate research. In practice cultures are imbued with power
relationships, which shape leadership systems, which reflect cultures. Structuration theory can be
used to explain why few hospitals have developed robust collaborative care capacity, what kinds
of organizational change would be necessary to develop this capacity, and how this change could
be facilitated. The answer to all of these questions lies in communication. It is through
communicative interaction that health care actors continue to reproduce non-collaborative
structures and systems. A change in the norms and systems of meaning as well as the available
COLLABORATIVE CARE CAPACITY 52
resources that actors draw from and reproduce would be necessary to develop collaborative
capacities, and because these norms, systems of meaning, and resources exist only in the
instances when actors use them, change occurs through strategic communication-in-action when
agents break from routine and “act otherwise.”
The two empirical studies in this dissertation project use structuration theory to examine
this relationship between constitutive communication and collaborative care capacity. Chapter
Four looks at the relationship between care discourse and perceptions of collaborative capacity.
Chapter Five develops a pilot survey to examine collaborative care capacity through measures of
culture, power relationships, leadership, and social networks. Barbour (2010) explains that most
“communication-focused interventions” are limited in their effectiveness “because they do not
take into account the realities of day-to-day life in institutionally moored health care
organizations” (p. 452). He calls for the development of new kinds of intervention “that address
routinized, ritualized care—care guided by assumption and heuristic methods . . . [that
determine] who should do what, who should know what, or who has a legitimate right to ask
questions” (Barbour, 2010, p. 452). This research, grounded in theory and an expanded
understanding of the (constitutive) role communication plays in hospitals, aims to identify those
interventions and develop a tool for measuring collaborative capacity.

COLLABORATIVE CARE CAPACITY 53
Chapter 3: The Case
All of the data for this project were collected at the same site location—a private,
nonprofit children’s hospital located in southern California, which will be referred to by the
pseudonym “SoCal Children’s Hospital” (SCCH). The qualitative study detailed in Chapter Four
explores the relationship between communication and collaboration at SCCH while the survey
pilot described in Chapter Five tests an instrument at SCCH for measuring collaborative care
capacity. This chapter provides an overview of the site location as well as background
information relevant to the study.
Research Site
SCCH is typically ranked within the top 20 hospitals in the U.S. in multiple pediatric
subspecialties by U.S. News and World Report and has received Magnet Recognition from the
American Nurses Credentialing Center. With more than 250 beds, the hospital admits over
10,000 patients and provides emergency and clinical care to more than 50,000 patients each year.
SCCH is an active research and teaching institution that draws physicians from around the world.
Research Access to SCCH
The principal investigator (PI) developed a relationship with the director of the Family
Resource Center (FRC) at SCCH and agreed to share data in exchange for access and
professional support during data collection. The FRC director became an advisor and mentor to
the PI over the course of the two-year period during which study design and data collection and
analysis took place. As an RN, she worked at SCCH for almost 30 years as a nursing unit
manager before getting her PhD and moving into an administrative/research position in the FRC.
Because of her long tenure at the hospital in different roles, she had many established
connections with people across the whole organization. She helped with navigating the complex
COLLABORATIVE CARE CAPACITY 54
hospital system and provided introductions to key contacts on the nursing units, physician teams,
and ancillary care teams that enabled the researcher to set up interviews and observation sessions
and recruit survey participants. She also arranged for the PI to obtain a hospital badge and an
SCCH email account to correspond with study participants. Badge access is essential for moving
throughout the hospital buildings since badges serve as key cards that enable employees to enter
the buildings, use staff elevators, and open doors to enter units. Without the help of the FRC
director, this project would not have been possible. However, the researcher did not have the
access to involve high-level hospital administrators in the project, which could have improved
her credibility and may have increased interview participation and survey response rates.
Participants
Units and team. Collaborative care is especially important for chronic or complex
conditions that require repeat visits and treatment by a large, diverse group of care providers
(Sia, Tonniges, Osterhus, & Taba, 2004). In an effort to establish boundaries for data collection,
a purposive sample of six units and one team at SCCH that provide care to patients with chronic
or complex conditions was selected for this research—two that provide general care, two that
provide critical care, and two that provide surgical care. I defined “unit” and “team” with respect
to shared patient populations. All care providers who provide patient care in a given unit or on a
given team were considered part of that unit or team and were given an opportunity to participate
in the research. Hospitalists and ancillary care providers who provide care to patients on multiple
units were considered to be a part of multiple teams—though they were asked in the interviews
and survey to consider the team they work with most often in providing patient care. These units
and one team included: the Pediatric Intensive Care Unit (PICU), the Bone Marrow Transplant
Unit (BMT), the Hematology and Oncology Units (Hem/Onc), a general care unit that includes
COLLABORATIVE CARE CAPACITY 55
patients with a range of illnesses including neurological and genetic disorders (“5A”), the
Cardiovascular Acute Unit (CVA), and the general pediatric surgery team (GenPedSurg). Table
3.1 provides more details about the participating units and team.
Table 3.1
Overview of Units and Teams
Unit or Team Care Staff

Beds Type
Pediatric Intensive Care Unit 120 24

Critical
Bone Marrow Transplant 60 14

Critical
Hematology and Oncology 150 48

General
5A 110 32

General
Cardiovascular Acute 90 21

Surgical
General Pediatric Surgery 30 core N/A

Surgical

Note. The care staff numbers are estimates provided by an SCCH contact

Individuals. Individuals were selected to participate based on the fact that they provide
patient care through one of the six groups in the study and availability. Care providers in
hospitals are extremely busy, which creates methodological challenges around recruitment. This
recruiting approach was deemed appropriate for the case study method given the constraints of
the setting. A range of different kinds of providers from the included units and team participated
in the research, including: resident, fellow, and attending physicians (both medical and
surgical—specialists as well as hospitalists); nurse practitioners; nursing managers, charge
nurses, and staff nurses (including registered nurses, licensed vocational nurses, and nursing
aids); pharmacists; clinical care coordinators; case managers; discharge specialists; nutritionists;
COLLABORATIVE CARE CAPACITY 56
social workers; translators/interpreters; child life specialists; speech-language pathologists;
physical therapists; occupational therapists; respiratory care managers; and chaplains.
Collaborative Organizational Trends in Health Care
Collaboration has become a powerful force in health care change efforts from the inter-
organizational level down to the level of hospitals and even units and teams within hospitals. The
changing health care environment and evolving demands of the patient care process have been
met with new market-based forms of governance and management philosophies borrowed from
business that aim to reduce costs and increase efficiency while maintaining quality (Scott et al.,
2000). The forces pushing collaborative changes forward at SoCal Children’s Hospital are riding
on the tide of change that is taking place across the health care industry.
Policy Change
The Affordable Care Act (ACA) known popularly as “Obamacare” was signed into law
on March 23, 2010 and upheld by the Supreme Court in a decision issued on June 28, 2012.
Although most people are familiar with the part of the law that aims to provide access to
affordable insurance for all Americans through insurance marketplaces, the ACA also includes
provisions aimed at “transforming how the nation’s medical system provides care” (Washington
Post Staff, 2010, p. 129). Legacy health care delivery systems based on fee-for-service models
reward care providers for quantity rather than quality of care, resulting in an overreliance on
testing and unnecessary treatments—both of which are very costly. Through Medicare and
Medicaid pilots, the ACA incentivizes bundled payments in which hospitals are “paid a set
amount for a period of care . . . giving the hospital an incentive to coordinate care in cost-
effective ways” (Washington Post Staff, 2010, p. 130). The new law also supports the
development of accountable-care networks of providers, which are similar to, though ostensibly
COLLABORATIVE CARE CAPACITY 57
better regulated than, early capitation-based models like Health Maintenance Organizations
(HMOs). And it also creates a new Medicare payment process to reward hospitals that provide
“‘high value’ care” by spending “less per Medicare patient without reducing the quality of
services” (Washington Post Staff, 2010, p. 131).
Integrated Care
By creating new incentives for accountable-care networks, the ACA encourages
widespread collaboration at the inter-organizational level—an extension of care integration
practices that began in the U.S. in the 1990s. Integrated care involves some form of coordination
“between systems providing preventive services, primary care, long term care and hospital care”
(IJIC editors, 2000, p. 1). HMOs like Kaiser Permanente (KP) integrate all of these forms of care
as well as the insurance component into one organizational system facilitating collaboration and
information sharing between the different KP organizations (Schiøtz & Strandberg-Larsen,
2008). Integration—when done effectively—can reduce administrative costs and improve
quality.
Medical Home Model
The ACA also develops new incentives for collaboration at the organizational level
within hospitals and other health care organizations. Hospitals that hope to take advantage of
Medicare incentive payments for “high value” care will have to improve collaboration among
providers and between providers and patients to increase efficiency while maintaining or
improving quality. New models of care have been developed around the need for improved
collaboration—especially in pediatric care. A medical home model calls for a “partnership
approach with families to provide primary health care that is accessible, family centered,
coordinated, comprehensive, continuous, compassionate, and culturally effective” (Sia et al.,
COLLABORATIVE CARE CAPACITY 58
2004, p. 1473) and has also gained popularity in hospitals that provide long-term care to patients
with chronic or complex conditions. Though the term originally referred to a centralized medical
record for patients, it has evolved into a collaborative care model with the patient and family at
the center and a primary care provider who is able to “manage or facilitate essentially all aspects
of pediatric care” (Sia et al., 2004, p. 1475). Communication has been identified as one of the
major barriers to implementing the medical home model in existing health care organizations
(Sia et al., 2004).
Collaboration at SCCH
It became apparent through early talks with SCCH and preliminary observations that the
hospital is committed to a collaborative, patient-centered approach to care and is working toward
changes that support this approach. Early in the study design process, the hospital was awaiting
funding from the state to begin developing and piloting a medical home model of care for the
hospital. However, budget cuts at the state level delayed funding for this project. In the
meantime, SCCH has continued to conduct its own research and make improvements that further
develop collaborative care.
Language access. As an urban hospital in southern California, SCCH serves a diverse
demographic base. Seventy-five percent of patients are Spanish speakers from South/Central
America and Mexico; roughly half of these Spanish-speakers speak only Spanish. The hospital
also serves significant numbers of Korean, Chinese, Persian, Japanese, Thai, Laotian,
Vietnamese, and Hmong patients among others. SCCH faces a language and cultural challenge
with respect to collaborative care. The PI’s SCCH advisor received a grant to conduct a
language-access study aimed at improving access to interpretation services via videophone carts
and learning more about challenges in the provider-family collaborative relationship.
COLLABORATIVE CARE CAPACITY 59
Consultant interventions. SCCH also hired a team of health care consultants to work
with units and teams on improving efficiency—especially around the patient discharge process.
The consultants observed and interviewed hospital staff to learn more about the discharge
process. A number of interventions and changes took place between phase one and phase two of
data collection for this project, creating some interesting, natural pre- and post-conditions for
studying organizational change.
Research Design
Communication and Collaborative Care Capacity
SCCH’s commitment to collaborative care and efforts to develop it made the hospital an
ideal case site for collaboration research. In spite of the hospital’s commitment and efforts, staff
and care providers readily admit that they still face many challenges with communication and
collaboration. Many hospitals recognize that these variables are important for providing safe,
quality care, and research reflects this importance but often based on an underspecified definition
of communication and collaboration and without much understanding of the relationship
between them. Chapters Four, Five and Six explore empirically a structuration-based model of
how communication constitutes collaborative care capacity in an actual hospital. Chapter Four
examines the discursive and interactive structuring of collaborative care capacity. Chapter Five
tests an adapted instrument for measuring collaborative care capacity. Chapter Six considers
possible interventions for developing collaborative capacity and evaluates the tested instrument
in light of findings from the qualitative study to make recommendations for further measurement
improvement.

COLLABORATIVE CARE CAPACITY 60
Overview of Data Collection
The data collection for this project took place in three phases. Phase one involved
observation of the patient rounding process for all five units and one team to collect
communication data. All units were observed on at least two occasions and as many as seven
occasions depending on access and information saturation. Phase two involved qualitative
interviews with care providers from across the five primary units and one team in the study to
collect communication data. Phase three involved the dissemination of a pilot survey that
measures collaborative capacity. A more detailed description of data collection is included in the
method sections of Chapters Four and Five.
COLLABORATIVE CARE CAPACITY 61
Chapter 4: Discourse and Interaction Constitute Collaborative Care

In many hospitals, interdisciplinary health care teams are touted as a way to overcome
legacy structures that create barriers between different functional areas within the organization.
These teams are intended to improve collaborative care by providing structures through which
different disciplines and different functional areas with shared responsibility for the same
patients can share knowledge and information and make better joint decisions. Unfortunately the
mere creation of these teams almost never results in the desired level of collaborative care
(Cashman, Reidy, Cody, & Lemay, 2004). In most industries including health care, if you “put
an org chart in front any executive today . . . he or she will tell you that the boxes and lines only
partially reflect the way things are done in the organization” (Cross, Nohria, & Parker, 2002, p.
68). This is because the formal structure and pattern of relationships provides only a partial
understanding of how communication constitutes collaborative care in a hospital. Equally
important are the ways in which discourse and interaction work through these relationships to
enable and constrain collaboration.
Discourse can be defined “as a way of knowing or a perspective for understanding
organizational life . . . a lens or a point of entry for seeing, learning, and understanding ongoing
events” (Putnam & Fairhurst, 2001, p. 79) while symbolic interactionism refers to the interactive
processes through which individuals form meanings (Blumer, 1986). Hospital care providers
tend to reproduce discursive patterns and patterns of interaction in ways that create enduring
social structures, which persist across space and time. These structures intersect or interpenetrate
to create institutions, which shape human action (Giddens, 1984). Barbour (2010) explains that
within health care organizations, “Institutional logics offer established ways of communicating,
perceiving work, and adjudicating disagreements” (p. 451). The structures that comprise these
COLLABORATIVE CARE CAPACITY 62
“institutional logics” in a hospital are shaped by interactions that reproduce elements of
educational and professional background, the nature of work, the type of work, and especially in
a teaching hospital, level of experience, among other factors.
Communication shapes, and is shaped by, these institutional logics that have evolved
over time and across space. In this study, I examine how communication, conceived of in terms
of symbolic interaction and discourse, structures collaborative care capacity in a hospital.
Interaction and language patterns among care providers reflect the rules and resources that agents
draw from, and reproduce, in caring for patients. An examination of these patterns provides
insight into how communication supports and inhibits the development of collaborative care
capacity as reflected in diverse, participatory cultures; balanced power relationships; and
flexible, bridging leadership.
Literature Review

In the past 30 years, interdisciplinary health care teams have grown in popularity as a
management solution to the demand for increased collaboration across disconnected functional
areas; they are thought to improve the comprehensiveness of care, especially for complex patient
cases. However, research suggests that reality does not always reflect this ideal (Banta & Fox,
1972). Efforts to improve interdisciplinary collaboration through teamwork are often challenged
by “overwhelming barriers of disciplinary territoriality and systems inertia” (Baldwin Jr, 2007, p.
32). The challenges associated with improving collaboration stem from the same cause driving
the need for collaboration—the increasing complexity of disease and treatment.
Early on, concerns about staff and provider collaboration focused primarily on the
physician-nurse relationship, and this remains a key concern today (Baggs et al., 1999; Dechairo-
Marino, Jordan-Marsh, Traiger, & Saulo, 2001; Dougherty & Larson, 2005; Hojat et al., 1999,
COLLABORATIVE CARE CAPACITY 63
2001; Shortell, Rousseau, Gillies, Devers, & Simons, 1991; Simpson et al., 2006). However, as
the complexity of care has increased so has the number and type of physicians, nurses, and other
kinds of care providers whose knowledge and training are important to the patient care process.
Also relevant are the recent paradigm shifts in health care education, training, and management
that view patients as whole people rather than disembodied sets of symptoms and ailments
(Beloff & Korper, 1972; Cassell, 2010; Cloninger, 2010; Mezzich, Snaedal, van Weel, & Heath,
2010; Ponte et al., 2003; van Weel-Baumgarten, 2010; Wang, 2005). The type of comprehensive
care that truly aims to put the patient “at the center” of the care process requires a larger body of
expertise than what can be provided by physicians and nurses alone. And yet the growing size
and increasing professional diversity on these teams often exacerbates the challenges associated
with interdisciplinary teamwork. A review of the research on health care teams reflects many
challenges and opportunities related to the development of collaborative care capacity, especially
with respect to organizational cultures, power relationships, and leadership support.
Collaborative Care Capacity on Health Care Teams

Collaborative cultures. Hospital cultures are comprised of complex systems of meaning
that are “coconstructed in everyday conversations, [in] textual evidence of patterns, and also [in]
the entire non-verbal, semiotic field from the structure of parking lots to the structure of work
processes” (Eisenberg & Riley, 2001, p. 295); it is care providers’ knowledge of these systems of
meaning that enables them to work within the context of a hospital (Sewell, 1992). Hospital
subcultures are perhaps most powerfully impacted by professional discipline (e.g., surgeon,
medical doctor, nurse, therapist, etc.) and by service or specialty to varying degrees (e.g.,
emergency care, critical care, oncology, etc.). Although cultures will tend to vary across different
types of organizations, research on collaborative capacity (reviewed in Chapter Two) suggests
COLLABORATIVE CARE CAPACITY 64
that there may be at least some elements of collaborative culture that are relatively enduring and
should be observable in hospitals, and on care teams, that have developed collaborative capacity.
These include a value of and a felt need to collaborate, openness and sharing with respect to
information and knowledge, an appreciation of diversity, and a norm of participation in
collaborative work.
Health care team cultures. The foundation of health teamwork competencies comes
from motivations that are shaped by organizational and group cultures. Collaborative teams must
be committed to working collaboratively and to working toward quality patient outcomes
(Leggat, 2007). Mickan and Rodger (2000) reviewed research on effective health care teams and
identified many elements of team and organizational cultures that are important for collaborative
success. First, sub-cultural conflicts in values and behavior have to be addressed if they
negatively impact team norms. Teams also need to develop a norm of full participation to take
advantage of diverse skills and experiences, which requires an established system for two-way
communication. Finally, team cultures should encourage task-based conflict, which will improve
team outcomes when managed through consensus decision-making processes. Team cultures that
either inhibit conflict entirely or fail to manage relationship-based conflict will suffer from
inferior decisions or lack of cohesion respectively.
Early research on health teams applied principles of general group behavior to the
specific context of health care organizations. Rubin and Beckhard (1972) use group dynamics
research to explain how decision-making is hampered on these teams by disciplinary conflict
stemming from cultural differences among the disciplines. Hall (2005) provides a more in depth
explanation of how different professional cultures can create barriers to interprofessional
teamwork. She argues that educational, systemic, and personal factors contribute to cultural
COLLABORATIVE CARE CAPACITY 65
differences. Professions in the past often aligned with gender (i.e., female nurses and male
physicians) and social class (lower to middle class nurses with middle to upper class physicians)
(Hall, 2005, p. 189), which created powerful “faultlines” in groups that could lead to
unproductive conflict (Lau & Murnighan, 1998) and could negatively impact health team
integration (Lichtenstein, Alexander, Jinnett, & Ullman, 1997).
Whereas nursing education and training emphasize the importance of teamwork, medical
students are trained to be self-sufficient and learn to be competitive to succeed. Professional
values differ as well; physicians tend to privilege hard facts over feelings, to take action when
they feel it is appropriate, and to focus on outcomes whereas nurses tend to care for the patient as
a whole and as a result may privilege patients’ stories over objective data and relationships over
outcomes (Hall, 2005, p. 191). Existing professional cultures often under prepare or actively
work against the development of key collaborative skills, like: cooperation, assertiveness,
responsibility, communication, autonomy, and coordination (Norsen et al., 1995 as cited in Hall,
2005) and can prevent interdisciplinary teams from cooperating to stage “a single routine”
(Goffman, 1974, p. 79).
Disciplinary cultures play an important role in shaping attitudes and values. One group of
scholar-practitioners studied differences in attitudes toward teamwork among medical residents,
advanced practice nursing students (NPs), and graduate social work students (MSWs) (Leipzig et
al., 2002). Though all three groups agreed that teamwork was beneficial to patient care, NPs and
MSWs had significantly higher positive attitudes toward the value of teamwork than medical
residents. A study of surgical teams found that nurses and anesthesia providers rated teamwork
and communication less favorably than surgeons (Mills et al., 2008, p. 110). Another study
found similar results among critical care nurses and physicians (Thomas et al., 2003 as cited in
COLLABORATIVE CARE CAPACITY 66
Mills et al., 2008, p. 111). Value differences extend beyond the need for teamwork to who on the
team is most important in terms of skills and knowledge. Kvarnström (2008) examined care
providers perceived difficulties with interprofessional teamwork and found three main themes
that capture these difficulties. First, when team members use their professional background as
“the basis for negotiations” with other team members, this often leads to defensiveness and
conflict (p. 199). Second, difficulties arise when the knowledge base and skills of certain
disciplines are valued unequally in team interactions. Finally, the influence of the larger
organization creates teamwork challenges with respect to the value of different disciplines and
the distribution of different professions across interprofessional teams.
In a longitudinal study of interdisciplinary team development in a community health
organization, Cashman and colleagues (2004) found that after one year, active team development
improved team friendliness, acceptance of team task orientation, and the level of proactive
participation of team members. However, after the second year, these improvements began to
decline back to base levels. An investigation of why the regression occurred revealed a lack of
support for the teamwork structure at the organizational level. The organization failed to reward
team members for increased work and improved outcomes related to team processes. Also, team
members with a long tenure at the organization became frustrated with the lack of policy and
structural change at the organizational level to better support the team structure and admittedly
reverted back to their old ways of doing things.
Based on this existing research and experience in the field, I propose the following
research question and hypothesis to examine how the discursive and interactive structuring of
health care team cultures enables and constrains the development of collaborative capacity:
COLLABORATIVE CARE CAPACITY 67
RQ1: How do care providers draw from and reproduce elements of collaborative and
non-collaborative cultures through discourse and interaction?
H1: Most care providers will explicitly express a felt need to collaborate, but there will be
variations by team and/or discipline in the extent to which care providers demonstrate
open communication and information sharing, norms of team participation, and an
appreciation of diverse perspectives.
Collaborative power relationships. Power relationships in hospitals, like all
organizations, are based largely on the extent to which certain actors have control over “the
possible field of action of others” (Foucault, 1982, p. 221). Individuals wield power based on
their access to resources, and patterns in resource access over time and across space are
embedded in institutions (Castells, 2009). Although all care providers derive some degree of
power from their ability to “act otherwise” in any given situation, resource access is naturally
imbalanced in hospitals as in all organizations (Giddens, 1984, p. 14). This imbalance results
from the fact that “there is always a greater degree of influence of one actor over the other”
(Castells, 2009, sec. 318). This natural imbalance may be useful for efficient decision-making,
but research on collaborative capacity suggests that it is not conducive to effective collaborative
problem solving because it undermines trust and communicative openness. Collaborative
problem solving requires sufficient authority for all parties to contribute and share their
perspective. Hospitals and care teams that have developed collaborative capacity will have
practices and processes in place that disperse and balance power during collaborative problem
solving.
Health care team power relationships. Established power relationships play an important
role in shaping norms and assumption that guide behavior on interprofessional teams. Based on
COLLABORATIVE CARE CAPACITY 68
historical relationships between health care disciplines, many health teams reflect the assumption
that doctors are the most important team members and others should not disagree with them.
This assumption shapes key elements of team cultures—like trust and participation as well as the
interpretation of silence in team interactions as implicit consent (Rubin & Beckhard, 1972, p.
327). Witman (2011) describes how these power relationships play out across physician ranks
during patient rounds:
Seniors ask juniors questions to test their knowledge, but not the other way around.
Senior specialists discuss complicated patients, while residents are silent listeners . . . The
meaning of authority becomes even clearer when authority is not respected: the resident
who, during a review meeting, takes the ‘wrong chair’—the chair informally reserved for
seniors—offends: he has no sense of proportion. The irritation lies in the lack of respect
for seniority and experience, which is so highly valued in medicine (pp. 483-4).
In their review of nurse-physician collaboration survey instruments, Dougherty and Larson
(2005) indicate several power-based reasons for the apparent lack of collaboration between
nurses and physicians, including: physicians low level of interest in interprofessional
relationships, physician preferences to avoid group involvement and interaction, disparities in
perceptions of teamwork and communication by nurses and physicians, and different perceptions
by nurses and physicians about existing and ideal levels of authority for nurses (p. 2).
Sutcliffe, Lewton, and Rosenthal (2004) looked at a range of interprofessional
relationships among different kinds of physicians who were at different points in their medical
educations and between physicians and nurses. They found that hierarchy and power have a
clear, negative impact on communication quality and openness. In particular, they found that:
Communication is likely to be distorted or withheld in situations where there are
COLLABORATIVE CARE CAPACITY 69
hierarchical (e.g., power/status) differences between two communicators, particularly
when one party is concerned about appearing incompetent, does not ant to offend the
other, or when one party perceives that the other is not open to communication (Sutcliffe
et al., 2004, p. 188).
Other research supports this finding that hierarchical power relationships are related to lower
levels of patient safety climate and poorer outcomes for patients (Hartmann et al., 2009).
Greenwald (2010) contends that the prominence of the medical field over that of nursing
derives not just from physicians’ extensive education and training but from the “fact that nursing
developed after medicine had established itself as a profession” (sec. 3508). This may provide a
better explanation for why nurses have traditionally practiced under the supervision of physicians
until the recent establishment of Advanced Practice Nursing. The historical marginalization of
nurses and their resulting lack of independent authority is somewhat unusual given their
relatively high level of education compared to many other hospital employees and their high
level of responsibility in caring for patients (Greenwald, 2010, sec. 3527).
Although the physician-nurse power relationship has been the focus of much research,
some studies have looked beyond this dyad at other interprofessional relationships. One study
focused on social workers' perceptions of collaboration with other health care providers during
hospice care found that perceived levels of collaboration are high (Parker-Oliver, Bronstein, &
Kurzejeski, 2005, p. 280). However, other research has found that approval seeking between
social workers and physicians is one-sided with social workers seeking approval from physicians
while physicians do not reciprocate (Abramson & Mizrahi, 1996).
COLLABORATIVE CARE CAPACITY 70
A survey study conducted by Leipzig and colleagues (2002) examined differences in
attitudes toward teamwork among medical residents, advanced practice nursing students (NPs),
and graduate social work students (MSWs), they found that:
About 80% of PGY-2 trainees [medical residents] versus 35% to 40% of MSW or NP
trainees agreed that physicians have the right to alter patient care plans developed by the
team and that the physician has the ultimate legal responsibility for decisions made by the
team (p. 1146).
They explain these differences largely in terms of educational and training experiences. Whereas
the fields of nursing and social work are built on a foundation of interdisciplinary practice,
“physician education and training is nested within a hierarchical and unidisciplinary model . . .
[with] a chain of authority that is strictly adhered to from the ranks of the medical student, to the
intern, the resident, the junior attending physician, and the senior attending physician” (Leipzig
et al., 2002, p. 1146).
Another study examining how other care providers perceive the role that medical
residents should occupy on care teams found that none of the attending physicians who
participated in the research emphasized the importance of the “resident as team collaborator”
role. This collaborator role requires residents to participate in team care in a way that enables
other members of the teams to do their jobs effectively. Only non-physician research participants
felt that this was an important role for residents to play on care teams. Given that attending
physicians often determine the role requirements and key competencies that residents should
work to exhibit, the lack of felt need to collaborate would likely be perpetuated (Graham et al.,
2009).
COLLABORATIVE CARE CAPACITY 71
Janss and colleagues (2012) suggest that the ephemeral nature of health care teams might
actually exacerbate disciplinary power differences. In the absence of clear team-based mental
models that develop over time and provide a detailed understanding of team members’ “attitudes,
preferences, strengths, [and] weaknesses,” care providers will likely rely on past experiences or
stereotypes to quickly assess power relationships (p. 841). At the same time, feelings of power
shift depending on the particular composition of any given team. A resident physician may feel
like she has very little power in a patient conference with two attending physicians but she may
feel like she has a great deal of power during interdisciplinary rounds when she is the only
physician rounding with staff nurses, a social worker, a pharmacist, and a hospital chaplain.
Research suggests that conflicts and challenges can arise from unequal power distribution alone
but are even more likely when there are asymmetries in the perceptions that result in some
individuals believing they are more powerful than the rest of the team perceives them to be
(Janss et al., 2012, p. 843). The latter problem can cause status conflicts where team members
attempt to reinforce their personal power relative to others instead of focusing on productive
conversation aimed at shared problem solving (Janss et al., 2012, p. 840).
As a compliment to the social psychological focus on attitudes and outcomes in health
teams research, Kvarnström and Cedersund (2006) conducted a discourse analysis of focus group
interview data from six multiprofessional health care teams to learn more about how these teams
discursively construct the process of teamwork. They focused on how team members referred to
the group—especially how they used group pronouns like we, they, and I. They found that these
pronouns are often used in a flexible way as resources to manage power relationships both within
and between different care teams. Another study applied structuration theory to the study of
patient safety culture in a hospital organization in an effort to better understand why new nurses
COLLABORATIVE CARE CAPACITY 72
referred to medical error reporting negatively as 'writing someone up' even though the hospital's
leadership had been supporting error reporting as a positive form of organizational learning for
many years (Groves, Meisenbach, & Scott-Cawiezell, 2011). Through a structurational analysis
rooted in communication, they found that nurses who had been at the hospital for a long time still
referred to error reporting as 'writing someone up,' and in doing so clearly signified the meaning
of error reporting while their relative positions of power over newer hires sanctioned this
interpretation over that of the hospital administrators. The veteran nurses were, in effect,
reproducing structures of blame around medical errors. Beringer and colleagues (2006)
discovered that no matter how communication played out during the care process, all members
of health teams clearly understood that final care decisions would be made by physicians.
Based on this existing research and experience in the field, I propose the following
research question and hypothesis to examine how the discursive and interactive structuring of
health care team power relationships enables and constrains the development of collaborative
capacity:
RQ2: How do care providers draw from and reproduce collaborative and non-
collaborative power relationships through discourse and interaction?
H2: Care providers from all disciplines will reproduce unbalanced power structures with
respect to team decision-making, but teams that are more successful in providing
collaborative care are more likely to reproduce balanced power structures with respect to
team problem solving.
Collaborative leadership. The role of formal leaders in organizations is changing.
Leaders no longer command a workforce from the top of a steep organizational hierarchy but
instead work as motivators in and among a complex web of connections (Borgatti & Foster,
COLLABORATIVE CARE CAPACITY 73
2003). Leadership is an inherently interactive phenomenon. From a communication perspective,
leadership has become a process of goal-oriented “influence and meaning management”—
essentially a process of framing through dialogue (Fairhurst, 2008, p. 511). Collaborative care
leaders promote collaborative approaches to patient care through their words and actions and in
doing so present collaboration as a viable process that other care providers recognize as useful
(see Robinson, 2001). Research on collaborative capacity suggests that leadership support is
critical to collaborative goal attainment, but this support process is flexible and involves all
members of the organization—not just formal leaders. In hospitals and on care teams that have
developed collaborative capacity, flexible, bridging collaborative leadership should be
commonplace.
Health care team leadership. The research that examines team leadership typically uses
a more traditional definition of leadership as an activity tied to a formal supervisory or
management position. Cashman and colleagues (2004) found that the role of health care team
leaders was more supportive than prescriptive. This support came in the form of invitations to
share unique perspectives prior to decision-making or even (quite literally) finding everyone a
seat around the table for team meetings, when in the past, lower status disciplines had sat against
the wall instead (Cashman et al., 2004, p. 188). Leaders encouraged team members to work
together to identify ways to improve care processes instead of recommending their own changes.
This perspective differs dramatically from recommendations 30 years earlier suggesting that
health care leaders should: help care teams to integrate diagnoses and treatments for increasingly
complex patient populations, structure the organization appropriately, deal with “human
problems” cause by interdisciplinary collaboration, build primary care teams and establish
COLLABORATIVE CARE CAPACITY 74
communication patterns to support them, develop appropriate training and education programs,
and maintain patient-focused care (Beckhard, 1972, pp. 290–1).
Janss and colleagues (2012) suggest that health care teams today include many
overlapping disciplinary hierarchies, which make it challenging to determine who is in charge.
As a result, leadership is somewhat fluid and is determined on an ad hoc basis depending on the
individuals present. This fluidity is a relatively recent development as well. Rubin and Beckhard
(1972) once claimed that the historical disciplinary power of physicians leads to rigid norms of
team leadership when in fact “the complexity of the environment and the task to be done demand
flexibility” (p. 327). Issues related to power and leadership intersect in research on physician
managers. The default “follow the doctor” leadership model can be damaging for
interprofessional collaboration because physicians are trained to make decisions on their own or
with other physicians making them less likely to actively draw all disciplines together to solve
problems and make decisions (Rubin & Beckhard, 1972).
More flexibility in health care team leadership requires a greater commitment to
leadership skill development. Leadership was among the critical teamwork competencies
identified by Leggat (2007) as important for team training. Hall (2005) explains that
interprofessional team leaders need to understand and be able to recognize potential pitfalls that
come from blending multiple different subcultures. Important to a team’s legitimacy and
relationship with the larger organization is its ability to maintain two-way dialogic
communication across team boundaries and up to the organizational level (Firth-Cozens, 1998 as
cited in Mickan & Rodger, 2000, p. 205). Considering that physician leadership of health care
teams is mandated in most states in the U.S., O’Brien, Martin, Hayworth, and Meyer (2008)
developed a more flexible, transformational model of physician team leadership instead of a
COLLABORATIVE CARE CAPACITY 75
model based on disciplinary flexibility in leadership. They suggests that doctors and NPs should
actively negotiate physician supervision levels based on NPs’ education and experience, that
mentoring should be a reciprocal process between physicians and NPs, and that both disciplines
should be open to learning from the other.
Based on existing research and experience in the field, I propose the following research
question and hypothesis to examine how the discursive and interactive structuring of health care
team leadership enables and constrains the development of collaborative capacity:
RQ3: How do care providers draw from and reproduce collaborative and non-
collaborative leadership structures through discourse and interaction?
H3: Teams and disciplines that provide formal leadership support for collaboration will
practice more bridging leadership.
Information and communication technologies. An important and relatively recent
development in health care organizations is the growing use of information and communication
technologies (ICTs) to collect and track patient medical information and to share this information
and coordinate care with colleagues and patients/families. The adoption and use of these
technologies is a social process that both shapes and is shaped by cultures, power relationships,
and leadership in ways that impact the development of collaborative capacity. Fulk, Schmitz, and
Steinfield (1990) proposed a social influence model of technology use in organizations that
challenge the common assumption of technological determinism. The basic premise of the model
is that technology use in organizations occurs within a complex social context, and the use of a
new technology will be shaped by interactions in this social context more than the technology
itself. By looking at the social construction of communication technology in organizations, Fulk
(1993) discovered that the social influence of an individual's work group on attitudes and
COLLABORATIVE CARE CAPACITY 76
behavior toward communication technologies is stronger for those individuals who have a high
level of attraction to their work groups than for those who have a lower level of attraction. This
important finding confirmed speculation about the potential influence of social relationships on
ICT use.
Contractor and Eisenberg (1990) further suggest that not only does one's participation in
an organizational communication network influence social information processing—which
influences perceptions of, and use of, ICTs—but one's perception of, and use of, ICTs
reciprocally influences one's participation in an organizational communication network.
“Because communication networks are informal, emergent, and hence always changing, they are
continually both antecedents and consequents of behavior with and attitudes toward technology”
(Contractor & Eisenberg, 1990, p. 151). By their account—which draws on Giddens' theory of
structuration and Burt's theory of structural action—ICT use in an organization is inherently a
structuring activity. The social nature of this process makes communication a critical element in
the process of technology appropriation and use. Communication is also central to Leonardi's
(2009) ethnographic study of how people in the R&D department of a large car manufacturing
company form interpretations of a new technology both through interaction with others
(discussion) and through interaction with the technology's material features. He finds that even
when people support a technological change they can work against successful implementation of
this change by how (and how much) they use it.
ICTs and collaboration in the health care context. Information and communication
technologies play an increasingly important role in the collaborative patient care process. ICTs
have co-evolved with changes in patient care to enable effective, comprehensive treatment of
complex and chronic conditions. Reddy and Jansen (2008) make the argument that
COLLABORATIVE CARE CAPACITY 77
understanding the collaborative information behavior (CIB) of health care teams—which is
different from individual information behavior (IIB)—is a precursor to understanding the role of
information technologies in information seeking. They examined CIB in two units: the surgical
intensive care unit (SICU) and the emergency department (ED) and found that communication
was typically face-to-face because team members were co-present on the unit, and it was focused
on weaving together different pieces of information to answer complex questions. They also
found that when information needs are complex, the team often splits up information tasks. One
major difference between IIB and CIB is that in the latter case, Information Retrieval (IR)
technologies—like electronic patient records or web-based information tools—are typically the
first step in the information-seeking process (followed by team communication) where as in the
former case, IR technologies are often the last step in the process.
In a review of research on collaborative technology use by health care teams, findings
suggest that synchronous technologies are more often used for time sensitive issues related to
patient care while asynchronous technologies are typically used more for administrative issues
(Patel et al., 2000 as cited in Househ & Lau, 2005). Other research partially supports and
partially contradicts this conclusion. Time sensitivity with respect to patient care does seem to
drive synchronous face-to-face communication though asynchronous communication is often
still used for less urgent patient care-related communication. Conn and colleagues (2009)
explain:
Impromptu, face-to-face conversations occurred in common workspaces such as the
nursing station and charting room. Such interactions were valued for the more in-depth
interprofessional planning around patient care they potentially afforded, as compared to
organized ward rounds. In addition, opportunistic communication allowed
COLLABORATIVE CARE CAPACITY 78
interprofessional staff to connect with one another when care plans unexpectedly changed
(p. 947).
Unfortunately the use of synchronous technologies often results in a failure to document the
information exchanged, which can result in errors from lack of shared understanding and an
inability to confirm instructions. Asynchronous technologies, including patient electronic
medical records, status reports, and whiteboards, were typically used in conjunction with other
technologies—either to document orders and information in multiple ways or to document
(asynchronous) and report (synchronous) information (Conn et al., 2009).
Other research has examined differences between teams using an integrated group
information sharing platform and teams using traditional information sharing approaches and
found that teams using the integrated group technology had higher rates of team participation
during planning, more flexibility in leadership, better access to shared notes and information, and
emergent goals whereas on the traditional teams, the formal team leader defined goals, led
discussions, determined task assignments, and controlled notes and information (Dennis &
Garfield, 2003 as cited in Househ & Lau, 2005). Other research has found that the benefits of
shared technologies may not be realized unless the organization has developed collaborative
capacities that support a collaborative work environment (Lange, 1991 as cited in Househ & Lau,
2005) which is consistent with Fulk and colleagues’ (1990) social influence model of technology
use.
There remains an opportunity to look at the iterative relationship between how health
teams shape ICT use and how team adoption of ICTs recursively shapes collaborative care
capacity in terms of culture, power, and leadership. I pose the following research question and
hypothesis to further investigate this relationship:
COLLABORATIVE CARE CAPACITY 79
RQ4: How does the use of ICTs by different teams and disciplines support or inhibit the
development of collaborative care capacity in a hospital?
H4: Care providers’ use of ICTs will reproduce elements of team and disciplinary
cultures and power structures.
Method

The exploratory questions and predictions presented in this study, and the focus on
communication as discourse and symbolic interaction, lend themselves to qualitative methods of
data collection and analysis, including field observation and interviews. The participating
hospital organization and teams are described in detail in Chapter Three.
Observation

Observation procedures. I conducted at least two observation sessions with each of the
five SCCH units and one team included in the research: CV Acute, PICU, BMT, Hem/Onc, 5A,
and the General Pediatric Surgery team. After the first two observation sessions on 5A during
which I shadowed a bedside nurse and a charge nurse, I realized the shadowing approach may
not be the most efficient and effective way to observe interdisciplinary collaboration-in-action
for two reasons. First, shadowing one individual for an entire day often yields only a handful of
moments in which to observe collaboration-in-action. Second, my presence created an additional
variable for the nurses to have to consider throughout the day, and it felt like a potentially
unnecessary imposition. Fortunately I had the opportunity to observe interdisciplinary rounds on
my first day of shadowing, and I found this to be a particularly useful observation experience due
to the presence of, and interaction between, many different kinds of care providers all
responsible for the same patients. After reflecting on this experience, I decided to focus my
observation sessions on patient rounds as a key collaborative moment.
COLLABORATIVE CARE CAPACITY 80
To minimize disruption, I observed rounds in a particular unit only once per week. The
number of observation sessions conducted in a given unit or team depended on their
receptiveness to having me present and on how quickly I could develop an understanding of the
standard rounding process and interactions that took place on that unit or team (see Table 4.1 for
number of observation sessions for each unit or team).
Table 4.1

Number of Observation Sessions for Each Unit or Team

Unit or Team Sessions

Pediatric Intensive Care Unit

2
Bone Marrow Transplant

4
Hematology and Oncology

7
5A (General Care)

3
Cardiovascular Acute

2
General Pediatric Surgery

2
TOTAL

20

Field notes were collected during each observation session. Although I could not actively
participate in the rounding process, I was acutely aware of how my presence affected (or did not
affect) the process, and I recorded these observations as well as reflections on how my
observations were filtered through my own perspective (Emerson, Fretz, & Shaw, 2011). If the
unit conducted bedside or walking rounds, notes were initially written in a small notebook and
then transcribed into digital form immediately after the observation period. If the unit conducted
office rounds, notes were taken on a laptop. The decision to use a laptop during office rounds
was based on three factors. First, I can type faster than I write, so I was able to collect more
COLLABORATIVE CARE CAPACITY 81
details in the moment, and did not have to rely on memory recall after the session. Second, it
saved time because I did not have to fully transcribe my notes into digital form; I only had to
review and reflect. Third, during office rounds, most of the care providers at the table would
have laptops open, so I felt like my presence was less obvious when I was typing on my laptop
than when I was writing in my little notebook.
During the observation sessions, I recorded details about time and location, who was
present, where people sat or stood, who led the discussion, who participated, how the discussion
unfolded, and what kinds of interactions took place between care providers. I paid particular
attention to formal and informal leadership in action, the ways in which individuals reproduced
or challenged power relationships, and the reproduction of disciplinary, team, and organizational
cultures throughout the rounding process. From the 20 observation periods, 70 single-spaced
pages of field notes were collected.
Interviews

Interview procedures. I also conducted 49 interviews with care providers from each of
the five SCCH units and one team included in the research project. In order to protect the
identities of interviewees, I opted not to include exactly how many of each type of staff or
provider came from each unit or team. Summary information detailing the disciplinary and team
breakdown of interviewees separately can be found in Tables 4.2 and 4.3 respectively.
COLLABORATIVE CARE CAPACITY 82
Table 4.2

Number of Staff and Care Providers Interviewed by Discipline

Discipline

Type Number
Attendings

7
Hospitalists

2
Fellows

5
Residents

1
Physicians
Surgeons

3
Nursing Managers

3
Nurse Practitioners

4
Charge/Lead Nurses

5
Nurses
Staff Nurses

8
Therapists

3
Social Workers

5
Interpreters

2
Dieticians

2
Child Life Specialists

1
Respiratory Care Managers

1
Clinical Care Coordinators

1
Ancillary
Care Staff
Pharmacists

1

COLLABORATIVE CARE CAPACITY 83
Table 4.3

Number of Staff and Care Providers Interviewed by Team

Unit or Team Number

Pediatric Intensive Care Unit

9
Bone Marrow Transplant

8
Hematology and Oncology

5
5A

7
Cardiovascular Acute

9
General Pediatric Surgery

8
ALL

3

Note. “ALL” refers to care providers who regularly work across all units

I aimed to interview a range of disciplines and ranks/positions within the disciplines from across
each of the five units and one team. Interviews had to be relatively short to accommodate the
busy schedules of the interviewees. On average they lasted between 15-20 minutes—though they
ranged from five minutes with an extremely busy attending to an hour. The semi-structured
interview format allowed for flexibility, and priority questions were highlighted in advance to
prepare for interviewees with very little time. All interviews except for one were conducted in
person at the hospital in locations identified by the interviewees as convenient (the café, on the
unit in empty consult rooms, in private offices, etc.). One interview was conducted over Skype
because the interviewee was on a leave of absence from work.
Interviewees were assured of confidentiality and asked if recording was okay for research
purposes. Only two interviewees opted not to be recorded, so extensive and careful notes were
taken during those interviews. I asked questions about their professional background and their
COLLABORATIVE CARE CAPACITY 84
role in providing care, about organizational culture, the rounding process, collaboration outside
of rounds, support for collaboration, ICTs and collaboration, and the most challenging aspect of
their job (see Appendix for interview protocol). Questions were designed to access information
about team, disciplinary, and organizational cultures; power relationships between individuals
and groups; and collaborative leadership.
Data Analysis

Field notes and interview transcripts. Interview recordings were transcribed and
uploaded along with the field notes from observation into MAXQDA, a qualitative data analysis
program.
1
Saldaña (2010) recommends using two iterative cycles of coding. First cycle coding
focused on identifying the collaborative and non-collaborative elements of team/disciplinary
cultures, power relationships, and leadership in care provider discourse and interaction. Initial
codes were driven primarily by collaboration research and theory. Emergent codes that
developed during first cycle coding were defined and applied systematically (see Table 4.4).
Second cycle coding identified themes based on patterns within and across codes.
Table 4.4

Field Note and Interview Analysis Codebook

Code Definition Example
Culture: Felt Need or Value Expressed or demonstrated
need to collaborate/value of a
collaborative approach to care

Teamwork, shared goal,
valuing particular
collaborative relationships,
lack of felt need

1
http://www.maxqda.com/
COLLABORATIVE CARE CAPACITY 85
Culture: Openness and sharing Open communication and
information sharing in the
patient care process

Questioning, sharing
information, speaking freely,
communication problems,
failure to share information
Culture: Participation Inclusion of multiple teams
and disciplines in the patient
care process (especially during
rounds)

Presence/absence of particular
individuals or groups during
rounds or need for particular
individuals groups to attend
rounds
Culture: Appreciating diverse
perspectives
Expressed or demonstrated
willingness to attend to
diverse perspectives in the
patient care process
Diverse provider perspectives
(professional background) and
diverse patient/family
perspectives (ethnic, religious,
linguistic, SES)
Culture: Time
(Emergent)
The different ways in which
staff and care providers
structure time to enable or
inhibit collaborative care
Time per patient, waiting for
others, rotations/shifts,
conflicting schedules,
Culture: Space
(Emergent)
The different ways in which
staff and care providers
structure space to enable or
inhibit collaborative care
Workspace, colocation, unit
layout
COLLABORATIVE CARE CAPACITY 86
Power: Balance and dispersion The degree to which power is
distributed among different
members of a patient care
team
Decision-making and problem
solving
Leadership: Support for
collaboration
Formal leadership support that
enables or encourages
collaborative care
Work processes and
structures, leadership skills,
staff empowerment
Leadership: Bridging Staff and care providers
working with others of either
the same or a different
discipline but from a different
team
Bridging roles, challenges that
inhibit bridging
ICTs: Asynchronous Staff/care providers use of
ICTs that enable asynchronous
communication
Paging, texting, emails, EMR
ICTs: Synchronous Staff/care providers use of
ICTs that enable synchronous
communication
Face-to-face, phone calls,
polycom calls

Findings

Research question 1 asked: How do care providers draw from and reproduce elements of
collaborative and non-collaborative cultures through discourse and interaction? Observation field
notes captured cultural differences and similarities between units or teams and disciplines;
interviewees were explicitly asked to describe the culture at SCCH and on their unit or team.
COLLABORATIVE CARE CAPACITY 87
Culture was not initially defined to allow for interviewee interpretations of the term—though
prompt questions were offered if the initial question confused them. Participants answered the
question most often in reference to their team or unit and only about half as often in reference to
the whole hospital. Some individuals interpreted culture with respect to their discipline. Field
notes and interview transcripts were coded initially for the four culture-based elements of
collaborative care capacity—felt need/value, participation, openness/sharing, and appreciation of
diverse perspectives—as well as for emergent cultural themes relevant to collaborative care (i.e.,
time and space)
Felt Need

Hypothesis 1 predicted that most care providers would explicitly express a felt need to
collaborate. Although some individuals clearly expressed or experienced a lack of felt need to
collaborate in providing patient care, interviewees far more often experienced a felt need to
collaborate and expressed the value of collaboration, which supports Hypothesis 1. Because this
element of culture is largely value-based and thus difficult to observe, interview data were
particularly important for assessing felt need to collaborate. Interview questions about patient
rounding processes and whether the respondents see other staff and providers around SCCH who
lack motivation or incentives to communicate and work with others yielded useful data. The way
respondents described their role and responsibilities and the culture of SCCH or their unit or
team also offered relevant insights.
Teamwork and collaboration. Many interviewees referred to the importance of
teamwork and collaboration in describing the culture of the hospital or their team/unit. A
pharmacist compared the culture at SCCH to other hospitals where her friends work and
described SCCH as “very collaborative.” A bedside nurse from the Hem/Onc unit described the
COLLABORATIVE CARE CAPACITY 88
hospital culture in terms of “teamwork, pretty much collaborating with all team members of the
care team, which may include . . . other departments or other units.” A physical therapist
provided a similar description:
I mean definitely teamwork is one of the first things that come to mind because we all
have to work together as a team. We are often seeing the same patients and we are all
working in different aspects to help this patient’s overall well being, so we are
communicating with each other and co-treating . . . often on a daily basis.
A social worker with a unit-based assignment in the PICU described the culture of the unit as
“really collaborative; the different disciplines for the most part work very well together. There is
a high level of respect between disciplines, which is very nice.” Similarly, a dietician with a unit-
based assignment in the PICU explained that nurses on the unit work well together and other
members of the team are well-integrated—“it’s very multidisciplinary, which is really, really
nice.” A nurse practitioner from the general pediatric surgery service explained that her team is
“very family oriented . . . very supportive with each other within the team and of other teams as
well.”
A therapist talked about the importance of intra-disciplinary collaboration because of
staff shortages within her subspecialty due to maternity leave and young mothers working only
part-time. “I feel like we really have to rely on each other a lot, because you are covering, you
have- like maybe half the people are part-time now, so if you are gone, you have to be able to
have somebody see the kids while you are gone so your child can keep making progress.” A
bedside nurse from the BMT unit also noted the importance of collaboration with other nurses on
her unit. “I think we also work really well as a team here. We’re always helping each other
constantly, and if a nurse has a particularly hard assignment, I think we all notice that, and we go
COLLABORATIVE CARE CAPACITY 89
to her and will help her out.” A bedside nurse from the CV Acute unit considered
communicating “with my other RNs and other team members, including RTs [respiratory
therapists], nurse practitioners, and MDs” to be part of her job responsibilities. An attending
from the BMT service described her team as rising above disciplinary differences: “So it’s not,
‘I’m a doctor, I’m a nurse.’ It’s like there’s a team, so that’s the thing, which is very critical in
[bone marrow] transplantation—that there is a team sense. Everybody is responsible.”
For the kids. A theme emerged around why people are able to work together successfully
despite team and disciplinary differences—because everyone at SCCH has the same goal: they
are all there “for the kids” and their families. A PICU nursing manager explained, “there is a lot
of enthusiasm for the work that we do, which probably goes hand in hand with being
pediatrics—you generally don’t go into it unless you are really passionate about it.” A critical
care (PICU) attending echoed the sentiment, pointing out, “Most people that work here have
awful commutes, probably don’t make that much money, but they all are very, very strongly
committed to being here and they have tremendous love and care for the families and the
patients.” A PICU bedside nurse expressed the same sentiment:
The other thing, I think, about the hospital culture is the level of respect between all
disciplines, and then, of course, our mission that we are here for our children and I think
that that really does- is shown in day-to-day actions; it’s not just words.
Similar thoughts were expressed on other units and teams across the hospital. A dietician from
CV Acute said, “I mean people are so happy, they smile, everyone has the same mission, we all
love children, we all want to help children.” A BMT bedside nurse similarly said, “I think we
just really care about our patients and our job, and we really like working for each other, and we
do whatever it takes to provide care for our patients and advocate,” and a BMT nurse practitioner
COLLABORATIVE CARE CAPACITY 90
agreed, saying, “I think we work together pretty close, and we would point out mistakes to each
other without- by the end of the day, it’s for the patients . . . so I am sure we can come to an
agreement most of the time.” A nursing manager from 5A similarly noted, “everybody has pretty
much the same goal; they want to make the patient better.”
Many ancillary care providers shared a similar understanding of this motivation as nurses
and physicians. A PICU dietician explained, “I think everybody cares so much for the kids and
cares deeply about what they do.” An interpreter for the medsurg units noted, “We all have the
same goal, which is patient care.” An occupational therapist (OT) tied this goal to information
sharing, “I think overall everyone really likes to share information and I feel like people are there
for the kids,” while a physical therapist (PT) focused on advocacy, “I feel that we are all very big
advocates for the patients.” Even hospital technicians like this respiratory care practitioner
shared a similar perspective, “I feel like everyone here is motivated. I think it’s the population
that we work with—they love the children and you never see someone that really complains
about work.”
Key players. Many interviewees described the value of working with a particular
individual, discipline or group. During rounds, a charge nurse from the BMT unit explained that
they really try to have bedside nurses join rounds to hear the discussion about each of their
patients because this helps them to better understand and carry out physician orders. On the first
day of a new resident team rotation in the PICU, the fellow leading rounds explicitly reminded
residents to “make friends with the nurses” because “they are very helpful and knowledgeable.”
An attending physician from the Hem/Onc team explained in her interview that bedside nurses:
really are some of the most important people in caring for the patients because they are
the ones that spend the most time at the bedside and get to know the patients the best, so
COLLABORATIVE CARE CAPACITY 91
their value is tremendous on our team, and there’s no way we can manage the team
without them.
A resident physician, referring to her rotation in the PICU where bedside nurses collect basic
stats and “present the patient” to the team during rounds, said in her interview:
I found it really useful, yeah, especially because there [PICU] the patients were so
complicated. It’s nice to have someone else help gather the information because we kind
of have to process everything and come up with a plan and I think if we had to also
gather all the information . . . I feel like it’s nice to have someone else helping out. I
thought it was really helpful.
Physicians and nurses also expressed a felt need to collaborate with ancillary care providers,
including social workers, pharmacists, dieticians, clinical care coordinators (CCCs), and
therapists as well as with parents/families. A fellow from the critical care team (PICU/CTICU)
compared his experience of ICU rounds to rounds on a non-ICU unit and said:
I have been over there and it’s just—you don’t have the support because you don’t have
the pharmacist on rounds likely because you are not making quite so many changes, but
the dietician you won’t have on rounds, the [subspecialty] team probably isn’t quite as on
top of things, and so I feel like they don’t have as much support as we do and so when we
talk about something, we can come to a conclusion right away because we have all the
people there for support instead of having to call everybody or page everybody after
rounds and then trying to close the loop.
A Hem/Onc attending explained that patient and family care must go beyond medicine and this
requires a team approach:
COLLABORATIVE CARE CAPACITY 92
When we take care of the patients, it’s not just the medical issues that are important, but
it’s also the psychosocial aspects of what the families are going through, and which—the
nurse care managers and the social worker provide that input—because if the families are
not in agreement with their plans or have issues that they may not necessarily bring up to
the physicians, it makes our work for the families and the patients much more difficult. In
my experience there are a lot of times that parents will say something different to the
social worker than they will say to me, and so having that input makes a big difference;
having the pharmacist there to help facilitate the med adjustments or dosing of different
medications and understanding interactions, it’s extremely helpful.
A charge nurse from 5A explained the importance of collaborating with parents and families.
“The families are really involved to have a good baseline for their kids and you need to always
listen to them. The parent who says to me, ‘Joey is not right today,’ I listen. It doesn’t matter to
me that they can’t actually tell me why.” A bedside nurse from the same unit told me that he
loves to watch the moms prep their kids’ meds because they often have the best techniques.
Many of them do not have a lot of money, so they do creative things with household items. One
mom brought a leg brace from home because she noticed her son’s leg was swelling from all the
time spent lying in the hospital bed. Then she tied a sock around the brace to add extra pressure,
which she had found from experience would reduce the swelling. The nurse felt like he often
learned from parents.
Personal issues. A distinct theme emerged from interviewees who described a generally
positive experience with teamwork and collaborative care but acknowledged rare negative
experiences with non-collaborative individuals or groups who were often depicted as having
some kind of personal or dispositional issue. A charge nurse from the CV Acute unit said, “I
COLLABORATIVE CARE CAPACITY 93
think overall as an organization we’re very—we have good relationships with everybody.
Everyone has their bad moments of being a little grumpy but overall I think we communicate
well.” A care provider from the general pediatric surgery team said he sees people who are not
motivated to collaborate, “but it’s individuals with personality issues. I can give you a list of
people who don’t want to work with you, who are obstructive and they are not on our team,
thank God. There are people in the ER; there are people in the ICUs. And they are doctors. They
are not—it’s not usually nurses. It’s other physicians that just don’t really care to work with us.”
A BMT beside nurse said that people are generally motivated to work with others, “but there is a
handful of people that just don’t- they are done with their job and just haven’t retired yet.” A
physical therapist also noted that she sees people who lack motivation to work with others. “I
don’t know what the reason is, whether they are having a bad day or they feel like they are in a
rut or they have been in the same position for so long or they don’t feel like they have a voice.”
A CV Acute bedside nurse explained that he also sees people who lack the motivation to work
with others, but “it’s individually based. I think- what I know is, a lot of nurses sometimes can
bring personal issues to the workplace, and that can be a negative effect to care or just make
them kind of difficult to communicate with.”
Lack of felt need. Although most participants seem to value collaborative care and felt
that others in the organization also value collaborative care, there were some participants who
felt differently. One care provider from the general pediatric surgery service noted that even
though 70 percent of the time people are motivated to work with others, that still leaves 30
percent of the time that you have to make phone calls and push people to “do what they need to
be doing.” A Clinical Care Coordinator explained that she also sees people who lack the
motivation to work with others at SCCH but that “you would see that in any institution . . . There
COLLABORATIVE CARE CAPACITY 94
are always problems—you will find somebody who doesn’t like to communicate.” A critical care
(PICU) fellow mentioned resident physicians in particular: “there have been a couple of
residents—I have worked with them in the past that are towards the end of their third year, that I
feel probably just have burned out and are very tired” so they stop making an effort to really
work with others.” One nursing manager identified doctors as the individuals who are least likely
to feel the need to work with others: “I am sure there are physicians that have that attitude that I
don’t have time to be telling people what I’m doing. People can be great clinical physicians but
not great communicators.” However, she also explained that this is not the norm at SCCH.
A few participants framed this issue as a problem with certain teams or services. The
surgical service was explicitly identified as a team that does not value or feel the need to
collaborate. A critical care fellow said, “Maybe the medical consult teams are a little bit better
about doing a multidisciplinary plan together whereas the surgical teams somewhat more dictate
the plans sometimes or would attempt to.” A BMT bedside nurse similarly noted that
communicating with other services can be really difficult—“particularly surgery. They’ll come
onto the unit and take a look at the patient and leave” without updating the nurses. Other
participants expressed similar issues with consulting teams in general—not just surgery. An
ancillary care provider from the PICU explained:
I have seen that repeatedly where other services will come in, walk straight to a patient
room, talk to the family, and leave [even though] they may not have the most up-to-date
information. And so families frequently get different stories from the service that they are
familiar with . . . than they get from [our PICU] doc that comes in and that says
something totally different.
A nursing manager from the PICU echoed his concern, noting that:
COLLABORATIVE CARE CAPACITY 95
other services come to round on their patients [when they are in the PICU]; we have brief
interactions with them. I really like to be there for that, but the other services are not as-
it’s not as big of a priority for them to involve the bedside nurse in their rounds, which I-
some services are different than others, but that’s kind of an issue we all struggle with
here.
A Hem/Onc attending explained that she sees a range of differences across the hospital:
I think there are certain groups that are very responsible and other groups that are more
difficult to work with. Well, I say that on my behalf but also on behalf of residents,
because sometimes there are situations in which they are not easily accessible, or they
have limited time that’s available for in-patient care, or decisions are not made until later,
so then the care of the patient can get delayed.
Ancillary services experienced frustration because physicians and nurses sometimes do
not fully understand or value the scope of their work and, as a result, fail to include them in team
care. A speech therapist explained that her biggest challenge in doing her work “is still medical
staff not knowing what a speech therapist’s scope is and valuing what we do.” She goes on to
explain that:
in any unit, it’s been a battle of teaching, constantly teaching physicians, teaching new
residents, teaching nurses when to ask the doctors for consults, and still our highest
degree or greatest frequency of consults come from other therapists. They still don’t
come from nurses. I’ve done PR projects on it, and I’ve done like tons of in-services, but
with this- being in a teaching hospital, I think that’s one of the downfalls because you’re
constantly getting new people.
COLLABORATIVE CARE CAPACITY 96
A social worker similarly described the biggest challenge she faces in her work, “I would say, I
don’t want to say it wrong—consideration of everyone being a part of important things. So like if
I’m there physically, I end up in the family conference or the meeting with the doctor, but if I’m
not there often it doesn’t come to my attention. I kind of have to find it myself.” A Spanish
interpreter experienced a similar challenge noting that “some doctors won’t use us because they
think they can get by with the Spanish they have, and I’m sorry to say but there is a lot of room
for confusion.”
Cultural Differences

Hypothesis 1 also predicted that despite the fact that most people from across all units
and teams would express a felt need to collaborate, there would be variations by team and
possibly by discipline in the extent to which other elements of collaborative capacity are
reproduced. The data demonstrate support for this hypothesis. Differences were found between
disciplines with respect to openness, participation, and appreciation of diversity and between
teams particularly with respect to participation.
Openness and sharing. Two groups of sub-themes related to openness and sharing
emerged from the data. The first group focused on questioning, sharing information, and
generally communicating openly. A few participants described the hospital culture in terms of
open communication. A medical resident with experience working on many different teams
during different rotations commented, “A lot of times I see people, they will just contact each
other with like consults and questions and I feel like it’s a very family feel for such a large
hospital . . . like there was really open communication like between nurses and residents and
fellows.” A provider from the general pediatric surgery service noted that across the hospital, “I
think it’s probably more of a open line of communication just because we have so many
COLLABORATIVE CARE CAPACITY 97
residents and fellows and attendings and so you get used to getting the spectrum of education
when you get phone calls.”
Open communication. Some interviewees specifically noted that communication is open
within their unit or team. A critical care (PICU) attending said, “I think the ICU itself has a very
collegial atmosphere and I hope—I like to believe the staff really feels like they are part of the
care team and that their input is heard and listened to and considered heavily.” A charge nurse
from the PICU noted that she thinks communication is successful within the critical care team
“during rounds, and I will specify during rounds” because the rest of the day can be more
challenging. A BMT nurse explained that the nursing team in the BMT unit works “together
pretty close and like we would point out mistakes to each other” openly. A nurse practitioner
from the general pediatric surgery service explained that the surgery team is very close, which
makes it easier to communicate openly:
I think for the most part, there are 13 attendings in the Ped Surgery department—the vast
majority of them I have no problem picking up the phone and giving them a call. If there
is an issue, certainly with the fellows, and I even tell them if they are wrong about
something, or if I don’t think this is a smart thing to do . . . So I think the communication
on the surgery team is for the most part very open with each other.
The individuals who commented on openness and sharing within their team were typically from
very close-knit teams with clearly defined staff and provider populations.
There were differences between disciplines with respect to openness and sharing.
Almost all physicians said they feel comfortable speaking openly with other staff and providers,
especially the attending physicians. However, junior physicians clearly felt less comfortable
sharing openly in situations where they disagreed with senior physicians. In these instances they
COLLABORATIVE CARE CAPACITY 98
tended to use polite questioning—often framed in terms of their own learning—to interject. One
resident said, “if it’s a fellow, I probably wouldn’t fight it too much because they have a lot more
experience than I do, so I would go along with it, but sometimes I will ask, ‘like why are we
doing this,’ just for my own learning.” A fellow from the Hem/Once team said, “It really
depends on the [attending] provider, but I think here you can always ask them” when you
disagree with a decision.
Some nurses agreed that communication is fairly open—though this was more likely
within the same care team, when people were face-to-face, and when nurses were interacting
with other nurses. A nurse from 5A explained that, “The nurses all communicate fine with each
other.” In one instance that I observed on 5A, a bedside nurse found that a nursing aide had put a
large stack of the wrong size diapers in a baby’s room and because the baby was a “combined
precautions” patient, all the diapers had to be thrown away. The nurse went directly to the PCSA
and confronted her about the mistake and she promised to be more careful. When they disagreed
with physicians, many nurses replicated the process of polite questioning that junior physicians
use with senior physicians. A bedside nurse from the PICU explained that if this happens during
rounds, “I always make a note in the margin if there is something I have a question about . . . It
tends not to be so much something I disagree with but something I just have a question about . . .
usually I wait until the end and ask questions.” A bedside nurse from the Hem/Onc unit similarly
noted, “I would kind of question like ‘are you sure that’s what you kind of want to do?’” A
Hem/Onc charge nurse echoed this approach explaining that she would “usually question it—like
why, I want to know the reason, or I’ll give my input as to why I don’t think that may work, but
in a very politically correct way just because I feel that if you say or present it to them in a way
like I know more than you do, they [residents] get right away very defensive.”
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Ancillary care staff generally seemed to feel more comfortable disagreeing or sharing
advice with care providers than nurses and as a result felt that communication was more open. A
therapist who works across the whole hospital explained:
Yeah, I’m very open and I feel like at all levels, whether you’re talking to residents or
attendings, our culture is good here, and that people listen, and that they want your advice
or they want your clinical impressions. So I’ve never run into you know a barrier in terms
of not wanting to speak up or being afraid to speak up.
A social worker from the medsurg floor similarly noted that he’s usually “pretty comfortable
with going directly to that person [I disagree with] . . . and usually it’s something when it’s a
glaring issue that someone hasn’t taken into account, not their fault, it’s just something that they
don’t know about or something like that that I want to make clear.” A pharmacist from 5A
explained that “the communication here [at SCCH] and the working relationships are very nice
and open,” and an interpreter from CV Acute similarly shared that “as an organization, I do
believe that SCCH is doing their best they can to keep an open communication.”
Communication problems. The second group of sub-themes focused on communication
problems and a failure to share information. An attending hospitalist identified communication
as one of the biggest challenges she faces in doing her job. Many participants specified that
during rounds when everyone is in the same room, communication is very open and generally
successful, but throughout the rest of the day, it can be more of a challenge. Some participants
described problems with open communication specifically with respect to particular groups. A
fellow from the PICU explained that surgical subspecialties are typically harder to reach than
medical subspecialties.
COLLABORATIVE CARE CAPACITY 100
I found that everyone is responsive to a consult, to when they are being paged—getting
back to us pretty quickly, but it is just, for whatever reason it’s a little bit easier to contact
like nephrology or cardiology or something discussing a patient’s care then maybe calling
neurosurgery.
A provider from the surgical service explained, “There are definitely some subspecialties and
some teams that are a little bit more frustrating to communicate with than others.” Other
participants described communication challenges in terms of individual interpersonal or
personality issues. According to a critical care physician:
Something that I will say is lacking a little bit here compared to past institutions is that if
you make a new consult . . . they will come by and see them, [but] they don’t always
close the loop and tell you what the plan is, even on the- especially the first consult is the
most important.”
Some respondents also described a failure to communicate or share information across
disciplines or disciplinary levels. A Hem/Onc fellow explained that he often forgets—and does
not really make an effort—to update residents about chemotherapy changes, which can upset
patients who expect their residents—their primary care providers—to know everything about
their care. He said, “You don’t talk about things which have changed in terms of chemotherapy
plans because we don’t- because we don’t expect them to know and we don’t expect them to be
interested.” While observing rounds in the Hem/Onc unit, a resident explained to me that she felt
they had many communication issues. For example, charge nurses from the Hem/Onc units are
supposed to come to rounds and listen to what the physicians say about each patient and then
inform their nurses, but this just does not happen the way it should. A bedside nurse explained
that when she has had problems communicating with physicians, her “charge nurse will step in
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and take care of it and they will do what needs to be done to get the communication across.”
Finally, a nursing manager from 5A explained that the “[nursing] staff is well-trained and so are
the physicians in SBARQ [a tool for improving hand-off communication], but they don’t use it.”
Team participation. To examine who is regularly a part of the routinized care process I
focused on rounds. The process typically called “rounding” or “patient rounds” in a hospital is
actually comprised of multiple processes that can differ dramatically between units and care
teams. Rounding happens at different times and places, and it involves different groups of staff
and care providers. Themes emerged around who is present for teams’ various rounding
processes, who is absent, who should be present, and the value of attending rounds.
Pediatric Intensive Care Unit. Morning rounds in the PICU begin on the floor in the
physician workroom with the on-service fellow and attending, the team of residents, and the
PICU nurse practitioners. After an initial discussion about any new patients they received over
night, they split into two groups and prepared for walking rounds. The first PICU rounding group
consisted of the on-service fellow and the resident team. The second PICU rounding group
consisted of the on-service attending and the PICU nurse practitioners. Sometimes others joined
when necessary—including pharmacists, respiratory therapists, and nutrition. The team stood
outside each patient room, and the bedside nurse joined the team. Sometimes the family also
joined as well. A unique aspect of PICU rounds is that the bedside nurses “present” the patient
instead of the residents or nurse practitioners. A PICU bedside nurse explains this process:
The ICU bedside nurse which will be someone like me is expected to present the
patient—to give a full report on vital signs, on access, on all kinds of issues, so we are
very much a part of the multidisciplinary discussion, which is a really unique thing in our
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unit and something I really love, because not only do I get to ask questions, but I get to
understand why we are doing the things that we are doing.
She compares this to the NICCU where the bedside nurses “are kind of like more quiet
bystanders” and says she prefers to be actively involved. A fellow provided a physician
perspective. “Here [in the PICU] they have the nurses present on rounds, which I have never
seen anywhere else, which makes a- it’s a big change or a paradigm shift almost, but it makes the
nursing team I think much more invested in the care of the patient.” Families were also supposed
to be invited to join the team for these rounds—though this does not always happen. A critical
care (PICU) attending explained, “Families are a plus/minus on those rounds, just depends, but
often times you will say [to the parents], ‘oh we are like- we are going to round on your patient
and 75 percent of the time they prefer not to [join] . . . I feel like there is not quite as much
participation as we’d like.” During observation, I found this to be true. When parents chose to
join, they would stand awkwardly at the door listening to all the medical jargon and looking
confused. A PICU charge nurse explained that the sheer size of the rounding group can be a
problem for families, “It is, sometimes it can be as many as fifteen people with all these different
computers and they really clog up the traffic flow and I think parents are quite intimidated.”
Cardiovascular Acute. In the CV Acute unit, rounds were truly “bedside” rounds. There
were two types of groups who follow these patients—a cardiothoracic (CT) surgical team and a
hospitalist team. When I observed rounds, I followed the surgical team, which included attending
physicians from cardiology and radiology as well as a CT surgery nurse practitioner, a CV Acute
nurse practitioner, a discharge specialist, and a dietician. The bedside nurses joined the team for
their patients. Unlike many other units, the team actually entered the patient rooms, and each
member of the rounding team examined the patients. Like other units, CV Acute started doing
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care progression rounds, which include the provider (NP or physician), a nursing manager, the
charge nurse as well as all the other disciplines that are not able to join bedside rounds in the
morning. A CV Acute nursing manager explained that these rounds are working really well—
except that some ancillary staff like spiritual care, child life, and OT have struggled to find a date
and time when they can join the group. Many CV Acute interviewees noted that it would be nice
to have OT on rounds every day. The CV Acute unit was piloting a new system during my
interviews that involved the charge nurse running care progression rounds instead of nurse
practitioners or hospitalists in an attempt to empower the charge nurses within the team and
improve the flow of information. A charge nurse explained that not everyone appreciated the
new process:
My job is to lead it and make sure that they don’t talk too much and if they do, I have to
cut the conversation . . . NPs are not- they are not happy about this. Actually this morning
they were saying, ‘I don’t understand why you’re leading it when all you say is room
number, the patients name and that’s it,’ and I was like, ‘that’s what you want me to do.’
You know what I mean—they are saying why when I can just say that and give you the
whole background and diagnosis [later].
One bedside nurse mentioned that the cardiothoracic surgeons round on the unit in the afternoon
at four o’clock, so “sometimes I just follow them around and listen to what they’re saying.”
5A. When I first observed on 5A, the unit was not yet doing “family-centered” rounds.
Instead, there were many different rounding processes that would take place throughout the
day—primarily as seated meetings in workrooms or offices. I observed interdisciplinary rounds
once at this time, and it involved a hospitalist, a chaplain, and a CCC, and they would call each
bedside nurse into the workroom to discuss their patients. By the time I was conducting
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interviews, the unit had started family-centered rounds, so each patient room had a sign on the
door that parents would fill out, which noted whether they would like to be included in rounds. A
5A charge nurse explained “that the family rounds have helped . . . [by] making it easier for
families to get some of their issues addressed.” An attending hospitalist explained that when she
is on teaching service, her team—including a senior resident and a group of interns—will round
between 9 and 11 o’clock in the morning and during this time they will generally see some
patients on 5A as well as the other units where they have patients. They always call the nurses to
join and ask the families to join as well.
A nursing manager from 5A explained that this works well only some of the time because
the process is complex; it involves five different teams of physicians. “They will call [the
bedside nurse] to say which room, but sometimes by the time the nurse gets there, the rounds are
over.” Because there are so many physician teams simultaneously rounding on 5A patients, the
charge nurse cannot join morning rounds, which is unfortunate because “she is the pusher. She is
trying to push people out [i.e., discharge patients]” (5A charge nurse). They also have care
progressions rounds once a week, which involves all of the disciplines, like social work, spiritual
care, child life, nurses, etc., but the physicians do not attend these, which many people said was a
challenge. Also there are often people missing, which creates challenges, “So they can say on
these . . . interdisciplinary rounds, okay, well, maybe we should ask PT if they could get
involved with this—this kid has a problem swallowing or whatever, and then PT isn’t there, so
they can’t make a recommendation.” Toward the end of my interviews, 5A started doing daily
30-minute care progression (discharge) rounds. A 5A Child Life Specialist (CLS) I interviewed
explained that her team is often busy during this time, so they just try to attend once a week.
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Hematology and Oncology. There are two medical teams who follow patients on the
hematology and oncology units. Attending teams round independently with nurse practitioners.
The senior resident team, called “Team Onc,” follows patients across the whole floor. When I
observed Team Onc rounds, they were office rounds and typically took place in the physician
workroom on the Hem/Onc floor. First they discuss solid tumors with the solids team and then
the liquids team comes and they run the list of liquids patients. Team Onc rounds typically
include the team of residents, a nurse practitioner, a CCC, a case manager, and the unit charge
nurses. Either a fellow or an attending physician runs rounds. Residents present the patients, so
most interaction occurs between residents and the fellow/attending. Others occasionally
contribute. The one group that does not attend Hem/Onc rounds is the bedside nurses. One
Hem/Onc bedside nurse had a problem with this system:
I actually think that if the bedside nurse went to rounds on their patients it would be so
much better . . . Yeah, years ago we used to do it that way, like the charge nurse would
call the nurse as they went through and she would come . . . but they stopped doing that
being they didn’t feel it was efficient.
Instead the charge nurse from each Hem/Onc unit is supposed to attend rounds and report back to
the bedside nurse, but one resident told me that this just doesn’t happen the way it should. In
fact, once while I was observing rounds there was confusion about whether a patient had diarrhea
or constipation. Had the bedside nurse been present, the confusion could have been cleared up
immediately, but without him or her there, they had to make a note to check with the bedside
nurse after rounds in order to determine the patient’s course of treatment. In an interview with
two Hem/Onc fellows, they discussed having CCCs present in rounds. Apparently CCCs are
trying to find a way to avoid attending rounds, which are very long, by doing a brief “huddle”
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with the team after rounds. One of the fellows explained that it would be unfortunate if the CCCs
stopped coming to rounds because “they make things happen . . . if the patient needs home
antibiotics, they are the ones that set it up.” Besides bedside nurses, the group missing from
Team/Onc rounds is the families. They are typically updated after rounds, but they miss the
opportunity to hear the discussion.
Bone Marrow Transplant. The BMT team is relatively small compared to many of the
other teams—both in terms of staff and providers and in terms of patient numbers given that they
have just 14 pressure-controlled BMT beds. The team rounds in a small workroom on the unit
with two nurse practitioners, a hospitalist, usually one of the three BMT attendings, the charge
nurse, sometimes a CCC, sometimes a pharmacist, sometimes a dietician, and sometimes a social
worker. The charge nurse calls the bedside nurses as their patients come up. A BMT hospitalist
mentioned that it would be nice to have the dietician there everyday since “nutrition is such a
huge part of these patients’ care.” Unfortunately he believed that the BMT dietician was only at
SCCH part-time, and so he thought they only saw her at rounds once a month on average. He
said that he’s “talked to people at other institutions where the dietician is part of their daily
rounds—that they are there Monday through Friday every single day and are involved in all of
the decisions . . . [about] feeds” and he felt like this would be extremely helpful. However, the
bedside nurses are generally pleased with the process. One BMT bedside nurse commented that
she thinks her unit has multi-disciplinary rounds on a more consistent basis than the rest of the
hospital. Another BMT bedside nurse said she likes being invited to rounds because she has
“floated to other units and I have never gotten invited and I rarely see the doctors actually, [but]
they are so visible here. It’s weird for me to go somewhere else.” The one group missing from
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BMT rounds was the family. When asked about family-centered rounds, which was something
most other units in the hospital were moving toward, a BMT hospitalist explained:
I know there is a lot of HIPPA issues with that and they [attendings] don’t want to, if
there is- there’s often issues with the families that we want to talk about . . . The
attendings I know don’t want to see this process, they don’t want the family to see this
process, the plan, and they wanted to just present, ‘okay this is what we’re doing’ and it’s
been discussed as opposed to ‘well, we could do this but—wavering and stuff.
However, some BMT team members feel differently. A bedside nurse said they would have to
watch what they say around families more carefully but that “it would be interesting to get the
parents’ opinion on things and discuss stuff in front of them.” An ancillary care provider who
works with BMT patients also noted, “I think that it would be better to do patient-centered
rounds. That’s my personal opinion.”
General Pediatric Surgery team. The general pediatric surgery service, unlike the other
five teams is not tied to a single inpatient unit. Instead they follow patients across the entire
hospital. Their rounds begin at 5:45 am, and they have to finish by 7:30 am so the surgeons can
get to the OR. First they run the list—usually 30 to 40 patients—and talk about events that
occurred overnight with the whole team, which includes multiple NPs, multiple fellows, a
surgical resident, and sometimes a surgical attending. Then the entire team goes bedside to
examine each patient on the list and come up with a care plan for the day. One nursing manager
from an inpatient unit described the surgical rounds as “lightening rounds” because “they just
like run through the hospital.” She lamented the fact that the surgeons do not call the nurse—not
even the charge nurse—when they round. One provider from the surgical team noted that it
would be better if they could get the bedside nurses more involved in rounds. Another provider
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from the team mentioned that only about half of the attendings round with the team in the
morning. She said the plans are not really different when they are there, but it saves a lot of time
because the team gets “a lot of inappropriate consults, and [the attendings] help us to take care of
those inappropriate consults quickly.” When there’s an attending there “that says ‘this is
ridiculous,’ then all we have to do is put in our note that it was seen and examined by the
attending and then it’s done.” But if another member of the team says it, “then they are still
calling and asking about well, should we do this or that, and that’s not appropriate. I don’t need
to waste my time on that, so it helps me not to waste time” when attendings are present. Another
provider from the surgery team described the benefit of having CCCs participate in rounds with
their team:
On one of the floors we do have the clinical care coordinators rounding with us, which
really helps because we will review the plan, the patients’ plan with them and they can
help to implement that plan. So what they do is they look at what the kids need as far as
discharge, supplies, and follow through and they can get a head start working on that- any
prescriptions . . . and they are there with us. They will also bring up to us any problems
that they have had with the child that we need to work on and that’s not true of every
floor.
Appreciation of diverse perspectives. Participants primarily expressed or exhibited an
appreciation, or lack of appreciation, of diversity with respect to either other staff/care providers
or patients/families. Diversity with respect to other staff/care providers referred to different
specialties within a discipline, different disciplines, or different units, teams, or services.
Diversity with respect to patients/families referred more to religious/ethnic/language-based
cultural differences. Although professional diversity is most relevant to the innovative decision-
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making capabilities referred to in the organizational collaborative capacity literature, cultural
diversity among patients/families is equally or perhaps even more important in health care
practice warranting a description of both sub-themes.
Staff/care providers. The major theme that emerged around staff and care provider
diversity was recognition of the benefits, despite the challenges, that come with a wide range of
different clinical approaches. A charge nurse from the CV Acute unit described the challenges of
coordination in other units with patients followed by many different physician teams:
We only have the CT surgery nurse practitioner group. If you are not followed by them,
and have heart surgery, you are followed by the hospitalists. So it is either one and each
group has specific people that are assigned to those groups, and so for us it is very easy to
round with only two groups. I can only imagine . . . [on] 6A, you had not only team 6
[hospitalists/residents] and then you have the GI team and then you have the transplant
team and then you have all these different groups.”
Yet many staff and providers acknowledge the benefits of diversity—in general and in specific
moments throughout the care process. A BMT attending physician explained that “everybody [in
the unit] goes through this very stressful management of the patient” and she has to “admire this
nurse . . . what responsibility she has that she is going to be spending the next 12 hours- 12 hour
shift in that patient’s room. There’s tons of admiration in that.” I frequently observed bedside
nurses sharing important details that only they knew about their patients’ status during rounds. A
pharmacist from 5A explained how useful it is to have the bedside nursing perspective at rounds.
Before we did rounds in the physician’s rooms and just physicians and the pharmacy
were there, but now it’s required for the nurses to be there and that’s really important.
They come to close the loop because they know the most about the patients, and so they
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will be able to tell us like can he take this or not, like for me I may recommend a
medicine, and they are like, ‘oh no, he can’t swallow that,’ and I am like, ‘oh, okay,
good, let’s push to liquids.’ So before we waste time doing something else . . .
Some providers recognized the personal benefit they receive from working with diverse others.
A nurse practitioner from the surgery service explained, “I think it’s probably one of my favorite
aspects of the job is that I think for Ped Surgery we are kind of the jack of all trades of the
surgical subspecialties and we have kids in every department of the hospital and so it’s fun to get
to be a part of all the different units.” A resident physician similarly noted, “Actually that’s one
of the things I wanted. I grew up in [a metropolitan city], it’s like a really diverse city, and I have
always like gone to diverse institutions, so that’s something that I really enjoy. I think you learn
a lot from different people that way.”
Ancillary care providers were more likely than others to express frustration with
primarily physicians’ but also nurses’ frequent failure to consider their unique perspectives in
making patient care decisions. One physical therapist noted that often post-surgical patients are
rushed to discharge even when she believes they need more physical therapy:
Sometimes they are like, ‘she [the patient] has been here for a week now.’ But sometimes
they don’t take into account while she was on bed rest for four of those days, we couldn’t
do a whole bunch or we were only allowed to do like exercises in bed. That’s not getting
her ready to go up the flight of stairs she has to get into her apartment . . . You know, we
all just come from a different view, and so when I am going to see a patient, of course, I
am going to really be looking at how are they moving, and whereas a nurse might be like,
‘no, no,’ you know, ‘they need to stay in bed because they have received this medication
or they are really not feeling well. So everyone just has their different focus. For one
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physician, it might be the chemo that’s going to make them not feel great, but that’s okay
because that’s really important. And for me, I am like, ‘wow, we have got to schedule
meds, figure out a schedule of these medications so we can figure out a time to see them
[for physical therapy] when they are not nauseous and after they have had radiation. So
we all come from a different place, so I don’t know that we always successfully
understand each other . . . [or] the importance of someone else’s role.
Yet some ancillary care providers, like this Child Life Specialist from 5A, have found that over
time and with proper education about their work, physicians and nurses really grow to value their
unique knowledge and approach to care.
I’ve been on this floor for two and a half years, but before—the specialist that was here
had been here for eight years, so they are very used to having Child Life and had been
very consistent I think. That really helps with getting the name out and getting people to
use us . . . The culture is really accepting as of now I feel on our floor . . . they [nurses
and doctors] are really accepting of what we do and value what we do—really here to
make physicians and nursing staff’s lives easier.
Patients/families. Some interviewees explicitly expressed an appreciation or at least an
awareness of the diverse cultural backgrounds of their patients/families. A nursing manager from
5A said:
Well, I think being in Southern California certainly makes a difference about your
attitude, and we do—we just do have a lot of different cultures. We have a lot of cultures
with our patients, so multi-culture is sort of like—I think people see it more as enriching,
and not really necessarily challenging.
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A charge nurse from 5A noted the importance of listening to families and trying to understand
their perspective:
you want to listen to them [the families] and why do they feel that way and you also need
to just—there’s also cultural things, there’s reasons for parents to make decisions that
even though I have made sure by process of having conversations that they have all of the
facts, there’s other things that they are processing, cultural beliefs, religious beliefs that I
have to respect.
An interpreter for the medsurg units explained that although she is most often utilized to interpret
language, she frequently also engages in cultural advocacy for the patients and families.
I do advocate, and many times it's like cultural advocacy because they [families] might
believe, they might have a certain cultural belief and I will have to explain to the medical
team, ‘it's cultural.’ So for example, a patient had a biopsy and was crying and parents
wanted to comfort him with food right away, but because of the anesthesia he couldn't
have it, so I had to tell the nurse that it might be cultural that food will comfort the child.
In many of our Hispanic cultures food is the comforter . . . So I have to explain to the
nurse that it might be something cultural. We can explain that maybe he cannot have this
[food] right now but he can have something else.
Although it was less common, some interviewees demonstrated attitudes or ways of thinking that
that clashed with an appreciation of patient/family diversity. One provider from the surgical
service explained that families are always asking them to do things in a particular way:
If it's something like appendicitis or something that is common, that you see all the time
that they want us to do different stuff from— We don’t do that. It's only in like the rare
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patient with a rare disease, and they’ve had a complicated course that we will do things
that we wouldn’t normally do to make the families feel better.
There are certainly time and resource limitations that prevent care teams from appeasing all
families’ preferences with respect to the course of care for their child. However, the general
attitude may be somewhat problematic.
Perhaps the more important theme that emerged primarily from observation was the lack
of discussion around the topic of cultural diversity in the patient care process. While observing
rounds, I noted many occasions where the topic of patient/family culture or beliefs was either
overlooked entirely or awkwardly hinted at without open discussion. I observed a resident from
the Hem/Onc team speaking on the phone with someone after rounds to arrange a conference
with a Vietnamese family whose son was very sick. She said to the person on he phone, “I don't
know, they wanted Aunt to be there as well [giggles], I don't know about the family politics, but
they wanted Aunt to be there.” I also observed an awkward situation during PICU rounds. The
patient was a seven-year-old girl from a small town in Mexico who came to the hospital having a
seizure. Her dad and brother came to the door to listen. The resident began her assessment,
noting that it was not clear what her condition was caused by. She then smiled and looked
awkwardly from the fellow to the family and back again and said, “But they’re from a very small
town, just FYI.” Fortunately her dad and brother spoke no English. The group later discussed the
fact that the specialists treating the girl believe she has a genetic condition due to the accepted
practice of inter-marriage among her ethnic group; the residents all expressed their disgust.
In another situation, a Hem/Onc fellow asked during rounds about bringing in the
palliative care team for a patient who was not doing well. A charge nurse responded that they
could not do that at this point. The family had a list of 50 words they were not allowed to use in
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the room around the patient, so there is no way they would allow palliative care [which is often
brought in for end-of-life situations]. A resident asked if mom knows he is not cured—that the
surgery did not cure him, and the nurse responded that mom knows, but . . . [shrug]. The
resident’s question indicated a possible language or cultural barrier in terms of understanding the
situation, but there was no discussion of this aspect of the situation.
Although patient/family culture was rarely discussed openly in the course of patient care,
staff and care providers seemed to have a sort of proxy for culture that they were more
comfortable discussing openly: language. Nurses now list family members’ language abilities on
their chart, or “brain,” for the day noting languages spoken and language preferences and
sometimes reporting this detail during rounds. Increasingly, hospital units are posting signs on
the doors of patient rooms listing languages spoken and interpretation needs. Beyond simply
recognizing language differences, some interviewees framed language as a barrier to
communication—especially languages other than Spanish. A critical care (PICU) fellow said:
When other languages [besides Spanish] are spoken, using the phone or the video
translating, it’s a little bit harder to arrange and so I think things definitely get delayed
and there is probably not always the daily update on the care plan for the family unless
they are asking or they will do with broken English.
A provider from the surgery service similarly explained that they are lucky to have two Spanish
speakers on their team, which is extremely helpful, “But I have a patient right now whose mom
speaks Cantonese. Nobody in the hospital speaks Cantonese, we have to get the phone and the
phone interpreters, they are awful, I mean it works but they are awful.”
Some participants framed language, particularly Spanish, as a minor issue because so
many staff and providers at SCCH speak Spanish that there is almost always someone around
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who can interpret for those who do not speak Spanish. However, problems sometimes arise when
language skills are lacking. I observed a bedside nurse who claimed to have only high school-
level Spanish skills carrying on a conversation in Spanish with a Latina mother about her son’s
medication. When the nurse left the patient’s room, he chuckled and said that he had no idea
what the mother said as he was leaving. Many interviewees recognized the challenges presented
by families speaking different languages but also acknowledged that they have access to
resources like hospital interpreters or phone/video interpreters. One provider from the surgery
service mentioned that if she could make one change at the hospital, she would fund an
interpreter to round with all of the teams. An attending from the BMT team also noted the
importance of patience and taking the time required to use a proper interpreter to ensure that
families truly understand the plan of care for their children—especially when the family has to
give their consent.
Time. Time emerged early on as a code relevant to collaborative culture from which four
sub-themes emerged. Participants described time as a resource that is always in short supply—
often identifying a lack of time as the biggest challenge they face in doing their jobs. A physical
therapist noted that time is also used as a common excuse for why people are unable to
communicate and collaborate with others. I experienced this strategic use of time myself in the
interview recruiting and scheduling process. While trying to coordinate interviews with an
ancillary care group, a supervisor told me that everyone on her team was too busy that month to
do even a brief 15-minute interview with me. I suggested that I contact her next month, and she
agreed. I emailed her the next month multiple times, and she never responded to my emails. In
sharp contrast to this experience, when I emailed a surgical attending from the general pediatric
surgery team to inquire about interviewing some individuals from his team, he responded within
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minutes giving me the “okay” to contact his team and offering to do an interview himself—even
though when I contacted his scheduler, the first open 15-minutes slot he had available was 5
weeks away. That surgical attending is one of the busiest physicians in the entire hospital, but he
kept the appointment. It turned out that he had only 5-minutes to talk, and during the interview
he was standing at his desk eating a bowl of soup and putting on his OR scrubs. I am certain he
has far less free time than the ancillary care providers I had hoped to interview, but the surgeons
structure time differently than others. They are always busy, but as long as there is a time slot on
their schedule open, they are willing to fill it with work.
Some interviewees framed time in terms of each patient they care for or each patient in
their unit. A nursing manager from 5A explained that, “Our patients are very complicated. They
have many different services [following them], and going around and talking about a patient for
five minutes is not going to do it.” A therapist mentioned that sometimes rounds are very fast
paced and the team needs to get through their list of patients quickly, which means that non-
physician care staff “may not have a chance to really chime in with their take on what is going
on” with each patient. A BMT nurse practitioner distinguished between rounds in her unit versus
other units, “It might be for GenPed if you have bronchiolitis kids—like 10 patients—okay . . .
you are fine, you are going home, fine—but for BMT, it will- that takes forever for one or two
kids.”
Rounds were clearly a time issue for many staff and providers. The team of consultants
working with the hospital was in the process of implementing care progression rounds in each
unit. This process—focused on discharge planning—was supposed to include all relevant staff
and providers and take each day of the week for just 30 minutes. Some participants—especially
nursing staff—found these rounds to be extremely helpful while others thought they were a
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waste of time. A CV Acute nursing manager said, “One of the things that I know that the
providers [physicians, NPs] are feeling is why are we having care progression rounds when we
are already doing bedside rounds and reporting the same thing . . .” Another ancillary provider
from the PICU noted:
I personally feel it’s a waste of time. Already there is so much on our plate that there
simply is not- there aren’t enough hours in the day. I work nine-hour days and don’t’ take
lunch and that’s before the care progression rounds. Now they want- initially they wanted
us to do this five days a week and approximately an hour each day. I simply don’t have
the time.
Others echoed this concern about busy work, duplicate work, or unnecessary work in general
cutting into their time to provide patient care or manage their staff. A nursing manager from the
PICU explained, “My days are always running short, and I wish that I had less what I consider
busy work, so that I could do more coaching and meeting with people- with my own staff.”
Another common way that participants framed time was in terms of waiting for others.
Interviewees expressed frustration with parents who would say they were going to be at the
hospital at a particular time for a physician meeting or a teaching session related to using medical
equipment at home and then arrive 20-30 minutes late. Participants also expressed issues around
waiting for other staff/providers—either having to waste time waiting for others or not having
the time to wait for others. A nursing manager from 5A noted that they were working with the
surgical team to try to get them to involve nurses in their rounds, but she said it was not
happening. “They don’t want to wait for anybody, and they can’t really” because they have so
many patients across the entire hospital. As if to confirm, a provider from the surgical service
mentioned language challenges with families, but said, “I don’t have time to wait for an
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interpreter” during rounds. An attending hospitalist expressed frustration with waiting on
subspecialty consulting services. “And then there’s some services that just are too busy to come
talk to you right away or do the consult right away, and then it can take a long time with the
consultant.” A BMT charge nurse similarly noted that it can be challenging to work with other
teams or services “because you are going with different people’s schedules and you are not their
priority, but it’s your priority.”
Some participants expressed issues with collaboration and time related to the nature of
working in rotations and shifts. A charge nurse from the PICU said, “I would really like to work
on physician handover for these 12 hours, and I think what happens, again this is just my
opinion, that things get put off or not communicated properly or people don’t want to take any
responsibility in the off hours.” She also noted the challenges of having no CCC present in the
PICU on weekends. Others mentioned the challenges of new legal or administrative
requirements that limit the number of hours that different groups can work. A charge nurse from
5A explained that:
over the years they have changed how many hours the residents can work . . . They have
all these things they have to do, but the nurses need to communicate with them and the
family needs to communicate with them, so it’s gotten very tough because of these legal
requirements.
A provider from the surgical services also mentioned these limitations as an issue related to the
timing of rounds.
Our residents have work hour limitations, the nurse practitioners don’t show up to work
till 6. We start rounds at 5:45 even without them. If they were present earlier, the
communication would be better but they work 6 to 6—that’s their shift. So we have to get
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the work done in their presence because they need to be part of the team. So we really
can't see any patients until 6 when they are here. So because of the time constraint—
meaning we have to get to the operating room by 7:30 and if we have 10 patients or 60
patients, they are going to be seen by 7:30. That’s just how it is, and so that certainly does
impede communication and—no, certainly if we had more time it would make things
easier but that’s not an option.
A pharmacist also noted challenges with her pre-set schedule in terms of preparing for morning
rounds in her unit:
It’s not the best for my shift because I start at 8:00 and rounds are at 9:00, so I don’t get
to do all my work if I go to rounds because I start at 8:00 and then just hand off from the
night pharmacist—trying to put out whatever fires may still be burning and then maybe
look over a couple of patients, but I then already have to go to rounds . . . I’m an hourly
employee, so I’m here 8:00 am to 4:30 pm. I can’t come in earlier. Well I could, but I’d
have to volunteer my time, which probably is not so okay.”
A charge nurse from one of the Hem/Onc units mentioned to me that there is a whole range of
communication problems related to resident rotations, which are just one month on each unit or
team. She explained that just as they get to know the residents and their likes/dislikes, that team
of residents moves on and a whole new group comes in.
Time was also a challenge with respect to conflicting schedules. Many participants
explained that they often struggled to balance multiple commitments that conflicted in their
schedules. A charge nurse from the CV Acute unit explained that she could not attend bedside
rounds because she has to attend the charge nurse “huddle” where charge nurses from every unit
in the hospital get together to discuss staffing and patient progress. A CV Acute bedside nurse
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said the biggest challenge in working with other services and teams is finding a time when
everyone is free and the family is present as well. A provider from the surgical team told me she
doesn’t like how early they do rounds because they have to wake up all the patients as well as
their families, and everyone is kind of out of it, so they cannot really include them in rounds.
Unfortunately, she said, it was the only time they could do it because the surgeons are in the
operating room the rest of the day, so it is the only time they could get everyone together.
Another provider from the surgical team mentioned that the night nurses are often doing their
sign-out reports at that time when they round, “so it’s hard to get them involved at the bedside,
too, so they’ll know the plan.” Ancillary care staff often use the time in the morning when the
medical teams are rounding to work with their patients, so they struggle with attending rounds.
“It is that kind of a thing, so you are like, should I see a kid or go to rounds?”
It was common for participants to use time as an explanation for why certain
collaboration-based problems could never and would never be solved. Despite this defeatist
attitude toward time-based challenges, some individuals offered ideas for changes or
improvements. A pharmacist explained that she feels like her team is always “failing before we
start” because by the time a physician confirms an important medication order for a patient, “the
nurse needed it 10 minutes ago.” Sometimes the dosage is wrong, and she has to call and discuss
this with the doctor, and by the time the meds actually go out, a lot of time has passed. She
explained that if the computer system had a way for nurses to identify meds orders as routine
(i.e., vitamins) vs. urgent, the pharmacists would be better able to get the important meds out on
time.
Space. The issue of space also emerged as a code relevant to collaborative culture from
which four sub-themes emerged. First, based almost entirely on my observation experiences, I
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found that space plays an important role in structuring leadership and power relationships during
rounds—especially for teams that do office rounds where people are seated around a table. For
the Hem/Onc team that rounded in the physician workroom, there was a particular end of the
conference table where physicians gathered. When the fellow was running rounds, he or she
would sit at the head of that end of the table. If the attending was running rounds, he or she
would sit at the head of the table, and the fellows would sit in the chairs closest to the attending.
The residents would sit in the next four chairs on that end of the table. The other end of the table
was left for all remaining participants and because there were more people than could fit at the
other end of the table, some of these other care staff—the CCC, case manager, nurse practitioner,
charge nurses, pharmacist, observers—would have to sit around the perimeter of the table. It was
clear who was expected to be a core participant in the discussion from how the seating was
configured. The people at the “other” end of the table and around the perimeter spoke only on
occasion. The surgical team had almost exactly the same configuration when they met in the
surgical workroom to “run the list”—with the person running rounds at the head of the table,
other senior providers next to them, and those lower on the totem pole at the other end of the
table.
The BMT team was a much smaller group and more people were able to sit around the
small table in the workroom where they did rounds; also non-physicians certainly played a more
integral role in this process. But the physician running rounds still always sat in the same place—
facing the door where he or she could easily speak with consulting services that dropped by
during rounds. It was also common for the charge nurse, social worker, or CCC to get up and
offer their chairs to other physicians that dropped by. Although teams that did walking or bedside
rounds structured power and leadership relations in different ways, space was used less in this
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way during rounds. Because they were constantly moving and typically standing in a circle, there
was no “head” of the table and more people seemed to be comfortable speaking up. Also, this
configuration seemed to make it easier for the group to shift attention from, for example, the
fellow running rounds to a bedside nurse joining the group to do her patient report.
Another key theme emerged around workspace. SCCH built a new building many years
ago. Despite the fact that years had passed since the move to the new building, many participants
remained frustrated by the lack of available workspace. Most people recognized that the new
space was wonderful for patients and families but felt that it was not well designed for staff.
Ancillary teams in particular felt that they lacked sufficient space for their work. A physical
therapist mentioned that they no longer even have shared desks—instead they have little
cupboards that lock but that apparently are not even big enough to fit a purse. A speech therapist
said that space is a challenge. “It’s really important for us to establish co-treatments and talk
amongst therapists, but we don’t have a place to do that, which is a huge barrier. A nutritionist
from CV Acute said she wished she had her own space “or at least somewhere I could go to [on
the unit] because I find that I have been often waiting for one of the nurses to go on a break so
that I can use the computer.” A BMT attending noted that they really have no conference room
on the unit—just a small workroom—so they can barely fit everyone in the room for rounds. An
attending hospitalist expressed the same concern, “We have a great sort of area here [in the
Department of Hospital Medicine], but we still don’t have any real like meeting space.”
While all participants were pleased that the building was constructed with families in
mind, some felt frustrated that the common spaces created for families often went unused
throughout much of the day while they were left without enough space for staff to do their work.
The general pediatric surgery team acted on their frustration. They initially had a small office
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with shared desks, which quickly became too tight of a space for them, so they eventually took
over the family conference room on the medsurg floor as their new offices. Certainly not
everyone in the hospital has the power to make a change like that, but it worked out well for the
surgical team, and they were very happy with the space.
Another spatial theme involved the degree to which different members of a care team are
co-located within the same space. Changes in team structures for general care physicians have
resulted in resident/hospitalist teams following patients across many different units whereas they
used to be unit-based. Nurses complained that doctors used to work with nurses more regularly
because their offices were located on the unit. With the “traveling teams” this is no longer the
case. One nurse from 5A mentioned that they used to call interns by their first names—but now
they do not even know the interns because they hang out in their little workrooms and make no
effort to talk to nurses or hang out with them. The situation is different on units with special
populations—like CV Acute, BMT, or the PICU. These units have defined physician groups that
only work with their patients, so physicians and nurses seem to be more regularly in close
proximity, which facilitates communication.
Ancillary staff noted challenges related to the fact that their offices are not usually
located on or near their units, and this sometimes results in nurses and physicians failing to
include them in discussion about patient care. One social worker said:
I wish I had more space on the inpatient side. It would make it easier for like an office to
be over there instead of having to go back to my own office . . . I like the exercise
[walking back and forth], but the providers would see me as more available if I was able
to be there.
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A PICU dietician echoed this concern with having an office located away from the primary unit
where she sees patients:
I think within the PICU team, there is a lot of communication. I think because my office
is not there with everybody else, there is a little bit of a disconnect. They know how to
get in touch with me, but I think if my point of work was up there, probably more visible
they would probably reach out more than they usual do.
A pharmacist expressed a similar concern explaining that in the old building, they had satellite
offices on each floor:
and we had more of an open door- like literally the door was open and so people would
see us in there, you know, people like physicians would stop in and talk and see what was
going on real quick or nurses would stop in and talk whereas now I can count on my
hands the number of times the nurses stop in here, you know, it’s hard to do that, it’s very
uninviting, and it just feels like everything is further away.
Despite the challenges expressed by some, there were also individuals who felt like their space
was great and that the families’ comfort was all that really mattered.
A lot of participants, especially nurses, expressed issues around collaboration with
respect to the unit layout on the new units. In order to make all of the patient rooms single
rooms, the units had to be spread out over a larger area. Most units now have four or more
nursing stations whereas before there was usually just one central nursing station. A charge nurse
from the PICU explained that the extended space on the new unit “has really made it a little bit
more difficult to coordinate all that’s going on because out of sight, out of mind at times . . . I try
to set an alarm for every two hours to make sure I communicate with those nurse,” but it does not
always happen. Many bedside nurses commented that the new layout is isolating and feels
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disjointed. “The units aren’t designed for effective communication because they’re so closed off
and dispersed” (5A bedside nurse) whereas the old units “used to be kind of like this warm nest
of people where we were all around each other” (PICU bedside nurse). Physicians also
mentioned challenges with the unit layout, “I think communication with the nursing staff in this
building is really bad because when we round you can't find the nurse and it's not like the nurses
are given patients that are in like the three rooms that are next to each other, they are all over the
place” (provider from the general pediatric surgery service). A nurse practitioner from the
surgical team shared the same feelings but more from a nursing perspective:
I think that having all the nursing stations be so apart from each other and so separated is
awful . . . because the nurses don’t have any back up, they don’t have- they don’t know
who their senior people are on their shift, which then means we get a lot more phone calls
that are really unnecessary, because either their charge nurse or their more senior nurse
on that shift should be able to answer that question for them.
Research question 2 asked: How do care providers draw from and reproduce
collaborative and non-collaborative power relationships through discourse and interaction? Field
notes from observation were particularly useful for examining how power relationships are
structured as well as interviewees’ descriptions of rounding processes, the culture of the hospital
and of their teams, and how they react when other staff members or care providers makes a
decision they disagree with.
Decision-making, Planning, and Problem-solving
Hypothesis 2 predicted that care providers from all disciplines would reproduce
unbalanced power structures with respect to team decision-making, but teams that are more
successful in providing interdisciplinary, collaborative care are more likely to reproduce
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balanced power structures with respect to problem-solving. Data supported this hypothesis. The
entire corpus of observation and interview data was examined to determine which teams seemed
to be more successful in providing interdisciplinary, collaborative care. All six teams understood
the value of collaboration, but the PICU, the BMT unit, and the CV Acute unit had the most
clearly defined and clearly applied processes for working across disciplinary boundaries, and this
was reflected in how interviewees from these teams talked about their work. Coincidentally,
these units are all critical care units (or ICU step-down units in the case of CV Acute), which is
likely important given that each unit has a defined team of physicians, nurses, and even ancillary
staff. The 5A nursing team seemed to work very closely with each other but struggled in working
with physicians. Similarly, the general pediatric surgery team seemed to work very
collaboratively but primarily among the core providers on the team and not as much with other
teams and units. The Hem/Onc team also seemed to be less integrated across disciplines.
Decision-making. All six units and teams reproduce unbalanced power structures with
respect to team decision-making. A PICU attending explained, “I am the one in charge of the
ICU that day or that shift, that week, what not. So, I am the lead physician in terms of decision
making for everything that comes in and out of the unit, for everything that’s done in the unit.”
An attending from the BMT team similarly notes, “The whole [BMT] program is my
responsibility. Everything is my responsibility. The buck stops here—that is from the standpoint
of clinical or it is related to academics or it's related to research, it's related to official business,
contracting, whatever you name it.” Lower-level staff reflected similar perspectives with respect
to end-of-line decision-making. A beside nurse in the CV Acute unit said, “to be very honest,
there’s some [physicians] that do well with feedback and there’s some who are like, no.
Basically they are the ones making the decision and . . . I just don’t bother.” Another similarly
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noted, “most of the time I feel like a lot of the hospitalists or providers kind of listen to us, so if
there was an issue, I’d kind of bring it up . . . I don't know, for me it's like okay, well . . . I mean
you are the doctor, so I mean- but if it's something like drastic where I feel it's going to affect
like the outcome of my patient then of course, I voice my opinion.” A nurse practitioner from the
general pediatric surgery team explained:
I feel equal in terms of making suggestions or asking questions, but I do not feel that the
final decision is mine to make . . . I feel equal in terms of making suggestions or saying,
hey, have we considered this aspect or hey what do you think about this kind of situation,
and I feel like it is taken under consideration in a respectful way, but then whatever the
attending or the fellow decides, that’s what we go with.”
When asked how he would respond in a situation where he disagrees with another provider’s
decision, a fellow from the surgery team said, “Well, there’s a hierarchy. If it's somebody who is
superior to me, I try to politely share my thoughts, and if it's somebody who is sort of my
responsibility to teach, I try to sort of teach them why the plan will be different.” He went on to
say that “generally, me and [the other fellow] and the attending make the decisions.” A bedside
nurse from the Hem/Onc team explained why rounds (which she does not get to attend) are an
important time of the day: “that’s where the attending is there and they are the ones who pretty
much- they are the big guys—they make the decisions.” An attending hospitalist who cares for
patients on 5A explained that typically if there are disagreements with respect to the course of
care for a patients, they defer to the patient’s primary team, “so if it’s my primary patient, then I
will usually explain why I feel that different might be better and why we are doing it that way.”
Problem solving. The PICU, BMT, and CV Acute teams reproduce more balanced
power structures with respect to team problem solving than the 5A, Hem/Onc, and GenPedSurg
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teams. The PICU, BMT, and CV Acute teams all include bedside nurses in their daily physician
rounds. The PICU and CV Acute actually have nurses report on their own patients instead of
having residents or nurse practitioners do this. In the BMT unit, nurses are often actively
involved in the discussion of their patients even though nurse practitioners do the patient report.
A PICU nurse noted, “We really have a great medical team in the ICU that is willing to explain
things, to work with everyone, to work with nursing especially to provide the best care. And a lot
of times they take input from us and make changes because of that.” I noticed while observing
the team during rounds that nurses in the PICU often caught medication issues or anticipated
medication changes and proactively brought these up with the physicians. Nurses from the BMT
unit seemed very comfortable contributing their perspective when they have a strong opinion.
One nurse said that if she disagrees with a provider, she will “make a phone call, and I always
say ‘so, you want to do this?’ and I want to know why we are doing what we are doing. I want to
know—why do we do something. I need to have that rationale for why we are doing it.” Another
BMT nurse said, “I think we’re a very friendly group, and it's very easy for the nurses to talk to
doctors and other way around. We call the doctors by their first name here. We don't say doctor
so and so.” A charge nurse from CV Acute explained that patient care on her unit
is really a collaboration between the med physician that day and the bedside nurse that
day to figure out what that plan is going to be at bedside rounds and just making sure we
are all on the same page, like is it a feeding issue, is it a respiratory issue, is it a cardiac
issue and what I love about it is, physicians will say what they think is the plan and if
something- there is always a possibility something will go wrong and always to say, okay
if that doesn’t work let’s try this as well. So there is always an A plan and a B plan a
majority of the time so that if you as a nurse are dealing with one thing and you are trying
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to work out that A plan, you already know what the B plan is before we even get to that
point because you can anticipate it.
These three units also clearly work to empower ancillary care providers and physician trainees.
The PICU organizes teaching sessions with the unit’s dietician to educate residents about this
aspect of care and the role of the dietician. Beyond the knowledge-based learning, this process
also empowers the dietician and gives her legitimacy in interacting with the residents. Fellows in
the PICU are also formally in charge of resident rounds, which a PICU attending says is “what’s
sort of really letting them sort of practice being in charge.” The fellows then similarly work to
empower their residents. One fellow explained:
I try to give as much autonomy as I can to the residents . . . As long it is not going to
impact patient safety, [and] I don’t think it's going to keep the patient in the ICU longer, I
usually let them decide which plan they want to do . . . I think it's really important for
learning to be able to try to formulate your plan and see the results of that . . . So, I try to
step back and let them do that.
A hospitalist from the BMT unit explained, “all the major decisions are usually things that we've
talked about as a team. So if we don’t agree with that then we have our chance to voice our
opinions, which I think we've all done many a times.” The BMT team also had perhaps the most
multidisciplinary rounds on a regular basis of any unit in the hospital. While the balance of
power is by no means equal on these teams with respect to problem solving, relationships
appeared to be more balanced than on the 5A team, the Hem/Onc team, and the general pediatric
surgery team.
While observing rounds on 5A, nurses complained to me that they used to really get to
know the interns who saw patients on their unit. They were on a first name basis and frequently
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interacted with them, but that was no longer the case since physicians had switched to a team-
based structure. I once observed an awkward exchange between a 5A charge nurse and resident
physician. The charge nurse who also served on an IT committee asked if residents had been
taught how to document a sepsis alert using the new sepsis alert system. One resident seemed
particularly annoyed by the question and responded defensively explaining that they had not had
any training on how to use the system or document the alerts, which is why there were unaware
that the current patient had an alert during the previous night. The charge nurse—a 30 year
veteran of the unit—started to respond, but the resident cut her off with a smirk and said, “Sorry,
we need to move”—meaning move on to the next patient.
Bedside nurses from Hem/Onc also seemed less empowered and less certain of their
ability to contribute to team decision-making than nurses in the BMT unit, the PICU or CV
Acute. When asked what she would say if she disagreed with a care provider about a patient care
decision, one Hem/Onc nurse said, “I would kind of question like, ‘are you sure that’s what you
kind of want to do.’” Another nurse said she would “usually question it like why, I want to know
the reason or I'll give my input as to why I don’t think that may work, but in a very politically
correct way.” The physical space and the process of Hem/Onc rounds reinforce power
differences between physicians and other care staff, and bedside nurses are notably absent from
these rounds.
The general pediatric surgery team seemed to structure more balanced power
relationships between providers in some ways with respect to problem solving, but in other ways
the team remained highly imbalanced even during the discussion and problem solving process.
More senior providers from the team recognized the importance of including lower-level
providers in discussions, which made these individuals feel more comfortable voicing their
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opinions. One lower-level provider explained that if there is a disagreement about the course of
treatment for a patient, “We discuss it. We go head on; we definitely go head on if we feel
strongly about something.” Another provider echoed this sentiment, saying “if there is an issue,
certainly with the fellows- and I even tell them if they are wrong about something, or if I tell
them that I don’t think this is a smart thing to do.” Yet when more senior level providers disagree
with the decisions of those below them, they are accustomed to using their influence to
determine the course of action—even when they give their permission to the other person to try
something different. One more senior-level provider explained:
If [a lower-level provider] wants to get a certain test and things like that, that I would
normally get- if it's an invasive test, if it's like, if it’s going to expose the kid to radiation
then I'll say, no. But if it's something reasonable that I probably wouldn’t do- if that’s
something that he is interested in doing then I would say, that’s fine, that’s fine it's not
something that I would do and I don’t think it's needed and I don’t thing it's going to
change anything but if you just want to check on it, it's fine.”
Another senior-level provider noted, “I usually in the form of a question would ask them if they
would consider doing it in a different way, or why they want to do it that way versus another
way, therefore it’s both educational and provides patient care.” Another senior provider
acknowledged that when “all the fellows are scrubbed in the operating room, I think our nurse
practitioners are hesitant to actually come into the operating room and talk to us. So if we don’t
answer a text on our phone or whatever, there can be a breakdown of communication.” A nurse
practitioner confirmed this, explaining that when all the surgeons are in the OR, “it’s hard to
formulate the plan because I’ve kind of seen the kid and made up my mind of what I think is
wrong with the child, and then they have to see them because ultimately they're the ones that are
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making the decisions.”
Perhaps an even more insidious issue with respect to power balance involves the
relationship between the surgical team and other individuals who are not on the surgical team but
are responsible for caring for surgical patients—like bedside nurses on the units and ancillary
care staff. A senior-level provider from the surgical team expressed frustration about the number
of “inappropriate consults” they get from the floors because these are a waste of their time. A
lower-level member of the surgical team who used to work on one of the inpatient units at SCCH
noted, “People [from that unit] thought that Ped Surgery was intimidating to call, or to make sure
that when you did call that you had appropriate questions or appropriate concerns,” suggesting
that people feel the power differential between their units and the surgical team; this imbalance is
reinforced when those individuals avoid consulting the surgical team—perhaps even in situations
where a consult is warranted. Someone from nearly every inpatient unit I spoke with expressed
concerns with the accessibility and approachability of the surgical team.
Research question three asked: How do care providers draw from and reproduce
collaborative and non-collaborative leadership structures through discourse and interaction?
Interviewee responses to questions about support for collaboration as well as descriptions of unit
or team and organizational culture were particularly useful for examining collaborative
leadership.
Collaborative Leadership Support
Hypothesis 3 predicted that teams and disciplines that provide formal leadership support
for collaboration will practice more bridging leadership. Data partially supported this hypothesis.
Field notes and interview transcripts were examined for instances of formal leadership support
for collaborative care at the team/unit level and for flexible leadership and collaborative bridging
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at all levels within and across teams/units. Leadership support often involved individuals
drawing on the influence inherent in their position in order to support the development and
perpetuation of elements of collaborative culture—or to challenge unbalanced power
relationships while flexibility and bridging involved individuals drawing from their discursive
resources that were not necessarily tied to a formal leadership position in order to enable
collaborative care.
Leadership support. Support for collaboration, or a lack of support for collaboration,
was framed or observed in many different ways, including: work processes and structures,
organizational policies, resources, interpersonal skills, and staff empowerment/advocacy. Work
structures and processes include the ways in which staff and providers are organized and the
opportunities they have for collaborating with others. Leaders largely determine who will attend
rounds and the degree to which different people participate and different perspectives are heard.
Leaders also coordinate how staff will be organized. Although the new hospitalist team structure
may have simplified how physicians coordinate patient care, it also negatively impacted
relational development between nurses and physicians on general care units and has impacted
how these disciplines work together. A social worker shared this observation about physician
teams and communication on his unit, “I think big lapses in communication happen between the
medical teams and the nursing staff . . . well just by the fact that medical teams are so spread out
amongst the hospital, because it would be like me covering eight different floors.” These leader-
determined structures and processes work together to support or inhibit collaboration. According
to one attending hospitalist:
I think we still have work to do in terms of our systems. I think we have made some big
changes with how we round, but we are still working within some artificial constraints,
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that there are time constraints and there are sort of team structure constraints that I don’t
have control over, but they don’t necessarily- they are not designed around- they are not
very patient-centric, they are sort of meeting other goals for the hospital. I think if we
truly want to be family and patient-centered and have like the most simplified
communications, I think there are some things that could be changed so that the teams,
let’s say, were more unit-based and decisions around team assignments and rounding
times and all that were made solely kind of focused on the patients and the families and
not anyone else.
Because of the high levels of autonomy of different care groups, coordination can be a challenge.
During my interviews, the OT department was in the process of considering a switch to unit-
based assignments (rather than a patient case-load assignment) in order to develop more
established relationships between OTs and other providers, but many sub-specialties remain
organized in a way that makes collaboration difficult.
Participants also mentioned organizational or legal policies mostly that create barriers to
collaboration. A 5A charge nurse and a fellow from the surgical team both mentioned new legal
requirements that have decreased the number of hours that residents can work. Although hospital
leaders have no control over these legal requirements, the way they are implemented can be
problematic. Despite the decrease in hours residents can work, the residency program has
increased their work requirements. The 5A charge nurse felt like this has resulted in the residents
spending less time communicating with nurses. An interpreter who is an hourly employee also
complained about a policy that requires her to take lunch by a particular time of the day, “I get a
lot of grief because I don't go to lunch by a certain time. But if my lunchtime is at 1 o'clock and
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at 1 o'clock the doctor comes in and tells me, ‘I need your help for a result.’ How am I going to
tell him, ‘I am sorry. I have to go to lunch?’”
Some participants talked about leadership support for collaboration in terms of resources
like money, staff, materials, and space. An attending hospitalist who cares for CV Acute patients
noted how lucky they are to have dedicated ancillary services for the floor. Nurses often
mentioned a shortage of nursing staff on their units as a challenge because without enough
people there, it can be hard to support each other. Ancillary services were more likely than other
disciplines to express frustration over lack of material resources or space that would enable them
to better work with the care providers and patients. However, one therapist mentioned that when
she started a new program at the hospital, her manager “took me seriously, took my proposal- he
was able to obtain funding for a startup phase and the second year phase, so I do feel like we
have support here. You just have to seek it out.”
Another element of leadership support for collaboration that emerged is the important
role of leader personalities or interpersonal skills. One fellow from the Hem/Onc team explained,
“you quickly learn which personalities- you let them just run the show.” When asked if she felt
like an active participant in rounds, a staff nurse from the CV Acute unit said, “Generally, yes, I
mean everything depends on the person’s [attending’s] personality—if they really wanted an
input or if they just want you to stand there.” A provider from the general pediatric surgery team
explained that there “are some of the members on the team that have bigger ego than others”
though most people agreed that there were fewer personality problems at SCCH than at most
other hospitals. Nursing leaders were more likely to be described as having the skills and
personality to create an environment that supports collaboration. According to a charge nurse
from the PICU, “Our managers are terrific as far as wanting to be welcoming- to have the face of
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a unit that is a welcoming place to come and that people aren’t intimidated when they walk
through our doors.”
Finally, leadership support for collaboration was often described in terms of staff
empowerment—especially of disciplines and teams that have historically had less status or less
of a voice within hospitals. By empowering these groups to speak up and contribute to
discussions, a more diverse range of information and perspectives can be considered, which is an
essential component of effective collaboration. A nursing manager from the PICU mentioned
that the hospital is very pro-nursing, and nurses have a strong voice in part because of a leader at
the executive level with a background in nursing. A PICU bedside nurse felt the same support at
the unit level, “Our management is very strong advocates for the nursing staff here. And not in a
combative way, in a very multidisciplinary way, so they work really well with the medical staff
but they also work really well to advocate for us.” Similarly, a charge nurse on 5A explained
that:
[My nursing manager] is great. I can walk into [her] office and rant and rave to her. She
is totally okay; she is a very direct person and I like that because I am very direct and, I
can go in and rant and rave and say, ‘I think- and will you find out this?’ She has found
out the information for me by the next day, and if I have ideas- and then we’ll talk about
what we can do, and we’ll start working on it. But that it not the norm here—that is not
the norm.”
Almost all of the ancillary care staff that I interviewed seemed to feel empowered by their team
leaders. They all recognized that they were facing an uphill battle to establish the importance of
the work they do and were prepared to meet this challenge head on.
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Bridging. Formal leaders can use their access to resources to support collaboration, but
anyone in the hospital can practice collaborative leadership discursively through their approach
to patient care. Most interviewees expressed the opinion that working with others of the same
discipline on the same team was fairly easy. Working with people of a different discipline but on
the same team required a bit more effort but was also not too difficult. The real challenge came
from bridging—from working with others of either the same or a different discipline but from a
different team. Bridging is the most challenging collaborative activity, but it is also extremely
important in a hospital. Some individuals actually described their jobs primarily in terms of
bridging between two or more teams and disciplines. A nurse practitioner from the general
pediatric surgery team explained:
I consider us to be kind of like a bridge between the medical—surgical side of things and
then the patient—family nursing side of things. I like to say that we kind of have like a
foot in both camps, because we understand the perspective of the bedside nurse and what-
how things get done. But we now have the specialized, the more advanced education and
then the time in with the surgeons to understand how the surgeons think and what’s a
priority to them.
Clinical Care Coordinators, or CCCs, are responsible for multiple aspects of coordinating
inpatient care. One CCC described her responsibilities as:
keeping the doctors on the same page, making sure the patient moves easily from
admission to discharge, making sure that needs are handled like any needs for discharge,
making sure that appointments like MRIs happen swiftly, making sure that nurses are
doing teaching at the bedside . . . I am constantly needing to know what services are
available in our hospital, when are they appropriately called, who do I call, who do I
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refer, how do I set up meetings, how do I get this information to the parent or doctor?
And a lot of it, as I said, it's a teaching institution, so a lot of times I know something that
the doctor doesn’t know about a service that’s available, so I need to inform the doctor
and then they need to order it.
Charge nurses also serve as bridges since they are often the point of contact for consulting
services, and they coordinate transfers and new admissions for the unit.
Three themes emerged around the challenges of bridging. First, many interviewees
expressed challenges resulting from other teams failing to communicate with them. This seemed
like a particularly big problem in the PICU where patients are often followed by physicians from
other services as well as the critical care physicians. A PICU charge nurse mentioned that when
these other services come to round on their patients in the PICU, “it’s not as big as a priority for
them to involve the bedside nurse in their rounds.” A PICU social worker similarly note, “I have
seen that repeatedly where other services will come in walk straight to room talk to the family
and leave.” The PICU nutritionist further explained:
I think there is definitely a challenge when there is other consulting services involved and
that’s usually where there is a- it just seems that there is a breakdown in communication
where either PICU is waiting for home service to put a note in or whatever service . . . to
put their recommendations and their note in or one service will come and speak with the
family and then another with one perspective without talking to anybody else and that
gets challenging.
Another situation where there seems to be a failure to bridge between teams is between the
general pediatric surgery team and the inpatient nursing units. A nursing manager from 5A
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described a breakdown of collaboration on multiple levels that she felt could be remedied if the
surgical team would call the charge nurse to join them on rounds:
the communication there is very much- it’s very much lacking. As I was saying yesterday
in the progressive rounds, we don’t get a note from them—we don’t get an order. They
might go in and tell a parent, ‘okay, you can go home today,’ or ‘okay, you can eat today’
and then they leave. Then they go to surgery, and so the patients there want- I want my
breakfast, and we can’t get a hold of the surgeon because he is in surgery. There is an on-
call surgeon that’s supposed to call back. So it’s just a hassle. If there was a nurse right
there, then we would know.
The surgical team was aware of this challenge with their rounds but had not yet found a way to
be able to round quickly enough to get into the OR and still effectively include floor nurses in the
process. A surgical attending explained:
I think that we have systems in place that sometimes make it hard as I was alluding to
around trying to round with the nurses at 6:30 in the morning when they're changing shift
and how we get the right person to be part of that rounding process so that the nurses will
understand. So we are looking at different models to fix that. Involving the nurses, the
NPs, and CCCs will do that.
A second theme involved a lack of shared understanding or developed relationships
resulting in difficulties working across teams. A BMT hospitalist said:
Other teams don’t always understand the rationale behind why we do things the way we
do and why we would want to continue [a procedure] for a really long time when the
standard is seven days . . . but when you are dealing with an immune-comprised patient
to the extent that these [BMT] patients are, then the same rules don’t necessarily apply.
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A bedside nurse from the PICU similarly noted that communication breakdown happen most
frequently with “doctors from the different services” because:
everybody is overwhelmed and they see things from their particular point of view and
that doesn’t always take into account what we might be experiencing down here. So
that’s probably the only time I see medical communication breakdown is when I am
watching multiple services have to communicate about one patient.
The PICU nutritionist pointed out that when there is no established relationship with the other
team, this is often what leads to a lack of shared understanding:
If I needed to maybe talk with like a GI fellow or something like that, that’s where it can
get a little challenging because- just because I- you know- they are not, like I am not on
their team, they kind of don’t know who I am, and here I am calling them and you know,
most likely challenging their recommendation.
The last theme related to bridging involved the extreme complexity of many of the
patient cases at SCCH. A child life specialist explained the challenge well:
I think communication is probably across the board the biggest issue with this hospital. I
don’t know if it’s because so many different people are following one patient, a lot of
different services, and everybody feels like their specialty is the most important . . . I feel
like a lot gets lost in communication even from kid getting from PICU to the floor or just
a med being ordered and this service wanted this med and this service says no, so yeah, I
definitely think things get missed and I don’t think- there is obviously no ill intention, but
things definitely get missed and I think that that causes patients to be here longer . . . you
have like a primary, for like a Hem/Onc patient, you have the Hem/Onc attending, but
then you also have hospitalists and if there is any type of like adolescent involved, then
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you have like adolescent, you know there is just- all these kids are so medically
complicated, there is not just typically one diagnosis, there is multitude of them, and so
then you have everybody involved and like I said, I just think it gets really complicated.
The select few interviewees who described more positive experiences with bridging were those
with jobs that required it, and they were mostly from ancillary services. Hypothesis three was
partially supported. Despite the fact that the PICU provides a great deal of formal support for
collaboration, they struggled with bridging relationships to the consulting services. However, the
ancillary services, which receive formal leadership support for collaboration in the form of staff
empowerment were also the most likely to have a positive experience with bridging relationships
to other teams.
Research question 4 asked: How does the use of ICTs by different disciplines or teams
support or inhibit the development of collaborative care capacity in a hospital? Interviewee
responses to questions about how staff and care providers communicate and share information
outside of rounds and about how they use ICTs were most useful for examining this question.
Data were initially coded for synchronous versus asynchronous technologies and were then
coded within the synchronous category as either face-to-face or mediated communication and
within the asynchronous category as either analog or digital technologies.
ICT Use and Collaboration
Hypothesis 4 predicted that care providers’ use of ICTs would reproduce elements of
team and disciplinary cultures and power structures. Data supported this hypothesis. The most
prominent theme that emerged related to ICT use was the importance of face-to-face
communication across the organization. Despite the widespread use of many different
technologies for communicating and sharing information in a hospital, people clearly preferred
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face-to-face interaction with other staff and care providers. Every person I interviewed expressed
the importance of synchronous communication with families; there was a strong preference for
face-to-face interaction and phone calls were used only when parents were not able to be at the
hospital.
Face-to-face. Many participants expressed a preference for communicating in person
with other staff and providers. A CCC from 5A noted:
there is no substitute really for face-to-face communication, just because you can really
see what's happening with the other person. And to completely effectively communicate .
. . that's the best way, because emails can be misinterpreted just like any other message,
you know? And if you don't see that it has been misinterpreted in front of you, you can
set up a whole chain of reactions that didn’t need to happen. If you were just face-to-face
going, oh, she didn’t get that, I see a question mark on her face, let me go up to her, let
me re-explain this.
A nurse practitioner from the surgical team expressed a similar opinion in terms of the “human
element” in medicine:
I totally get that we want to utilize more technology in medicine, and we want to be cost
effective, but I think that we need to be really careful about totally eliminating the human
element of medicine . . . communication is such a huge thing that I think we need to be
really careful . . . because as we know with email and texts and all of these other
technological means of communication, there is a lot of room for miscommunication . . .
and a lot of room for misinformation or assumptions to be made, and so I actually think
that communication is something that should be done “old school” in my opinion.
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Many interviewees expressed a strong preference for in-person interpretation for non-English
speaking families, explaining that phone interpretation is really not effective because body
language and facial expressions are missing from the exchange. I also observed that the
preference for face-to-face communication often results in lot of ad hoc meetings—frequently
held on the units at nursing stations or even just in the hallway.
Given the preference for face-to-face communication, it was not surprising to learn that
most participants find rounds to be the most crucial time of the day for communicating and
sharing information with other members of the care team. Staff and care providers from across
all disciplines and all teams at SCCH expressed the opinion that rounding is “a rare opportunity
to have multiple health care professionals all together” (physical therapist) and “we are able to
get a lot accomplished in that one hour of discussion because everybody is there” (attending
hospitalist). Some interviewees explained that rounds are particularly useful when the families
are included and multiple disciplines attend. A resident from the PICU and a CV Acute dietician
both mentioned that when the entire team is present at rounds, they get fewer calls and pages
throughout the day because everyone leaves rounds knowing the plan for their patients. Some
ancillary staff felt like rounds with the medical team were a waste of their time to attend every
day and preferred to only attend when there was a relevant issue to discuss; however, many
nurses in particular and some physicians mentioned that it was sometimes a challenge to
coordinate patient care at rounds when ancillary staff did not attend regularly. Nurses, ancillary
staff, and physician trainees in particular expressed a strong preference for face-to-face
communication with other staff and elaborated on the importance of having a diverse group of
staff present during rounds.
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ICT use. Despite the fact that most care providers preferred face-to-face communication,
the hospital is just too large and the staff and providers are too busy to be able to communicate
this way all the time. Some clear themes emerged around norms of ICTs use in the hospital.
Physicians and ancillary staff typically call nurses who carry polycom phones at all times.
Nurses and ancillary staff typically page the primary physicians who care for patients on their
units and then wait for them to call back. The exceptions to this standard practice are the PICU
and the BMT unit where it is common for all staff and providers—regardless of discipline—to
use their polycom phones to call each other in real time. Although most nurses and physicians on
the units use email to communicate only about non-urgent issues, email is one of the primary
ways (along with office phone calls) they communicate with ancillary staff or with physicians
from consulting subspecialties.
In general, other disciplines were most likely to contact physicians via asynchronous
media (e.g., paging) that enable physicians to determine how and when to respond while
physicians typically used synchronous media (e.g., polycoms or phone calls) to contact nurses
and ancillary staff, which enables instantaneous communication. On some teams, junior
physicians also had to navigate the preferences of their seniors. A hospitalist from the BMT team
explained that he uses different technologies to reach different attendings. “Some of them prefer
cell phones and others prefer paging and stuff so they can respond when they are ready.” The
flexibility to choose a preferred means of communication and to determine when to
communicate seems like a privilege afforded only to high status teams (like specialty consulting
services), senior physicians, and to some degree to nursing leaders.
The pediatric surgery team primarily uses group texting as a means of communication
across all providers within the core team. A surgical fellow explained:
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We’re usually running through the ORs, but we need to know- everybody on the team
needs to know what was done in the OR, so whenever we finish a case, a text goes out to
all of the fellows, all the NPs, all the residents, to say, 'appie [appendectomy], it's
perforated, clear liquid diet, POP meds.' So everybody knows what order was put in,
what the diagnosis was, and so it's not a lot of scrambling at 5 o’clock to figure out what
went on all day.
Texting was actually described as a common way for many different teams to communicate
internally. PICU fellows use texting but just among the fellows. One PICU fellow noted, “people
are supposed to carry pagers, but I’ll say that people respond to texts much better.” Nursing
leaders will often use texting to communicate with each other. One nursing manager said, “I
would die without my cell phone.” Therapists also use texting or text paging within the therapy
team. Hospitalists use texting with other hospitalists and sometimes with their residents but not
generally with nurses. Child life specialists use texting within the Child Life team. Texting is
clearly considered a more personal privilege and a more invasive form of communication since it
often involves the use of personal cell phones, which may explain why teams frequently use it
internally but less often to communicate with other teams across the hospital. A bedside nurse
from the BMT unit mentioned that she typically pages BMT physicians when she needs to reach
them but that her charge nurse “is on a texting basis” with them. An NP from the surgical team
explained that they “ask for permission to text different services.” An attending hospitalist also
pointed out that her team is careful not to use patient identifiers while texting since this would
violate patient privacy laws.
Interviewees also explained norms—sometimes shared sometimes differing between
groups—for using the Electronic Medical Record (EMR) system. As a general rule, simply
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noting something in a patient’s record was not considered to be an appropriate way to
communicate with other staff or providers caring for that patient. A resident from the PICU
explained:
We put in notes [in the EMR] with like the patient plans, so yeah anyone can see it and
read it. But I think the expectation is that like for example if you consult a sub-specialty
they are expected to call you with their recommendation . . . I mean everyone has to leave
it in the medical record, but it is also ideal for them to contact you.
A CV Acute nursing manager noted that it is really only new or inexperienced physicians or
nurse practitioners who “might just put in the order and not communicate it to the nurse and now
it’s been like three hours and they are wondering why this wasn’t started, and it’s like, ‘okay, do
you have phones that we can communicate with?’” Specialty consulting services also seemed to
be regular offenders of this rule; they would put in orders but fail to communicate the change to
others responsible for the patient’s care.
Discussion

The findings from this study yielded many useful insights about communication and
collaborative capacity in a hospital.
Values, Goals, and the Need for Collaboration
Staff and care providers from across all disciplines and teams in the hospital expressed a
felt need to collaborate and an understanding of the value of collaboration that was rooted in a
shared goal: taking care of sick kids and their families. People truly felt like it was this shared
mission that enabled them to work with others to provide patient care because it helped them to
rise above their differences. An important theme emerged around individuals of a traditionally
higher status in hospitals recognizing the importance of working with individuals of a
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traditionally lower status. Physicians often recognized the important work done by nurses; both
physicians and nurses recognized the critical role of ancillary services; and all disciplines
recognized the need to actively collaborate with parents and families to care for their children.
Leggat (2007) argues that this commitment to working with others is the foundation of
successful collaboration on health care teams.
There was an undercurrent of dissatisfaction with certain individuals who were perceived
as non-collaborative, but most interviewees felt like these people had personality or interpersonal
issues, which Hall (2005) found was common in health care. Zimmerman and Amori (2011) tie
these “personality issues” to insidious intimidation and explain how they can result in
communication failures and medical error. Some people also felt like particular teams were less
collaborative than the rest of the hospital, and ancillary staff were more likely to feel like other
disciplines (i.e., nurses and physicians) lacked understanding of their work, which could result in
underutilization. Existing research has documented this possible lack of understanding with
respect to MDs and NPs. One study found that while NPs seem to have a fairly good
understanding of MDs background and knowledge, MDs do not share a similarly clear
understanding of the role that an NP could play on a care team (Martin et al., as cited in, O’Brien
et al., 2008, p. 138). The lack of understanding for the work of ancillary staff seemed to be a real
challenge at SCCH; however, I found that this was not really the issue between MDs and NPs.
On most units, NPs served a similar function to MDs in terms of caring for patients, but the
superiority of MDs was still reproduced in many ways—from hospitalists leading rounds to
medical research being primarily the domain of physicians. Still, most people across the hospital
felt the need to collaborate with others and believed others felt the need to collaborate with them.

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Openness, Participation, and Diversity
Research on collaborative capacity suggests that while a felt need to collaborate is a
necessary element of a collaborative organizational culture, it is not sufficient. Collaboration on
health care teams also requires: open communication and information sharing; participation by
all team members; and an appreciation of diverse perspectives, which enable task-based conflict
that can improve team outcomes (Mickan & Rodger, 2000). There was more variation between
teams and disciplines with respect to these elements of collaborative culture than with felt need.
Openness. People from the BMT team, the PICU, and the general pediatric surgery team
were more likely to feel like within the team, communication and information sharing was very
open. People from all disciplines on these three teams generally felt comfortable speaking up
when there were differences of opinion with respect to patient care. Senior physicians across all
units seemed to feel the most comfortable sharing their opinions in team care situations whereas
nurses were generally somewhat more hesitant. Physician trainees used similar caution when
interacting with senior physicians as nurses used when interacting with physicians of all levels;
both groups used some form of “questioning to understand” as a means of expressing
disagreement. Nurses who felt like communication was open often only felt this was true within
their team or with other nurses. Ancillary staff seemed to feel more comfortable disagreeing or
expressing their opinions than nurses.
Problems with openness and sharing were more of a challenge throughout the day when
different members of the team were spread throughout the hospital whereas during the morning it
was easier because group members were gathering in the same location for rounds. Open
communication was also a challenge with specific groups who often failed to share critical
information. Not surprisingly, these were often the same groups who were identified as lacking a
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“felt need” to collaborate. Some teams also expressed challenges or failures related to
information sharing between disciplines. A nursing manager from 5A expressed dismay that
despite extensive training, nurses and physicians on her unit did not seem to use the SBARQ
(Situation, Background, Assessment, Recommendation, Questions) method of communication
though Barbour (2010) explains that, “interventions like SBAR . . . offer limited assistance in
situations where professional status differences or fear of reprisals constrain conversations.
Power differences stemming from who has legitimate authority during a handoff might prevent
the raising of questions or doubts” (pp. 552-3). Although SBAR provides a method for open
communication, it does not address the socio-communicative reasons why people often fail to
share information in a hospital like power and status differences (Sutcliffe et al., 2004).
Participation. Participation in the important collaborative event of patient rounds also
varied significantly by team. The PICU included both bedside nurses and families in physician
rounds. Attendings rounded with nurse practitioners independently of the trainee group to give
fellows leadership experience. Unlike many other units, the bedside nurses presented their
patients’ basic status instead of the residents and then the residents would give their assessment
and plan with interjections from the fellow. Nurses in the PICU clearly felt more like they were a
part of the team than in some of the other units because of their role during rounds—they were
providers of information instead of just receivers. It made them feel more empowered to
understand why they were carrying out physician orders, and it made them feel more comfortable
sharing their opinions.
Families sometimes seemed to feel too intimidated to join the PICU rounding process, as
was the case in other units that did walking rounds. Unlike bedside rounds where the team enters
each patient room, walking rounds take place in the hallway outside each patient’s room.
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Families are asked if they would like to join, but joining involves walking out of their child’s
room to join a group of 10-20 staff and providers standing in a circle using complicated medical
jargon. Families were more likely to participate in bedside rounds, which they did in the CV
Acute unit where the team discusses the patient’s status outside of the room and then enters the
room to examine the patient and talk with the family. Unfortunately this process can be time
consuming because entering and exiting multiple patient rooms often involves complex hand
sanitizing and mask or glove wearing. 5A also did family-centered walking rounds and the
surgical team did “speed” rounds at the bedside, but surgical rounds happened so early in the
morning that families were usually sleeping and could not actively participate.
Besides the PICU, nurses were included in the primary rounding process on 5A, BMT,
and CV Acute. Only charge nurses attended Hem/Onc rounds and were supposed to share what
they learned with their bedside nurses, though a Hem/Onc resident told me this sometimes felt
like a game of telephone in which information would get lost or distorted in the retelling. The
surgical team typically rounded too quickly to include nurses in their rounds and so early that the
night shift was still there and was often busy with sign out reports at that time. Ancillary staff
attended daily rounds with the least regularity on all units with some exceptions. Feeding was
such an integral part of the critical care process that the PICU dietician attended rounds every
day. Other units like BMT had regularly scheduled ancillary staff (CCCs and pharmacists) that
would come to rounds on select days of the week. The newly implemented care progression
rounds across all units created a multidisciplinary rounding process, but physicians rarely
attended these, which nurses and ancillary staff often found frustrating though understandable
because of scheduling challenges.
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One important factor related to participation that became clear to me only toward the end
of my fieldwork was that my definition of interdisciplinary “teams” in the hospital was
somewhat artificial and only accurate in describing some of the groups that I included in the
study. I defined a team in terms of the staff and care providers who care for the same patients,
but really teams as defined by the staff and care providers themselves consist of those who care
for the same populations of patients. Sharing one patient in common does not make a nurse, a
doctor, and a social worker feel like part of the same team. Sharing all patients in critical
condition or all patients undergoing bone marrow transplant in common is what seemed to make
people feel like a team. I believe this difference is critical to participation but also to other
elements of collaborative culture. In the PICU there is a defined group of nurses, a defined group
of physicians, and a defined group on ancillary staff who provide care to the same group of
patients, but on 5A, the “team” consists only of nurses and some ancillary staff because the
physicians who care for those patients are organized into their own unique “teams” through the
department of hospital medicine, and they care for patients throughout the hospital—not just on
5A.
Diversity. The perceived value of diverse staff and provider perspectives varied most in
terms disciplinary background. Some physicians seemed to understand that nurses have unique
and useful knowledge of their patients because of the extensive amount of time they spend at the
bedside but some regarded the nursing perspective as less valuable than the medical perspective.
Ancillary staff were most likely to experience challenges related to physicians and nurses not
recognizing the value or range of their knowledge and skills. Even when providers and nurses
felt the need to include them in team care, they did not always acknowledge or consider their
recommendations as an important part of the decision-making processes. Within physician ranks,
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the divide between surgery and medicine was acknowledged with some staff and providers
explaining that while medical teams are more likely to integrate diverse perspectives into their
decision-making, surgical teams are more likely to dictate their plans without consulting or
seeking advice from others.
A second theme developed around diversity with respect to patients/families. Although
this study focused more on collaboration among staff and providers, this theme is important to
discuss since is has implications for collaboration more generally. While some providers
described the diversity of the patient population as “enriching,” many also noted that it can make
the care process more difficult—especially when there are language differences. The hospital has
Spanish interpreters, but for other languages they use phone or video interpretation, which
people described as better than nothing but certainly not great. The interpreters act as cultural
interpreters as well as language interpreters and often help both families and providers navigate
differences that would otherwise impede the care process. Ethnic and religious cultures shape a
patient’s/family’s clinical reality, which Kleinman (1980) describes as the “health-related
aspects of social reality—especially attitudes and norms concerning sickness, clinical
relationships, and healing activities” (p. 38). This clinical reality influences everything from
parents’ willingness to give consent for procedures to compliance with medication
administration or feeding instructions. Despite a great deal of work at the hospital-level to create
patient-centered models of care, there remains a lot of variation around staff and provider
understanding of families’ clinical reality and willingness to take this into account in the care
process.

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Time and Space
Time and space emerged as codes relevant to collaborative care early on in the interview
and analysis process. Both time and space were framed in terms of resources and used as
definitive reasons for why collaboration in patient care was sometimes unsuccessful and why it
would remain so. They were also used in the structuring of team culture and staff and provider
power relationships. For example, the surgeons’ position at the top of the hospital hierarchy
makes the surgical team’s inability to wait for and include other disciplines in their rounds totally
acceptable while at the same time the surgeons’ excessively busy schedule solidifies their
position at the top of the hierarchy—their time is considered to be most valuable. Ancillary
groups at the bottom of the hospital hierarchy were given very little workspace in the new
building due to their lower status in the hospital hierarchy and again their lower status was
confirmed by their lack of workspace. Space in terms of unit layout was described as having a
powerful impact on unit or team culture. Most nurses and some physicians felt that the more
spread out units in the new building with as many as six nursing stations had changed the culture
of their teams—making people feel more isolated and less like a family.
Power Relationships in Decision-making and Problem Solving
All five of the units and one team in the study reproduced unbalanced power relationships
with respect to decision-making. This is unsurprising given the historical prominence of
physicians within the institution of health care. Physician supervision of health care teams is also
mandated by law in most states within the U.S. (O’Brien et al., 2008). But many health care
organizations are also recognizing the importance of a more multidisciplinary approach to the
care process. As expected, the three units that had the most clearly defined and clearly applied
processes for collaborating across disciplinary boundaries also reproduced more balanced power
COLLABORATIVE CARE CAPACITY 154
structures with respect to planning and problem solving. Nurses and ancillary staff from these
units referred to practices that balance power between the disciplines from calling physicians by
their first names to physicians discussing a “Plan B” for the day with nurses during rounds so
that everyone understands what will happen if something goes wrong during the course of the
day. Most importantly, these teams recognize the unique value of each member of the care team,
which Kvarnström (2008) found is important since difficulties tend to arise when the knowledge
base and skills of certain disciplines are valued unequally in team interactions. Elements of
culture clearly intersect with power relationships, especially with respect to participation. People
included in important collaborative processes like rounds feel more empowered within the team.
There was a clear difference between teams that include nurses in rounds and those that do not
with respect to how comfortable nurses felt questioning physicians and sharing their knowledge
and opinions.
Power balance in hospitals will likely remain the most challenging area of collaborative
care capacity development because of the strict taken-for-granted hierarchy within the health
care system. Physicians will remain end-of-line decision-makers—especially in contentious
situations. Although there are many ways in which units and teams can work to develop more
balanced relationships around discussion and problem solving processes within physician ranks
and between physicians and other disciplines, there will always be influential forces rooted in
history working against these attempts to create balance. More than culture or leadership, power
balance is a capacity that may be hard to really develop without widespread changes in medical
education that emphasize the importance of team care and continual changes in nursing and
ancillary care education focused on empowering these individuals in their work with physicians.

COLLABORATIVE CARE CAPACITY 155
Leadership for Collaboration
Although participants framed leadership support for collaboration in many different
ways, some aspects of leadership support seemed to impact the bridging behavior of non-leaders
more than others. First, leader-determined work processes and structures (i.e., how physician
teams are structured or who attends rounds) determine who is perceived to be a part of the team
and who is perceived to be important. These processes and structures shape interaction on a daily
basis. If nurses and physicians see each other regularly and get to know each other, they will
develop trust in one another. If they do not and they fail to develop some level of trust,
collaboration will be more challenging. Second, leader empowerment of staff plays an important
role in bridging. Despite fewer material resources, ancillary staff have leader-advocates who
empower them to seek out opportunities for using their skills and knowledge, and these
individuals are often more comfortable with bridging than others. Third, leadership support for
collaboration fails to enable bridging when others lack a felt need to collaborate. This was
particularly clear in the PICU, one of the most supportive environments for collaboration, where
other services consulting on PICU patients often fail to communicate their care plans with PICU
staff and providers.
Using Information and Communication Technologies
The data also supported the prediction that the use of information and communication
technologies (ICTs) across the hospital reproduces cultural norms and power relationships. The
internal use of texting on teams reproduces norms of participation and defines in-groups. Nurses’
use of polycom phones through which physicians expect to always be able to reach them
instantaneously, and the physicians use of pagers through which others have to “page and wait,”
reproduces power relationships. The process through which individuals from other disciplines
COLLABORATIVE CARE CAPACITY 156
page physicians and then wait for the physicians to respond reproduces physician power because
the norms of use revolve around an expectation that physicians are busy and important and
should be able to determine when to respond to others. However, there are other disciplines that
use pagers, and when they are paged by physicians, the norms of use are the opposite. In both
cases, the paging process reproduces physician power despite the fact that in one instance the
physician is the one being paged and in the other, the physician is the one doing the paging.
Clearly the use of ICTs in a hospital is complex, and this process does not always work in a
simple way to reproduce physician power to the same extent. There are many physicians who
respond to pages with the same immediacy that a nurse would answer his or her polycom phone.
Still, the flexibility to shape communication patterns is generally a privilege that physicians
enjoy more than those in other disciplines and that higher status groups (e.g., surgeons) enjoy
more than lower status groups.
Summary
Perhaps the most important finding from this study is the degree to which different
elements of collaborative capacity intersect in a hospital to enable or constrain collaborative care.
Collaborative elements of culture are intertwined with more balanced power relationships and
leadership support for collaboration. For example, 5A was touted by multiple people at SCCH as
one of the best units for nurses in the whole hospital. Nurses like to “float” there; the unit has the
highest retention rate in the hospital for nurses. And yet collaborative care remains a challenge
because the 5A “team” that is very tight knit and highly collaborative does not include
physicians the same way that other units do, since the physicians who care for these patients
have their own separate team structure. The PICU reproduces all of the elements of collaborative
culture and has more balanced power relationships in the problem solving process (reproduced in
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part by the common use of polycoms by all staff and providers for communicating) but struggles
with bridging communication to consulting services.
Structuration theory offers a useful framework through which to consider the interplay
among the different dimensions of collaborative care capacity and the complexity of developing
this in a hospital where there are so many different competing priorities. First, the process of
developing collaborative capacity is not a linear one because the different dimensions are so
intertwined with one another. The intricate nature of collaborative capacity development can be
understood in terms of the dual nature of structure. Structures are used by actors at the level of
social interaction through the dimensions of communication, power, and sanction, but in drawing
from and using structures, actors play a role in reproducing institutions characterized by parallel
dimensions of signification, domination, and legitimation. Each element of collaborative
capacity—culture, power relationships, and leadership support—is reproduced in the interaction
of all three dimensions of structure (though one element may be more salient than another). For
example, it is unclear whether power balance is built on a cultural norm of group participation or
group participation is the foundation of developing power balance. This lack of clarity stems
from the fact that in action either can be true depending on the circumstances, so really all three
areas of collaborative capacity have to be considered when developing collaborative
interventions.
Second, it is important to recognize that hospitals are highly complex systems. When
decisions are made, many variables are considered, and collaboration will often not be among the
most important variables considered in the decision-making process. For example, at SCCH the
decision to move from a unit-based organization to a team-based organization for general care
hospitalist physicians was likely based on a need to improve coordination and patient distribution
COLLABORATIVE CARE CAPACITY 158
among hospitalists. While this goal may have been met by the change in physician team
structure, another consequence of the change was that nurses now feel like they no longer have
the same collegial relationships with physicians that they had when they worked regularly with
the same group of unit-based hospitalists. Giddens (1984) would call the change in nurse-
physician relationships an ‘unintended consequence’ of the decision to switch to a physician
team structure. Unintended consequences “are events which would not have happened if that
actor had behaved differently, but which are not within the scope of the agent’s power to have
brought about (regardless of what the agent’s intentions were)” (Giddens, 1984, p. 11). It is
possible that the group of people who decided to make the change were aware that it might
negatively affect nurse-physician collaboration but felt that the benefits of the change
outweighed this cost. It is also possible that this group of decision-makers did not anticipate the
negative impact on nurse-physician collaboration. I would argue that the latter case is
problematic. While collaboration among staff and providers may not always be among the most
important considerations in management decision-making, it should at least be included among
the variables considered in important work process decisions given the consequences
(documented in Chapter One) that failing to collaborate when necessary can have on patient care
quality and efficiency.
Limitations
The findings from this study are limited by a few factors. First, many scholars have
criticized the case study method for its deep grounding in the particular, which may limit the
general applicability of the research. While this is certainly a valid critique, others have
celebrated the method for its ability to closely unite theory with lived human experience in a
COLLABORATIVE CARE CAPACITY 159
ways that push the boundaries of current thought around a particular area or issue by exploring
new perspectives (Stake, 1978).
Second, the fact that SCCH is a children’s hospital may also be a limitation. Many staff
and care providers felt that the shared goal of caring for sick kids made people more dedicated
and more friendly and likely also made people more willing to work with others. In a non-
children’s hospital, people’s motivations for doing their work are likely to differ more and
collaboration may be even more of a challenge.
Finally, I was only able to do limited observation of the rounding process in order to
avoid disrupting the team. More in depth and involved observation would have been ideal but
that was just not possible in this hospital. There were also a couple of groups that were
underrepresented or not represented at all in the research. I would have preferred to interview
more resident physicians. Unfortunately, despite many attempts at recruiting via the senior
residents at SCCH, I was only able to interview one resident likely because of their busy
schedules. I also was unable to interview any chaplains from the spiritual care team, which
would have been an interesting perspective to include from the ancillary care group.
Future Research
Future research should replicate the observation and interview process in other hospitals,
including non-children’s hospitals. Ultimately the qualitative findings should be used to develop
a collaborative capacity survey instrument tailored to the health care context. The instrument can
be used to assess collaborative capacity across many hospitals and health care organizations and
to examine the relationship between collaborative capacity and performance outcome variables
like readmissions, time to discharge, per patient spending, etc. The findings from this study also
suggest the important role that empowered patients/families play in the health care process;
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future research should also attend more to this important collaborative relationship. Finally,
future research should focus in particular on identifying the team care situations in which
collaboration is most critical and the situations where it is less so. The time constraints in
hospitals make it impossible to involve all relevant individuals in every aspect of the care
process, so a better understanding of the moments and events where collaboration is particularly
useful would provide a focus for collaborative capacity development.
Conclusion
“Teamwork” is a loose concept—a buzzword—that often goes undefined in research on
health care teams. This study suggests that collaboration in a hospital is a complex phenomenon
than extends beyond this traditional notion of “teamwork” and involves the development of
organizational capacities that enable the process to succeed. Collaboration is a product of
communication—defined not just as the exchange of information but instead as the discursive
and interactional medium through which staff and care providers structure the social world
around them. Collaborative capacity research suggests that there are three key areas in which
organizations must develop their capacities to enable successful collaboration: organizational
culture, power relationship, and leadership. The findings presented here demonstrate patterns of
discourse and interaction that reproduce both collaborative elements of culture, power
relationships, and leadership as well as non-collaborative elements that serve as opportunities for
collaborative capacity development.

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Chapter 5: Measuring Collaborative Care Capacity
Hospital organization revolves around nursing units or wards, which are usually
physically distinct floors or wings in one or more buildings. In the not-so-distant past, hospitals
in the U.S. primarily employed nurses. Physicians had their own private practices and contracted
with hospitals to provide hospital-based care to their patients. As health care administration has
become more complex, hospitals have had to hire administrative teams. As the care process itself
has become more complex, hospitals have hired physician specialists to work for the hospital as
well as general care physicians (hospitalists) and a range of different kinds of ancillary staff
(social workers, therapists, interpreters, nutritionists, chaplains, etc.). Hospitals that have been
unable to adapt to the need for a larger workforce to provide care under increasingly complex
environmental and care practice demands have closed or been subsumed by larger health
systems. In fact, twenty per-cent of hospitals in the U.S. closed or were acquired by other entities
between 1975 and 2006 (Greenwald, 2010, sec. 2865).
Internal organization remains one of three major challenges, besides finances and public
image, facing U.S. hospitals today (Greenwald, 2010, sec. 2897). Many of the social and
organizational structures that enabled hospitals to provide care to patients in the past remain fully
intact today in spite of the fact that they no longer enable quality patient care and may in fact
prevent it. Plsek and Wilson (2001) explain that the legacy logic of “distinct operational units”
that enabled a hospital to work effectively as a “well oiled machine” is not as useful today (p.
746). Hospitals no longer resemble machines with separate, highly specified parts; they now look
more like complex adaptive systems (CASs) in which interactions between parts are “more
important than the discrete actions of the individuals parts” (Plsek & Wilson, 2001, p. 746).
These organizations are sometimes called network organizations (Poole, 1999). Although
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successful hospitals that have adapted to changing demands and environments are beginning to
resemble network organizations more and more, legacy logics that define and silo distinct units
and teams and discourage interdisciplinary work processes continue to persist and challenge
collaborative interaction.
Considering the important role of collaboration in the care process in these complex
health care environments, there should be a good way to assess this variable . While there are
many tools and instruments that examine nurse-physician collaboration (see Dougherty &
Larson, 2005) and a few that assess interdisciplinary collaboration—often specifically related to
hospice care (Oliver, Wittenberg-Lyles, & Day, 2007; Wittenberg-Lyles, Oliver, Demiris, &
Courtney, 2007), it is difficult to find an instrument specifically designed for the health care
context that measures organizational capacity for collaborative care. In this study, I explore
different ways to assess collaborative care capacity.
Research on health care teams indicates that “good social relationships maintain effective
teams” by enhancing “individuals’ access to strategic information” and facilitating “a better
understanding of team tasks and an increased belief in the team’s effectiveness” (Kirkman &
Rosen, 1999, as cited in Mickan & Rodger, 2000, p. 206). Relational patterns among care
providers reflect the communicative rules and resources—as institutional norms, power
relationships, and meanings—that are drawn from, and reproduced, in caring for patients. I
consider the potential for using social networks to measure collaborative capacity, and I also
pilot a collaborative capacity survey instrument that I have adapted to use in a hospital setting.

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Literature Review
Culture
Research on collaborative capacity reviewed in Chapter Two identifies elements of
organizational culture that enable collaboration in organizations, including a felt need to
collaborate, active participation by collaborators, a willingness to communicate and share
information openly, and an appreciation of diverse perspectives. These elements of culture are
closely related and are intertwined with power relationships as well as leadership support for
collaboration although the qualitative study locates subtle differences between them as they are
communicatively constructed in this hospital.
Diversity. An appreciation or lack of appreciations of diversity is particularly relevant to
team care relationships. Network research often assesses diversity in terms of homophily, which
refers to the tendency for people to establish relationships with others who are similar to them
(McPherson & Smith-Lovin, 1987). The perception of similarity has been explained theoretically
in terms of social identity (Turner & Oakes, 1989), shared focus based on shared activities (Feld,
1981) or structurally similar roles (Krackhardt & Brass, 1994) within a group or organization
(Monge & Contractor, 2001). Research has identified the effects of homophily in organizations
with respect to age (Tsui & O’Reilly III, 1989a) tenure (Zenger & Lawrence, 1989), education
(Liedka, 1991), and gender and culture (Cromie & Birley, 1992; Ibarra, 1992). This research is
often premised on, or finds effects for, the idea that homophily can be beneficial because it
improves group or organizational cohesion. For example, Monge and Contractor (2001) identify
a group of studies on age diversity in organizations, which has found that age differences make
communication more challenging and can result in decreased organizational commitment
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(Liedka, 1991; Tsui, Egan, & O’Reilly III, 1992; Tsui & O’Reilly III, 1989b; Wagner, Pfeffer, &
O’Reilly III, 1984).
Homophily research has also examined relational similarity in terms of professional
background (Galaskiewicz, 1979; Schermerhorn, 1977), which may be most relevant for
hospitals and other health care organizations. Despite the tendency for attraction on the basis of
professional background, Borrill, West, Shapiro, and Rees (2000) argue that disciplinary
diversity is an important input for health care teams because it contributes to the outputs of team
effectiveness, quality care outcomes, innovation, and cost effectiveness. Similar findings have
been identified in group process research as well with respect to diversity of training/background
and creativity of group outcomes (Thompson, 2003) and diversity of knowledge/skills and group
innovation (Janssen, van de Vliert, & West, 2004). Diversity is thought to increase the “pool of
task-related skills, information, and perspectives,” which makes team decisions more
“comprehensive or creative” (Janssen et al., 2004, p. 138); these factors also lead to better
problem-solving abilities (Cox & Blake, 1991).
Whereas job-relevant diversity (i.e., expertise, skills, and knowledge) has been found to
improve innovation outcomes, background diversity (i.e., age, gender, and ethnicity) may
actually interfere with group outcomes (Hülsheger, Anderson, & Salgado, 2009). From the latter
perspective, social identity differences are thought to be problematic due to their possibly
negative impact on cohesiveness and communication and their potential to perpetuate in-
group/out-group conflict. However, research on faultlines has found that background diversity
alone is not usually the cause of major conflict; it is when background diversity in groups aligns
in ways that create faultlines that conflicts arise (Lau & Murnighan, 1998). Research generally
supports the notion that disciplinary diversity should improve collaborative outcomes in health
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care organizations and that hospitals working to develop collaborative capacity should nurture
values and create processes that encourage interdisciplinary communication on care teams (Hays
et al., 2000; Hocevar, Thomas, & Jansen, 2006). However, there is an opportunity to formally
investigate the relationship between care network diversity and collaboration. Based on existing
research, I explore the following hypothesis:
H1a: Care providers with greater disciplinary diversity in their care networks will have
higher perceptions of collaborative capacity.
Structuring diversity relationally. The degree to which organizations or teams work
against forces of homophily to establish relationships with diverse others depends largely on
culturally structured values. Diversity is a property not of individuals but of relationships in that
it is determined relative to other individuals. Care providers’ decisions to communicate with
others similar to or different from themselves in the course of caring for a patient are shaped
largely by existing rules and resources. Though all care providers have the capacity to act outside
of these existing structures, social and system integration promotes the reproduction of existing
structures. The meanings different care providers draw upon and reproduce in working with
others are not the same for all groups or all individuals within groups in a hospital, though there
are often similarities among disciplines or sub-disciplinary groups. Research has found that
physicians may value team-based care less than other disciplines (Leipzig et al., 2002). Despite
this possibility, physicians often serve as a point of contact through which other staff filter
information about patient care. Interestingly, in spite of the differences in physician and nurse
roles in the patient care process, nurses also serve as a point of contact—either in the absence of
the physician or as a conduit through which to collect and filter information up to a physician.
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Because of this similar role that requires physicians and nurses alike to coordinate among a range
of other kinds of health care providers, I propose the following hypotheses:
H1b: Physicians and nurses will have greater disciplinary diversity in their care networks
than ancillary care providers and technicians.
H1c: Physicians and nurses will have different perceptions of collaborative capacity than
ancillary care providers and technicians.
Power Relationships
Research on collaborative capacity suggests that power relationships in collaborative
organizations are more dispersed and balanced—at least during deliberation processes. Power
imbalances create order and accountability in critical decision-making moments, but during the
course of discussion and problem-solving work, power imbalances undermine trust and prevent
collaborators from speaking openly and freely (Walton, 1969, p. 3, as cited in Gray, 1985, p.
927).
Structuring shared power. Collective action research uses public goods theory to
examine “‘mutual interests and the possibility of benefits from coordinated action’” (Marwell &
Oliver, 1993, p. 2, as cited in Monge & Contractor, 2001, p. 159). Knoke (1990) found that
organizational members with larger communication networks that tie them into discussions about
key organizational issues are more involved in those issues even when they do not have an
individual stake in the outcome suggesting that network size correlates with greater participation
and commitment. From a collective action perspective, higher degree centrality actually suggests
more dispersed and balanced power, which is consistent with the idea that care providers with
larger care communication networks are actually sharing, rather than accumulating, power.
Shared interests are firmly and clearly established in children’s hospitals both formally (i.e.,
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hospital vision and mission) and informally (i.e., professional cultures); everyone is “there for
the kids.” There are formal structures that mandate action in a hospital, which means that
patients will receive care even in the absence of ideal conditions for collective action. However,
the quality and efficiency of care vary a great deal depending on how well care providers self-
organize to optimize the contribution of knowledge-based and skill-based resources. Based on a
collective action perspective, I explore the following hypothesis:
H2: Care providers with more care network ties will have higher perceptions of
collaborative capacity.
Leadership Support
Collaborative capacity research indicates that leadership support is crucial to the success
of collaboration. From a discursive leadership perspective (Fairhurst, 2007), this support is
expressed communicatively through talk and action—both by formal organizational leaders and
by any other individuals who use their influence to encourage a collaborative approach to
problem-solving and decision-making. Siloed work structures in hospitals that in the past
enabled efficient hierarchical management when patient care was relatively simple now present a
major challenge to collaborative work processes that are necessary for providing complex patient
care. Individuals from different operational units and teams often care for the same patients and
need to communicate and share information but are prevented from doing so efficiently and
effectively by formal (e.g., policies and procedures) and informal (e.g., team cultures) divides.
Individuals practice collaborative leadership in action when they bridge communication divides
between different units and teams.
Bridging relationships. Bridging ties are often explained in terms of social capital,
which is basically an investment in social resources. Individuals who establish ties to others with
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resources gain social capital (Borgatti & Foster, 2003, p. 993). In particular, individuals who fill
structural holes—places in a network where people are unconnected—act as brokers (Simmel,
1955, as cited in Monge & Contractor, 2001) and may acquire a number of benefits, including
access to more resources and greater efficiency of resource exchange. Balkundi and Kilduff
(2005) explain that, “Leadership can be understood as social capital that collects around certain
individuals—whether formally designated as leaders or not—based on the acuity of their social
perceptions and the structure of their social ties” (p. 421). Bennis and Nanus (1985) found that
leaders’ development of “transformational visions” involves discussions with diverse others.
Weak ties are more likely to be embedded in diverse networks making people’s connections to
weak ties a surprisingly valuable source of novel information and, as a result, social capital
(Granovetter, 1973). One group of researchers actually examined social capital in the context of
a primary care practice and found that bridging was important both on an ad-hoc basis for
creative problem solving and on a long-term basis for establishing comprehensive patient care
systems that benefit from the expertise of care providers with different backgrounds (DiCicco-
Bloom et al., 2007). It is reasonable to conclude that collaborative leaders in a hospital will be
those with more social capital derived from their “contacts with a scattered, disconnected group
of actors, including actors in different functional areas,” (Brass & Krackhardt, 1999, p. 189).
Based on existing research, I explore the following hypothesis:
H3a: Care providers with more bridging ties to different units or teams will have higher
perceptions of collaborative capacity.
Finally, research suggests that formal organizational leaders are often unaware of informal
networks that are critical to employees success in collaborative work (Cross, Borgatti, & Parker,
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2002). This lack of awareness may result in a failure to accurately understand the collaborative
challenges facing employees or the collaborative potential of their workers.
H3b: Formal leaders will have different perceptions of collaborative capacity than non-
formal leaders.
Method
The questions and predictions driving this research are exploratory in nature; they are
intended to test quantitative measurement approaches and tools for the assessment of
collaborative capacity in a hospital.
Pilot Survey Procedures
Measuring Collaborative Capacity. Perceptions of collaborative capacity were assessed
using adapted sub-scales from Hocevar, Thomas, and Jansen’s (2006) Inter-Organizational
Collaborative Capacity (ICC) Assessment. After reviewing many potential instruments, select
subscales from the ICC were deemed to be the most reliable and appropriate for adaptation as the
subscales map well onto the key concepts underlying collaborative capacity in the literature
review. Although this instrument was originally designed to assess inter-organizational
collaboration among government organizations, it has previously been successfully adapted and
tested for internal organizational use. The subscales that map onto the theoretically derived
elements (30 items total) included: felt need to collaborate, rewards and incentives, collaborative
learning, information sharing, social capital, individual collaborative capacities, and
collaborative tools and technologies. Items from the ‘felt need to collaborate’ and ‘collaborative
learning’ dimensions assess culture; items from the ‘rewards and incentives’ and ‘social capital’
dimensions assess leadership; items from the ‘individual collaborative capacities’ assess culture
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and power relationships. All items use a Likert scale in which one indicates “strongly disagree,”
six indicates “strongly agree” and seven indicates “don’t know.”
The participating hospital units and team are described in detail in Chapter Three. The
survey was conducted after an extensive period of qualitative observation and interviews, which
resulted in an evolving understanding of the units and team. The same five formal units and one
team described in Chapter Three were all included in the survey with one important addition.
Observation and interviews were systematically conducted only with the core general pediatric
surgery team composed primarily of physicians and nurse practitioners. However, the researcher
decided it was important to also include the medical-surgical (“medsurg”) nursing units in the
survey to capture potential collaborative relationships between these units and the core general
pediatric surgery team.
Although these formal units/team provided useful boundaries for initially determining
which groups to include in the research, they do not always align with the informal or functional
boundaries established by care providers in their day-to-day work. These informal boundaries are
discussed in the data analysis section. Employees from all disciplines who provide care to
patients via the participating units or one team were invited by their unit or team managers to
take the survey. An online survey software program (Qualtrics) was used to collect the survey
data. The survey link was open for approximately five weeks, and unit team managers were
asked approximately every 10-15 days by the researcher or her SCCH adviser to remind
employees to take the survey.
Survey Data
Survey response rates are difficult to assess because of the fluid boundaries of the
hospital (i.e., contract vs. full employees) and the teams that work in it, so the response rate for
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the pilot survey was challenging to calculate (N=189). People who work with patients cared for
by any of the six units or one team included in the study were invited to participate, but the group
is fluid and it is hard to define absolute membership. However, based on estimates, the response
rate was likely between 20-30 percent. The response rate was deemed sufficient for a pilot
testing the adapted collaborative capacity scales. See Table x for more information about survey
respondents. Despite extensive recruiting, the researcher was unable to obtain census or near-
census network data from any of the groups included, so the network-based hypotheses could not
be tested.
Table 5.1

Pilot Survey Respondent Information

Discipline N Unit or Team SCCH Tenure
(years)

Age (years) Gender
Physicians 13 39% critical care

7% surgical

23% cancer

4% general

M=6.55,

SD=8.35
M=38.36,

SD=12.02
Men=36%

Women=64%
Nurses 116 41% critical care

1% surgical

19% cancer

9% general

26% medsurg

9% cardiovascular

M=9.68,

SD=9.63
M=37.59,

SD=10.73
Men=11%

Women=89%
Technicians 16 27% critical care

67% specialized
M=8.36,

SD=9.77
M=43.25,

SD=15.41
Men=42%

Women=58%
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consulting services

7% general

Ancillary 27 9% critical care

65% ancillary

4% cancer

4% general

9% therapy

9% medsurg

M=5.28

SD=5.95
M=38.76,

SD=11.90
Men=17%

Women=83%
Combined 172 35% critical care

1% surgical

9% ancillary

16% cancer

6% specialized
consulting services

10% general

1% therapy

16% medsurg

6% cardiovascular

M=8.63

SD=9.136
M=38.44

SD=11.55
Men=18%

Women=82%

Pilot survey measures. The survey instrument collected data about care communication
networks, perceptions of collaborative capacity, and demographics. The Cronbach’s alpha scores
for all composite measures in this study were above .80 (see Table 5.3 for individual scores).
Factor analysis. Because the sub-scales were adapted from their original form and used
in a new organizational context, exploratory factor analysis was used to examine data structure.
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First, the factorability of the 30 items was examined. Kaiser-Meyer-Olkin measure of sampling
adequacy was .93, well above the commonly recommended value of .6, and Bartlett’s test of
sphericity was significant (χ
2
(435) = 2705.50, p < .001). Finally, almost all of the initial
communalities were all above .5 (only one item had a communality of .320), which suggests that
each item shared some common variance with other items (see Table 5.2). Given these
indicators, factor analysis was determined to be a suitable approach with all 30 items.
Principle Axis Factoring was used as an extraction method to explore factor solutions.
This is the current recommended approach (Russell, 2002). The goal of the factor analysis was to
both find the best factor structure that would enable the creation of composite variables based on
the underlying factors and data reduction so that the instrument is parsimonious given the
difficulty of conducting surveys in hospitals. Initially four factors were indicated. Before rotation
the eigenvalues for the four factors were 16.95, 1.48, 1.25, and 1.16 respectively, and together
they explained 69 percent of the total variance. After rotation the eigenvalues for the four factors
were 6.88, 4.83, 4.16, and 3.57. The rotated four-factor solution explained 65 percent of the total
variance.
A total of 15 items were eliminated initially because of low factor loadings (less than .4)
or high cross-loadings on multiple factors (less than .2 between primary and other factor
loadings). After eliminating the 15 items, the analysis was redone, and it resulted in a two-factor
solution with eigenvalues of 2 and 3.92 respectively that together explained 60 percent of the
total variance. An additional 6 items were eliminated primarily due to cross-loadings and the
analysis was done again, which resulted in the final two-factor solution. The first factor had an
eigenvalue of 3.34, and the second factor had an eigenvalue of 2.18. Together the two rotated
factors explained 61 percent of the variance. The factor-loading matrix for this final solution is
COLLABORATIVE CARE CAPACITY 174
presented in Table 5.2. Based on the items represented, the first factor was labeled
“Collaborative Values” and the second factor was labeled “Collaborative Effort.” The factors
were assessed for internal consistency and were found to have high Cronbach’s alphas of .89 and
.82 respectively. The factors did not analyze according to the structure of the original ICC
instrument. This could be explained by the changes resulting from the adaptation for internal
organizational use or by the health care context, which was substantially different from the
original context in which the instrument was tested and used; however, given the sample size, the
items that make theoretical sense should be retained and reworded for clarity for testing in the
next hospital site.
Despite the limitations of these factors in their ability to fully measure collaborative
capacity, exploratory analyses were done using these measures to test potential differences
between groups related to their perceptions of collaboration that, although tentative, may offer
some useful suggestions for future research. Composite scores were created for each of the two
factors using the mean of the items for each factor. Higher scores indicate higher perceptions of
collaborative capacity either with respect to perceptions of collaborative values (VALUES) or
with respect to perceptions of collaborative effort (EFFORT). Z-scores of VALUES showed that
the variable was significantly, negatively skewed and leptokurtic (Skewness = -2.01, SE of Skew
= .177, Kurtosis = 7.02, SE of Kurtosis = .352). Z-scores of EFFORT showed that it was not as
highly skewed (Skewness = -.749, SE of Skew = .178, Kurtosis = .216, SE of Kurtosis = .354).
The VALUES variable was transformed by first reflecting and then log transforming it to
improve normality. The transformation successfully improved normality for VALUES (Skewness
= .408, SE of Skew = .177, Kurtosis = .339, SE of Kurtosis = .352). See Table 5.3 for summary
COLLABORATIVE CARE CAPACITY 175
descriptive statistics for the two factors. For the reflected and transformed VALUES_RLg10
variable, lower scores indicate higher perceptions of collaborative capacity.
Table 5.2
Factor Loadings and Communalities from Principal Axis Factor Analysis with Varimax Rotation
for Nine Collaborative Capacity Items (N = 189)

Factor VALUES EFFORT Comm-
unality
The success of SCCH’s mission requires staff and
providers to work effectively with each other

1 .57 .24 .38
Engaging in collaborative work is important to career
advancement

1 .49 .26 .30
My team has strong values and norms that encourage
sharing information with staff and providers from
others units/teams

1 .73 .42 .71
My team provides staff and providers from other
units/teams with adequate access to information that
is relevant to their work

1 .75 .28 .64
Members of my team understand how our work
relates to the work of other units/teams with whom
1 .77 .30 .70
COLLABORATIVE CARE CAPACITY 176
we need to collaborate

Members of my team are willing to engage in a
shared decision making process with other
units/teams

1 .81 .36 .79
My team rewards staff and care providers for
investing time and energy to build collaborative
relationships

2 .24 .82 .73

My team takes time to learn about the interests of
other units/teams

2 .37 .69 .61
Members of my team take the initiative to build
relationships with their counterparts in other
units/teams

2 .48 .67 .66

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Table 5.3

Descriptive Statistics for EFFORT and the Log Transformed Composite VALUES_RLg10 (N =
189)

No. of items M (SD) Skewness Kurtosis Cronbach’s α

VALUES_RLg10

6 .234 (.158) .408 .339 .89
EFFORT

3 4.47 (1.05) -.749 .216 .83

Demographics. Demographic questions collected data on respondents’ age, gender,
education level, ethnicity and race, presence or absence of a specialty, tenure in health care, and
tenure at SCCH. Group variables were created based on reported discipline and primary unit or
team.
Survey Analysis
SPSS was used to conduct all quantitative survey analyses. Simple independent samples t
tests were used to examine possible group differences with respect to the collaborative values
and collaborative effort. Network hypotheses (1a, 1b, 2, and 3a) could not be tested due to low
response rate.
Possible Future Findings
Hypotheses 1b and 3b were tested; however, considering the low response rate and the
problems with attaining a representative sample, these findings are very tentative and should be
considered useful only for testing the measurement tools and exploring possible avenues for
future research. Hypothesis 1b stated that physicians and nurses will have different perceptions
of collaborative capacity than ancillary care providers and technicians. A dummy variable was
created that grouped physicians with nurses and then ancillary staff with medical technicians.
The dummy variable was used in an independent samples t test to examine differences in
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perceptions of collaborative skills and collaborative effort. Significant differences were found on
perceptions of collaborative effort, t(169) = 2.32, p = .021, but not on perceptions of
collaborative values, t(170) = -1.28, p = .269. Physicians/nurses (M = 4.58, SD =.088) had higher
perceptions of collaborative skills and values than ancillary care providers/technicians (M = 4.16,
SD = .171). There was some tentative support for the idea that physicians and nurses have
different perceptions of collaboration than ancillary staff/technicians.
Hypothesis 3b stated that formal leaders will have different perceptions of collaborative
capacity than others. A dummy variable was created that grouped care providers with a formal
leadership role together and all other care providers together. Significant differences were found
on perceptions of collaborative values, t(170) = -2.06, p = .041, but not on perceptions of
collaborative effort, t(170) = -1.40, p = .163. Leaders (M = .174, SD = .027) had higher
perceptions
2
of collaborative values than non-leaders (M = .244, SD = .013). There was some
support for the suggestion that leaders may have higher perceptions of collaboration than non-
leaders.
Discussion
Perceptions of Collaborative Capacity
One of the most important possible findings from this study is the difference found in
perceptions of collaborative capacity between doctors/nurses and ancillary staff/technicians.
Much of the existing research on cross-disciplinary collaboration has focused on getting
physicians and nurses to communicate (Simpson et al., 2006; Tjia et al., 2009) and work together
(Baggs et al., 1999; Dougherty & Larson, 2005; Hojat et al., 2001; Schmalenberg & Kramer,
2009; Shortell, Rousseau, Gillies, Devers, & Simons, 1991). But this finding suggests that the

2
The reported numbers were reflected before being log transformed, so the lower number actually represents higher
perceptions of collaboration while the higher number actually represents lower perceptions of collaboration.
COLLABORATIVE CARE CAPACITY 179
challenges of care collaboration may be shifting. Interventions focused on improving nurse-
physician collaboration may be working effectively to improve the collaborative relationship
between the two most established disciplines in health care to the point where both physicians
and nurses have relatively high perceptions of collaboration while the challenges of collaboration
may have shifted to ancillary staff like social workers, therapists, pharmacists, technicians, and
care coordinators who together have significantly lower perceptions of collaboration—in terms
of both collaborative skills/values and organizational support for collaboration—than doctors and
nurses combined. Despite the fact that these ancillary groups have become a more integral part of
the care process, they may not feel as included in team care. One study of group discourse found
that the flexible use of group pronouns (like “I” and “we”) sometimes worked to draw a
distinction between team members from the core disciplines of nursing and medicine and team
members from ancillary disciplines like physiotherapy and occupational therapy (Kvarnström &
Cedersund, 2006, p. 250). Future research will need to investigate the specific prediction that
nurses and physicians will have higher perceptions of collaborative capacity—rather than just
different perceptions—to reduce the possible error margin for testing this prediction.
Another important finding with respect to perceptions of collaborative capacity involves
formal leaders from the hospital having higher perceptions of collaborative skills and values than
employees. This difference may result from leaders being somewhat more removed from day-to-
day work in the organization and therefore not fully understanding the collaborative challenges
facing employees. Future research should further investigate this difference in perceptions as
well as explanations for the difference.

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Limitations
This research was certainly limited by many different factors. First, the findings come
from only one hospital and a children’s hospital specifically, which could limit their applicability
to other hospitals and hospitals that primarily treat adults in particular. The survey response rate
was also somewhat problematic. Even though a low response rate is expected for a population of
people who regularly work 12-15 hour days with few breaks and consider lack of time to be one
of their biggest challenges, the researcher had hoped that tireless recruiting would yield a higher
proportion of respondents from each unit or team in the study. Because of the low proportion of
respondents from even one of the units or team, it was impossible to do the network analysis.
Another limitation is that physicians were underrepresented in the pilot sample and some teams
were underrepresented compared to others. Some studies have achieved higher physician
participation by handing out hard copies at meetings with the CEO or chief medical officer
present and this researcher will attempt this at the next site. It is also possible that a self-report
measure of collaborative capacity should be used in conjunction with another, less biased
measure of collaborative capacity because people may have an inflated sense of how well their
team collaborates due to the recognized importance of this ability to the hospital’s mission.
Future Research
There was limited support found for hypotheses that predicted differences in perceptions
of collaborative capacity between groups so this will be a focus on future instrument
development, which will be discussed in Chapter Six. Future research should also explore these
relationships across a wide range of hospitals—both other children’s hospitals and adult
hospitals—to see if the effects found in this research hold true. It is also important to explore
better ways to obtain social network data in a hospital. Given the almost impossibly busy
COLLABORATIVE CARE CAPACITY 181
schedules of care providers and staff who may not have time to take long network surveys,
opportunities for collecting trace data via phone calls, emails, or text messages should be
considered. Future research should also explore better measures of collaborative capacity that
may be more appropriate for the health care context. The adapted measures from the inter-
organizational collaborative capacity scale (Hocevar et al., 2006) did not factor analyze as
expected suggesting that the instrument may operate differently in the health care context than in
the inter-governmental context for which the instrument was developed or that the small pilot
sample size impacted the results. Qualitative findings from Chapter Four will be discussed in
Chapter Six to evaluate the adapted ICC instrument from the pilot test and make
recommendations for future collaborative care capacity instrument development.
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Chapter 6: Developing Collaborative Care Capacity
Hospitals are increasingly aware that they face extreme challenges related to
quality/patient safety and financial efficiency that will ultimately affect their survival over time if
they are unable to adapt to changing environmental conditions and changing health care demands
from the population. In an effort to incentivize change, policymakers included provisions in the
Affordable Care Act (ACA) that tie Medicare and Medicaid payments to more efficient
utilization of resources and reduced medical error. It is these organizational changes—more than
the coverage for previously uninsured individuals mandated by the act—that are expected to
have the greatest impact in reducing national spending on health care (Washington Post Staff,
2010, p. 129). Most hospitals will have to adapt and change their work processes in at least some
ways in order to maintain their public funding stream as these new provisions go into effect.
The law changes Medicare payments to hospitals from a fee-for-service model that
encourages extraneous tests and treatments to a set payment for a time period of care that starts
just before hospitalization and extends a month beyond discharge to cover follow-up and home-
based treatment (Washington Post Staff, 2010, p. 130). The latter model promotes efficiency by
encouraging hospitals to use evidence-based medicine to determine only the necessary tests and
treatments that must be done within that fixed time period. As an incentive to improve quality,
the act reduces Medicare payments to hospitals that have high rates of preventable readmissions
(Washington Post Staff, 2010, p. 131). The legislation also incentivizes the move to team-based
models of patient care—often called “accountable care organizations” or “patient-centered
medical homes”—which include “case managers, social workers, dietitians, telephone
counselors, data crunchers, guideline instructors, performance evaluators” as well as physicians
on teams that are responsible for total patient care over time (Washington Post Staff, 2010, p.
COLLABORATIVE CARE CAPACITY 183
135). Medical homes shift the burden of care coordination from patients to providers. A
central/shared electronic repository of medical information about each patient facilitates the
coordination process and encourages collaborative approaches to treatment. Early research on
medical home models is promising. Both patients and physicians seem to be happier with this
collaborative approach to care (Washington Post Staff, 2010, p. 136).
In light of these policy incentives and the general benefits that accrue to the individuals
and organizations that succeed in cultivating collaborative care, hospitals across the U.S. are
working to break down their siloed care processes and structures and develop more
multidisciplinary approaches to patient care. Researchers have been developing and testing
interventions to assess and improve communication among disciplines—especially physicians
and nurses though increasingly ancillary staff as well—and to improve hand-off communication
during shift changes and when patients are transferred to different units (e.g., SBAR). Studies
have examined ways to empower nurses to play a more active role in the problem solving
process and to voice their opinions when they catch physician errors. Hospitals across the nation
have adopted mission statements centered on the delivery of patient- and family-centered care
that treats the patient as a whole person instead of a collection of disembodied ailments and
includes the patient/family in medical decision-making processes. Hospitals are also increasingly
staffed with a range of different ancillary care groups that play an important role in the patient
care process, and research has examined new challenges faced by multidisciplinary teams. From
this corpus of knowledge, interventions have been developed to enable and improve
collaborative care, yet many hospitals that implement these interventions struggle to change in
real and lasting ways. One possible reason is that popular “collaborative” change interventions
often fail to address the deeply embedded social structures, reinforced and reproduced by
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communication and interaction on a daily basis that may be working against change. In the next
section, I consider the process going forward for developing and testing a survey instrument that
measures collaborative care capacity based on the findings from the qualitative study and the
pilot survey of the adapted ICC instrument. Then I discuss possible interventions for developing
collaborative capacity in a hospital.
Developing a Tool for Measurement
Summary Findings
From testing the adapted ICC instrument, a potential difference was discovered in
perceptions of collaborative effort between physicians/nurses as a group and ancillary
staff/technicians as a group. Ancillary staff/technicians had significantly lower perceptions of
collaborative capacity than physicians/nurses. The fact that physicians had higher perceptions of
collaboration is not surprising. They remain the most central discipline with the highest status in
the care process—the end-of-the-line decision-makers—and it is not surprising that they believe
they are working effectively with others and vice versa to care for patients, perhaps because they
are included and involved in all decisions. What was more surprising is that nurses have
similarly high perceptions of collaborative capacity given the traditional power and status
differences between nurses and physicians.
Despite these differences, many nurses actually felt like SCCH was more balanced than
other hospitals, which was evident in many small but important ways in the qualitative study.
Multiple nurses from the BMT unit mentioned that nurses and physicians call each other by their
first name, which they felt was really important since having to call physicians “Doctor”
reinforces the status difference between physicians and nurses in every interaction. In the PICU
all physicians and nurses carry polycom phones, which enables instantaneous communication in
COLLABORATIVE CARE CAPACITY 185
both directions instead of the more traditional arrangement in which nurses have polycoms and
are expected to be immediately available to speak with physicians whereas physicians carry
pagers that give them the flexibility to determine how and when to respond to communication.
Many units also include nurses in rounds and some even have nurses do the patient report instead
of residents, which gives them an important role in this process. Also, more units are doing
walking or bedside rounds, which create a spatial arrangement of staff and care providers that is
more conducive to participation by all present. All of these factors may help to explain why
nurses had relatively high perceptions of collaboration. Although ancillary staff generally felt
that communication was more open and they tended to be more comfortable voicing their
opinions than nurses, the nurses were more likely to regularly participate in rounds than ancillary
staff. Also, ancillary staff faced a unique problem with both physicians and nurses not fully
understanding the full extent of their knowledge and abilities, which often resulted in
underutilization of their skills.
Power differences may also play a role in ancillary staff’s lower perceptions of
collaborative capacity. In general teams/units with more balanced power relationships were those
that had dedicated ancillary staff and involved them more in the problem solving process. The
trust and familiarity that develop between people from different disciplines caring for the same
population of patients together on a regularly basis is part of what makes a group of people a
collaborative care team. But it was not the norm for all ancillary staff to be assigned to specific
units. Perhaps ancillary staff who are not embedded within a particular unit or team are less
likely to have developed trust and familiarity with nurses and physicians and as a result are less
likely to be included or to seek out opportunities to participate in team care. Ancillary staff were
also less likely to feel like they had sufficient workspace in which to collaborate with other staff
COLLABORATIVE CARE CAPACITY 186
and providers. Nurses had the units with multiple nursing stations, meeting rooms, and
patient/family consult rooms. Senior physicians had offices and junior physicians had
workrooms on every floor with meeting tables and computers. But ancillary staff had varying
access to workspace. Some did not even have shared workspace, which meant that it was less
likely for them to see their colleagues throughout the day and share patient updates. Those who
were given space often had offices located far from the inpatient floors on which they provide
care, which they felt negatively impacted the degree to which other disciplines thought to
involve them in team care.
The pilot survey also indicated possible differences in perceptions of collaborative values
between formal leaders and non-leaders. Formal leaders had significantly higher perceptions of
collaborative skills and values. Leaders’ inflated perceptions of collaborative capacity could
result in a failure to consider potential collaboration-related problems in their decision-making as
indicated in the qualitative data. Leaders from the Hem/Onc team decided to stop including
bedside nurses in rounds to save time but doing so has resulted in more communication
breakdowns and physicians answering more pages throughout the day from confused nurses.
Leaders from the hospitalists group decided to create a team structure that no longer corresponds
with the hospital inpatient units. This may have improved coordination among hospitalists, but it
also seems to have negatively impacted the trust and familiarity that nurses feel with the
physicians who care for their patients. Surely these decisions were made carefully—though
sometimes based on priorities that may have trumped the perceived importance of facilitating
collaboration and sometimes without considering the “unintended consequences” that Giddens
(1984) explains will always accompany action. Future research should work on identifying the
circumstances or types of decisions where unintended consequences of decisions negatively
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impact collaboration in such a way that it leads to the same mistakes and errors in patient care
happening over and over again. These are the situations where collaboration should be privileged
in leadership decision-making.
The qualitative study indicated that all staff and providers struggle to communicate across
unit or team boundaries. All interviewees were asked how much of their time they spent working
with people who are not a part of their team. Most people said 10-30 percent of their time is
spent working with people who are not on their team—but one nurse explained that even when it
was just 10 percent of her time, it was critically important to her work.
Qualitative findings suggest that the PICU reproduces more elements of collaborative
culture and collaborative power relationships than many of the other units or teams. However,
interviewees from the PICU indicated that the unit still struggled with bridging ties to other
teams, especially with consulting services and physicians from the non-ICU floors who come to
visit their patients while they are in the PICU. There are a few possible explanations for these
findings. Other physicians from the floors and from consulting services may simply lack a felt
need to collaborate with PICU staff and providers, which is certainly a challenging problem for
the PICU. Another possibility is that PICU staff are so used to working with members of their
own bounded team that they struggle more with the skills and abilities required to create bridging
relationships to people from other units or teams. Social identity theory (Tajfel & Turner, 1985)
may also help to explain these findings; perhaps discipline is a secondary factor of social identity
construction on teams that have a more salient group identity (like “critical care”). If PICU staff
are used to interacting with homophilous others from the critical care team, it might make the
differences of working with consulting services or physicians from the floors more salient.
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Findings from the qualitative study indicated that bridging collaboration was more
challenging than collaboration within unit or team boundaries, but there may be a good reason
why this is the case. Perhaps bridging is simply not as important to the work of staff and care
providers across all levels and disciplines as intra-team collaboration and so it is less essential to
develop bridging relationships. Future research should assess the circumstances under which
bridging is a critical part of the work of different disciplines and teams and the degree to which it
is important to providing safe, efficient patient care.
Developing a New Instrument
In this section I consider the development of a new instrument for measuring
collaborative care capacity that is tailored to the health care context and is based on an
assessment of findings from the qualitative study and the pilot test of the adapted ICC survey
instrument. The adapted ICC survey pilot proved perhaps more useful in identifying what does
not need to be included in a measurement instrument than in identifying what should be
included. The response to items that asked about intra-team collaboration received high positive
agreement across all units and teams with little variation, and none of these items loaded on any
of the final factors in the factor analysis. This suggests that people in this organization generally
value working with their teammates and already do so fairly well in caring for their patients. The
items that loaded on the two final factors differed in whether they focused on collaborative
values or collaborative effort, but all of these items were similar in that they focused on bridging
relationships to other units or teams. Rather than keeping these factors as they are and adding
new items to create the new instrument, I recommend keeping the items from the two factors that
emerged in the pilot but reassigning them to new constructs for further testing in order to retain
the conceptual consistency of these constructs, which have been developed primarily around the
COLLABORATIVE CARE CAPACITY 189
findings from the qualitative study. These new items could be added to the original items in a
further test as other organizations may not have such high levels of teamwork. Ultimately, the
instrument could be modular and organizations could choose to focus on internal team
collaboration versus collaborations across various disciplines and units. This might help keep
the instrument short enough to get good response rates, which are always a challenge in
hospitals.
The next section reviews the recommended constructs that should be measured and tested
for a new module in a comprehensive collaborative care capacity instrument. These constructs
are presented as they generally relate to each of the elements of collaborative capacity used
throughout this dissertation project, including culture, power relationships, and leadership.
However, these elements overlap and intersect in the survey constructs, so in testing and use, the
instrument should use the construct names only to avoid confusion.
Collaborative culture. The new instrument should measure felt need but should focus on
the organizational level and the individual level. The first two items from the VALUES factor
that ask about an organization’s mission and career advancement tied to collaboration assess
organizational felt need. New questions should be developed to assess individual felt need to
collaborate instead of focusing on felt need at the team level, which is how much of the adapted
ICC instrument assessed felt need. Lack of felt need should also be included focusing on the
degree to which this is isolated to individuals with personality or personal issues, to specific
groups, or is a more pervasive problem across the hospital. The second construct that should be
assessed is openness and sharing; this should look at the openness of communication and
information sharing as well as communication problems that hinder openness and sharing—like
failure to “close the loop” with someone who has initiated communication or requested
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assistance in the patient care process. The third construct is participation and should focus
specifically on formal patient care meetings like patient rounds—especially who is present, who
is actively involved in the discussion, and the degree to which the design of the process
encourages all team members to contribute. The fourth construct is appreciation of professional
diversity; this should assess people’s understanding of what other teams and disciplines do and
the degree to which people value the perspectives and approaches of other teams and disciplines
in the patient care process. The fifth construct, time, should assess the degree to which, and the
ways in which, time is a barrier to collaborative care (e.g., busy work, waiting for others,
rotation/shift schedules, and schedule conflicts). The sixth and final culture-based construct
should focus on space and how it impacts collaboration—specifically the amount, location, and
configuration of space and the ways in which these things enable colocation and ad hoc
communication, which are critically important to collaborative work in a hospital.
Collaborative power relationships. The seventh construct should focus on power
relationships and decision-making. Questions might focus on the degree to which respondents
feel responsible for making patient care decisions and how much of this responsibility is shared
with others from the same discipline or team versus other disciplines or teams—as well as the
extent to which people feel they have the ‘final say’ on tough decisions or should defer to
someone else on their team in these situations. The eighth construct should assess power
relationships and problem solving. These questions might hone in on respondents’ level of
comfort in sharing opinions about the care process with other team members and the frequency
with which they actually do share what they know and what they think in discussions; another
related issue is the degree to which people feel like they know and are somewhat friendly with
most of the other staff and providers they work with in providing patient care.
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Collaborative leadership. The ninth construct should assess formal leadership support
for collaboration—including work processes/structures, organizational policies (including
rewards), organizational or team resources, leaders’ skills for supporting collaboration, and
leaders’ empowerment of staff. The first item from the EFFORT construct in the piloted ICC
instrument fits into this construct since it focuses on the extent to which teams reward people for
the time and energy spent building collaborative relationships. The tenth construct should focus
on informal bridging leadership by looking at how often and how well people work across unit
and team boundaries in the patient care process. Some of the items from the VALUES and
EFFORT constructs in the piloted ICC instrument may be useful in assessing bridging
leadership.
Collaborative ICT use. The eleventh and final construct that should be included in the
new expanded collaborative care capacity instrument is information and communication
technology use. These items should examine the extent to which people prefer face-to-face
communication with other staff and providers, how much flexibility respondents feel they have
in deciding how and when to communicate with other staff and providers, how easy it is for
respondents to reach other staff and providers when they need to communicate, and what
technologies they use most in general and specifically in communicating with their own team or
discipline versus other teams and disciplines.
Collaborative Capacity Development
This research project has offered an alternative way to think about communication and
the role it plays in enabling or constraining collaborative care and has made recommendation for
future development of a measurement tool. Structuration theory provided a framework for
studying communication as a constitutive interactive process while the empirical studies
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examined how communication—defined broadly to encompass social structuring through
relationships, discourse, and interaction—enables and constrains collaboration on the ground in
an actual hospital. Though more research needs to be done to develop better measures and more
thoroughly investigate these findings, there is much to be learned from this project for
developing collaborative capacity in a hospital.
Organizational Change
Structuration theory provides a way of thinking about collaborative capacity
development. Interventions that seek to change the social structure of the organization without
addressing the ways in which actors within in the organization reproduce existing structures will
likely fail. For example, the mere creation of “collaborative” teams that are intended to transcend
the physical units of a hospital will not automatically improve collaboration—especially if the
individuals on those teams were trained to work alone. At the same time, interventions that seek
to change people’s interactions without considering the historical ways in which people have
typically drawn upon larger social structures to accomplish these interactions are also likely to
fail. Thus, the use of communication interventions like SBAR (Situation, Background,
Assessment, Recommendation) or STICC (Situation, Task, Intent, Concern, Calibrate) can
sometimes improve communication in hospitals temporarily, but without addressing the larger
socio-communicative context in which these moments of information exchange take place, long-
term change may not last (Barbour, 2010).
Challenges. The biggest challenge hospitals face in developing collaborative capacity is
the fact that this process will likely require significant organizational change. Real change is
challenging because it happens through people (Moran & Brightman, 2000). Change is
emotional (Vince & Broussine, 1996) and often met with resistance (O’Connor, 1993; Piderit,
COLLABORATIVE CARE CAPACITY 193
2000). But this study found that the greatest challenge to organizational change is not emotion or
resistance; it is the deeply embedded routinization of practices and communication buoyed by
longstanding tradition (Giddens, 1979, p. 219). By far the greatest challenge to change is the
existence of institutions comprised of structural patterns that are reproduced by actors across
space and time but are often taken for granted as simply ‘the way things are.’ Despite the fact
that the very definition of human agency is grounded in “a capability to do otherwise” (Giddens
& Pierson, 1998, p. 84), most human action involves the reproduction of existing structures that
enable people to ‘go on’ in daily social life. As Giddens (1998) explains, “For most of human
history, the most striking thing is constancy rather than change” (Giddens & Pierson, 1998, p.
91). Real organizational change then requires some degree of de-routinization, which involves
“any influence that acts to counter the grip of the taken-for-granted character of day-to-day
interaction” (Giddens, 1979, p. 220).
In a hospital, there are many ways in which historical norms and traditions continue to
shape the structures that are reproduced on a daily basis. Greenwald (2010) attributes the power
imbalance between nursing and medicine in part to “the fact that nursing developed after
medicine had established itself as a profession” (sec. 3508). He calls medicine “‘strongly
professionalized,’” which does not necessarily mean more skilled but does mean that physicians
were more “strongly organized, politically powerful, and publicly esteemed” earlier than was
nursing and certainly earlier than newer ancillary disciplines (Greenwald, 2010, sec. 3501). This
imbalance continues to be reproduced in hospitals today even in very small but impactful ways—
in the surly, clipped way that a young resident dismisses an older, experienced nurse; in the
obvious lack of information many physicians and nurses have about the range of work done by
ancillary staff (which demonstrates a gap in their training and education as well as little
COLLABORATIVE CARE CAPACITY 194
inclination to learn on their own); in seating arrangements during rounds; in who is and is not
given enough space to do their work; and in who is and is not included in team care discussions.
These power relationships are embedded in the institution of health care and changing them is
not a simple process—though some hospitals like SCCH are beginning to make headway
through micro changes and innovations at the individual level, like the simple act of physicians
asking nurses to call them by their first name as well as through larger change interventions.
Interventions. The communication constitutes organizations perspective and the
empirical findings from this project comprise a useful body of knowledge from which to evaluate
existing interventions and discuss possibilities for new hospital change initiatives that work to
develop collaborative capacity.
Work patterns and relationships. I have previously discussed the popularity of
communication interventions like the SBAR method, which provides a checklist to ensure that
staff and providers routinely discuss the details about a patient case that they sometimes assume
others already know. Research on this approach finds positive changes from utilizing the method
though it rarely looks at utilization of the tool over time. A nursing manager from SCCH
explained in her interview that all of the nurses and doctors at the hospital are trained in the
SBAR method but that it is rarely used. Given the demonstrated success of the method in
improving information exchange in one hospital (Beckett & Kipnis, 2009), the reasons why
people fail to use the tool may be tied to the larger social context in which the method is used.
Implementation of the tool does not directly address changes to the social context around issues
of organizational culture and power relationships that might impact use. For example, low status
individuals are unlikely to feel comfortable reminding high status individuals to use the method.
COLLABORATIVE CARE CAPACITY 195
Another study recommended a team building intervention involving expanded meeting
time. During meetings the team worked to reduce power differences by ensuring that everyone
from physicians to assistants had a seat at the table and everyone was invited to share their
opinions, although this was not mandated. Over a year after the intervention, team members
indicated that they felt more friendly and were better at listening to each other; they also had
increased respect and trust within the group (Cashman et al., 2004). Janss, Rispens, Segers, and
Jehn (2012) proposed the development of briefings for medical teams. They suggest that even
something as simple as an introduction to a physician team meeting should include an explicit
encouragement for junior physicians to speak up. I experienced a similar approach at SCCH
when a PICU fellow encouraged her residents on a new rotation in the PICU to take advantage of
the extensive knowledge and experience of the bedside nurses; however, this was not common
practice across the hospital.
Leadership. Lichtenstein and colleagues (1997) suggest the use of leadership
interventions. Based on social identity theory, they argue that health team members “magnify
both similarities and differences between themselves and team leaders” making it important for
leaders to represent multiple groups with which team members identify in order to support team
integration (p. 432; Alexander et al., 2010). Having more non-physician team leaders—either
nurses or ancillary staff—might reduce intergroup conflict and improve collaboration. Some
units at SCCH were trying this flexible leadership model with the new care
progression/discharge rounds by having charge nurses lead this process. A charge nurse from the
CV Acute unit explained that some of the nurse practitioners on her unit failed to understand
why the change was useful, but she liked the fact that her new role ensured her involvement in
the process. Flexible leadership roles might also work to balance power relationships between
COLLABORATIVE CARE CAPACITY 196
the disciplines. Another approach recommended by Hansen (2009) suggests working to develop
the collaborative behavior of existing leaders by training them to: redefine success around
bigger, more inclusive goals; involve others by inviting open sharing and debate around
decision-making; and hold themselves and others accountable for goal attainment.
High reliability team training. Other approaches have focused more on training at the
team level. Wilson, Burke, Priest, and Salas (2005) recommend high reliability team training to
prepare these teams to collaborate within the complex environment of health care organization.
They recommend a series of development strategies including: cross training, perceptual contrast
training, team coordination training, team self-correction training, scenario-based training, and
guided error training (Wilson et al., 2005, pp. 307–8). These strategies aim to develop five key
team values: 1) sensitivity to operations, 2) commitment to resilience, 3) deference to expertise,
4) reluctance to simplify, and 5) preoccupation with failure (Wilson et al., 2005, p. 305). These
strategies focus on developing collaborative mindfulness. High reliability teams (HRTs) are not
successful because of highly stable work practices—in fact just the opposite is true. HRTs
succeed because of stability in the cognitive processes of team members as they make sense of
team activities that often involve highly varied work processes (Weick, Sutcliffe, & Obstfeld,
2008). HRT training focuses on teaching people to think from a systems perspective, which
Edmondson (2012) argues is the foundation of teaming, an activity that is becoming increasingly
important in organizations like hospitals where complex work has to be coordinated across
multiple people fairly quickly. She explains that teaming is a process “largely determined by the
mindset and practices of teamwork . . . without the benefits of stable team structures” (sec. 395).
Behavior in a teaming organization involves asking questions, sharing information, seeking help,
experimenting with unproven actions, talking about mistakes, and seeking feedback
COLLABORATIVE CARE CAPACITY 197
(Edmondson, 2012, sec. 634); these behaviors are not the norm in most organizations and they
can be hard to develop. Leaders working to develop teaming environments have to frame
situations for learning, make it psychologically safe to team, learn how to learn from failure, and
span occupational and cultural boundaries (Edmondson, 2012, sec. 1449).
Education. Since many of the collaborative challenges facing organizations seem to stem
from clashing cultures and perspectives that hospital staff develop long before they ever set foot
in a hospital, some interventions have focused on changing the educational process for nurses,
physicians, and ancillary staff. Janss and colleagues (2012) recommended that all professionals
undergo team training in school to shape beliefs and skills around managing power and conflict
on teams. Leipzig and colleagues (2002) also suggest that physician education in particular needs
to increase exposure to interdisciplinary teamwork well before residency when attitudes toward
this kind of work have already been shaped. A social worker from SCCH commented that his
graduate education, which focused a lot on institutional change, “really did help out with
[understanding] how the floor can run and how to not only educate families but educate staff
about how to handle these tough situations [from a social work perspective].” This
interdisciplinary teaching and sharing is part of a process that Petrie (1976) calls idea
dominance, which requires an individual “to interpret information in light of his/her own
learning and then share this with other team members using appropriate collaborative skills” to
facilitate the development “of a common language between team members” (as cited in Hall,
2005). Hall (2005) argues that interventions to teach these skills must begin early in professional
education.
Strategic communication. Many of these interventions have great potential for
developing collaborative capacity. However, the success of all organizational change
COLLABORATIVE CARE CAPACITY 198
interventions depends to some degree on the strategic communication processes through which
they are developed and implemented. Strategic communication is a two-way process of meaning
creation aimed at achieving an organizational goal (Hallahan, Holtzhausen, van Ruler, Vercic, &
Sriramesh, 2007)—like improving collaborative care. Research exploring the success of strategic
communication over time in creating a willingness among health care providers to change their
work practices found significant improvements on consideration of new ideas and intention to
change work practices (Morténius, Fridlund, Marklund, Palm, & Baigi, 2012). The strategic
communication planning process engages all stakeholders in dialogue to carefully examine how
entrenched structures would have to change in order to achieve the goal. This process can take
many forms. In an action research project, Eisenberg, Baglia and Pynes (2006) created narratives
with staff about ER work processes and then used the narratives to spur discussion and
understanding around the different ways that people make sense of the world around them. This
process led to emergent ideas for creating a shared narrative. Many collaborative capacity
building interventions fail to engage in a strategic communication planning process—either
because of their design or because of how they are used—but those that do have a better chance
of success over the long-term because they are rooted in a clear understanding of the power of
continuity and the challenges of organizational change.
Conclusion
This project began with two major goals—to expand the definition of communication in
health care collaboration research and to empirically examine this expanded role of
communication in developing collaborative care capacity in a hospital. Both goals were
successfully accomplished. Structuration theory provided the vocabulary and explanatory
framework for looking at communication as the constitutive process through which actors
COLLABORATIVE CARE CAPACITY 199
reproduce the social structures in a hospital. Actors draw from existing structures to engage in
interaction with others and in doing so reproduce these structures, and when this happens in
distinct patterns across time and space, institutions are perpetuated. Health care is one such
institution and many of the socially structured patterns of interaction that comprise this
institution are deeply rooted in history. Using research on organizational collaborative capacity
as a guide, the empirical studies examined how communication patterns reproduce structures that
either support or inhibit collaboration in the patient care process.
Chapter Four used a qualitative approach to identify communication patterns around
elements of organizational culture, power relationships, and leadership that support or inhibit
collaborative care. Key findings indicate: first, that even when there was a pervasive felt need to
collaborate, other elements of collaborative culture (like openness, participation, and
appreciation of professional diversity) varied among disciplines and different units or teams;
second, that all disciplines and teams reproduced unbalanced power relationships around
decision-making but that some groups did a better job of balancing power relationships around
problem solving processes; third, that formal leadership support alone (in the absence of
elements of culture and balanced power relationships) could not reliably enable cross unit or
team bridging, which was a major challenge for most teams; and finally, use of information and
communication technologies in the hospital reproduced elements of collaborative (or non-
collaborative) culture and power relationships. Chapter Five piloted an adapted survey
instrument to assess collaborative care capacity quantitatively. The most useful outcome of this
research is a clear path forward in the process of developing a new measurement tool—based on
qualitative findings and lessons learned from the pilot test—that is specifically designed to assess
collaborative capacity within the context of a health care organization.
COLLABORATIVE CARE CAPACITY 200
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Appendix: Interview Protocol

Thank you!

>Consent form—
-This is my dissertation research on communication and collaboration in a hospital. I'm
interested in the role communication plays in enabling (or preventing) successful collaboration
around patient care.

-The interview questions focus on your role at SCCH and on your team AND on how you
communicate and work with other provides and with patients/families.

-This is NOT evaluative research; none of this information will be used to determine quality of
care in your unit/on your team.

-In fact, your responses will be kept entirely confidential. Only final results from interview
analysis will be shared. If any direct quotes or examples from the interview are used in my
dissertation, they will be anonymous (identified by position, not by name).

-Would it be okay for me to audio-record our interview for research purposes?

>This shouldn't be a long interview—15 minutes or so—but if you need to stop before we're
finished, just let me know.

>And of course, you can skip any questions you would prefer not to answer.

Interviewee #:

Time/Date:

Location:

1. BACKGROUND INFO (before interview)

1.1 Gender:

1.2 Position/job title/role:

1.3 Primary team/unit:

1.4 Medical/surgical specialty:

2. BACKGROUND INFO CONFIRMATION

-->2.1 Would it be accurate to describe your position as __________?

COLLABORATIVE CARE CAPACITY 223
2.2 And is there a primary inpatient unit/team that you work on/with?

2.3 (If specialty) You have a medical/surgical specialty in ___? N/A

-->2.4 How long have you worked at SCCH? ___ In health care? ____

2.5 To get started, I'd like to hear more about your role as a/n _______ at SCCH. What is it that
you do around here? What are your major responsibilities?

3. CULTURE

3.1 I’m interested in how you would describe the culture at SCCH? (open ended—let them
define “culture”)

3.2 What about specifically on _____ unit/team?

4. ROUNDING

4.1 Now I'd like to talk about the rounding process for the [BLANK] team. Can you describe
how rounds work?

--> What are the major goals that your unit/team tries to accomplish during that time?

--> Do you feel actively involved in the process? Do you feel comfortable talking openly during
rounds?

--> Is there anyone who doesn't attend/participate actively in [BLANK] rounds who you feel
should be there?

4.2 If another provider makes a decision about how to care for a patient (whether during rounds
or any other time) and you disagree with that decision, what would you say or do?

--> Would you react that way with any of the care providers who attend rounds?

--> What if it was a parent or family member?

4.3 Would you say that the [BLANK] team’s process for rounding is generally similar to or
different from other team's processes for rounding?

--> If different, how so? Specific comparisons? Better process/worse process than other
units/teams?

4.4 Do you think care providers generally communicate successfully with each other during
______ rounds? At other times throughout the day?

--> If so, what enables successful communication?
COLLABORATIVE CARE CAPACITY 224

--> If not, what makes communication difficult?

--> Are some providers better at communicating successfully than others?

4.5 Do you think providers from the ______ unit/team communicates successfully with
patients/families during rounds? At other times throughout the day?

--> If so, what enables successful communication?

--> If not, what makes communication difficult?

4.7 Do you feel like rounds are a really sort of the most critical time for communicating and
sharing information with other providers? With patients/families? Or do you find that other
times are better?

--> If so, why?

--> If not, when does most of this communication and information sharing take place? Why?

5. COLLABORATION OUTSIDE OF ROUNDING

Clearly there are other times throughout the day—besides rounds—when you work with
patients/families and other care providers in order to care for your patients.

5.1 How do you typically communicate with other providers when you need to:
Share information (medication, updates about a patient's condition)? Make decisions about
how to care for a patient?

--> Face to face? One-on-one? In group meetings? Through phone calls, pages, e-mails, or text
messages? It varies depending on the situation?

5.2 What percentage of that time do you think you spend working with people on the ______
team vs. other teams or services across the hospital?

--> That ____% of time you spend working with other services/teams – do you find that’s
important to your ability to successfully do your job?

5.3 Do you generally find it to be fairly easy or somewhat challenging to communicate and work
with other providers on your team? Across the hospital?

--> If so, what makes it challenging?

6. SUPPORT FOR COLLABORATION

COLLABORATIVE CARE CAPACITY 225
6.1 Do you see people who are not motivated or incentivized to communicate and work with
others?

6.2 Do you feel like you have the resources (like space, time, tools) that you need to successfully
communicate and work with other providers on your team? Patients/family members?

--> How do you feel about the new building? Does the new space make it easier/more difficult
to work with other care providers? With patients/families?

7. ICTs AND COLLABORATION

7.1 What sorts of information and communication tools/devices/systems do you use to
communicate with other providers throughout the day? Patients and families? Primary (“go-to”)
device/tool/system?

--> Phone? Mobile phone? Pager? E-mail? EMR? Whiteboard?

--> Do you use patients' EMRs as a means through which to share info with other providers?

--> Whiteboard pilot – Do you use to communicate with patients/families?

7.2 Would you say you more frequently communicate and share information through these
tools/devices/systems or in person, face-to-face?

8. CLOSING

8.0 What would you say is the single biggest challenge you face in doing your job?

8.1 Do you have any other thoughts to add about communication and collaboration around here?
Anything you think I should be asking that I didn't ask you?

8.2 Other providers that I should interview from your team?

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Asset Metadata

Creator Noyes, Allison L. (author)

Core Title Collaborative care capacity: developing culture, power relationships and leadership support for team care in a hospital

School Annenberg School for Communication

Degree Doctor of Philosophy

Degree Program Communication

Publication Date 04/03/2015

Defense Date 09/10/2014

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag collaboration,communication,health care,OAI-PMH Harvest,structuration

Format application/pdf (imt)

Language English

Contributor Electronically uploaded by the author (provenance)

Advisor Riley, Patricia (committee chair), Fulk, Janet (committee member), Greenwald, Howard P. (committee member)

Creator Email allisonnoyes@gmail.com,anoyes@usc.edu

Permanent Link (DOI) https://doi.org/10.25549/usctheses-c3-488375

Unique identifier UC11287024

Identifier etd-NoyesAllis-2997.pdf (filename),usctheses-c3-488375 (legacy record id)

Legacy Identifier etd-NoyesAllis-2997.pdf

Dmrecord 488375

Document Type Dissertation

Format application/pdf (imt)

Rights Noyes, Allison L.

Type texts

Source University of Southern California (contributing entity), University of Southern California Dissertations and Theses (collection)

Access Conditions The author retains rights to his/her dissertation, thesis or other graduate work according to U.S. copyright law. Electronic access is being provided by the USC Libraries in agreement with the a...

Repository Name University of Southern California Digital Library

Repository Location USC Digital Library, University of Southern California, University Park Campus MC 2810, 3434 South Grand Avenue, 2nd Floor, Los Angeles, California 90089-2810, USA