Allan Waters Family Simulation Centre, St. Michael's Hospital, Unity Health Toronto, Canada; Department of Medicine, University of Toronto, Canada; Wilson Centre for Research in Education, University Health Network, University of Toronto, Canada.
Allan Waters Family Simulation Centre, St. Michael's Hospital, Unity Health Toronto, Canada.
Soc Sci Med. 2021 Jun;279:113975. doi: 10.1016/j.socscimed.2021.113975. Epub 2021 Apr 29.
Labour and delivery units often become contested workplaces with tensions between obstetrics, nursing, and midwifery practices. These tensions can impede communication and raise concerns about provider wellness and patient safety. Remedying such tensions requires inquiry into the drivers of recurrent problems in interprofessional practice. We engaged in change-oriented inquiry informed by institutional ethnography (IE) within an academic hospital in Toronto, Canada (2017-2019). Clinicians identified critical incident analysis reports used to document recurrent issues for transfers of care (TOC) and consultations between professionals. We then mapped the everyday/everynight work of midwives, nurses, and obstetricians by observing (75 h) and interviewing them (n = 15). We also traced work processes to local (forms and hospital policies) and external (national policies and evidence-based guidelines) texts. Our IE-informed analysis made visible the otherwise hidden links between the everyday work of practitioners and its social organization. Three intrapartum work processes involving midwives consulting with obstetricians were identified: induction of labour with TOC back to midwife once labour was "active", consultation without TOC, and TOC for various indications. Three points of disjuncture complicated these processes: (i) a local "3 consult rule", linked to medico-legal governance and remuneration structures; (ii) subjective interpretations of the "4-cm dilation rule", a policy meant to standardize practice; and (iii) regulations delaying the timing of consultations. The Electronic Fetal Monitoring system served as a powerful text, materializing issues of professional scope and autonomy for midwives, and medicolegal accountability for obstetricians. Our study extends extant evidence that medicine-driven governance of midwifery practices can perpetuate interprofessional challenges. While practitioners spoke of the three disjunctures as 'laws', most also viewed them as ostensibly modifiable. Interprofessional tensions may be addressed by considering how social organization, materialized in texts detailing medico-legal liability and remuneration, can constrain possible practices through regulatory protocols, local ruling policies, and cultural expectations (e.g., documentation practices).
产房和分娩单位经常成为充满争议的工作场所，产科、护理和助产实践之间存在紧张关系。这些紧张关系会阻碍沟通，并引发对提供者健康和患者安全的担忧。要解决这些紧张关系，需要调查导致跨专业实践中反复出现问题的驱动因素。我们在加拿大多伦多的一家学术医院（2017-2019 年）进行了以机构民族志（IE）为指导的面向变革的调查。临床医生确定了用于记录护理交接（TOC）和专业人员之间咨询的反复出现问题的关键事件分析报告。然后，我们通过观察（75 小时）和访谈（n=15）来绘制助产士、护士和产科医生的日常/夜间工作图。我们还追踪了工作流程到本地（表格和医院政策）和外部（国家政策和循证指南）的文本。我们的 IE 知情分析使从业者的日常工作及其社会组织之间的隐藏联系变得可见。确定了涉及助产士与产科医生咨询的三个产程工作流程：一旦分娩“活跃”，就用 TOC 将分娩诱导回助产士；无 TOC 的咨询；以及各种指征的 TOC。三个不连续点使这些过程复杂化：（i）本地的“3 次咨询规则”，与医疗法律治理和薪酬结构有关；（ii）对“4 厘米扩张规则”的主观解释，这一政策旨在规范实践；以及（iii）延迟咨询时间的法规。电子胎儿监测系统是一种强大的文本，体现了助产士的专业范围和自主权问题，以及产科医生的医疗法律责任问题。我们的研究扩展了现有的证据，即医学驱动的助产实践治理可能会使跨专业挑战长期存在。虽然从业者将这三个不连续点称为“法律”，但大多数人也认为它们是可以修改的。通过考虑社会组织如何通过监管协议、本地裁决政策和文化期望（例如，记录实践）来限制可能的实践，可以解决跨专业紧张关系。文本详细说明了医疗法律责任和薪酬，使这一点具体化。
