Altered communication patterns between team members

Also noted by interviewees was the role that the IPCC played in communication between members of the team. This was also observed in practice although not covered in the IPCC job description. One view held by some interprofessional colleagues was that the IPCC role brought the interprofessional team together because of this liaison role between the different team members.

It is just a huge communication point because [the IPCCs] bring the whole team together, so they will often feed things back into the medical team or whatever or liaise between social work and OT. (Physiotherapist,

09119M, FG)

The IPCCs saw their role in this regard as an advantage.

Although they’re not actually talking to each other it’s positive in that because we are based here all year round we know who to contact, we know numbers; whereas if you are getting new people coming in it can be a process to find out who you need to talk to, what the numbers are. So it is negative in as much as those two people perhaps never talk to each other or even meet but it’s positive because the information needed can be supplied a lot quicker. (IPCC, 07128, Int)

In contrast, some team members felt that the liaison role of the IPCC between the team members increased the chance of miscommunication.

The [IPCC] role sets up another line of communication that gets distorted. I would prefer to talk to, for example, the registrar directly. Things change so quickly. The [IPCC] sets up another bureaucratic process… Our [IPCC] went off sick for about 6 weeks. I thought things worked better because communication was more direct. (Social worker, 12118, Int)

Perhaps the only thing to say [in identifying disadvantages to the IPCC role] is they are an extension to the team and if you have too many people on a team the chance for the information to get lost is greater. (Doctor, 15049, Int)

In summary, the IPCC role has altered communication patterns between

interprofessional team members, by acting as a liaison point. Both advantages and disadvantages were identified from this change.

6.1.3 Reduced nursing input into interprofessional activities

The IPCC role also affected interprofessional working by reducing opportunities for nurses to be involved in interprofessional team activities. We saw in the previous chapter how IPCCs rather than nurses were approached by team members for information about what was happening for individual patients.

For me it’s a luxury to have the [IPCCs] for I go to them to check

everything is sorted rather than the nursing staff. (Occupational therapist, 15020F, FG)

A comment by a ward manager suggested that this was also happening between nurses:

It’s simply because [the IPCCs] have all the information. I would pick up the phone and ask [the IPCCs] quicker than I’d ask one of my own nurses. (Ward manager, 15020F, FG)

In addition, the attendance of IPCCs at the weekly interprofessional meetings masked the absence of nurses (who found it difficult to attend meetings because of the mismatch between medical teams and ward bases – see introduction chapter, page 10). This is evident through observation and interview data. The field notes reflect that, while some nurses attended the weekly interprofessional meetings, the meetings continued in their absence, with no regular contingency being made for other team members being informed of the nursing view on individual patients or for informing nurses of decisions that were made in the meeting.

Consultant couldn’t attend (usually does). Present: 5 doctors, student social worker, OT, IPCC, physiotherapist arrived later. Meeting ready to go, then IPCC went off to get nurse off ward. Doctor to nurse: Do you

know all the patients? Nurse: some. Discussion of patients. Patient 1. Known to the team. Social worker updated that they were looking for residential home. Doctor: patient seems depressed. Might start him on anti-depressants. Patient 2. Doctor: getting better from pneumonia. Probably needs another week of treatment. Daughter has been to see me about social situation. IPCC: not aware of this. Had agreed with

patient/family that no services were needed. Doctor asks nurse: what do you think? Nurse responded with how patient felt about his medical condition. Doctor prompted IPCC to investigate some more. Nurse leaves meeting. Other patients then discussed. (Field note extract, 03128: 2-24) In the above extract from the field notes (typical of many taken of the weekly interprofessional meetings), the nurse appeared to be playing a passive role, contributing only when asked questions. The only contribution made by the nurse was in sharing how the patient felt about his medical condition. This information was apparently irrelevant in the light of the discussions being held and the nurse failed to convey the relevance of her contribution. It may be that the nurse played a more active role in decision-making about this and other patients outside of this meeting. However, the unclear sole contribution she did make to discussions and the fact that the meeting was able to continue in the absence of nurses after she had left suggested that the meetings were able to function without nursing input. Some nurses suggested that they relied on IPCCs being at those meetings in their place and on the systems set up to ensure that IPCCs communicated with them before and after the meetings.

All the ward managers agreed that it was hard to take nurses off the ward to go to the meetings, and impossible if the meetings were held off the ward. Some ward managers saw it as a higher priority than others. One ward manager felt that she had suitable systems in place for liaising with the IPCCs before and after the meetings, for working with

interprofessional team outside of the meetings, and for popping in to the meetings if there was something to raise about a particular patient -

because this worked well, and there was no evidence that patient outcomes were suffering (e.g. failed discharges), she questioned whether it was important that nurses were always at the meetings. (Field note extract from meeting with ward managers, 06060: 37-47)

Providing you’re putting the right things in order to enable other people to make the appropriate decisions and they are linking in and getting back, I think it’s okay. (Nurse, 11128, Int)

However, there are no observation data to support these claims by nurses. At no point in the field notes do the IPCCs appear to be preparing with nurses for the interprofessional meetings or briefing nurses about what they had missed. Some

interviewees also noted that there was a lack of suitable systems in place to ensure systematic communication between nurses and IPCCs:

Ward manager 1: I think there are some [IPCC] personalities we have that are very, very good and they regularly come to the ward and go through the files and pick people up and ask the nurses who are there at that time, what they think should be done and all the rest of it. But with the

multidisciplinary meetings it tends to be sort of us grabbing them on the way out or I think quite commonly with us is the ward physiotherapist who lets us know what is going on.

Ward manager 2: It is not consistent, there is no clear cut approach like ‘we go to the ward meeting and this is how we communicate it back

effectively’. There is no real clear cut way of ensuring that takes place apart from [the IPCCs] will document in the notes about it, but as I say its not verbalised and it doesn’t always get verbalised to anyone, and they might not necessarily tell you all the pieces…if you have got to do

something, then they will come and tell you but I don’t think it’s consistent enough. That is the trouble, it is not consistent enough that you can rely on it. (Focus group extract, 13049C)

What is also of importance here is the level of acceptance of this way of working by the vast majority of interprofessional team members. Nurses clearly saw the attendance of IPCCs at meetings in their place as an advantage given the demands of their other nursing responsibilities, although one ward manager felt that there should be consistency in whether or not nurses were attending:

One ward manager said, because there was clearly variability at the moment as to whether or not nurses were at the meetings, we should make a decision once and for all whether or not nurses should be at the meetings - there was no sense in the current situation, either you need a nurse there or you don’t. (Field note extract from meeting with ward managers, 06060: 37-47)

No other team members raised concerns, with the exception of one registrar interviewed.

[The IPCCs] take over the nurse’s role for the other wards at the

multidisciplinary team meetings. It’s always a junior doctor who leads the multidisciplinary team meetings27 and the absence of nursing means that it is too easy for the doctors. Nurses are not really involved in the social side of things which is a shame - I would like nurses to contribute more to the team meetings, so if they have got something important to say, they have an opportunity to say it. I have worked somewhere else where the multidisciplinary team meetings were nurse-led and that worked well. (Doctor, 23029, Int)

This general lack of concern either signals an acceptance of the difficulties nurses had in attending these meetings and/or a view that IPCCs were performing

effectively in their substitution for nurses. What is clear is that, however

unsystematic communication systems may have been between nurses and IPCCs, the IPCC role masked the absence of nurses at the meetings, at least to some degree. Given the reliance nurses had on IPCCs, it would also appear that they had reduced the impetus for the nurses or any other team members to think about what changes could be made to improve nursing input to the meetings.

I didn’t realise this was such an issue about the nurse representation at these meetings because I must admit I very rarely go to them, but that’s because I feel very confident in that if there’s a problem with a patient, or you need nurse representation I will tell [our IPCC] and she will be able to represent me and I think if it was absolutely vital that I was there or one of the nurses was there we would obviously try and get there, but I just feel that you know its not always the best use of our time. I mean there’s no point in having [the IPCC] there who is perfectly able to say if the patient could do this, that or the other, and me as well. (Ward manager, 21060N, FG)

To summarise the impact of the IPCC role on interprofessional working, it is clear that the role was highly valued by many of the IPCCs’ interprofessional colleagues. This is in spite of a sense by many interviewed that they did not fully understand the role or who does what in discharge planning, although their understanding had grown over time. The role had altered the patterns of communication between team members. Some team members saw this as an advantage, while others saw this as a disadvantage. The role had also reduced the input that nurses had into some interprofessional team activities. Interprofessional colleagues identified few disadvantages to this practice. Nurses generally saw this practice as positive, given their responsibilities elsewhere, but no systems are apparent from the observation data that ensured clear communication between nurses and IPCCs.

These findings reflect that the IPCC role has had an impact in a number of ways on interprofessional working. The findings in the previous chapter and in this section also point to the importance of examining some emerging issues that may impact on patient care, particularly the competency of the IPCCs in what they do and where the accountability lies for their work. The role shift into work previously undertaken by registered nurses, the liaison role the IPCCs have taken on within the interprofessional team and the key role they play at the weekly

interprofessional meetings have different implications for the impact on patient care depending on the level of competency of the IPCCs. Similarly, an indication that nurses and IPCCs do not have communication systems in place to enable the substitution at the weekly interprofessional meetings, the confusion noted by some practitioners about who does what and the leadership and decision-making

elements of IPCC work signal the importance of looking more closely at their regulation and supervision, and the impact of these arrangements on patient care. The next section examines the impact of the role on patient care, in particular focusing on these issues of competency and accountability.