|Keywords:||Medical anthropology; Medical error; Teamwork; Collaborative care; Multidisciplinary rounds; Ethnography; Anthropology, Medical and Forensic; Anthropology, Cultural; Health Sciences, General|
|Full text PDF:||http://pid.emory.edu/ark:/25593/r8hfn|
The medical community has increasingly focused on changing its culture. The reasons for this are two-fold – first, culture is hypothesized as a significant driver of mortality from medical error. Second, the rising complexity of healthcare delivery has necessitated the shift from traditional models emphasizing the autonomy of individual practitioners towards interdisciplinary teams. Despite an intense focus on quality improvement, however, healthcare has proven resistant to change and knowledge of how to implement such changes remains extremely limited. The process of cultural change and its conceptualization needs to be better understood by both researchers in anthropology and the healthcare implementation sciences. Ethnographic tools are critical for capturing this complex process of social and cultural change within hospitals. Drawing on methods from both cultural anthropology and healthcare quality improvement, this manuscript is a multi-sited ethnography of inpatient hospital units implementing an intervention called the 'Unit-Based Care Model.' The UBCM was intended to facilitate teamwork between doctors and nurses – including bedside multidisciplinary rounds, safety checklists, and dyadic physician-nurse leadership. This ethnography builds comparative case studies of hospital units in the United States and Australia, drawing on data from participant observation, interviews, and quantitative safety culture questionnaires. The central investigation of this manuscript is one of a curious and unexpected paradox. While the UBCM successfully disrupted norms on one American unit, the intervention had little effect on existing hierarchies on the other. In contrast, the Australian units utilized a different implementation strategy altogether. Explaining this variation requires an understanding of hospital units as cultural systems, and the interactions between UBCM and its local context. Changing Culture in Healthcare illustrates the social and cultural nature of a complex change, and highlights a fundamental epistemological tension between the values of medicine as an evidence-based science, and medicine as an applied practice. This research further demonstrates the utility of the anthropological concepts of meaning and culture, and the clear need for translational social sciences to bridge anthropology and medicine. 1: THE FATAL PARADOX OF CHANGE IN HEALTHCARE 1 – PRIMUM NON NOCERE 1 – THE RISE OF 'PIT CREW' MEDICINE 4 – THE CHALLENGE OF CULTURE IN MEDICINE 7 – EXPERTS IN UNDERSTANDING CULTURE 12 – THE EXPERIMENTAL UNIT 17 – AN ANTHROPOLOGICAL MYSTERY 19 – AN ANTHROPOLOGICAL APPROACH 22 – CAPTURING INSIDERS 27 – TRIANGULATING EVIDENCE 30 – SENSITIZING CONCEPTS 35 – AN OUTLINE 39 – 2: TRIBES IN THE HOSPITAL 43 – LOUIS EVANS, MD 46 – JUNIA MORGAN, RN 59 – THE NEW GAME 83 – 3: THE INTERVENTION AND RITUAL 88 – RITUALS IN THE HOSPITAL 89 – THE EMIC 91 – THE ROUNDS 94 – THE ROUNDS, EXPLORED 97 – THE UNIT-BASED CARE MODEL (UBCM) 112 – IMPLEMENTATION ARTIFACTS AND RITUALS 115 – THE ETIC 119 – 4:… Advisors/Committee Members: Konner, Melvin J (Thesis Advisor), Worthman, Carol (Committee Member), Buchman, Timothy George (Committee Member), Brown, Peter J (Thesis Advisor).