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Keywords:

  • anaesthesia;
  • boundaries;
  • communities of practice;
  • ethnography

Abstract

  1. Top of page
  2. Abstract
  3. The ‘crisis’ in anaesthesia
  4. Distributing work across a nursing-medical boundary
  5. Teamwork differentiated: method and theoretical resources
  6. Access, boundaries and their effects
  7. Regulating participation: processes and effects
  8. Acknowledgements
  9. References

The distribution of work, knowledge and responsibilities in the delivery of anaesthesia has attained particular significance recently as attempts to meet the demands of the European Working Times Directive intensify existing pressures to reorganise anaesthetic services. Using Lave and Wenger's (1991) notions of ‘legitimate peripheral participation’ in ‘communities of practice’ (and Wenger 1998) to analyse ethnographic data of anaesthetic practice we illustrate how work and knowledge are currently configured, and when knowledge may legitimately be taken as the basis for action. The ability to initiate action, to prescribe healthcare interventions, we suggest, is a critical element in the organisation of anaesthetic practices and therefore central to any attempts to reshape the delivery of anaesthetic services.


The ‘crisis’ in anaesthesia

  1. Top of page
  2. Abstract
  3. The ‘crisis’ in anaesthesia
  4. Distributing work across a nursing-medical boundary
  5. Teamwork differentiated: method and theoretical resources
  6. Access, boundaries and their effects
  7. Regulating participation: processes and effects
  8. Acknowledgements
  9. References

Pilnick and Hindmarsh (1999) argue that anaesthetic practice is accomplished by anaesthetic teams in collaboration with the patient and emphasise the necessity to understand how anaesthetic work is created in interactions. This interaction becomes increasingly salient when service reconfiguration and redistribution of work within the anaesthetic team is being considered. In the UK medically-qualified anaesthetists currently provide general and regional anaesthesia for operative procedures, they practice in high dependency and intensive care, provide obstetric epidural services, and acute and chronic pain management services. The ‘New Deal for Junior Doctors’ restricted the amount of time junior doctors spend training and working in hospitals (Simpson 2004) and, consequently, has significantly reduced the numbers of medical staff available to deliver anaesthetic services. In turn, this has limited the time available for consultant anaesthetists to provide training and supervision and lead commentators to suggest that staffing was near ‘crisis point’ (Seymour 2004, Simpson 2004). Exacerbating these difficulties (Simpson 2004) is the European Working Time Directive which introduced a 58-hour maximum working week in August 2004 (HMSO 2003).

The Royal College of Anaesthetists have responded to this ‘crisis’ by attempting to improve the flexibility and accessibility of anaesthetic training, and potentially to reshape the service by delegating some work to non-medically trained specialist practitioners, such as developing a ‘respiratory therapist’ role in intensive care, and by midwives providing the epidural service. Nurse anaesthetists provide general anaesthesia overseas but development of this role in the UK remains contentious (NHS Modernisation Agency 2003). Policies such as The NHS Plan (Doff 2000), and Shifting the Balance of Power (DoH 2002) encourage the development of new roles, service reconfiguration, modernisation and new ways of working. Little, however, is known about how work and knowledge are at present distributed amongst anaesthetic teams and how this may affect attempts to reshape anaesthetic services. The ability of individual practitioners to organise their own activities, and, crucially, those of other professionals, will have implications for how anaesthesia is reorganised. Alongside the redistribution of specific tasks, responsibilities and knowledge, we suggest the circumstances in which practitioners can legitimately initiate action should be considered.

Distributing work across a nursing-medical boundary

  1. Top of page
  2. Abstract
  3. The ‘crisis’ in anaesthesia
  4. Distributing work across a nursing-medical boundary
  5. Teamwork differentiated: method and theoretical resources
  6. Access, boundaries and their effects
  7. Regulating participation: processes and effects
  8. Acknowledgements
  9. References

Anspach (1987) argues that differentiation between medical and nursing knowledge is linked to the character of the work doctors and nurses perform. Doctors and nurses engage in different sets of daily experiences that define the character of knowledge available to them. Anspach found that physicians in neonatal intensive care had limited contact with patients and relied heavily on diagnostic technology. Nurses, in contrast, relied upon ‘interactive’ cues or ‘gut feelings’ they gleaned from continuous contact with infants. The organisation of the neonatal intensive care unit provided an ‘ecology of knowledge’, a hierarchy structuring different types of work and providing access to different forms of knowledge. According to Anspach, these forms of knowledge do not carry equal weight in decision making; the knowledge that neonatal physicians employed was prioritised by virtue of it being technologically generated and processed, whereas the worth of interactive cues, on which nurses relied, was actively devalued (Anspach 1987: 229).

Svensson (1996: 384) also recognised that ‘nurses get to know and observe the patient in an entirely different way from doctors’. However, Svensson argues that this differentiation does not disadvantage nurses; rather, doctors depend on nursing knowledge. Svensson highlights how changes in the organisation of nursing have increased the opportunities for nurses’ involvement in decision making, but he indicates that nurses are still wary of encroaching on medical terrain:

many [nurses] emphasise that they are somewhat careful when it comes to the ‘purely medical’. This is viewed as intruding upon another's area of competence, and as calling for some caution against presenting oneself in a way that appears challenging (Svensson 1996: 388).

The distribution of work and knowledge becomes increasingly complex as Allen (1997) describes how, when pressed, nurses routinely undertake a range of duties that fall outside their jurisdiction. Nevertheless, where it was possible to avoid additional responsibilities, nurses did so:

Nurses, however, had not simply incorporated this work into their everyday practice; rather, they undertook informal boundary-blurring work when the doctor was unavailable. When doctors were physically present on the ward, nursing staff adhered to hospital policy and asked the doctor to carry out these tasks (Allen 1997: 511–2).

This shift was not simply a delegation of medical responsibility to nurses; rather it was a response to organisational difficulties and an acknowledgement of the heavy workload doctors faced. Allen points out that such boundary-blurring work often means ‘breaking the rules’; nurses working beyond their formal boundaries are unsupported by organisational policies and are potentially exposed to disciplinary action. Allen also found the nurse's confidence and the extent to which s/he trusted individual doctors influenced the distribution of work between doctors and nurses, again highlighting a nurse's vulnerable position.

Tjora (2000) examined the ‘boundary-spanning’ activities undertaken by nurses in Norwegian emergency communication centres in which nurses handle requests for medical assistance in both emergency and routine cases. When prioritising emergency visits, nurses constructed descriptions of patients in particular terms to influence what the doctor did. When doctors were unavailable, nurses would ‘regularly draw on professional experience, and pooled knowledge of colleagues to try to diagnose patient's conditions over the phone’ (Tjora 2000: 733). As in Allen's study, such ‘boundary-spanning’ activity occurred only when doctors were absent. Whilst these boundary-spanning activities optimise the use of doctors’ time they inhibit nurses from taking ownership of ‘diagnosis’ and underestimate the complexity of nurses’ judgements.

These studies indicate that the distribution of work amongst healthcare practitioners is often organised flexibly and tacitly. The character of the work may change subtly depending on who undertakes it, and the work may be re-labelled. This delicate ordering of healthcare work is rarely scrutinised (Hindmarsh and Pilnick 2002: 141). In one of the few studies to look at the accomplishment of teamwork in anaesthesia, Hindmarsh and Pilnick show how anaesthetists and operating department practitioners (ODPs work in a manner comparable to theatre nurses) are simultaneously attentive and respond to one another's actions whilst engaged in seemingly individual tasks:

Part of learning to be an anaesthetist or an ODP is about developing expertise in reading the embodied conduct of colleagues. The uninitiated do not have an intimate understanding of the potential or likely trajectories of action that will emerge when a colleague has picked up a gas mask, lifts a mask from the face of the patient or approaches with a syringe at particular moments within the anaesthetic room activities. (Hindmarsh and Pilnick 2002: 152).

They observed how talk, ostensibly directed at the patient, served to camouflage collaboration with their colleagues. Hindmarsh and Pilnick direct attention towards the moment-to-moment practices that order and accomplish anaesthetic work. Such customary practices are implicated in the construction of boundaries between anaesthetists, ODPs and nurses, and the distribution of knowledge as we outline below.

Teamwork differentiated: method and theoretical resources

  1. Top of page
  2. Abstract
  3. The ‘crisis’ in anaesthesia
  4. Distributing work across a nursing-medical boundary
  5. Teamwork differentiated: method and theoretical resources
  6. Access, boundaries and their effects
  7. Regulating participation: processes and effects
  8. Acknowledgements
  9. References

The data used in this paper were collected for an ethnographic study of expertise in anaesthesia (financed by the NHS North West R&D Fund, project grant number RDO/28/3/05), between April 2000 and April 2001, in two NHS hospital trusts in the UK. For this study 34 anaesthetic ‘sessions’ were observed at the primary fieldsite, and five at the second site for comparative purposes. Typically a ‘session’ involved obtaining consent from anaesthetists, patients and theatre staff, then accompanying an anaesthetist for approximately four hours during an operating theatre list, a morning in intensive care or a period of on-call work. Contemporaneous field notes were taken and transcribed. We observed anaesthetic work in surgical specialties such as general and vascular, trauma and orthopaedics, obstetrics and gynaecology, ear, nose and throat, maxillofacial and dental, ophthalmics, paediatrics and day case surgery, and included practitioners ranging from novice ‘trainee’ anaesthetists and newly qualified ODPs to consultants, nurses and ODPs of up to 25 years experience. Occasionally, it was possible to ‘debrief’ with the anaesthetist, sometimes immediately following the observation period, allowing for discussion and clarification on their practice (on one occasion, discussed below, the debrief showed that the observational data had led to an inaccurate assumption), and twice using the observation transcript as an aid for reflection. The observation was primarily undertaken by the first author, a former anaesthetic nurse at the primary field site, and the particular ethical issues that arose are discussed elsewhere (Goodwin et al. 2003). We also conducted interviews with 20 staff selected to reflect the range of roles, levels of skill and expertise described above. These were tape recorded and transcribed, lasted between 30 minutes and two hours, and varied in style and purpose, some being quite general and exploratory, and others focused on a critical incident or a recent episode from the interviewee's practice.

In this paper we are concerned with anaesthetic work in relation to anaesthesia for operative procedures, we do not therefore discuss anaesthetic work in intensive care, pain clinics or other areas. We focus on instances that arose in which the limits of a participant's practice were questioned, with a view to elucidating the processes and patterns through which practice is organised and knowledge is generated. We enlist the concept of ‘legitimate peripheral participation’ (Lave and Wenger 1991) in ‘communities of practice’ (Lave and Wenger 1991 and Wenger 1998) to help explore how these boundaries are created and sustained.

A community of practice has three dimensions. In the first –‘mutual engagement’– participants work together contributing to a dense network of working relationships. The second dimension is a ‘joint enterprise’; this is the lynchpin holding the community together. This is not a given objective, it is the result of collective negotiation. Thirdly, the community must have a ‘shared repertoire’ of routines, words, tools, ways of working, stories, gestures, symbols and actions (Wenger 1998). Lave and Wenger's (1991) study of apprentices and Wenger's (1998) later study focused on single occupations. When practitioners from different disciplines form a community of practice the boundaries within the community become important, as we will show, rather than those at the margins, which Wenger discusses.

The anaesthetic community of practice, as configured in the operating theatre, consists of an ODP or an anaesthetic nurse, an anaesthetist and a recovery nurse. The ODP/anaesthetic nurse prepares for and receives the patient from the ward into the anaesthetic room, and assists the anaesthetist in the provision of anaesthesia. Although ODPs and nurses have different professional backgrounds, a factor that has engendered considerable dispute (Timmons and Tanner 2004) in our study, nurses with a specialist anaesthetic qualification and ODPs were considered as interchangeable in a practical sense, for example, on work allocation rotas. We do not, therefore, elaborate on the distinctions between nurses and ODPs. The anaesthetist – a consultant or ‘trainee’ (so-called as s/he will be enrolled on a seven-year specialist training programme), working either alone or together – assesses the patient, plans and administers the anaesthetic, monitors the patient throughout the surgery, then withdraws anaesthesia and prescribes care for the recovery period. A recovery nurse then takes responsibility for the patient in the immediate post-operative period until the patient can be transferred out of recovery. In addition to these core members, the community of practice may also include medical, nursing and ODP students. This community practises in three main environments – the anaesthetic room, the operating theatre and the recovery room – each environment involving further marginal members; these include ward nurses in the anaesthetic and recovery areas, and surgeons and scrub nurses in theatre.

Lave and Wenger (1991: 35) use ‘legitimate peripheral participation’ to describe ‘engagement in social practice that entails learning as an integral constituent’. For them, knowledge is located within the community, not within individuals, and learning occurs through ‘centripetal participation’, implying movement towards the centre as participation in practice increases:

For newcomers, their shifting location as they move centripetally through a complex form of practice creates possibilities for understanding the world as experienced (Lave and Wenger 1991: 122–3).

Whilst the ‘centripetal’ participation of nurses and ODPs is constrained by the boundaries of their occupation, the term ‘legitimate peripheral participation’ remains useful in underscoring these multiple overlapping learning trajectories and the limits to their development. Following Lave and Wenger's argument, that learning is shaped by the distribution of tasks and that attaining legitimacy to practice is more important than formal instruction, we suggest that the acquisition of legitimacy affords a kind of security clearance, enabling access to restricted areas, opportunities and experiences. Newcomers need an introduction or a sponsor to legitimate their presence, but like security clearance, legitimacy is stratified: the role to which a newcomer aspires correlates with the level of legitimacy, and with the rights to practice that they are granted.

Access, boundaries and their effects

  1. Top of page
  2. Abstract
  3. The ‘crisis’ in anaesthesia
  4. Distributing work across a nursing-medical boundary
  5. Teamwork differentiated: method and theoretical resources
  6. Access, boundaries and their effects
  7. Regulating participation: processes and effects
  8. Acknowledgements
  9. References

Below, we follow some of the disputes that occurred when the boundaries of a nurse's or ODP's practice were questioned. These struggles illustrate some of the issues Lave and Wenger suggest are integral to learning: the level of access permitted and the degree of legitimate participation. We discuss how limited participation affects the development of knowledge and subsequently the potential a practitioner has to inform anaesthetic practice.

Regulating access: preserving practices

Induction of anaesthesia occurs in the small anaesthetic room adjoining the operating theatre where access is usually limited to those who have a practical function to perform. In the excerpt below a consultant anaesthetist and a trainee, approaching the end of her anaesthetic training, are assisted by a senior ODP, and the ‘I’ in the data is the researcher. All names are pseudonyms and data editing is indicated by ‘( . . . )’. Quotes are near verbatim and ‘. . .’ indicates missing fragments. For reasons of expediency the surgeon wants to perform the first procedure, the extraction of two teeth from a child, in the anaesthetic room. The consultant anaesthetist does not object but the ODP does. As we join the scenario the child is lying on a trolley having only just been anaesthetised. As in this case, the application of routine monitoring devices before inducing anaesthesia is sometimes waived for young children, with the monitoring being applied immediately after induction:

The surgeon enters the anaesthetic room, goes round to the right hand side of the patient ( . . . ) and then pulls the teeth out. There is an exchange between the surgeon and the ODP that I don't catch. Someone (either the consultant or the ODP) says ‘Put the monitoring on!’

Consultant: ‘Done?’

Surgeon: ‘Yes, better find a specimen bottle for these’. He leaves the anaesthetic room ( . . . )

Consultant: ‘Pop her on her side’. The child is turned onto her side and the cot-sides of the trolley are raised. He looks at the ODP: ‘I’ll ask him not to come in the anaesthetic room for the next one’. The consultant is assembling the oxygen mask. The black face mask is replaced with the oxygen mask.

The surgeon returns and places the specimen bottle, containing the teeth, under the child's pillow. He turns to the ODP: ‘Sorry Steve, it was just . . .’ The ODP interjects: ‘No, my objection was right’. He takes the patient to Recovery with the trainee anaesthetist.

The anaesthetic room is a nexus of anaesthetic knowledge and expertise; it is where monitoring is applied, ‘lines’ and catheters are introduced, the patient is rendered unconscious, breathing tubes are inserted, and ‘nerve blocks’ (pain relieving techniques) are performed. The surgeon's encroachment of this territory disrupts routine anaesthetic practices aimed at safeguarding the patient: he removes the teeth before the monitoring is attached. In the recovery room afterwards the consultant anaesthetist went on to concede that the surgeon should be excluded from the anaesthetic room:

‘. . . I have no problem with you (researcher) being there but Steve (ODP) has already complained about four times this morning that there are too many people in the anaesthetic room . . . he's got a point actually, we should have put the monitoring on first . . .’ ( . . . ) We go back into the anaesthetic room and begin preparations for the next patient.

Consultant: ‘Fentanyl please’.

ODP: ‘That's what I was saying, you can't keep him [the surgeon] out’. (whilst opening the controlled drug cupboard).

Consultant: ‘You’re right, we should have put the monitoring on first’.

Access to the anaesthetic room permits exposure to anaesthetic room practices and the knowledge suspended within them. Such practices must be observed in order to preserve anaesthetic knowledge, expertise and patient safety. The above incident outlines how knowledge and expertise can be spatially bounded and protected as legitimate access to marginal actors is awarded and revoked. We now look at the boundary disputes between core members of the community which display how work, knowledge and practices are distributed, giving rise to a range of practitioner identities.

Inside the community: legitimacy disputed

Legitimate forms of participation become even more contentious where anaesthetic nurses, ODPs and trainee anaesthetists are concerned. This issue is played out between the ODP and the trainee anaesthetist later the same morning. Explanations of technical terms and devices are in italics:

As I enter the anaesthetic room the trainee anaesthetist and the ODP are present and the patient is lying on a trolley already anaesthetised. The trainee stands at the head of the patient and the ODP by the patient's shoulders and next to the anaesthetic machine. The trainee removes the laryngeal mask (LM – a device inserted into the throat of an unconscious patient to hold open the airway and allow for ventilation). The ODP takes a new face mask out of a packet. I look at the oxygen saturation monitor, it is reading 100 per cent, the patient looks pink, normal colour. ( . . . )

Consultant: ‘Is it just a poorly fitting LM?’

Trainee: ‘Umm’.

ODP: ‘It's not down far enough’. (He seems to answer for the trainee.)

Trainee tries to reinsert the LM, she is unsuccessful.

ODP: ‘Come round this side . . .’ (gesturing to the right hand side of the patient).

Trainee: ‘I will try it my own way, please, if you don't mind’. She reinserts the LM.

Consultant: ‘It's turned, you can tell it's not in right because the black line is twisted’. (A black line runs along the upper side of a reinforced laryngeal mask.) Trainee removes the LM.

ODP: ‘Come round this side . . .’ Trainee follows the ODP's instructions and successfully inserts the LM.

Consultant: ‘You've just made Steve (ODP) a very happy man. (ODP secures the LM with tape.) You happy?’ to the trainee, she nods.

Here, the ODP contests the trainee's expertise attempting to instruct her how to insert the airway device – a simple technique usually mastered early in an anaesthetist's career. This trainee is experienced and approaching the end of her training. She is somewhat resistant to this attempt to instruct her, but when a further attempt fails she successfully follows the ODP's directions. There is a palpable tension that the consultant recognises and which his light-hearted observation about making the ODP a ‘happy man’ is designed to dissolve. This incident raises questions about the extent to which different community members’ participation is legitimated. After the session, the consultant commented on the incident:

It was obvious as soon as we walked in the room the LM wasn't in the right place and I think they had removed it by that time. What had happened was Steve (ODP) had put the cannula in and then put the LM in, and it wasn't in right, now it doesn't matter to me who puts it in. . . .  Fatima (trainee) removed it and was trying to reinsert it, and Steve was trying to tell her how to do it, she said she wanted to do it her way. ( . . . ) The important thing was that she took it out and tried from the side, the way Steve had suggested and it went in. ( . . . ) I have no problem with Steve telling people how to do things, it doesn't matter to me who it is.

This consultant is perhaps unusually egalitarian concerning the distribution of tasks. The tension noted earlier reflects the perceived illegitimate participation by the ODP. Wenger (1998) suggests that a learning trajectory defines a member's identity and the consultant's commentary here indicates that the ODP was appropriating experiences central to the development of the anaesthetist's identity. The ODP had apparently cannulated the patient, then incorrectly positioned the LM which the trainee removed. The ODP continues to assert his expertise by answering the consultant's questions and instructing the trainee. (It is perhaps worth noting that the debrief revealed the full sequence of events, something we would have missed if reliant only on the observational data.) Although ODPs may develop anaesthetic knowledge and skills, undertaking such procedures impinges on the rights of a trainee anaesthetist both to develop the skills themselves, and crucially, to perform the techniques and procedures that define their identity. Wenger et al. (2002: 146) refer to the potential of communities to stratify participants creating distinct classes of members as a ‘community disorder’. We use ‘stratified legitimacy’ to refer to the extent to which an individual's participation is contingent upon their professional identity, but see this not as something to be remedied (although modification may be desirable) but as a constitutive element in the organisation of healthcare to be engaged and studied.

Fortifying professional boundaries

In contrast to the scene above, the next scenario illustrates a more usual distribution of work and knowledge, and indicates how the stratification of legitimate participation – who has the right to question, to act, in which circumstances – is continually reaffirmed. In an interview, a consultant anaesthetist recalls an incident in which a very ill elderly patient had a cardiac arrest on induction. After giving a combination of drugs to induce anaesthesia and paralysis, the patient went very pale and the team were unable to feel the patient's peripheral pulse:

We all looked at each other for a couple of seconds and we were all saying the same thing: shall we, shan't we? It took maybe 10 seconds to establish she hadn't got a carotid pulse either and I felt that we probably had to do cardiac massage. ( . . . ) after the second brief episode of cardiac massage ( . . . ) she just suddenly restored an output, and then under the influence of the adrenalin she had a heart rate of 100 and a blood pressure 200/100 and she very, very quickly pinked up. ( . . . ) I said ‘well let's get on and put the lines in’ at which stage I think John (ODP) and Priya (trainee anaesthetist) found it a bit too much because they just said ‘I don't think you should be going on any further’. That's where I think they had a valid point. You could question what on earth they are doing saying that in an anaesthetic room in that circumstance, and I found that quite challenging actually, particularly from John. I think with Priya it's OK, because Priya is in a position of training to make those decisions, so Priya has a right to know why I'm doing that. ( . . . ) John has to do what you ask.

Whilst this scene has not been observed the consultant's account does convey his approach to appropriate participation. The consultant strongly positions himself as the arbiter of legitimate participation; the trainee anaesthetist had a valid right to question the consultant's decision because her professional trajectory points to full membership as a consultant anaesthetist. In contrast, the ODP's questioning was challenging because his professional trajectory reifies his peripheral status. The legitimacy of the ODP's participation is restricted to the level of performing prescribed tasks, its ‘centripetal’ movement constrained. The consultant returns to this issue:

I was actually very angry that he challenged me in the middle of that but in a sense he was right, he was playing it by the book. If we were going to resuscitate this woman we should do it properly, get a few more people along, you know give X mgs of adrenalin, according to a protocol, defibrillate at X joules. But ( . . . ) this is my patient, only I know what her medical history is, and only I know how difficult it is to resuscitate somebody with aortic stenosis. Therefore, only I am competent to make the decision as to whether or not we progress. I don't need six theatre nurses who have all been on an ALS course telling me what drugs to use!

This interview suggests that whilst nurses and doctors learn alongside one another on ‘Advanced Life Support’ courses, and must demonstrate the same competencies, in practice the opportunities for participation are once again stratified with doctors retaining the interpretive, diagnostic and prescriptive functions, and ODPs and nurses typically performing the prescribed tasks.

The effects of stratified legitimacy on knowledge resources

The above discussion indicated how access and legitimate participation are regulated so as to reaffirm occupational boundaries and support the customary distribution of practices. The scene below illustrates how this stratification of legitimate participation affects the resources a participant has to guide anaesthetic care. A consultant anaesthetist, a trainee, a medical student and the senior ODP (featured in the first scenario) are working together. As we join the scenario the trainee anaesthetist is ventilating the patient and the ODP stands beside him waiting to assist when inserting the laryngeal mask (LM).

ODP is holding the LM.

Trainee: ‘I’ll just give her a bit more (anaesthetic) . . .’ he connects the propofol syringe to the cannula and injects. He ventilates then lifts the face mask off. ODP holds the LM hovering over the patient's face. Trainee: ‘No, not yet. (He repositions the guedel airway – a device to prevent the tongue falling back and occluding the airway.) Is she biting her tongue? No (quietly)’. He continues ventilating, holding the face mask on with one hand and squeezing the reservoir bag with the other, he repositions the face mask and then resumes ventilating. ( . . . ) The trainee lifts the patient's jaw and holds the mask on with both hands and looks at the reservoir bag, it moves but is not clearly inflating and deflating. The patient makes muffled groaning noise. ( . . . ) The trainee turns the Sevoflurane (anaesthetic gas) down from eight per cent to five per cent. The reservoir bag is now clearly inflating and deflating.

Consultant: ‘So you can see what Peter (trainee) is doing, getting her deep and settled so she will accept the LM . . .’ (to the medical student). Trainee lifts the face mask off and suctions, he hesitates but the ODP inserts the LM, it stays in position.

Trainee: ‘That's good’. Moments later patient coughs. ‘Oh mama mia’.

Consultant: ‘This is where 20 a day doesn't help . . . airway irritable. She looks like she's trying to cough the LM out. She is breathing down the anaesthetic so she might actually settle (to the medical student) . . .’

Here the ODP and the anaesthetists evaluate the depth of anaesthesia differently. The ODP relies on ‘current’ knowledge to interpret the depth of anaesthesia whereas the anaesthetists draw on information from the preoperative visit – the patient is a smoker and will therefore have an ‘irritable airway’ necessitating a deeper level of anaesthesia for insertion of the LM. Excluded from the preoperative assessment, the ODP has fewer resources to evaluate the patient's condition and appropriately inform the course of anaesthetic care.

Another example of how the stratification of participation limits the ODP's knowledge resources occurred in the operating theatre. Surgery is already underway and the consultant and ODP stand together looking at the anaesthetic machine.

Consultant mentions the CO2 (carbon dioxide measurement).

ODP: ‘What are you thinking? MH?’ (MH – Malignant Hyperthermia, a rare inherited disorder triggered by anaesthetic agents, characterised by climbing temperature and a high carbon dioxide)

Consultant: ‘I'm not really thinking MH, he's had too many anaesthetics, but he shouldn't have a CO2 of that either’. ( . . . )

(Later, during a quiet period, I ask whether the consultant was worried about the CO2 measurement.)

Consultant: ‘Yes, because the trace didn't drop to the baseline which means that he will have inspiratory CO2 which you shouldn't have at all. ( . . . ) So that means either a leak in the circuit or MH, it's unlikely to be MH as he has had too many previous operations’.

The consultant's problem solving involves the interleaving and verification of many sources of knowledge, but ultimately the patient's medical history mitigates against a diagnosis of malignant hyperthermia, details available to the anaesthetist, but not the ODP.

Initiating action: the persuasive potential of knowledge resources

We now examine the resources ODPs and nurses do have, and their potential to inform the course of anaesthesia. We draw on data set in the recovery room. Of all operating theatre roles, recovery nurses are possibly the most autonomous (Timmons and Tanner 2004). Practising independently, facilitating the ‘emergence’ of patients from anaesthesia, the need for recovery nurses to inform the course of events is perhaps more acute, and their activities therefore more distinct, than for anaesthetic nurses and ODPs who assist doctors. Below a recovery nurse describes how a patient in her care deteriorated following a routine operation. Suspecting an internal haemorrhage the recovery nurse repeatedly raised her concerns with the consultant surgeon and suggested a blood transfusion might be necessary. After briefly examining the patient this suggestion was rejected. The nurse then spoke with the trainee anaesthetist who administered the anaesthetic and obtained a prescription for a blood transfusion. The recovery nurse continues:

Kate (the patient) continued to slowly deteriorate over the course of the morning and at 12.20 I was extremely concerned, agitated and frustrated, having continuously raised my concerns strongly to all involved parties, I felt unsupported and ignored. Kate by this time appeared pale and clammy, her blood pressure was being maintained with colloid (type of fluid) infusion but her conscious level was deteriorating and it was becoming difficult to rouse her. ( . . . ) Again I voiced my concerns, this time with the surgical senior trainee as the consultant had left. During my conversation with the senior trainee Kate's blood results returned from the laboratory. Kate's haemoglobin was recorded at 6.8. It was now obvious that Kate was haemorrhaging internally but by now she was visibly and physiologically shocked. Despite Kate's critical condition the senior trainee remained reluctant to take Kate back to theatre without first discussing it with the consultant surgeon. ( . . . ) The consultant anaesthetist in charge of the critical care directorate (entered and) ( . . . ) quickly assessed the situation, and began to make immediate arrangements for six units of blood to be transfused as a matter of urgency and for Kate to return to theatre ( . . . ) whereupon following an emergency laparotomy it was discovered that she had been haemorrhaging from a small incision to her liver.

This incident was not observed. The interview data, however, do highlight how the need for nurses and ODPs to persuade other participants to act orientates their work. The recovery nurse develops an account of the situation but the solution lies outside her remit. She cannot prescribe a blood transfusion or perform surgery so must persuade the doctors to act. Later in the interview the nurse indicated the different resources the nurse and the surgeon draw on:

The surgeon was so reluctant ( . . . ) because she didn't display the typical textbook signs of haemorrhage. ( . . . ) I can remember saying to him ‘you need to look at this patient as a whole, look at her holistically, don't look at her vital signs look at her, she has deteriorated’. He said ‘Well how's she deteriorated, her blood pressure hasn't got any lower?’, ‘Look at her, she was conscious before, she was easily rouseable, she was warm, alright she was pale, but now she's pale, clammy, hypothermic, and I'm having to put a warming blanket on her, and she's not easily rousable. ( . . . ) Look at the patient, don't look at the monitors, look at her!’

The lack of ‘textbook’ indicators strip the nurse of the resources with which to persuade the surgeons to act. The surgeons rely on measurements, which are partly being offset by the manipulation of the fluid infusion. Interestingly, the recovery nurse was able to persuade the anaesthetists. The work of anaesthetists and recovery nurses are closely aligned, both adjust their care to the effects of a surgical intervention, they look for the same signs and indicators and come to appreciate the significance of the less tangible signs. However, the boundaries of her profession dictate that the nurse must rely on persuasion and cannot initiate action. Legitimacy regarding diagnosis and prescription is retained within the boundaries of medical practice.

Regulating participation: processes and effects

  1. Top of page
  2. Abstract
  3. The ‘crisis’ in anaesthesia
  4. Distributing work across a nursing-medical boundary
  5. Teamwork differentiated: method and theoretical resources
  6. Access, boundaries and their effects
  7. Regulating participation: processes and effects
  8. Acknowledgements
  9. References

Hindmarsh and Pilnick (2002: 158) describe teamwork as ‘a practical accomplishment that emerges despite the fact that team members often have unequal power or status’. We have focused on the ways in which status, as configured in identities, is developed and achieved through the stratification of legitimate participation in anaesthetic practice. We have also elaborated how a differential in knowledge develops, and the effects this has, in terms of initiating action, for the nurses and ODPs of an anaesthetic team.

Lave and Wenger's (1991) concept of legitimate peripheral participation highlights the processes through which different roles and identities are sustained. We have demonstrated that legitimate access and participation are stratified in line with professional or occupational identity. Our departure from Lave and Wenger (1991) and Wenger (1998) is our focus on a multidisciplinary community. The ‘joint enterprise’ to provide safe anaesthesia for operative procedures is partitioned across the members of this community of practice. However, the peripheral positions of the ODP and the nurse are not transitory resting places for apprentices as they develop a skill and move on; rather they are designated forms of engagement. One can engage in anaesthesia as an ODP, a nurse or an anaesthetist but movement between these positions is not endorsed. Lave and Wenger's emphasis on legitimacy elucidates members’ responses to attempts to cross boundaries – the exclusion of the surgeon from the anaesthetic room, the friction between the ODP and the trainee anaesthetist when he appropriated anaesthetic responsibilities, the consultant's anger as the ODP questioned his judgement – because movement outside accepted boundaries jeopardises another's identity.

Wenger's (1998) discussion of boundaries focuses on those that encompass the community and that overlap with other communities. Our analysis has concentrated on the boundaries within a community that distinguish and contain the different members and their participation. Legitimate participation in the anaesthetic community of practice involves occupying one of the ‘peripheral’ positions and performing the tasks consistent with that role. Development here is not a seamless progression towards a central position, there may be some overlap between positions but there are significant constraints on the ‘centripetal movement’ of nurses and ODPs. Developmental trajectories are contingent upon the adoption of a peripheral position and the degree of legitimate participation awarded in line with that identity. Consequently, the nurses’ and ODPs’ participation is capped, limiting the resources they have to participate and influence the care of the patient.

The effects of these disciplinary boundaries are felt in terms of initiating action: when the required intervention falls outside a participant's remit, initiating action hinges on persuading other participants to act. Stein's (1967) classic analysis of the doctor-nurse game indicates that this need for persuasion is not new. Indeed, Hughes (1988) describes how nurses do not necessarily cloak their suggestions, but are at times decidedly forthright about their recommendations. Prowse and Allen (2002) suggest that the ‘routine’ or ‘emergency’ status of the clinical situation is particularly relevant in shaping nurse-doctor interaction. They describe how nurses adopted a diplomatic and sensitive approach when acting in ways that blurred occupational boundaries in routine situations, whereas in emergencies, status differences were less influential. Our study suggests a need also to consider the orientation of different doctors – anaesthetists and surgeons – and indicates that successfully persuading others to act requires legitimate access to the same resources. Doctors do not draw only on technologically produced measurements, and nurses/ODPs do not only use ‘interactive cues’, other configurations are possible. The perspectives of anaesthetists and recovery nurse in the final scenario are closely aligned, they interpret the significance of both the technologically-produced measurements and the subtle signs in the same way. This runs counter to Anspach's (1997) suggestion that ‘information from diagnostic technology assumes a superior epistemological status’ (1987: 219).

Allen (1997) and Tjora (2000) show how nurses undertake work that blurs the boundary between medicine and nursing, particularly when doctors are unavailable, and Tjora contends that nurses do perform diagnostic activities, but do not take ownership of it. Our analysis supports this assessment and goes further to illustrate how and why this is problematic. The recovery nurse accurately diagnoses an internal haemorrhage but encounters difficulty when initiating a course of action as those practitioners required to act disagree with her assessment. Lacking legitimacy to prescribe care, her only option is to attempt to persuade another participant whose role formally legitimates the necessary activity. Such persuasion points to how, in order to achieve optimal care of a patient, nurses and ODPs routinely operate beyond the official boundaries of their role. A tension arises when this informal means of organising care fails: officially and unofficially the practitioner has no means of securing appropriate care of the patient.

If the reconfiguration of NHS anaesthetic services follows current trends towards increasing use of protocols and clinical practice guidelines (Timmermans and Berg 2003) the development of non-physician anaesthetists is likely to be a protocol-guided service. This means that whilst the scope of practitioner's work may increase the overall shape of the service, and the relationships between the participants, would remain much the same with doctors retaining their diagnostic and prescriptive capacities, and nurses and ODPs implementing the prescribed care. It is likely that this ‘new’ arrangement will inherit the same problems as the old, in that boundary ‘blurring’ will still be necessary but it will remain obscured. When working across boundaries, nurses and ODPs will continue to be unsupported by organisational policies precisely because diagnosis and prescription lie outside the boundaries of their practice. A more radical reconfiguration of the service, to meet the staffing crisis identified in the introduction of this paper, would require challenging the legitimacy of current boundaries, and re-stratifying participants’ access to knowledge and resources that enable them to practice.

Acknowledgements

  1. Top of page
  2. Abstract
  3. The ‘crisis’ in anaesthesia
  4. Distributing work across a nursing-medical boundary
  5. Teamwork differentiated: method and theoretical resources
  6. Access, boundaries and their effects
  7. Regulating participation: processes and effects
  8. Acknowledgements
  9. References

We would like to thank all the patients and staff who participated in this study and the anonymous reviewers whose comments were most helpful in improving this paper.

References

  1. Top of page
  2. Abstract
  3. The ‘crisis’ in anaesthesia
  4. Distributing work across a nursing-medical boundary
  5. Teamwork differentiated: method and theoretical resources
  6. Access, boundaries and their effects
  7. Regulating participation: processes and effects
  8. Acknowledgements
  9. References
  • Allen, D. (1997) The nursing-medical boundary: a negotiated order? Sociology of Health and Illness, 19, 4, 498520.
  • Anspach, R.R. (1987) Prognostic conflict in life-and-death decisions: the organization as an ecology of knowledge, Journal of Health and Social Behaviour, 28, 21531.
  • Department of Health (2002) Shifting the Balance of Power: the Next Steps. Available from http://dh.gov.uk/assetRoot/04/07/35/54/04073554.pdf[downloaded on 29th June 2004].
  • Department of Health (2000) The NHS Plan: a Plan for Investment, a Plan for Reform. Available from http://www.nhs.uk/nationalplan/nhsplan.pdf[downloaded on 29th June 2004].
  • Goodwin, D., Pope, C., Mort, M. and Smith, A. (2003) Ethics and ethnography: an experiential account, Qualitative Health Research, 13, 4, 56777.
  • Hindmarsh, J. and Pilnick, A. (2002) The tacit order of teamwork: collaboration and embodied conduct in anaesthesia, The Sociological Quarterly, 43, 2, 13964.
  • HMSO (2003) The Working Time (Amendment) Regulations. Available from http://www.hmso.gov.uk/si/si2003/20031684.htm[downloaded on 25th October 2004].
  • Hughes, D. (1988) When a nurse knows best: some aspects of nurse/doctor interaction in a casualty department, Sociology of Health and Illness, 10, 1, 122.
  • Lave, J. and Wenger, E. (1991) Situated Learning: Legitimate Peripheral Participation. Cambridge: Cambridge University Press.
  • NHS Modernisation Agency (2003) Anaesthesia practitioner trial under way, New Ways of Working, Winter 2003, 34.
  • Pilnick, A. and Hindmarsh, J. (1999) ‘When you wake up it’ll all be over’: communication in the anaesthetic room, Symbolic Interaction, 22, 4, 34560.
  • Prowse, M. and Allen, D. (2002) ‘Routine’ and ‘emergency’ in the PACU: the shifting contexts of nurse-doctor interaction. In Allen, D. and Hughes, D. (eds) Nursing and the Division of Labour in Healthcare. Basingstoke: Palgrave Macmillan.
  • Seymour, A. (2004) Non-medical delivery of anaesthesia, Bulletin 24. Royal College of Anaesthetists.
  • Simpson, P. (2004) The Impact of the Implementation of the European Working Time Directive to Junior Doctors Hours on the Provision of Service and Training in Anaesthesia, Critical Care and Pain Management. Available from http://www.rcoa.ac.uk/docs/ewtd.pdf[downloaded on 29th June 2004].
  • Stein, L.I. (1967) The doctor-nurse game, Archives of General Psychiatry, 16, 699703.
  • Svensson, R. (1996) The interplay between doctors and nurses – a negotiated order perspective, Sociology of Health and Illness, 18, 3, 37998.
  • Timmermans, S. and Berg, M. (2003) The Gold Standard: the Challenge of Evidence-Based Medicine and Standardization in Health Care. Philadelphia: Temple University Press.
  • Timmons, S. and Tanner, J. (2004) A disputed occupational boundary: operating theatre nurses and Operating Department Practitioners, Sociology of Health and Illness, 26, 5, 64566.
  • Tjora, A.H. (2000) The technological mediation of the nursing-medical boundary, Sociology of Health and Illness, 22, 6, 72141.
  • Wenger, E. (1998) Communities of Practice: Learning, Meaning, and Identity. Cambridge: Cambridge University Press.
  • Wenger, E., McDermott, R. and Snyder, W.M. (2002) Cultivating Communities of Practice: a Guide to Managing Knowledge. Boston, MA: Harvard Business School Press.