Communication about patients during ward rounds and verbal handovers: A gender perspective

ABSTRACT

This article investigates gender patterns on how two interprofessional teams communicate about patients in their absence. Thirteen ward rounds and 17 verbal handovers were audio-recorded and analyzed through a qualitative content analysis. The ward rounds consisted of 1 physician and 2–4 nurses. The verbal handovers consisted of 2–3 nurses and as many assistant nurses. The data were collected at a cardiac clinic at a hospital in southern Sweden. The results indicate that when patients acted according to socially-accepted gender norms, the communication among the interprofessional teams was characterized as ‘professional’, including communication primarily about the medical situation of the patient and statements of a non-judgmental nature. When patients did not act according to socially-accepted gender norms, the communication among the interprofessional teams switched to become more ‘informal’, including non-medical oriented statements of a negative nature. When the healthcare workers take the patient’s psycho-social condition into account, as advocated by concepts like ‘holistic care’ and ‘patient-centered care’, the risk for speculation and arbitrariness may increase, especially within interprofessional teams who hold a nursing responsibility for patients. Establishing more defined guidelines of how non-medical aspects should be dealt with are thus of importance to the development of an equitable provision and delivery of healthcare.

KEYWORDS:

• Content analysis
• counter-stereotypical actors
• gender
• holistic care
• patient-centered care
• stereotype actors

Introduction

This article investigates gender patterns in how two interprofessional teams communicated about patients in their absence. Previous research indicates the presence of substandard communication regarding heath care workers’ communication with each other (Berry, 2006; Desme et al., 2013; Kripalani et al., 2007), especially concerning communication within interprofessional compositions (Rovio-Johansson & Liff, 2012; Wauben et al., 2010; Woloshynowych, Davis, Brown, & Vincent, 2007). In addition, communication within interprofessional teams is described as particularly important since these compositions constitute “the way forward” in healthcare when it comes to meet the requirement of the so called “Triple Aim”: improving the individual experience of care; improving the health of populations; and reducing the per capita costs of care for populations (Berwick, Nolan, & Whittington, 2008; Earnest & Brandt, 2014).

In the light of this research, efforts have been made to avoid substandard communication, in order to improve cooperation and ultimately the individual experience of care. Earlier research shows that general cooperation difficulties within interprofessional teams may occur due to insufficient communication skills (van Dijk-de Vries, van Dongen, & van Bokhoven, 2017) and role understanding (Suter et al., 2009) as well as due to a lack of appreciation for other professions’ work (Bjurling-Sjöberg, Wadensten, Pöder, Jansson, & Nordgren, 2017; Dow et al., 2017; Ryland, Akers, Gowland, & Malik, 2017). Therefore, in a variety of regulatory and policy documents (Diskrimineringsombudsmannen, 2012; Socialstyrelsen, 2006; Svensk författningssamling, 1982; 1998), and in specific concepts that are used in healthcare such as ‘holistic care’ (Andreasson & Winge, 2010; World Health Organization, 1994) and ‘patient-centred care’ (Sidani, 2008; Wasson, Godfrey, Nelson, Johnson, & Batalden, 2007), several ideas and suggestions on how to improve communication have been presented. The above-mentioned two concepts and associated ideas are a response to the emerging notion that patients’ own experiences of their ailment and their body should be considered together with psychosocial aspects, which significantly impact the health status of the patient and thereby also the overall quality of life. This broadens the perspective on what health/illness is comprised of by adding social-, cultural-, and environmental aspects to the physiological or biological aspects of health/illness (Margereson & Trenoweth, 2009), which should facilitate for the healthcare staff to make more informed decisions about examinations, treatments and diagnosis. This holistic and patient-centered perspective has been implemented in the Swedish healthcare system during the last several decades (Andreasson & Winge, 2010), and has consequently extended the role of the healthcare worker who now needs to pay attention to the patient’s psychosocial context in addition to the physiological symptoms that the patient may present with (Axelsson, Brink, & Lötvall, 2014; Carlsson, Pettersson, Hyden, Öhlen, & Friberg, 2013; Hedegaard, Rovio-Johansson, & Siouta, 2013; Miracle, 2011). Moreover, the work condition of the healthcare staff has also gained more and more attention the last couple of years as the “Triple Aim” has been extended with psychosocial aspects and renamed as the “Quadruple Aim” (Bodenheimer & Sinsky, 2014; West, 2016). The notion that the well-being of the healthcare staff influences the delivery of care is something that has been described previously, both linked to New Public Management and the administrative and bureaucratic burden it entails (Hedegaard & Ahl, 2013), but also through reports on increasing stress levels (Bodenheimer & Sinsky, 2014) and threats of psychological and physical harm (Sikka, Morath, & Leape, 2015) among healthcare staff.

However, the whole idea of cooperation and “interprofessionalism” has been problematized from an equality perspective. The different sets of collaborative models that are offered benefit not only different staff groups, but also certain patient groups over others. This is evident, for example, through the power imbalance between doctors and other staff, but also due to the fact that different patient groups have different possibilities to comply with the directives of ‘patient-centred care’ and be a cooperating and responsible part in the co-production of care (Fox & Reeves, 2015).

Furthermore, the most common concern in healthcare communication between healthcare workers is the goal of ‘efficiency’. Making the communication more effective and decreasing the number of mis-communications or mis-understandings is often the stated ambition (Enlow, Shanks, Guhde, & Perkins, 2010; Miracle, 2011; Sidani, 2008). This entails that communication merely becomes a question of information transfer between a sender and a receiver, whilst little or no attention is paid towards the qualitative and constructive part that influences how patients emerge as patients in, and through, the communication. Although efficient information transfer is important, it is also essential to consider the qualitative and constructive parts of communication, since they are part of the culture within which healthcare is provided and healthcare actors operate. The communication between healthcare workers is also part of their professional identity (Lingard, Reznick, DeVito, & Espin, 2002) and thereby, ultimately affects the patients as well (Hewett, Watson, Gallois, Ward, & Leggett, 2009). Moreover, such communication also contains patient categorizations that are based on both medical and social factors, which are taken into account in order to legitimize various decisions and actions (Hall, Slembrouck, & Sarangi, 2006). How patient categorization actually takes place has been the subject of numerous studies (e.g., Cooper et al., 2012; Foss & Sundby, 2003) and ‘gender’ and other social positions have been found to have a major impact on the treatment of, and the communication that takes place with, patients within a healthcare context (Lyratzopoulos et al., 2012; Shavers, Klein, & Fagan, 2012; Viswanath & Ackerson, 2011). However, these studies focus primarily on either the healthcare workers’ communication with patients or on the overall efficiency of the communication. The healthcare workers’ communication about patients is an area of research that has not received previous attention, especially with respect to the categorization of patients based on their social positions. Hence, the current interest in this area is directed toward constructions and categorizations that are made on the basis of, or are informed by the patient’s gender (where ‘gender’ is defined as but one marker of the patient’s social position). The choice to pay attention to gender is based on the fact that this social position is possible to identify in the conversations that the staff had about the patients. Other interesting social positions such as educational level, ethnicity, sexual preferences and more, could not be identified in the conversations. Medical factors are also excluded from the study as it is the communicative construction of and categorization of patients who are in focus. All in all, this means that this study contributes with knowledge on how social factors, specifically socially-accepted norms on gender, are taken into account when decisions and actions regarding patients are discussed among healthcare staff.

Background

The communicative construction of and categorization of patients

Depending on the patients alignment with various social positions, they are categorized, spoken to, and treated differently. Thus, certain characteristics are stereotypically ascribed to patients based on their membership to different social positions such as black patients not having the necessary knowledge/capacity to take part in patient-centered dialogue (Cooper et al., 2012) and female patients being more demanding (Ekstrand, 2010; Foss & Sundby, 2003). Furthermore, female and male patients are assumed to be different in regard to communicating (Andersson, Salander, Brandstetter-Hiltunen, Knutsson, & Hamberg, 2008), their attitude towards medical treatment (Ziefe & Schaar, 2011) and their perception of information (Dearborn et al., 2006).

This categorization and communicative construction of patients has been previously analyzed primarily from a patient/healthcare worker perspective. With respect to ward rounds, previous research has mainly focused either on the relationships that exist in the interprofessional teams based on the professions of the different team-members (Bradfield, 2010; Prystajecky, Lee, Abonyi, Perry, & Ward, 2017; Reeves et al., 2009; Walton & Steinert, 2010), their cultural background (Andersson, 2009), or the teams’ communication with the patients (Liénard et al., 2010; Subramony, Schwartz, & Hametz, 2012). When the research focus is on communication about the patient from an interprofessional perspective, it is primarily strictly medical factors that are dealt with and communication is viewed from an efficiency perspective (Blough & Walrath, 2007; Burns, 2011; Desai, Caldwell, & Herring, 2011; O’Leary et al., 2010). This is also the case regarding research on verbal handovers; the efficiency perspective prevails. A large part of this type of research deals with finding practical areas for improvement, such as increasing the amount of information that is transferred within the interprofessional team (Bhabra, Mackeith, Monteiro, & Pothier, 2007; Patterson, 2012; Randell, Wilson, & Woodward, 2011). The few studies that do incorporate the qualitative and constructive aspects of communication merely state that the involved healthcare workers’ attitude can influence the verbal handovers (Thurgood, 1995), and that the interprofessional group who is involved in this specific activity express their shared values about the patients (Philpin, 2006). The existing research suggests that verbal handovers should be characterized by (inter)professional communication and should revolve around the patient’s clinical situation and factors influencing this (Currie, 2002; Malestic, 2003). Despite somewhat narrow focus, studies have shown that up to 50 per cent of the content in verbal handovers is actually irrelevant to the task on hand (Dowding, 2001), and that the activity is more accurately characterized by containing informal communication, instead of professional communication within the interprofessional team (Bomba & Prakash, 2005). Given these results and observations from previous studies, the question emerges: How does the patient’s gender influence the interprofessional teams’ communication about the patient during the ward rounds and verbal handovers? This question remains unanswered in the current literature, thereby adding interest to the present study.

Methodology

This study had an interpretative qualitative approach (Elliot & Timulak, 2005) when studying how the patient’s gender influence the interprofessional team's communication about the patient during the ward rounds and verbal handovers and what type of attitudes and values are mediated during these interprofessional settings. To address these research questions, observations were carried out and subsequently analysed through a qualitative content analysis (Graneheim & Lundman, 2004).

Data collection

The material that was used in this study was collected at a cardiac clinic in southern Sweden between October and December, 2012. The clinic treats all types of heart disease, including angina/myocardial infarction, heart failure, valvular disorder, arrhythmias, and atrial fibrillation. Two sets of interprofessional settings, ward rounds and verbal handovers, that were selected for study after several sample participant observations were made (Bernard, 2012). Through these sample participant observations, appropriate situations where conversations about patients were conducted could be identified. Since there was no access to background information about the patients, the purpose of the observations was also to find the social position(s) that appeared in the conversation, which turned out to be gender. The ward rounds in this study (so-called ‘routine ward rounds’ between nurses and physicians), were later followed by ‘final ward rounds’, which included the patients. However, this type of ward rounds was not included in this study as it was the communication about patients in their absence that was in focus. The two settings were chosen based on the fact that they contained organized- and professional communication about patients. The two settings also differed in their design. During the verbal handovers, there was an in- and outflow of healthcare workers (nurses and assistant nurses), whereas the ward rounds took place under quieter and calmer conditions and consisted of communication between nurses and physicians.

Two meetings were held to properly inform the healthcare workers about the study. The first meeting was with the assistant nurses and nurses, and the second was with the physicians. After the meetings, the healthcare workers received written information about the study where they were provided with the opportunity to give their consent to their participation in the study. All the healthcare workers gave their consent, which meant that ward rounds and verbal handovers could be observed and recorded without any restrictions. A total of 30 interprofessional settings were audio-recorded (13 ward rounds and 17 verbal handovers). The participants consisted of 2–4 nurses and 1 physician during the ward rounds, and 2–3 assistant nurses and as many nurses during the verbal handovers. Among the physicians, all of the participants were men, and among the assistant nurses and nurses all, but one, were women. The author was present when the ward rounds and verbal handovers took place and audio-recorded the settings from start to finish. Given that the focus of the present study was on communication about patients, no actual patient visits were included during the ward rounds. The duration of the ward rounds ranged between 7 and 76 minutes, and the verbal handovers took between 7 and 38 minutes to complete. The taped conversations were later transcribed, which generated 219 pages of text.

Data analysis

The empirical material that was collected (which consisted of the audio-taped ward rounds and verbal handovers described in the previous section), was analyzed by using a method of ‘qualitative content analysis’ (Graneheim & Lundman, 2004), with the interest directed towards both ‘manifest content’ and ‘latent content’. The manifest content primarily consists of content that is found on a descriptive level such as explicitly expressed statements. Latent content, in contrast, involves interpretation on the analyst’s part. Qualitative content analysis can be defined as “a research method for the subjective interpretation of the content of text data through the systematic classification process of coding and identifying themes or patterns” (Hsieh & Shannon, 2005, p. 1278). The point of departure associated with this method is the claim that there are always multiple meanings about, and perceptions of, reality (Graneheim & Lundman, 2004). Consequently, the goal of the analyst is to identify and analyze condensed- and broad descriptions in terms of concepts or categories that express one or several understanding(s) of a particular phenomenon (Elo & Kyngas, 2008).

The first step of the analysis consisted of comprehensive readings of the transcribed material, in order to get an estimation of the content. Through this procedure, different ways of communicating about the patients appeared as evident, and meaning units were subsequently identified. In the second step, the material was sorted through further readings and the meaning units that were previously identified were condensed. In the third step, the condensed meaning units were assigned codes to illustrate the overarching content contained therein. This included (i) non-evaluative communication about patients, and (ii) evaluative communication about patients. In the fourth step, the codes were sorted into two sub-themes; ‘neutrality’ and ‘belittlement’. These two sub-themes clarified the manifest content that consisted of variations in the way healthcare workers communicated and by the different attitudes that were displayed towards the patient(s) who were being spoken of at the time. In the fifth and final step of the analysis, the categories were further explored in order to reveal the latent content, which generated two themes: (i) patients acting according to socially-accepted gender norms are unquestioned, and (ii) patients acting according to socially-accepted gender norms are questioned. These two themes constituted the response to how the patient’s gender influenced the healthcare workers’ communication about them during the ward rounds and the verbal handovers. The socially-accepted norms are taken-for-granted truths based on gender stereotypes about how women and men should be and act such as for example, that women should be caring and emotional while men should be competitive and self-confident (Kite, Deaux, & Haines, 2008).

Trustworthiness

Shenton (2004) presents four concepts that are important for qualitative research in terms of trustworthiness; ‘credibility’, ‘transferability’, ‘dependability’, and ‘confirmability’. The credibility of the study is supported by the author providing a clear overview of the central phenomena through previous research, unequal healthcare with reference to communication and gender/social positions in this case. Regarding the specific context for this study and the internal validity, the author carried out approximately 100 hours of sample participant observations (Bernard, 2012) at the clinic in order to find appropriate settings that offered professional communication about patients among healthcare workers in interprofessional teams. This detailed view of the phenomena, together with an extensive description of the context and the actual implementation of the study, enables others to make comparisons between the present study and other studies, thereby suggesting the transferability of the results along with the dependability of the study. Finally, the section where the analysis is presented, explains the point of departure for the interpretation of the empirical material, and, together with a presentation of the study’s limitations, the confirmability of this study should be increased.

Ethical considerations

Ethical approval was obtained for the study from the National Ethics Committee in Stockholm, Sweden (Dnr Ö 5–2012).

Results

In the two different interprofessional settings described above, the communication about the patients differed. The search for latent content revealed that the patients’ relation to gender stereotypes (as perceived by the healthcare professionals) was of particular interest. Whether the patient acted according to socially-accepted gender norms or whether the patient acted in a way that was incompatible to socially-accepted gender norms influenced the type of communication that took place during the ward rounds and the verbal handovers. Two themes emerged from the analysis of these conversations; gender-stereotypical behaviour is unquestioned and counter-stereotypical behaviour is questioned. These themes represent different types of communication about patients in their absence from a gender perspective within the two sets of interprofessional teams. The overall occurrence of statements that were in line with these two themes was higher during the ward rounds than during the verbal handovers. The majority of the statements during both the ward rounds and the verbal handovers were expressions of professional communication with focus on strictly medical aspects. There were, however, multiple examples of informal communication, including judgments of a non-medical and a degrading nature as well. Statements in line with the two themes emerged when the patients acted according to socially-accepted gendered norms (correlating with the production of professional communication), or when the patient acted in a manner that was incompatible with socially-accepted gender norms (correlating with the production of informal communication). The excerpts below clarify how utterances that corresponded with the two themes were expressed.

Gender-stereotypical behaviour is unquestioned

In the cases where the patients acted according to socially-accepted gender norms, the healthcare worker’s communication about the patients was characterized by a professional approach. The healthcare workers’ statements primarily contained information about strictly medical aspects and the statements that did contain non-medical content was neither judgmental nor degrading of the patient. The patients acted according to gender expectations, something which did not lead to any evaluations of a non-medical nature. In such cases, the professional communication continued as usual, and did so more often within the interprofessional teams during the ward rounds compared to the corresponding teams during the verbal handovers. Note however, the excerpt below, from a verbal handover. The interprofessional team communicates about a female patient’s concern about her husband being home alone:

A:

But she is a bit worried because it’s she who takes care of her husband. He’s had some TIA-attacks and is a bit weak, so she thinks it feels a bit tough…

B:

It has become worse since they poked around because she wasn’t like this…

C:

I don’t think she is the same as when she sought care but…

A:

Otherwise, I think she was quite stable yesterday when I had her..

B:

Yes, but she had some pain…

The female patient who is being referred to above is described as being worried about her husband. The fact that a female patient with a severe heart disease expressed concern about her husband at home, attracted little attention. The stereotype of a woman as being nurturing and attentive was confirmed through her concern for her husband, which was mentioned without judgment on the part of the healthcare workers. This characterized much of the communication about the patients who acted according to socially-accepted gender norms. In the excerpt below, the remarks made during a ward round address a similar situation, but it concerns the situation of a male patient instead:

A:

He lives with a fit and healthy wife and he told me today that “I would very much like to go home”, but I said I think that…tomorrow I said then

B:

But even if I put it off…then he’s not getting it tomorrow but..

C:

He has not received it, he’ll get it tonight actually, so he has not had any today..

A:

Well…no…okay..

C:

So..because of that, we might be able to try, but it’s..as you say, then there’s only four..

A male stereotype emerges here in this exchange; it consists of the patient’s wife being described as ‘fit and healthy’, which can be seen as an expectation from the healthcare workers’ side, in the sense that they hold the expectation that the male patient will be cared for by his wife. These differences (when we compare this exchange to the previous excerpt in terms of attentiveness) are quite remarkable in the sense that it is the female patient in the first excerpt who is referred to as providing care and attention, while in the second excerpt, the male patient is referred to as receiving care and attention from his wife. Thus, two diametrically different ways of communicating about these patients can be observed; despite the fact that they are both heart patients who are hospitalized and are about to be sent home. Note too, how they assume socially-accepted gender norms (in terms of assuming that the unequal spousal roles between men and women in the domestic setting is applicable to both of the patients referred to above) which remain unnoticed, in the sense that these unequal spousal roles are not subject to any judgment or disparaging remarks from the healthcare workers. In the following two excerpts from verbal handovers, female patient’s tearfulness is mentioned, and sympathetic understanding is expressed by the healthcare workers before they continue their conversation about the patient’s medication and legitimate concern respectively:

A:

She is tearful, it’s a lot for her. She was on prevastatin but it was removed because she gets such a pain of it. Spironolactone today and set on gabapentin, this little capsule of 100 milligrams

B:

Did we have available or?

A:

Yes, we had it available

A:

She got so sad, she had been in there and cried a lot and I had to sit and hug her

B:

In the afternoon, she also got a little pressure and she got breathless as soon as she breathed, and she found it difficult

The four patients who were spoken of in the excerpts above were living up to expected gender norms (in the eyes of the healthcare workers). Regarding the first two patients, they were living in relationships characterized as ‘caring’, which, allowed them to be allocated different positions with respect to receiving and giving care. In the excerpts involving the third and fourth patients, another female stereotype is confirmed’ the female patients’ sensitivity is first taken note of, but by immediately moving on to medical-oriented content and confirming the expressed concern, the healthcare workers avoid evaluating and/or judging this stereotype. Instead, they affirm the stereotype by expressing understanding for the tearfulness/sensitivity. These types of statements occurred quite frequently in the total of 30 settings that were analyzed. When the patients acted according to socially-accepted gender norms, the healthcare workers were able to engage in professional communication about the patients.

Counter-stereotypical behaviour is questioned

In the cases where the patients did not act according to socially-accepted gender norms, the healthcare workers’ communication about their patients was characterized by an informal approach. This meant that their communication, besides containing statements about (expected) medical content, also included judgments of a non-medical and somewhat degrading nature. There were several instances where the patients’ behaviour went against prevailing norms, prompting a communicative shift; from a professional- and medical-oriented approach to an informal and judgmental approach. This type of communication occurred more often within the interprofessional teams during the verbal handovers when compared to the corresponding teams during the ward rounds. In the excerpt below, the interprofessional team is performing a verbal handover in which the female patient’s loudness and lack of docility attracts attention:

A:

She has probably slept herself, but she talks in her sleep and screams at the ladies that they have taken her coat, in her sleep and lies there and screams and she, nah it’s the hags, she said, the hags they’re taking my coats and she nags on. It’s often like this, I said

[Laughter among the healthcare workers]

A:

She screams all the time

The female patient is described as ‘nagging’’ prompting (somewhat insensitively) one of the healthcare workers to imitate the patient and repeat a statement that the patient had made earlier in the day. Judging by the subsequent reaction and statement, it seems that the motive behind the healthcare worker’s imitation of the patient was not to reach a better understanding of the patient and her condition, neither was necessary medical information communicated to the rest of the team members. The healthcare worker’s remarks, instead, can be understood as a comment on the patient not acting according to socially-accepted patient- and gender norms with respect to showing gratitude, for example. The communicative shift is quite apparent here. The instance of imitation (which was met by laughter) represents an informal, non-medical oriented and judgmental act of communication. During another verbal handover and then a ward round, sadness among male patients was discussed:

A:

But this is a man who is a bit depressed, his wife passed away not long ago and very tearful, crying as soon as you look at him, but now he’s mostly disappointed and sour instead

B:

Maybe we should put him on the single so he does not bother anyone else?

A:

He wasn’t pleased with that

A:

He is dizzy and sad

B:

But he says he’s been dizzy at home too, in the morning

A:

There’s nothing to be sad about when New Year’s Eve is coming

B:

Great

C:

Finally!

A:

Yes, it’s about time

C:

Well maybe we should do an abdominal biopsy after all

The male patients were perceived as ‘oversensitive’ and they do not live up to the male stereotype of being strong. When we compare these remarks with the excerpt above (concerning the tearful female patient), it seems clear that the male patients were perceived as not acting according to socially-accepted gendered norms, thereby prompting the communicative shift to an informal and judgmental approach on the part of the healthcare workers. Below, a female patient’s leg is being discussed during a ward round. The discussion quickly switches to the topic of treating the appearance of the leg from an aesthetic perspective:

A:

The question is how much weight she has lost, because she had quite hefty legs and then I saw that she was a bit marbled on .. did you see it or? She was a bit marbled there ..

B:

Yes, yes

C:

You notice such things (laughter)

B:

She is swollen and is so big around her legs ..

A:

It’s a rather dull sight

C:

Yes absolutely

A:

So swollen

B:

It looks…well not nice to say the least

C:

I would’ve been devastated

A:

Yes me too

B:

Mmm…

The communicative shift occurs in all of the excerpts presented in this section, but what is of interest is not the shift itself but, rather, what the informal communication consists of. A female patient who does not show any gratitude but, instead, appears as fairly demanding; two male patients perceived as tearful; and a female patient with unattractive legs are the triggers in this respect, and consequently, these “actions” from the patients’ side were subject to judgement by the healthcare workers. The judgments were rather unflattering. In the first case, the healthcare workers entertain themselves at the patient’s expense. In the second and third cases, the tearfulness is mentioned in a rather contemptuous way, suggesting that the perceived ‘excessive’ tearful behaviour is unjustified, despite the fact that the first patient’s partner had recently passed away and that both patients suffered from severe heart failure. In the fourth case, the healthcare workers spent time discussing the aesthetic value of a symptom, from their own perspectives. These types of statements were not nearly as common as the statements linked to the previous theme. However, when patients acted incompatibly to socially-accepted gender norms, a communicative shift from professional communication to informal communication became apparent.

Discussion

The purpose of this study was to examine gender patterns in how two interprofessional teams communicate about patients, in their absence. First, the results of the study indicate that the degree to which patients follow socially-accepted norms influences the nature of the communication about these patients. Second, the communication about the patients varied, depending on which norms were at play. Third, the attitudes and values held by the interprofessional teams were brought to the fore when the patients were perceived as violating the norms, and thereby lead to the expression of judgmental statements. Previous studies have also demonstrated that certain characteristics are ascribed to patients which are based on the patients’ affiliation to different social positions (Cooper et al., 2012; Ekstrand, 2010; Foss & Sundby, 2003). This study finds that such characteristics are not only ascribed to the patients, but judgments are also made about the patients. Whether they are positive or degrading, the judgmental statements may be regarded as what Dowding (2001) termed as ‘insignificant content’, falling into the category of informal communication, which is characteristic of verbal handovers (Bomba & Prakash, 2005). The fact that not only strictly medical content was expressed during the ward rounds and verbal handovers, but that informal communication was also given space, presented both advantages and disadvantages. Positive statements may add to a positive professional culture, and even if such statements might be considered redundant or unnecessary in a professional setting where time-space is limited, such statements are not necessarily controversial but the degrading judgmental statements are. Because communication about patients is a major factor which forms and informs a healthcare worker’s professional identity (Lingard et al., 2002), uttering degrading, judgmental statements about patients can result in creating further disadvantages for the patient in the future. The professional identity of the healthcare workers is, in turn, part of a professional culture, wherein common ways to communicate, act, and relate to the patients (and each other) becomes routine and taken-for-granted (Kvarnström, 2008).

When the two sets of interprofessional settings are analyzed separately, the informal and judgmental statements were more frequent during the verbal handovers than during the ward rounds. The practical circumstances of the two settings differed markedly, even though they both contained ‘communication about patients’. The different conditions and arrangements in the two sets of interprofessional settings can be seen as examples of what Fox and Reeves (2015) described as unequal conditions when it comes to the possibilities to work in accordance with holistic care and patient-centered care. This might provide some explanation as to why the informal- and judgmental communication that took place had the distribution it had. The physicians, who tend to dominate the ward rounds, drive the ‘medical discourse’ forward, while it is the nurses that dominate and drive the ‘nursing discourse’ forward. The nursing discourse, of which the interprofessional teams that carried out the verbal handovers are a part, provides wider- and more ‘open contextual’ understandings of the patient when compared to the ‘medical discourse’, which provides narrower and more ‘contextually demarcated’ understandings of the patient (Kitson, Marshall, Bassett, & Zeitz, 2012). Even though the medical discourse was challenged by the nurse discourse (upheld by the participating nurses) during the ward rounds, the medical discourse tended to prevail due to the higher value credited to the physicians’ competency domain (Suter et al., 2009) based on the traditional hierarchical order within healthcare (Bjurling-Sjöberg et al., 2017). As a consequence, the focus in the communication ended up primarily around the medical situation of the patient, which may explain the fewer statements about social-, cultural-, and environmental aspects and thereby also less utterances of informal, judgmental and arbitrary nature. During the verbal handovers, the nursing discourse was not challenged as both participating groups (nurses and assistant nurses) upheld the discourse.

However, informal and judgmental statements were made during the ward rounds as well. It should therefore be in everybody’s interest to reduce the presence of belittling attitudes towards patients and prevent such attitudes from getting a foothold in the professional culture, and thereby, ultimately, running the risk of affecting interpersonal treatment negatively. The provision of quality care which respects everyone’s equal value and the dignity of the individual is mandatory in the Swedish and international healthcare communities (Committee on Quality of Health Care in America, 2001; The National Board of Health and Welfare, 2006), and this includes verbal handovers, as well as ward rounds.

The results of the present study question the communicative approach that is advocated in holistic care. Questions are also raised as to which extent social- and non-medical communicative content should be dealt with in healthcare communication (Andreasson & Winge, 2010; World Health Organization, 1994). The essential feature of holistic care is that the individual, as a whole, is in focus, instead of just the person’s illness (World Health Organization, 1994). As Strandberg, Ovhed, Borgquist, and Wilhelmsson (2007) have shown, this entails, inter alia, that nowadays, healthcare workers are expected to be interested in the patient’s so-called ‘hidden agenda’; namely, what a patient says is necessarily not what he/she means, and the patient’s social context. The realization that a human being is a complex social being is in itself not a problem, quite the contrary, but the possibility of arbitrariness, speculation, and potential infractions in the delivery of healthcare remain present. This fits poorly with another discourse that is dominant in healthcare; the discourse of science, proven experience, and evidence-based medicine.

Concluding comments

The present study has shown that when we closely examine communication about patients, the presence of negative and disparaging judgmental statements may well be the consequence of interprofessional teams perceiving patients as not acting according to socially-accepted gender norms. This perception triggers a communicative shift from professional communication to informal communication. In the latter communicative setting, a judgmental approach, including negative statements, appears to be more accessible to the healthcare workers. Undoubtedly, the concepts of ‘holistic care’ and ‘patient-centred care’ have advantages, and it is generally accepted that social- and non-medical aspects are important parts of healthcare delivery, but more distinct guidelines are needed which will reduce the risk of arbitrariness (in the delivery of healthcare) and ensure equal treatment for all patients. For practicing healthcare professionals, the results of this study indicate that the development of deeper knowledge with respect to communication, in general, is needed and more specifically, we need further awareness of how one’s own perceptions and stereotypes affect our communication about others.

Limitations and future research

The fact that specific patients were not followed during the study is one limitation on this study. Had specific patients been followed, it would have been possible to explore the potential consequences of negative and disparaging judgmental statements towards patients who were considered to be not acting according to socially-acceptable norms. As things stand now, it is merely the presence of the negative and disparaging judgmental statements and how these are expressed that has been scrutinized. Moreover, the study was conducted at a cardiac clinic where many of the patients were returning patients. This may lead to fairly close relationships developing between some of the patients and healthcare workers, which can explain part of the somewhat ‘overly familiar’ atmosphere. A comparative study between the cardiac clinic and one or more other clinics would therefore add further robustness to this line of enquiry.

Acknowledgments

I would like thank the health care workers who participated in the study. Many thanks also to Professors Helene Ahl and Airi Rovio-Johansson for critical readings of the article.

Disclosure Statement

The author report no conflicts of interest. The author alone is responsible for the content and writing of this article.

Additional information

Funding

This study was founded by the School of Education and Communication, Jönköping University together with VINNVÅRD, a research program that includes The Ministry of Health and Social Affairs, Vårdalstiftelsen, VINNOVA (Sweden’s Innovation Agency) and The Swedish Association of Local Authorities and Regions;VINNOVA [A2008-026].