Negotiating Professional Tasks in a Hospital: A Qualitative Study of Rheumatologists and Occupational Therapists in the Management of Hand Osteoarthritis

Figures & data

Table 1 Participant Demographics

	Occupational Therapist	Rheumatologist
Gender
Male	1	1
Female	7	5
Age
Under 40	4	1
40–55	1	4
Over 55	3	1
Years of professional experience with hand OA
Under 2	3	–
2–20	2	5
Over 20	3	1

Table 2 Overview of Empirical Sources for the Two Hospitals

Empirical Source	Hospital A	Hospital B
In-depth interviews with health professionals	Rheumatologists (3) Occupational therapists (3)	Rheumatologists (3) Occupational therapists (5)
Negotiated interactive observation in clinical consultations	Clinical consultations between rheumatologists and persons with hand OA (0)	Clinical consultations between rheumatologists and persons with hand OA (5)
	Clinical consultations between occupational therapists and persons with hand OA (4)	Clinical consultations between occupational therapists and persons with hand OA (7)

Table 3 Codes and Themes Development

Examples of Early Data Driven Recurring Codes	Examples of Refined Codes	Preliminary Themes	Themes
Interviews RTs set the agenda RTs make decisions OT auxiliary role to RT RTs available to support OTs RTs take account of OT ideas OTs adapt own schedule to RT availability RTs have a fuller hospital schedule OTs accept higher rank of RTs Autonomous practices of OTs influenced by RT acceptance Negotiated interactive observations RT exclusive use of private consultation rooms OT consultations in shared spaces Outpatient consultations preplanned in time and space	Elite professional status of RTs in the hospital Hospital organizing based on elite professionals’ needs RTs prioritize what constitutes important and less important work in the hospital Unequal access to and use of clinical space and equipment Routine tasks in the hospital are taken for granted Unanimity in the distribution of tasks	Status differentials between RTs and OTs in the hospital embedded in day-to-day work Medical work at the core of hospital services Hand OA not a priority in acute care settings Ordering of outpatient services influenced by power, prestige, and resources	Hierarchical ordering of hospital work impacts interprofessional negotiations
Interviews RTs evaluate patient referrals RTs diagnose hand OA RTs base evaluations on biomedical principles Difficult to make mistakes in hand OA care RTs decide which patients OTs encounter OT capacity to handle more complex patients OTs know when to consult RTs OTs consult other OTs over ambiguity Challenging to contact RTs when OTs in doubt Biopsychosocial model of care directs OT practice Negotiated interactive observations RTs address diagnostic uncertainties in consultations RTs use ultrasound for diagnostics RTs use ultrasound to inform patients about hand OA	RTs responsible for classifying disease Diagnosing an exclusive task of RTs Conservative RT referral practices impact OT autonomy Few risks in hand OA care enables increased OT responsibilities Complementary forms of knowledge allocate tasks Bidirectional conduct of quality control of clinical work Hospital work rooted in biomedicine	Power to name disease and trajectory with RTs Vertical stratification of knowledge systems Daily work influenced beyond the workplace of the hospital	Diagnostic organization of tasks preserves RT authority
Interviews: Medical treatment alternatives for hand OA scarce Injections and pain medicines RT domain OTs provide recommended treatment OT approaches based in a biopsychosocial care model Hand exercises under OT expertise RTs provide hand exercises upon OT unavailability EULAR recommendations a joint norm Local differences in disease trajectories Negotiated interactive observations: RTs frequent OT area ad hoc OTs use a drawing of a joint to inform patients about hand OA OTs instruct in hand exercises OTs provide orthosis OTs provide information about functional aids	Shared understandings under the influence of rheumatology Uncontested protocols through a joint evidence based approach OTs and RTs do not work on common tasks Boundary crossing initiated from the higher ranking professional Bidirectional professional flexibility in accommodating patient needs	From curing to coping with hand OA shifts professional involvement and responsibilities from RTs to OTs Boundary crossing enacted to get work accomplished in the hospital	Evidence-based recommendations in rheumatology enhance OT professional responsibilities