We present the analysis of the FGDs under the following three major headings: Conceptualization of professional domains; Organization and leadership issues; and Communication forms, strategies and processes. The impact of existing hierarchies, including how they are conceptualized and acted out in practice, was noted throughout these data.
Conceptualization of professional domains
RT RNs’ perspectives of their domain
One of the main challenges the RT RNs described in their professional role was the integration of humanistic patient care into the high-tech RT environment. The RT RNs said they had too little time for nursing care in the 10-minutes allotted to each patient, although they described themselves as “specialists in the short encounter” (FGD #1). They said this problem was somewhat compensated for by having special clinics for particular patient problems (e.g. for patients with head and neck cancers experiencing eating difficulties, weight loss, pain, etc). On the other hand, throughout the FGDs, RT RNs’ descriptions of an ideal day did not include reference to patient care, but involved: all technological equipment working without problems; patients arriving on time; full staffing without sick leave or other absences; and a well-prepared RT preparation process for each patient, completed in advance. Although this description is consistent with the complexity of the RT RN role noted above, it points to difficulties in maintaining a patient focus, highlighting the ‘conveyor belt’ organization of RT care.
This organizational complexity may be one factor involved in the sense of a general passivity and resignation expressed by the participating RT RNs. RNs were unanimous in their conviction that they lacked possibility to change their working conditions and had little or no impact on decision-making. When discussing how decisions were made, one RT RN said:
RN1: “It feels like I stand…pretty far down on the hierarchical ladder. I’m the one who works, works, works, works all the time, all day long, but I make no decisions…I’m not involved and have no influence in any way…someone else has to influence things for me” (FGD #2).
This nurse continues after a few minutes in dialogue with a colleague:
RN1: “I think that there are pretty many decisions that I don’t have the possibility of influencing…sometimes it feels a bit powerless actually…And I think that I hear this from many of my colleagues”.
RN2: “It [efforts to influence change] will just fail anyway, and I think you…especially if there are a lot of patients, and people are stressed—then you don’t have the energy to deal with things, and especially if you know that you aren’t even going to be heard…” (FGD #2).
This lack of power appears to be internalized by RNs, who describe a lack of agency in matter-of-fact terms as well. One frequently occurring example of this is that RT RNs often identified themselves in terms of the geography of their workplace, personifying the “corridor”, “RT room” or “machine” with which they work: ”Some rooms are more generous than others” or “we have rooms that don’t understand why we book more patients” (FGD #2).
It is also notable that in all the FGDs with RNs, there is an initial explicit denial of the existence of a hierarchy between professional groups working at the RT units, although the language used tends to reinforce hierarchical thinking, e.g. “when doctors decide something amongst themselves, there can be poor information comingdownto us, but they have so very much to do” (FGD #6). This is further reinforced by a RN, external to the RT unit but with a position demanding close contact with the unit, who explains the role of the nurse in general without questioning: “We ease the jobs of other and are praised for that” (FGD #3).
Other professions’ perspectives of RT RNs’ domain
The RT RNs’ ambition to integrate good patient care with their provision of high-tech treatments was not always supported. In the FGD with other professionals, one MD indicates both through words and tone of voice a blatant criticism of what is considered RNs’ undue pampering of patients, saying that:
“Nurses are very keen that patients can come in almost right away and then leave. And they get the patients used to [this]. And then they attend to the patients so carefully. You should be able to work in a different way, and then take a real coffee break and relax” (FGD #4).
This physician also describes the RT RN role in terms of “RT machine hours”, seeing the RN function as equivalent with treatment production, and the inclusion of nursing care in the RT unit as time-consuming and clashing with effective treatment of large numbers of patients. This tension is also expressed in other ways, not only through the words used, but also through a critical tone of voice and body language:
…”when they [RT RNs] take the patients into the treatment room and when they are in the room, they talk to them and such, and afterwards as well. So I think there is a whole lot of time given to nursing care” (FGD #4).
This MD describes RT RNs’ nursing role as primarily psychosocial. An assistant nurse states that many physical care needs are also not within the realm of the RT RN, instead describing the assistant role as a “consultant” (FGD #2) for RNs, including both assessment and management of e.g. skin reactions for patients undergoing RT.
On the other hand, the same MD as above also expresses—albeit indirectly—respect for the RT RNs’ competency and role, suggesting that doctors should have a mandatory auscultation with RT RNs each year, even if only to appreciate the importance of the physician responding quickly when the RN pages the MD.
Most tension is described between the groups of RT RNs and physicists, particularly at one RT site, due to what both professional groups describe as a lack of clarity and clear lines of demarcation between their professional domains. As one physicist says: ”…[there are] different ways of handling things … I don’t know exactly what the division [of responsibility] should be and what the rules are and so…” (FGD #4).
The same physicist explains this further, saying:
“in my experience, this is absolutely not an area of conflict. What I can see sometimes is that … RNs … think the physicists aren’t really actively initiating things, and so maybe the RNs start to do things that actually should be up the physicists”.
In general, other professionals’ descriptions of RT RNs are not personally negative; RT RNs are seen on the whole as receptive to teaching, engaged in their work, and supportive of others, although there is limited congruence in RT RNs’ own conceptualization of their role and that expressed by other professional groups at the RT unit.
Organization and leadership issues
As mentioned above, role differentiation was least clear between RT RNs and physicists. The RNs at one site often used derogatory language when describing interactions between these professional groups; this interestingly occurred at the RT site where RNs expressed their own professional position as strongest. RNs considered a variety of organizational reasons for this, as shown in this dialogue:RN1: “They [physicists] have a very difficult role here with us, and I think they haven’t found their own position yet, where they should be…that’s the problem, that they don’t know which piece they should be involved in…”RN2: “But at brachytherapy they’ve managed, they found their role here, assignments and tasks are much clearer, who does what”.RN3: “And there theydosomething. Here with us they just stand around and watch” [laughter].
RN4: “And it can’t be much fun to just stand and watch and then sit in your room…maybe that’s the problem” (FGD #1).
The moderator interjects here, asking if physicists function as consultants. A fifth RN responds, clarifying that that RNs have traditionally been responsible for the RT set-up process, only contacting physicists if they deemed it necessary, but that new routines call for team involvement from the onset: “Yeah, that’s the way we usually use them, if we have a problem, we call! They haven’t always been booked in advance, but now they say that they want advance notice…”
It seems that this lack of clarity and overlap in responsibility is a complicating factor in the RT organization, and is also compounded by a lack of clarity in hierarchical relationships, as RN1 above also points out: “And I would say the physicists are also fighting to try to have a higher position than that they actually have here with us…fighting their way up”.
This lack of clarity in organization has a number of problematic effects. In addition to pointing out an ineffective use of resources, a sense of mutual disrespect is expressed by both groups, who make generalizations about categories of staff. Individual contacts with particular staff members are relied on for smoothing the way in problematic situations, rather than more stable organizational solutions.
Ineffective use of a wide variety of resources is a recurring theme in the FGDs. MDs complain that RNs are protective of their territory, rather than considering how RT as a whole might be reorganized to be most effective: “We are lacking RT RNs, that’s a bottleneck today, how many ‘machine hours’ can we have? If we were to have more machine hours, more staff, we could get rid of the queues. But it is set in stone, that RNs protect their own” (FGD #4).
On the other hand, RNs, MDs and engineers—although not physicists-- all express criticism of the general organization with different structures deciding rules, norms and policies for the different professions involved in the RT process in the FGDs, although RT needs to be tightly coordinated to run without hitches. In addition, unanticipated service needs for machinery cause problems, with engineers critical of RNs’ lack of understanding of the engineer’s role in addressing such problems.
RNs are recognized to be the ones left to deal with the patient, when RT preparatory work is not completed in time, machines malfunction, and other professionals are delayed or remain absent. RNs describe being caught between their loyalty to the MDs they work with and patients’ needs for access to RT; the RNs describe providing care and service for both these parties, but not for engineers or physicists.
We had expected leadership issues to be a more prominent part of the FGDs; such discussions instead focused on informal leadership and formal management. As one RN criticized:
"“We have invisible leaders. The managers are sitting far from RT and walking around in their private clothes and only come around for guest appearances…the head nurses that is, who barely have an idea of what we do in the treatment rooms” (FGD #1)."
Despite these criticisms there was a lack of consensus about the need for visible leadership, with some arguing “the tougher the situation, the more important with good leadership” (FGD #3) and others stating: “it’s good for us not to have a boss there on a daily basis” (FGD #2). On the other hand, there was agreement in a lack of faith in the complicated organizational hierarchy, with multiple levels of managers with little clinical knowledge and experience of the workings and needs of the RT unit. But this situation was also seen to leave a vacuum, allowing the proliferation of informal leaders among MDs and physicists, with backing from previous department heads. Informal leadership is thus accepted and institutionalized with parallel structures developing, instead of changes proposed in accordance with the hospital-wide first-line management policy newly in place. This situation may be in part in response to the merger between hospitals, as a means of maintaining existing power structures informally. An example of this is one MD declaring himself to be “the extended arm of the department head—his eyes and ears” (FGD #4).
The development of informal structures is only one of the remaining effects of the hospital merger. This is evidenced, e.g. by differences in nursing culture, with one site being called “hell” and the other “heaven” by a RN with work experience from both. A remaining hierarchy was also described, with one site said to be favored: “X site decides…all the bosses come from X site” and slurs about medical breadth and competence at the other site. One the other hand, some participants in the FGDs do acknowledge that after several years, a shared system with benefits for RT staff and patients has been developed. Other staff point out tensions that also exist between different units on the same geographic site, and even between different teams on the same unit.
Communication forms, strategies and processes
Communication is generally described as based on ad hoc behaviors and solutions in impromptu encounters, rather than occurring through systematic and planned forms and processes. Information within and between professional groups is described as occurring ‘on the fly’. This appears not to be a matter of choice, but a result of the lack of structures for information transfer. As one RN says:
“…there is this ‘flying information’ that I am totally allergic to. That you get new information at the same time as you are doing other things. You aren’t receptive…what I miss are short sittings, don’t have to have many, maybe just for 10 minutes, those of us working together today, so that you can raise issues that—yeah, important things, and that it is done repeatedly” (FGD #1).
A second RN agrees, adding:
“That’s just what we experience working at our machine also, when you are running a treatment and someone can come in and interrupt. In my experience, you can’t concentrate on more than one thing at a time”
Poor systems, or in some cases, lack of systems for communicating information are said to take several forms, including second-hand information, spread of unsuitable information, information that misses parts of the RT organization, etc. RNs also describe a feeling that the organization “has a low ceiling” and censures discussion. A particular problem discussed by several professional groups was a lack of clarity around decision-making, with information about new decisions and policies often spread in what several people metaphorically called “Chinese whispers” or “playing telephone” (FGD #2) referring to children’s party games. This was said to lead not only to a lack of transparency, but also the lack of acknowledgement of mandates for implementing change. Notably, there was even debate about whether common meeting forums did in fact exist, which could then serve to improve communication. At one site, FGD participants complained that even informal meeting places were lacking, which they felt might have compensated for the lack of formal forums.
Another notable communication difficulty was that the professions involved in RT used language differently. The most extreme example of this was the lack of consistent meaning in describing right and left in the RT treatment field. Right and left is described from the perspective of the patient’s own body by MDs but these designations change with different patient positions. The other professional groups instead use the terms right and left to refer to placement in the treatment room. The implementation of a new digital verification system demands that MDs change their language use to adapt to that used by other professional groups, but this was said to be met with resistance.
This type of resistance was also common among RT RNs, with numerous examples matter-of-factly provided by the RNs. In the FGDs a number of different situations and strategies for silently opposing new regulations were noted, e.g. not reporting medical errors—a behavior shared by the other professionals—, or not contacting physicists or MDs in accordance with regulations in routine situations deemed unproblematic. This ‘silent’ communication of dissent was repeatedly described, whereas few situations of open, verbal resistance or discussion were provided in the FGDs. Situations in which RT RNs describe themselves as directly confrontational were most evident when RNs felt patients were treated disrespectfully by other professionals, e.g. when MDs or physicists enter a treatment room and approach an undressed patient without presenting themselves.
Yet another feature of communication which was raised by patient representatives in a FGD, as well as by various professionals, was the ‘silo’ organization of cancer care in general, including RT. This meant that RT teams functioned as “cocoons” often not involved in other aspects of the RT department, but also that information to patients was fragmented and relevant only to specific units. One patient representative explained:
“I have a lot of experience of the way information around patients is handled, and it rarely follows the patient’s path through the health care system. It is instead more focused on units, the different specialties and so on, but for the patient, cancer care is a new world they have to orient themselves to, and therefore it is important that information structures also follow the patient’s pathway throughout the trajectory”. (FGD #5)
In general, professionals repeatedly stated that patients remained oblivious to the organizational and communication problems discussed in the FGDs. However it was clear from the FGD with patient representatives, that patients were indirectly affected by many of the issues discussed by professionals.