The existing literature focused on exploring the impact of the hospitalist role on patients and health care costs. There has been little attention paid to the impact the hospitalist role has on other staff members within a hospital. This study examined the impact of the hospitalist role on staff from the departments of nursing, surgery, medicine, anesthesiology, physiotherapy, pharmacy, and administration. Most study participants reported that they felt the hospitalist positively influenced patient care by increasing patient safety, expediting transfers, enhancing communication, and providing continuity of care. The hospitalist supported other staff members in the hospital by providing medical directives and education.
However, the impact of the hospitalist on staff workload was not uniform among participants. Many staff members were undecided regarding the impact the hospitalist had on their workload, but others reported that their work had increased or decreased. The staff agreed that the hospitalist role worked well in this particular facility, but that there was a potential for interprofessional conflict if a hospitalist was placed in the wrong environment.
The participants in this study were asked to define their role at the beginning of each interview. Throughout the study they were asked to comment on the impact of the hospitalist on their work. Participants often expressed views regarding how the hospitalist was regarded by other professions. For these participants, there was potential for role overlap between hospitalists and other staff. As a result, the importance of interprofessional collaboration to implementation of the hospitalist role was a recurring theme in our analysis. The patients being treated by the hospitalist had been admitted for elective orthopedic surgery. Numerous physicians were working with these patients including the hospitalist, the surgeon, the internist, and the primary care physician. Several participants discussed the possibility of conflict among these professions and the importance of clear boundaries. The hospitalist role may have worked well in this particular center because professional roles appeared to have clear boundaries where surgeons focused on orthopedic problems, internal medicine physicians operated the preoperative assessment clinic, and the hospitalist managed medical problems that were not related to orthopedics. Some staff members elaborated that there was a potential for conflict if someone did not understand their role.
The role boundaries between the hospitalist and nurses, pharmacists, and physiotherapists created both positive and negative impacts. The positive impacts were that the hospitalist would educate other staff members, particularly those in nursing, and that he would provide support and medical orders as necessary. Many of the staff members commented that nurses had easier access to the hospitalist than internists or orthopedic surgeons; however, staff mentioned that the wait times for consults could be lengthy since there was only one hospitalist.
Nurses and pharmacists commented that the new initiatives implemented by the hospitalist had increased their workload. This increased work was attributed to more testing and orders being written. The staff commented that while this may have improved patient care, it added work to their own roles. This may highlight that the boundaries between the hospitalist and both nurses and pharmacists are less distinct than among the physicians.
It has been argued that poor conceptualizations of interprofessional activities persist.27
There has been confusion distinguishing between interprofessional collaboration and interprofessional education. In this study, we classified the interactions between the hospitalist and staff as interprofessional collaboration because participants perceived that their work and communication with the hospitalist affected patient care. This aligns with the definition of collaborative practice put forth by the Canadian Interprofessional Health Collaborative:
Collaborative practice occurs when health care providers work with people from within their own profession, with people outside of their profession and with patients/clients and their families.28
Another critique of the studies conducted on interprofessional collaboration is that few have actually used theory to explain this relationship.27
Theory is always present in qualitative studies, but may vary in terms of the source, temporal placement, centrality, and function.29
In this study, theory played a peripheral role. It was not known how participants would respond to questions about working with the hospitalist at the outset of this study; however, role boundaries emerged as a prominent concept during the interviews. The literature describing interprofessional collaboration and role boundaries was considered as these concepts were constructed from the data.
The strength of this study is that it explored the impact of the hospitalist role on other staff in an orthopedic environment. One potential limitation is that each of the study participants personally knew the hospitalist at this facility. Many participants commented favorably on his personality. This relationship among the participants and the hospitalist may have impacted their ability to assess the hospitalist role without feeling they were being critical of the individual holding this position. To reduce this impact we were careful not to identify participants in the study, and we did not permit the hospitalist to know who participated in the study, nor did we allow him to view complete transcripts. Furthermore, the hospitalist interacted with primary care physicians in the community by providing letters to update them on any complications their patient experienced during surgery. However, we did not interview any primary care physicians in the community, so we cannot comment on their experience working with the hospitalist. Despite these limitations, the data provided insight into the interprofessional collaboration necessary to support the hospitalist role.
In summary, this study underscores the importance of defining professional role boundaries prior to implementing a hospitalist at a facility. In our study, the hospitalist role worked well because its scope of practice did not interfere with the internal medicine or surgical physicians. Nurses and pharmacists generally were supported by the hospitalist role in their decision-making and medical education. At times, they supported the hospitalist by assisting him and carrying out tests and medical directives as ordered. Some staff members commented that his role had increased their workload as a result of increased testing and medical orders. It may be important for the hospitalist to include explanations for increased orders and testing as part of the medical education he provides. Furthermore, this study demonstrates the importance of educating staff about the hospitalist role boundaries prior to implementing this role. The findings of this study may not be applicable to another setting where there might be a different model of patient care.