In this study, we explore the collaborations from the NGDs’ point of view. Firstly, we describe who their most essential collaborators were and what they predominantly were collaborating on. Secondly, we explore how the NGDs employed different strategies when striving to establish and maintain their collaborations. In the discussion, we address the why to explore what is at stake.
The collaborators and the nature of collaboration
During the field study, it became evident that the NGDs consulted different collaborators depending on the challenge they were facing: peer NGDs were seen as a safe haven where uncertainty could be shared; registered nurses were consulted about local know-how; senior doctors were addressed in decision-making; and junior doctors were addressed concerning decision-making and local know-how (see Fig. 1). It is important to notice that the figure illustrates who the NGDs predominantly consulted when in need of help and is as such a simplification. The NGDs sometimes asked registered nurses about clinical decisions, for example which blood test to order, and the NGDs sometimes consulted senior doctors about local know-how, for example where the nearest place to dictate was. However, the aim of the figure is to point out the prevailing and preferred pattern.
In the transition period, the presence of peers was crucial. In the interviews, the NGDs expressed how the community with other NGDs provided a feeling of solidarity and a safe haven where both insecurities, difficult experiences, doubts and “stupid” questions were shared (Fig. 1). One NGD expressed: “I honestly don’t know what I would have done without you guys [nearest peers]”. In the field study, it was likewise evident how the NGDs used one another, e.g. when having doubts concerning the patients or when an NGD felt frustrated about her new workplan, she discussed it with one of her peers.
The registered nurses (RN) were constantly consulted by the NGDs about local procedures, and a common phrase during the field study was “how do you usually do this?”. This included both practical issues such as how to use a pager, and issues concerning handling the patients. Contrary to the NGDs, the RNs were predominantly affiliated with one department or unit, which endowed them with experience and knowledge about both local procedures and the patient population of the given department:
NGD8: I also think, still, when I’m called to the department during the night when a patient has died, and the relatives are present and want to talk to the doctor (snorts). If it’s a patient who has died of something I can’t even pronounce, and I have to explain “was the patient in pain? Did it go as planned?”. In such moments I just feel SO incompetent. It’s just crap. Luckily, luckily, LUCKILY I’ve only experienced working with great nurses in such situations who were really an essential support. (Group interview)
When the NGDs trotted across the hospital premises multiple times each shift to see patients and work in various sections of the hospital, the RNs were often the ones present, knowing the history and condition of the patients, and thus they became key collaborators to the NGDs.
While the peers and RNs were often addressed concerning struggles about local know-how, the NGDs consulted the senior doctors in decision-making issues; for example, concerning diagnostics, further treatments, admission or discharging (Fig. 1). This was evident when following NGD5 during her shift as she received a patient who remained hypotensive despite being administered large amounts of intravenous fluids. In this case, NGD5 was unable to obtain the support from the senior doctor on call because of more acutely ill patients in the A&E. Even though many peers and RNs were present, NGD5 persisted her waiting and wandering. When she contacted the RNs, it was only to ask if they had seen the physician on call. In the end, NGD5 was flushed and seemed really frustrated. When the observer asked if she was feeling insecure about treating the patient alone, she said: “no, I can always call anaesthesia. It’s just because I don’t know what to do to get on with treating the patient”.
The use of senior doctors in decision-making concerning patients was also evident in the observation that they were chasing the senior doctors. There were often several NGDs looking for the senior doctors, and despite the presence of several RNs and NGDs, there were often a crowd gathering around the more experienced doctors:
During the supervision there is much disturbance. Many people are present, there are many who talk or make phone calls, and many NGDs are waiting for the senior doctor. Several seem impatient. They are moving uneasily from side to side, taking deep breaths looking at the clock and their notes. (Field note)
The last group of collaborators were the more experienced junior doctors. These were often addressed concerning local know-how and procedures, but also in decision-making (Fig. 1). The consulting with junior doctors in decision-making happened particularly with junior doctors from other departments, for example cardiology or gastrointestinal surgery. As junior doctors were more accessible, the NGDs found it easier and contributing to the pace of work to ask junior doctors present rather than contacting seniors on call.
The NGDs’ strategies in the interactions with collaborators
During the field study it became apparent that the NGDs actively committed themselves to establishing and maintaining good relationships with their collaborators. In this endeavour, they used different strategies: 1) Displaying competence; 2) Appearing humble; and 3) Playing the game. These three strategies were performative and were neither exhaustive nor completely separated.
The NGDs were acutely aware of projecting competence when collaborating with colleagues. This was strongly related to demonstrating independence. Sentences and words used by the NGDs like “not being a burden” and “disturb” indicate how the NGDs did not want to be an encumbrance to their colleagues by interrupting with what might be seen as “banalities”. This sometimes made them consult other peers or junior doctors before asking the senior doctors, for example, when the NGDs were in doubt about ordering a scan or the correct dose of medicine. When the NGDs needed to consult the senior doctors in decision-making it could take many considerations:
NGD17 is on the fence about whether to call the attending doctor. He is seriously in doubt about calling and thereby waking up [the physician on call] to ask what to do with the patient […] I ask if it is because he has had a bad experience previously when waking up his colleague, but that’s not the case. It is ”probably just one’s own professional pride in being able to handle it yourself” that makes him indecisive. (Field notes)
A few hours earlier during the same shift, NGD17 expressed (after talking on the phone with the senior colleague on-call who was headed home) how it was comforting being told that “you can always just give me a call”. What makes NGD17’s many considerations further paradoxical is the formal rule on conferring patients with senior doctors because the NGDs have not yet received their authorisation to work independently. So even though NGD17 did not have any bad experiences with doctors on call, he was told to call, and the formal rule stated that he should call, he was still in doubt whether to call or not.
The concern about displaying competence was also seen in the collaboration with RNs. For example, when NGD10 followed the advice from the physician on call and ordered an extra scan of a patient, even though the RNs expressed how they found this as a waste of time. Hours later when the result came and nothing was wrong with the patient, NGD10’s first response was “now the nurse probably thinks I’m a fool”.
A common strategy among the NGDs was understating their expertise in order to get help. Comments such as “I’m just an NGD” or “this is my first shift; I don’t know ANYTHING” were commonplace. This was especially conspicuous in the collaboration with RNs. The following quote is from observations in the A&E’s break room, where two NGDs and a small group of RNs were present:
NGD2 tells that today she has half a ”training day” before her first night on duty tomorrow. Multiple times she says (very) loudly that she intends to bring cake ”in order to apologise in advance to the RNs” for asking many questions, since she ”doesn’t know anything”. (Field note)
The same understating strategy was evident when NGD18 leaves the A&E after her first shift and tells the RN, who she has been working with all day, that she was sorry that the RN had to be her “babysitter”. When the NGDs in the interviews were asked about this strategy, they explained how they were warned about the RNs in the A&E from the more experienced NGDs:
NGD17: When I started, I was kind of warned about the nurses in the A&E. I mean in general by the other NGDs who had been in our department […] You shouldn’t feel too bad if you meet someone harsh. (Group interview)
These warnings made the NGDs have reservations and they tried to tone down their conduct, which they feared could induce conflicts. During the observations it became clear, that there was sometimes a tense and sneering atmosphere in the A&E. For example when the RNs asked for a “grown-up doctor” when several NGDs were present, or when NGD19 late at night asked the RNs – not the senior doctor – for permission to have his evening meal, and one of them replied: “Hold on… [addressed the other RNs present] What do you think? Do you think he deserves a break?” follow by all of them laughing. Even though the comments might be said with a tongue in cheek, the NGDs sometimes found the A&E RNs tough and making them feel unwelcome. In an interview where the NGDs discussed how they were struggling when everything was new, NGD16 explained:
Then it helps a lot to call and say (makes the voice “small/innocuous”, pulls up the shoulders): “I’m just new here, so I don’t know”, ‘cause then it’s very hard to yell at people. (Group interview)
This quote illustrates how the NGDs’ used a submissive approach as a strategy to get help: Who could make oneself scold/turn away somebody that new and humble?
Playing the game
The NGDs quickly learned that when working first-line, an important task was to free the beds and sustain the flow of patients. The long line of waiting patients put pressure on the staff, and focus was on “turfing” the patients (i.e. moving them from one department to another). First and foremost, this was about the patients’ needs and safety as well as ensuring capacity for new admissions. However, during the fieldwork, it was clear how being someone who contributed to sustaining the flow was highly valued:
I hear how a nurse tells “how it is so nice, when a doctor finally comes who can move things along”. (Field notes)
The quote indicates how contributing to the flow was not only about patient care but also a matter of being well-reputed among colleagues. In the interviews, the NGDs discussed how this sometimes meant bypassing the reflections and thereby potential learning situations. Instead of doing all the reflections and investigations themselves, they sought answers from their colleagues to get the patients through faster.
NGD6: ”It’s often a productivity demand, and it impedes all sort of opportunities for education, in my view. That’s my opinion (the others laugh). It’s like: well, that doesn’t matter, now I just have to get going, and it’s probably good enough, right?”. (Group interview)
The awareness of contributing to the team goal also had an impact on the NGDs’ asking for feedback on their work. A well-known structured observation tool, “Mini-CEX”, was often described as a way to get specific feedback on their work from another professional that observe them with patients. This model however required a more experienced doctor to prioritise this feedback ahead of attending to patients, and it therefore made hard for the NGDs to ask for:
NGD7: I think you should ask for it [mini-cex, observations and feedback]. […] They’re [senior doctors] just so busy […], and they have plenty to do with taking care of their own patients, so you can’t get one of them to go along for the entire round and say “please observe my work…”. I believe that in general it’s all been a bit too pressed for time for me to think that this is something I could to do. (Group interview)
The quote illustrates how the NGDs were often opting out the opportunity for feedback (and thus a possible learning situation) because they did not want to interrupt the senior doctors by asking many questions or requesting feedback. However, receiving feedback is an important part of being a trainee doctor in order to learn and demonstrate mandatory competences.
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