Gatekeeping practices of nurses in operating rooms
Introduction
Gatekeeping is a communication tactic that involves limiting or facilitating access to information. The term gatekeeping was first used by Lewin, 1947a, Lewin, 1947b in the 1940s in reference to housewives as the people who selected what food ended up on the family dinner table. Lewin proposed that his concept had implications far beyond food choices and that his idea could be applied to the flow of news and how items are selected and rejected as they pass through ‘channels’. Applied at the mass communication level, gatekeeping came to be understood as “the process by which billions of messages that are available in the world get cut down and transformed into the hundreds of messages that reach a given person on a given day” (Shoemaker, 1991, p. 1). Since its inception, concepts of gatekeeping have developed in various fields of scholarship including political science, communication, sociology, information science, management and law, and in a broad sense it came to be understood as “all forms of information control that may arise in decisions about message encoding, such as selection, shaping, display, timing, withholding … ” (Donohue, Tichenor, & Olien, 1972, p. 43). The concept of gatekeeping has been further developed (Barzilai-Nahon, 2004, Barzilai-Nahon, 2008, Barzilai-Nahon, 2009) to provide a means of in-depth analysis of information control, a point that is a focus in this paper.
In nursing, gatekeeping appears only sporadically in the literature (Farley, 1987, May et al., 2001, Sinivaara et al., 2004, Street, 1992) and usually emerges as a secondary concept in data rather than being the primary focus of studies. In medicine, the term has a slightly different meaning and is used in relation to providing or limiting access to healthcare. Overall, across all healthcare disciplines, there has been a lack of analytical frameworks with which to examine the phenomenon of gatekeeping and, as a consequence, relatively few attempts to create a common ground for discussion and critical review of the concept (Barzilai-Nahon, 2004). Furthermore, studies exploring gatekeeping in healthcare are important because of the possible impact on patient safety. Poor communication, which may include gatekeeping, has been shown to be one of the leading causes of clinical errors (Joint Commission on Accreditation of Healthcare Organizations, 2007).
Accordingly, in this paper we aim to provide an in-depth understanding about gatekeeping in relation to the operating room context, and show how it has practical and ethical ramifications for patient care, clinical work and professional relationships. In the first part of this paper we provide an overview of how gatekeeping has been referred to in the nursing literature and briefly explain how the concept is referred to in medicine. Next, we provide an outline of theoretical frameworks of gatekeeping and greater clarification about how we understand and use the concept for the purposes of this paper. We then examine gatekeeping practices in operating room nursing by drawing on data from an ethnographic study of communication processes in the clinical environment. Lastly, we discuss the implications of gatekeeping in terms of the power that is available to nurses and colleagues as they engage in gatekeeping, the professional ethics of the practice, and inter-professional and social relationships.
Only a few authors have written about the concept of gatekeeping in nursing. One such author, Annette Street (1992), noted the concept when undertaking a critical ethnography of clinical nursing practice in general medical and surgical hospital wards. Gatekeeping involved nurses withholding or providing incomplete information about the location of equipment and supplies. Normally a taken-for-granted concept, gatekeeping practices became more noticeable when a hospital ward was relocated to a new site. Any underlying advantage that had accrued to individual nurses through the gatekeeping practices used in the old ward was negated by the need for all nurses to create new storage routines. As a consequence, nurses competed with each other to gain information about where equipment was located, by sometimes arbitrarily relocating supplies. Advantage was gained by “creating a dependence on the owner of the knowledge for ongoing information necessary to engage in effective clinical practice” (p. 109): nurses wielded power over those who did not have information about where supplies were stored.
May et al. (2001) explored the gatekeeping practices of nurses in their dealings with informal carers in a rehabilitation ward. They described how, upon a carer's request to speak with non-nursing healthcare workers such as a social worker, nurses screened the request by establishing the legitimacy of carers' enquiries. In doing so, nurses retained control over the decision to make contact with a colleague. Gatekeeping influenced how social relationships were framed as nurses constructed themselves as authoritative in their relationship with carers. Nurses became more than a “knowledgeable intermediary” by making decisions on behalf of absent team members. From this perspective, the authors suggested that gatekeeping was seen as collaborative as nurses supported their colleagues by limiting information flow to them, which subsequently helped to control workload by avoiding unnecessary interruptions to clinical practice.
In an ethnographic study examining the interrelationship between knowledge and decision-making in a critical care unit, Manias and Street (2001) described how nurses engaged in gatekeeping practices to help them remain in control. Nurses ‘staged’ the release information to medical staff by selectively imparting their knowledge. This ‘staging’ encouraged inexperienced critical care doctors to make decisions that worked in favour of nurses, as nurses guided doctors towards a particular, predetermined outcome. The effect was to avoid open disagreement and confrontation between nurses and doctors and subsequently to harmonise interdisciplinary relationships. Similarly, Sinivaara et al. (2004) described how midwives withheld information about managing labour when communicating with women in delivery rooms, but recognised that judging how much information women needed to make informed decisions was an individualised matter and difficult to determine.
In the medical literature, gatekeeping has focused on how physicians control access to healthcare (Glasgow, 1996, Willems, 2001), and is often discussed in ethical terms, a dimension that is largely absent in the nursing literature. For instance, Pellegrino (1986) explained that physicians are positioned at the entry point, or gate (Barzilai-Nahon, 2008, p. 1496), through which patients must pass to receive care and services. Hence, gatekeeping in medicine can be controversial as it can be used to restrict use of medical services. It also has economic considerations that can impact on clinical decision-making when physicians make choices between treatment options and the associated cost of each.
To summarise, in medicine gatekeeping is usually discussed in terms of access to services and treatments, and how physicians control this. In nursing, while examples of gatekeeping have been cited in the literature, it is usually not the primary focus of studies. There has been little attempt to situate nurses' gatekeeping in a theoretical framework or offer a detailed explanation of its impact on individuals, work practices, or the social environment. In operating rooms, as in other clinical areas, gatekeeping may have a profound impact on patient care. Before beginning our discussion of these factors, in the section that follows we outline theoretical models of gatekeeping to situate our understanding of the concept in the broader discussion of the paper.
Models for analysis of gatekeeping can be thought of as ‘traditional’ (Shoemaker, 1991) and ‘network’ in nature (Barzilai-Nahon, 2004, Barzilai-Nahon, 2008, Barzilai-Nahon, 2009). In a traditional sense, Shoemaker synthesised the gatekeeping literature to form a five-level hierarchical model. These elements are: individual, communication routines, organisational, social/institutional, and social system levels of gatekeeping. At the individual level, the focus is on the extent to which people are responsible for gatekeeping selection, and analysis centres on the gatekeeper's personality, their background, values, role and experiences. At the level of communication routines, analysis is on the “patterned, routinized, repeated practices and forms that [media] workers use to do their jobs” (Shoemaker, 1991, p. 48). Here, information characteristics such as clarity of the message or whether information is visual are important, in which case it is less likely to be subjected to gatekeeping. The organisational level of gatekeeping refers to the repeated communication-related decision-making patterns made internally by people within the organisation that help constitute the organisation as a symbolic environment. Organisational forces that affect gatekeeping may include policy, standards of the different professions, and value of the message. In contrast, at the institutional level, gatekeeping is affected by market pressures, audiences, governments, politics and interest groups. Lastly, at the social system level, gatekeeping can be understood and analysed from the perspective of ideology, culture and social structures. Table 1 shows the factors that impact on gatekeeping in a traditional sense, from the perspective of Information Science, Management and Communication literature. These factors extend beyond Shoemaker's model, and include external factors such as cost and time constraints.
Network models originated from the distribution of information through the Internet and have been adapted to incorporate social analysis. Building on the traditional models from different disciplines, including Shoemaker, 1991, Barzilai-Nahon, 2004, Barzilai-Nahon, 2008, Barzilai-Nahon, 2009) proposed a multidimensional, network model that places greater emphasis on the relationship between the gatekeeper and those upon whom gatekeeping is exercised. In network gatekeeping the actual gatekeeping process or activities used to carry out the act can be examined. These processes include: selection of one message over another, withholding, manipulation, deletion, censorship or disregarding of information, the timing of delivery, adding or uniting information, localising or adapting information for particular target audiences, and conveying information through particular channels (Table 2). In network gatekeeping the reasons for the gatekeeping act can also be examined as a means of understanding the motives that underpin it. Such reasons identified from the literature include access, editorial, protection, preservation of culture, change agent, facilitator, disseminator and linking agent, as detailed in Table 3.
In summary, traditional models view gatekeeping as a one-way, top-down selection process, in which gatekeepers are the main actors. These models ignore the impact on those whom gatekeeping is exercised, viewing them as passive (Barzilai-Nahon, 2008). Network gatekeeping has a much greater emphasis on the ‘gated’, or “the entity subjected to gatekeeping” (Barzilai-Nahon, 2008, p. 1496), and the power relationships between the gatekeeper and the gated; that is, the political power in relation to the gatekeeper, information production ability, the relationship and interactions between the gatekeeper and the person subjected to gatekeeping, and the available practical alternatives to decide on other courses of action. Network gatekeeping is a dynamic, discretionary process of information control where the gatekeeping role can be modified depending on the stakeholders and context of the interaction.
Accordingly, while we acknowledge gatekeeping in a traditional sense, in this paper we draw upon network gatekeeping in order to explore the power relationships involved in how operating room nurses control information and how this affects intra- and inter-professional relationships and shapes clinical practice.
The ethnographic study from which the data are drawn explored interactions among nurses, and between nurses, surgeons and anaesthetists, with the aim of examining power and control in clinical operating room practice. Data collection were undertaken in 2003–2004 and comprised over 230 h of participant observation, 11 individual and 4 group interviews utilising photographic techniques, and the keeping of a personal diary by the first author. Using a method based on ‘Photovoice’ (Wang & Burris, 1997), photographs were taken by participants and used as a catalyst to promote conversation at interview. Data were collected from three different operating room departments, including a not-for-profit private hospital, a suburban public hospital with a university affiliation and a specialist cancer hospital. Ethics approval was gained from each of the three hospitals in accordance with national guidelines (National Health and Medical Research Council, 2007). Participants comprised 11 operating room nurses who were purposively selected to act as informants about their cultural group and social environment and were representative of the predominant demographic of Australian nurses (Australian Institute of Health and Welfare, 2001). Observations extended across participants' rostered morning and afternoon shifts.
The data from interviews, which were recorded verbatim, and the transcribed observations from fieldwork notes, were analysed using the approach developed by Ritchie and Lewis (2003). This process enabled identification and categorization of gatekeeping practices into the different levels of Shoemaker's (1991) framework. The stages of this approach involve: familiarisation, or gaining an overview of the data; identifying a thematic framework to derive recurring patterns; indexing or assigning a label to the data; charting of data and annotating with a particular theme; and mapping and interpretation which involve comparing and contrasting the data and searching for patterns and connections in the dataset as a whole. Through constant comparative analysis of data and using the items detailed in Table 2, Table 3 as units of analysis, gatekeeping rationales and processes were identified.
To add another layer of complexity we undertook a deconstruction of the data (Cheek, 2000) using questions based on the attributes of Network gatekeeping theory (Barzilai-Nahon, 2004, Barzilai-Nahon, 2008, Barzilai-Nahon, 2009). These attributes were power, information production and relationships. For example, we asked questions such as: “Who exercised power in the gatekeeping interaction?”; Who was gate and who was the gatekeeper?”; “What was the information at the centre of the gatekeeping act?”; “How did power work in gatekeeping practices?”; “What was the effect of the gatekeeping practice on the gated?”; “How did the gatekeeping shape professional roles and practice?” and “What was the rationale for engaging in the gatekeeping practice?”. These questions provided a means of deconstructing the gatekeeping practices used by nurses in the operating room to explore and examine them at the micro-level of their production.
Section snippets
The gatekeeping practices of operating room nurses
The examples of gatekeeping that follow occur at the individual level of Shoemaker's (1991) hierarchy as they involve interpersonal interactions between nurses and doctors in the everyday clinical operating room setting. We have labelled the four examples, “Protecting”; “Facilitating and Disseminating”; “Providing Access” and “Negotiating Social/Cultural Position”, according to the rationale of each example.
Discussion
Our analysis demonstrates the pervasiveness of the gatekeeping in operating rooms, the dynamism of its operation and how it circulates between the different hierarchical levels of the nursing profession, and between nursing and medical professionals. In each case, gatekeeping involved the exercise of power. In some instances, inexperienced nurses were able to exercise power to overcome their gated position and to influence the circulation of information, while in others they were subjected to
Conclusion
In summary, network gatekeeping (Barzilai-Nahon, 2004, Barzilai-Nahon, 2008, Barzilai-Nahon, 2009) provides a very useful framework for examining the flow and control of information. Although originally proposed as a means of examining gatekeeping in technologies such as the Internet, network gatekeeping models can be successfully adapted to examine social networks and contexts. In this paper we have shown how the power relationships that are inherent in gatekeeping acts can impact on social
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