The impact of context on interphysician collaboration and learning: A focused ethnography around hip fracture patients in the emergency department

Older patients with complex care needs are increasingly seen in the emergency department (ED), requiring patient-centered care that involves collaboration among multiple specialists. Inadequate interphysician collaboration (IPhC) can increase the risk of adverse outcomes. Although the ED presents opportunities for learning IPhC, it is unknown how this potential could be exploited. This study examines ED interactions between residents and supervisors caring for hip fracture patients to explore influencing contextual factors and how IPhC (learning) can be improved. Interactions between residents and supervisors from anesthesiology, emergency medicine, geriatric medicine, trauma, and orthopedic surgery concerning eight hip fractures patients were observed. Thirteen residents and twelve supervisors participated in field interviews to discuss observed behavior. Thematic analysis was conducted on observation notes and interviews. Themes were discussed with participants in four focus groups to reflect on interactions and explore opportunities for improving (learning) IPhC. Residents primarily performed their own tasks with remote supervision. Repeated tasks and contradictory treatment plans were common. Five contextual factors influenced IPhC interactions: swarm of unacquainted professionals, bustling ED environment, lack of coordination, silo mentality, and limited, hierarchical feedback culture. Residents viewed their IPhC interactions as sufficient, despite observed contradictions. In focus groups, participants recognized these issues but were unaware of the associated risks. Interactions in acute care lack coordination and integration. The complex acute care context impedes connectivity between specialties and IPhC learning, which may lead to increased risk of adverse outcomes. To improve IPhC and learning, addressing both contextual aspects and improved role modelling and feedback are needed. • Interactions between residents of different specialties working in the emergency department mostly occur through emergent encounters with a lack of integration and coordination, prompting the risk of unaligned treatment plans for patients with complex care needs. • Complex contextual factors influence collaboration and learning of, with and between residents in the emergency department, including the factors of the bustling ED environment, a swarm of unacquainted professionals, a lack of coordination, a silo mentality and a limited, hierarchical feedback culture. • Facilitating workplace learning on IPhC can also improve to the collaborative practice of residents and supervisors within the complex ED context. This highlights the need to address contextual aspects that hinder connectivity between different specialty residents in the emergency department.