Hello everyone. My name is Candice Bonaconsa, and I’m a researcher working on the Aspire study at the Cape Town site. Welcome to this presentation, where we’re going to be focusing on using sociograms to share findings in our study. From the previous talks, you would have heard how we are using social science research methods to help us understand antibiotic prescribing practises in hospitals. In this very practical session, we will look at what sociograms are and how we developed and use them to capture and report team interactions relevant to our research question. So what are sociograms? A sociogram is a graphic representation of social links that a person has in a group situation.
These links could represent a number of aspects, such as relationships, hierarchies, communications to name but a few. It all depends on what is being pursued by the sociogram. It is a diagram, where individuals are depicted as nodes and relationships between individuals are demonstrated through connecting lines. In other words, a sociogram provides a strong visual representation of a social structure, where aspects of the relationship are highlighted. Sociograms are not new. Diagrams of social connections were first developed by Moreno in 1934 and are evolving at an unprecedented pace. Hand drawn diagrams have progressed to the use of automatic software capturing multi-dimensional and complex social networks. So why use sociograms?
For the past 20 years, a strong link has been made between the quality of communication amongst health care workers and patient outcomes. Numerous studies have used various forms of sociograms to investigate aspects of communication in health care settings. Here are some examples which looked at teen behaviours, multi professional patterns and methods of communication during patient handovers, family involvement in the care of hospitalised children, and the use of sociograms to design health care quality improvement teams. Sociograms have evolved over time, but despite this, the use of symbols and lines still form the foundational blocks to illustrate almost any social connection, relationship, or interaction.
The most important starting point is to clarify what you are looking for, as sociograms can be organised to capture many different dimensions of information within a network. In our study, the aim was to investigate cultural norms, establish hierarchies, team rules, antibiotic stewardship, and infection prevention and control practises, which operate within the surgical pathway. A very important part of this study was to understand communication practises around how a surgical team makes decisions about antibiotics and infection management and control. Although one of the primary data collection tools was direct observations, this is where the researcher captured the main interactions related to antibiotic prescriptions and infection management, sociograms became a powerful way of visualising interactions between team members around the patient’s bed space.
In many cases, sociograms are used to record and analyse social networks in the abstract, but our intention was to record and analyse interactions in real time. We chose to record observations using a form of sociogram called, a directed graph. We will practically demonstrate this from the context of a team of health care professionals around a patient’s bed space during a patient hand over. Let’s look at the basic elements of a directed graph. Symbols can represent various role players or contributors to the group dynamic. A line represents communication. When you add an arrow to the line, it helps identify the direction of communication, so who is talking to who.
A small return on that line indicates a response and adding colour to the line helps to illustrate the content of the conversation. So how do you assign a colour to a line which represents the content and communication? The simple answer is to extensively observe a group interaction. Colour codes for this particular sociogram was developed by a researcher observing and recording communication around the bed space on a multidisciplinary ward around. The dialogue was captured and the content was analysed, yielding some of the following broader themes. Treatment information, eliciting information, instruction, and casual conversation. This framework was then used and refined in another study, which was focused on care through family, where the researchers were interested in capturing information involving families.
Each content theme had an allocated colour, making it easy to identify what health care workers were talking about. A key learning was that the colour codes could be adjusted to suit the inquiry. In this study, team dynamics around antibiotic prescription and infection management and control is one of the influencing factors we are looking at. Although a large part of the study’s data collection methods is by direct observations of ward rounds, we have found that accompanying sociograms contributes strong and immediate visual depictions of communication and team dynamics.
We have a special interest in conversations around antibiotics, cultures and sensitivities, source control, as well as who is deciding on the plan, and therefore, these became colour codes in the drawing of the sociograms. So how did we do this practically? The researcher used a prepared page, which had the colour keys and symbols to serve as a reminder. The researcher ensured that they had appropriate coloured pens to match the colour keys. The first step was to represent the different members of the multidisciplinary team using symbols and their respective positions in the bed space. Next, the researcher captured the communication using arrowed lines to connect symbols.
So in other words, connecting who was talking to who with colours, which indicated what they were talking about. The point was not to quantify the words, and so a decision was made to the effect that one line signified one thought. Now, let’s look at an example. The team gathers around the bed. Present are the senior consultant, two registrars, an intern, and a professional nurse. The consultant moves to the head end of the bed, while the two registrars and interns stand at the foot end. The professional nurse is on the opposite side of the bed to the consultant. The consultant ask the patient how she is doing, and she replies that she’s feeling better than the previous day.
He asks about the pain, and she replies that it has improved. The registrar commences the hand over. He gives the patient’s name, age, brief surgical history, stating the surgical procedure the patient had undergone four days ago. He then says that the patient has developed high temperatures two days ago, which had settled after the central line was removed. The registrar mentions the antibiotics that the patient is on. The consultant asks whether there have been any microbiology results, and the registrar replies that he has checked, but he’s still waiting on these. The registrar then continues to share information about the patient’s vital signs, fluid intake, and output, as well as electrolytes. All the levels are within normal range.
The consultant asks the nurse if the patient’s family has been to visit. She replies that they were there the previous day. The consultant asks the registrar what the plan is, and he replies that the plan is to carry on with antibiotics, to repeat bloods, and to keep an eye on the patient. He turns to the intern and asks him to repeat the bloods in the morning. So if we look at the sociogram, we can think about the following questions. Who is on the ward round and where are they standing? Why could this be important to think about related to team dynamics and hierarchies? How many people are actively contributing? Who makes the decisions and who has enacted them?
Why is this important to think about? Has communication been clear? If we think about the patient’s role in the process, are they actively engaged, or are they passive observers?
So how have sociograms helped us? As mentioned, direct observations are a primary source of data from the ward drounds. Sociograms have been extremely useful as an additional data source for two main reasons. Firstly, sociograms help us to triangulate and validate observational data, and secondly, they act as a powerful visual aid, which enables the researcher to see additional and relevant information by providing a different perspective, as well as being a powerful illustration to feedback to teams. It is said that a sociogram is worth a thousand words. We have found that these illustrations quickly highlight aspects that might be slightly harder to describe.
For example, how people positioned themselves around the bed space, who is talking the most, who are they talking to, what are they talking about, are there multiple initiators of dialogue on the round? Who is asking the questions? When people are asked questions, are they responded to? And are patients included in the dialogue? All of these aspects are very important when one is trying to understand team dynamics and how decisions are made. Furthermore, sociograms have helped us to see who is leading and who is engaged in the conversations around antibiotics, cultures and sensitivities, source control, infection markers, as well as who is making the plans. The next part of our research is to feed relevant findings back to the teams involved.
Already we have received a lot of positive interest on ward rounds when we do sociograms, and team members have expressed an interest in hearing back from us. This has been a short introduction to the practical use and value of sociograms. We look forward to hearing your thoughts and inputs. I would just like to acknowledge the hard work of the various role players in the Aspire study, and a special thanks to all the participants, including the patients, who have allowed us the privilege of doing this study in these settings. Thank you.