Week 4 Reading Conn: Communication and culture in the surgical intensive care unit: boundary production and the improvement of patient care

Question 1

Healthcare providers engage in communication behaviours that either mitigate or magnify 3 contested symbolic boundaries:

Conn et al.

Answer 1

1. Expertise
2. Patient ownership
3. Decisional authority

Question 2

Boundary mitigation effects

Conn et al.

Answer 2

collaborative, high-quality patient care

Question 3

Boundary magnification effects

Answer 3

conflict and perceptions of unsafe patient care

Question 4

High quality and safe patient care produced through …

Conn et al.

Answer 4

complex social and cultural interactions among surgeons, intensivists, nurses that are also expressions of knowledge and power

Question 5

ICU multidisciplinary teams information and communication-targeted interventions to improve provider communication and foster collaborative team culture

Answer 5

• daily goals sheets
• interprofessional rounds

Question 6

Knowledge gap identified

Conn et al.

Answer 6

production of quality communication with specialists external to, but consulting within, the ICU
- mostly surgical specialties

Question 7

Surgical patients percentage of ICU

Conn et al.

Answer 7

30% or more

Question 8

Survey among >900 surgeons in US found

Conn et al.

Answer 8

43% sometimes or always experience conflict with intensivists about postoperative goals of care for surgical patients with poor outcomes

Question 9

“Diverging moral economies” (Joan Cassell)

Answer 9

= different values they hold and display that affect clinical decision making within medical social system

Question 10

Surgeons aim vs intensivists aim

Answer 10

Surgeobs uphold battle against death, intensivists uphold battle against suffering

Question 11

Aim of article

Conn et al.

Answer 11

develop a rich understanding of communication culture among surgeons, intensivists, ICU nurses and identify how mutually acceptable collaborative patient care occurs between these specialist teams

Question 12

Research approach

Conn et al.

Answer 12

Ethnographic approach

Question 13

Boundaries

Answer 13

= a social construct that symbolize conceptual and material disticntions between groups
- can be used as ‘thinking tool’ through which behaviours, beliefs, norms, practices, values can be interpreted to explain “the dynamic dimensions of social relations”

Question 14

Inventor of “boundary work”

Conn et al.

Answer 14

Gieryn (1983)

Question 15

Boundary maintenance work in ICU

Answer 15

locked doors, cordoned spaces

Question 16

Intensivist-led model of ICU care/high-intensity staffing/closed model of ICU

Answer 16

= model of organising care where specially trained intensivists (critical care physicians) staffing ICUs full time + assuming responsibility for all patients
(+) reduced mortality and hospital stay lengths
(-) produces symbolic division between ICU team and consulting teams from whom patient received prior care

Question 17

Low-intensity staffing/open ICU model

Answer 17

= intensivists consult on care of critically ill patients but admitting physicians maintain responsibility for primary decision making

Question 18

Conn et al. Study setting

Answer 18

Large tertiary academic trauma centre with 7 ICUs, focused on 3 where most trauma, general surgery, neurosurgery patients treated:
- 1 medical-surgical ICU with 20 beds
- 1 surgical ICU with 12 beds
- one medical-surgical ICU with 8 beds
intensivist model in place for over 15 years

Question 19

Conn et al study data collection and analysis

Answer 19

• Ethnographic data
• 50hrs observation Jan-May 2014, weekdays 6:00am to 6:00pm: shadowing routine patient care
• collected by primary author (Conn), anthropologist with ethnographic experience
• handwritten notes
• formal and ethnographic interviews
• 23 semi-structured formal interviews scheduled –> audio recorded –> transcribed, avg. 35 mins, exploring participants views and experiences with interspecialty patiet care
• 20 informal ad hoc/spontaneous interviews
• iterative data analysis
• Nvivo data organisational software
• data collection ceased at point of theoretical saturation

Question 20

ICU recent interventions to improve communication

Conn et al

Answer 20

• red-yellow-green indicators on whiteboards for patient discharge
• neurosurgeon attends morning ICU rounds
• neurosurgery and ICU team meet daily 6:50am in ICU
• verbal postoperative handover from surgery to ICU team

Question 21

Conn et al. participants/sampling

Answer 21

Theoretical sampling for participant shadowing and intervoews

Question 22

Seven communication behaviours that aimed to either mitigate or magnify contested boundaries

Conn et al

Answer 22

Mitigate:
- consulting (acknowledges expertise)
- mobilizing (action to involve others in care/decision-making)
- adapting (to others’ communication styles and behaviours)
Magnify:
- enforcing (pulling rank, disregarding opinions, obstructing others; participation)
- avoiding (other team)
- limiting
- expecting (belief that others had responsibility to seek you out and update you, available whne you are)

Question 23

Surgeon experience of patient ownership

Answer 23

• invested time in operating room
• prior relationship with elective patients

Question 24

Intensivists experience of patient ownership

Answer 24

• on-call when patient was admitted
• developing relationships with family members of patients with long stay

Question 25

SBAR tool

Answer 25

= Situation, Background, Assessment, Recommendation
- structured recommendation protocol

Question 26

‘boundary objects’

Answer 26

= structured recommendation protocols that mediate existing occupational hierarchies, positively facilitate communication and collaboration between groups