Week 4 Reading Conn: Communication and culture in the surgical intensive care unit: boundary production and the improvement of patient care Flashcards
Healthcare providers engage in communication behaviours that either mitigate or magnify 3 contested symbolic boundaries:
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- Expertise
- Patient ownership
- Decisional authority
Boundary mitigation effects
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collaborative, high-quality patient care
Boundary magnification effects
conflict and perceptions of unsafe patient care
High quality and safe patient care produced through …
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complex social and cultural interactions among surgeons, intensivists, nurses that are also expressions of knowledge and power
ICU multidisciplinary teams information and communication-targeted interventions to improve provider communication and foster collaborative team culture
- daily goals sheets
- interprofessional rounds
Knowledge gap identified
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production of quality communication with specialists external to, but consulting within, the ICU
- mostly surgical specialties
Surgical patients percentage of ICU
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30% or more
Survey among >900 surgeons in US found
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43% sometimes or always experience conflict with intensivists about postoperative goals of care for surgical patients with poor outcomes
“Diverging moral economies” (Joan Cassell)
= different values they hold and display that affect clinical decision making within medical social system
Surgeons aim vs intensivists aim
Surgeobs uphold battle against death, intensivists uphold battle against suffering
Aim of article
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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
Research approach
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Ethnographic approach
Boundaries
= 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”
Inventor of “boundary work”
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Gieryn (1983)
Boundary maintenance work in ICU
locked doors, cordoned spaces
Intensivist-led model of ICU care/high-intensity staffing/closed model of ICU
= 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
Low-intensity staffing/open ICU model
= intensivists consult on care of critically ill patients but admitting physicians maintain responsibility for primary decision making
Conn et al. Study setting
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
Conn et al study data collection and analysis
- 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
ICU recent interventions to improve communication
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- 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
Conn et al. participants/sampling
Theoretical sampling for participant shadowing and interviews
Seven communication behaviours that aimed to either mitigate or magnify contested boundaries
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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)
Surgeon experience of patient ownership
- invested time in operating room
- prior relationship with elective patients
Intensivists experience of patient ownership
- on-call when patient was admitted
- developing relationships with family members of patients with long stay
SBAR tool
= Situation, Background, Assessment, Recommendation
- structured recommendation protocol
‘boundary objects’
= structured recommendation protocols that mediate existing occupational hierarchies, positively facilitate communication and collaboration between groups
