Five key categories of cognitive activities were identified in the data analysis.
Pattern recognition is a key aspect of critical care expertise and a principal area in which less-experienced physicians need further skill development. Members of the ICU team were observed frequently using the term 'pattern', so patterns is a well-recognised construct. However, when asked to describe what was meant by patterns and to give examples, no clear, consistent definition emerged.
We observed pattern recognition in two forms. One pattern was of a complete 'template' or mental model [10
]. Asthma is one such complete template based on a minimal history, appearance and breath sounds. A typical asthma mental model includes the constellation of cues of a patient who is in an upright position, sweaty, speaking in one word answers, exhibiting labored breathing and attentive to his or her own breathing. However, such 'classic' complete mental models are uncommon.
The second but distinct cognitive task is the real-time merging of pattern fragments (also called 'packets') into unique (patient specific) mental models. Observed more frequently than identifying the complete template, these packets are recognised as cues that are postulated to be related. It is only through a flexible and dynamic integration of these packets that a complete (or partial) mental model can be created. These mental models are highly context specific. The cue of blood pressure of 80/40 mmHg is quite different in a patient with respiratory failure than in a patient with congestive heart failure, chronic hypertension and high serum troponins.
Strategic versus tactical thinking
Both strategic thinking (long term, often multi-patient, goal oriented) and tactical thinking (short term, single patient, detail and task oriented) were observed. Particularly in the minds of junior housestaff, strategic thinking was not routine. The focus of their activities tended to be much more tactical as they were immersed in the details of testing and treating the patient and coordinating with members of the staff to get a specific treatment plan delivered. Junior housestaff were occasionally observed struggling when required by the attending physician to transition from tactical to strategic-level thinking. For example, an attending physician expressed displeasure with an intern when learning a tracheostomy the patient was supposed to receive had been postponed by several days. The attending physician was thinking at the strategic level (toward the goal of ICU discharge), while the intern was thinking tactically (substituting an imaging study as it was also on his task list).
Substantial evidence documented uncertainty (from various sources) as a defining feature of critical care medicine. Members of the critical care team may be uncertain, for example, about a patient's missing or erroneous laboratory values. They may be uncertain if a patient's symptoms do not fit a complete pattern or about the underlying cause of a patient's illness. One ICU team was grappling with uncertainty surrounding the declining cognitive functioning of a patient. They asked questions such as, "Why is she continuing to experience decreased cognitive functioning? Is she still sedated, and if so, why are the drugs still in her system? Are there other areas of infection we are missing? What haven't we tested for?" Uncertainty permeates all aspects of critical care medicine.
Creation and transfer of meaning through stories
A critical cognitive task within strategic thinking appears to be the creation and use of stories. The term 'story' was used explicitly during rounds as an attending asked the intern or resident, "what's the patient's story?". Reference was also made to the patient's 'picture'. Despite differences in terminology, the observational and interview data suggest a common cognitive activity. In both settings, health care teams were developing a framework of causal connections and a central theme that tied the various packets of patient data (medical history, test results, etc.) together in a meaningful way. These stories appear to provide the critical care team with an organising mechanism to make decisions about patient care and treatment. Story creation served to create a mental model as a diagnostic tool, to generate expectations and predictions about a patient's trajectory of illness and a way to catch inconsistencies.
There appear to be two key components of stories in the ICU. Firstly, there is story building: activities involved in constructing meaning and creating the story as a means of understanding the patient (i.e. the coalescing of partial templates into a mental model). Secondly, there is story telling: activities involved in sharing the story as a means of communicating and maintaining a common mental model within the health care team.
These two processes appear to occur in real time, sometimes in an emergent fashion. The mental model, or story, of the patient is created and communicated in the moment, during rounds where different members of the ICU team contribute unique template fragments.
The observations showed story creation and story sharing are skills. As with any skill, it is developed through experience. During rounds, interns and residents often presented a lengthy list of problems the patient was facing and data they had at that point, but seemed to have little sense of how to tie the information together into a coherent mental model.
An additional finding that emerged from the interviews is that the complete story is not captured fully in any one place and, often, not by any one caregiver; rather it emerged over time. Important elements of the story may be missing altogether from the patient record or may be fragmented so that one portion is captured in nursing notes, another in the patients' electronic chart and another in a paper-based consultant's note. Moreover, the overall picture, and its supportive data, may not be adequately communicated during shift hand-overs or between members of the health care team. There was evidence suggesting that shift hand-overs often involve a series of checklists, and it is questionable whether or not the essence of the story is captured in these exchanges. When asked about the consequences of losing parts of the picture/story, physicians and nurses readily acknowledged there are negative consequences for decision-making and quality of patient care.
It was clear in the observations that the two ICU environments studied were characterized by collaboration, where cognitive work and expertise are distributed among members of a multi-disciplinary team that includes nurses, physicians, respiratory therapists, pharmacists, and other professionals.
During the interviews, one of the themes that emerged was the presence of communication difficulties between nurses and physicians. Communication problems between nurses and physicians are complicated, in part, because physicians and nurses believe they speak different languages. Nurses interviewed explained that nurses and physicians use different terminology to refer to patient needs. Their distinct professional backgrounds and training lead to different ways of seeing the world, different concerns and different goals.
Another complicating factor observed that can impede a common understanding (often called common ground) in the ICU team relates to the sub-teams or smaller dyads (Table ) that communicate and make important assessments and decisions about patient care throughout the course of the day. Fragments of the larger ICU team – the nurse with the intern, the intern with the pharmacist, etc – were observed engaging in important conversations, during and outside of rounds. In some of these cases, notes from the conversations were recorded. In others, they were not. In some cases these smaller teams were discussing specific tests and specific pieces of data, but were not aggregating it with other data to see the bigger picture. Fractured teams were observed during rounds when team members were interrupted by phone calls, visiting consultants or other ICU issues.
Challenges in coordinating and maintaining common ground in the ICU were also found to stem from the unstable and shifting nature of the teams. ICU teams perceive their performance to be negatively impacted by the fact that they change every two to four weeks as residents and attendings rotate in and out.
Increasing numbers of shift hand-overs
Clinicians interviewed indicated that in many shift hand-overs, important information is not communicated. Critical aspects of the patient picture or story can slip through the cracks, hindering the team's ability to make sense of the patient's condition and to make vital decisions about treatment and care.
Role ambiguity in the ICU
Confusion surrounding roles and functions in the critical care team were uncovered. These confusions were particularly pronounced surrounding where a nurse's role ends and a physician's role begins. A relatively common sentiment among the nurses was captured in one nurse interview. She explained that sometimes she is asked to use her own discretion regarding certain decisions such as sedation. But when she does use her discretion, the physicians then tell her not to give the patient any more sedatives. As a result, she is frequently unsure about what to do and she questions whether certain decisions are truly at her discretion.
External collaborators in critical care
During the data collection, difficulties were observed resulting from coordination problems between members of the ICU team and the consultants. It was clear from the observations in both ICUs that the critical care team plays a pivotal role within the context of the larger organisation. A host of challenges arise when members of the ICU team must coordinate patient care and maintain common ground with other members of the larger multi-disciplinary team.