Complex decision making in an intensive care environment: Perceived practice versus observed reality

Abstract

RationaleAdvancing our understanding of how decisions are made in cognitively, socially and technologically complex hospital environments may reveal opportunities to improve healthcare delivery, medical education and the experience of patients, families and clinicians.Aims and ObjectivesExplore factors impacting clinician decision making in the Boston Children's Hospital Cardiac Intensive Care Unit.MethodsA convergent mixed methods design was used. Quantitative and qualitative data sources consisted of a faculty survey, direct observations of clinical rounds in a specific patient population identified by a clinical decision support system (CDSS) and semistructured interviews (SSIs). Deductive and inductive coding was used for qualitative data. Qualitative data were translated into images using social network analysis which illustrate the frequency and connectivity of the codes in each data set.ResultsA total of 25 observations of eight faculty‐led interprofessional teams were performed between 12 February and 31 March 2021. Individual patient characteristics were noted by faculty in SSIs to be the most important factor in their decision making, yet ethnographic observations suggested faculty cognitive traits, team expertise and value‐based decisions were more heavily weighted. The development of expertise was impacted by role modeling. Decisions were perceived to be influenced by the system and environment.ConclusionsClinician perception of decision making was not congruent with the observed behaviours in a complicated and dynamic system. This study identifies important considerations in clinical curricula as well as the design and implementation of CDSS. Our method of using social network analysis to visualize components of decision making could be adopted to explore other complex environments.

From theory to practice: The pragmatic value of applying systems thinking and complexity sciences in healthcare

“…The articles [19][20][21][22][23] in this edition of the Complexity Forum provide further insights that will shape the ongoing development of systems thinking informed healthcare. Sturmberg and Marcum discuss the philosophical basis and consequences of systemic thinking on research and conclude that the observable outcomes of health, health care delivery and health systems are governed by causes and effectsevery cause leads to effects that themselves become causes for other effects.…”

“…The papers by Rusoja 22 and Teele 23 and colleagues discuss the translation of systems and complexity thinking to improve care in the emergency department and intensive care unit respectively.…”

“…Their approaches provide a practical example that synchronises well with the work of the Complexity Working Group of the North American Primary Health Care Research Group on Superutilization. 35 Teele and colleagues, 23 using network analysis, have uncovered a discrepancy between practitioners' perceptions and actual clinical decision-making in the complex context of critically ill children in a paediatric cardiac intensive care unit. They identified that "clinician perception of decision making was not congruent with the observed behaviours in a complicated and dynamic system", a finding that calls for the reconsideration of the nature of clinical decision-making curricula and teaching approaches at the ward level.…”