Perceptions of Risk and Safety in the ICU: A Qualitative Study of Cognitive Processes Relating to Staffing.

OBJECTIVES: The aims of this study were to 1) examine individual professionals' perceptions of staffing risks and safe staffing in intensive care and 2) identify and examine the cognitive processes that underlie these perceptions. DESIGN: Qualitative case study methodology with nurses, doctors, and physiotherapists. SETTING: Three mixed medical and surgical adult ICUs, each on a separate hospital site within a 1,200-bed academic, tertiary London hospital group. SUBJECTS: Forty-four ICU team members of diverse professional backgrounds and seniority. INTERVENTIONS: None. MAIN RESULTS: Four themes (individual, team, unit, and organizational) were identified. Individual care provision was influenced by the pragmatist versus perfectionist stance of individuals and team dynamics by the concept of an "A" team and interdisciplinary tensions. Perceptions of safety hinged around the importance of achieving a "dynamic balance" influenced by the burden of prevailing circumstances and the clinical status of patients. Organizationally, professionals' risk perceptions affected their willingness to take personal responsibility for interactions beyond the unit. CONCLUSIONS: This study drew on cognitive research, specifically theories of cognitive dissonance, psychological safety, and situational awareness to explain how professionals' cognitive processes impacted on ICU behaviors. Our results may have implications for relationships, management, and leadership in ICU. First, patient care delivery may be affected by professionals' perfectionist or pragmatic approach. Perfectionists' team role may be compromised and they may experience cognitive dissonance and subsequent isolation/stress. Second, psychological safety in a team may be improved within the confines of a perceived "A" team but diminished by interdisciplinary tensions. Third, counter intuitively, higher "situational" awareness for some individuals increased their stress and anxiety. Finally, our results suggest that professionals have varying concepts of where their personal responsibility to minimize risk begins and ends, which we have termed "risk horizons" and that these horizons may affect their behavior both within and beyond the unit.

Developing effective feedback on quality of anaesthetic care: what are its most valuable characteristics from a clinical perspective?

OBJECTIVES: Research suggests that better feedback from quality and safety indicators leads to enhanced capability of clinicians and departments to improve care and change behaviour. The aim of the current study was to investigate the characteristics of feedback perceived by clinicians to be of most value. METHODS: Data were collected using a survey designed as part of a wider evaluation of a data feedback initiative in anaesthesia. Eighty-nine consultant anaesthetists from two English NHS acute Trusts completed the survey. Multiple linear regression with hierarchical variable entry was used to investigate which characteristics of feedback predict its perceived usefulness for monitoring variation and improving care. RESULTS: The final model demonstrated that the relevance of the quality indicators to the specific service area (ß=0.64, p=0.01) and the credibility of the data as coming from a trustworthy, unbiased source (ß=0.55, p=0.01) were the significant predictors, having controlled for all other covariates. CONCLUSION: For clinicians to engage with effective quality monitoring and feedback, the perceived local relevance of indicators and trust in the credibility of the resulting data are paramount.