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. This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's website (http://ift.tt/29S62lw). Drs. D'Lima and Murray share joint first authorship. Dr. D'Lima contributed in thematic structure and analysis, writing of first draft, writing of final draft, revision of articles, and approval of final draft; Dr. Murray contributed in original concept and study design, collection of data, thematic structure, writing of first draft and final draft, revision of articles, and approval of final draft; Dr. Brett contributed in original concept and study design, review of emerging themes, revision of articles, and approval of final draft. The views expressed are those of the authors and not necessarily those of The Health Foundation, National Institute for Health Research, the NHS or the Department of Health. Supported, in part, by the National Institute for Health Research comprehensive Biomedical Research Centre, the Patient Safety Translational Research Centre based at Imperial College Healthcare National Health Service Trust and Imperial College London, and The Health Foundation. Dr. Murray's institution received funding from The Health Foundation. Dr. Brett's institution received funding from The Health Foundation, and he received other support from the National Institute for Health Research Comprehensive Biomedical Research Centre based at Imperial College Healthcare NHS Trust and Imperial College London (general support for research). Dr. D'Lima disclosed that she does not have any potential conflicts of interest. For information regarding this article, E-mail: eleanor.murray@sbs.ox.ac.uk Copyright © by 2017 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.

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