Search

Background: The built environment in acute care settings is a new focus in patient safety research, with few studies focusing primarily on the design of ward environments and the location and choice of material objects such as light fittings and hand-washing basins., Methods: We report on an interventionist video-reflexive ethnographic (VRE) study that explored how clinicians used the built environment to achieve safe communication in an intensive care unit (ICU) in a metropolitan Sydney hospital. We conducted 40 semistructured interviews, 5 weeks of observation and four reflexive focus groups with a total of 87 participants (including medical, nursing, allied health and clerical staff)., Results: We found that the accessibility of staff and patients in the open spaces of the ICU was both a safety feature and a safety risk, enabling safe communication flow, but also allowing potentially unsafe interruptions. Staff managed interruptions while allowing for a safe degree of accessibility by creating temporary protected spaces, using physical markers such as curtains, tape and signs as well as behavioural cues, movement and the development of policies restricting activities at certain areas. Furthermore, clinicians were able to use the VRE method to gain insight into their own practices and problems, and to develop meaningful solutions for other problematic spaces., Conclusions: ICU staff enable safe communication in their wards by creating temporary spaces that are both 'connected' and 'protected'. The flexibility of these 'soft' strategies is especially well suited to the fast-paced clinical context of intensive care., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

The care of people who die in hospitals is often suboptimal. Involving patients in decisions about their care is seen as one way to improve care outcomes. Federal and state government policymakers in Australia are promoting shared decision making in acute care hospitals as a means to improve the quality of end-of-life care. If policy is to be effective, health care professionals who provide hospital care will need to respond to its patient-centered purpose. Health services will also be called upon to train health care professionals to work with dying people in a more participatory way and to assist them to develop the clinical processes that support shared decision making. Health professionals who manage clinical workplaces become central in reshaping this practice environment by promoting patient-centered care policy objectives and restructuring health service systems to routinely incorporate patient and family preferences about care at key points in the patient's care episode.

The aim of this study was to understand the environment of health care, and how clinicians and managers respond in terms of performance accountability. A qualitative method was used in a tertiary metropolitan teaching intensive care unit (ICU) in Sydney, Australia, including interviews with 15 clinical managers and focus groups with 29 nurses of differing experience. The study found that a managerial focus on abstract goals, such as budgets detracted from managing the core business of clinical work. Fractures were evident within clinical units, between clinical units and between clinical and managerial domains. These fractures reinforced the status quo where seemingly unconnected patient care activities were undertaken by loosely connected individual clinicians with personalized concepts of accountability. Managers must conceptualize health services as an interconnected entity within which self-directed teams negotiate and agree objectives, collect and review performance data and define collective practice. Organically developing regimens of care within and across specialist clinical units, such as in ICUs, directly impact upon health service performance and accountability.

In this article, we outline a study method with which structural changes to clinical communication were achieved within a local intensive care unit (ICU). The study method involved in-depth, round-the-clock observation, interviewing, and video filming of how intensivists conducted their practices, as well as showing selected footage to the clinicians for feedback. This feedback component iteratively engaged clinicians in problem-solving their own communication difficulties. The article focuses on one such feedback meeting and describes changes to the morning ward round and planning meeting that this feedback process catalyzed: greater time efficiency, a greater presence of intensivists in the ICU, more satisfied nursing staff, and a handover sheet to improve the structure of clinical information exchanges. We argue that in embodying not a descriptive but an interventionist approach to health service provision, this video-ethnographic method has great significance for enhancing clinicians' and researchers' understanding of the rising complexity of in-hospital practices, and for enabling them to intervene in these practices.

Conflict in health service delivery is common. It is often attributed to disputes between clinicians and patients or their families about treatment decisions and is particularly common in intensive care units (ICUs), in the form of ;futility disputes' between families and medical clinicians about decisions to terminate the active treatment of a dying family member. More common, but less prominent in the literature, is conflict within the medical profession about patient care goals and treatment. We contend that managing the plurality of medical interests is essential in achieving a more managed and positive experience for patients and families of the care they receive, and for achieving standards of quality and resource use. From an ethnographic study undertaken in a large ICU in Sydney, Australia, we found that the knowledge and practice differences of multiple medical decision-makers generated conflict, inconsistency of practice and subjectivity of decision-making that impeded coherent clinical decision-making and integrated patient care planning, coordination and care review. Improving patients' and families' experience of care requires medical clinicians and medical managers to accept responsibility for institutionalizing effective communication and decision-making processes within clinical networks and between clinical and managerial domains. Thus, strategies to improve patient care will need to extend beyond the medical profession to incorporate administrative management. We conclude that restructuring communication and decision-making processes is imperative to achieve clinical accountability in the workplace and systems accountability in the organization.

This paper explores the relevance of a specific kind of sensed connectedness or 'teleo-affectivity' to the organisation and enactment of end-of-life care. Referred to as heedful inter-relating, this teleo-affective connectedness has been found to occur among employees as they carry out their highly complex and dangerous work. This paper focuses on the proposals put in the literature for confronting the complexity of end-of-life care in the intensive care unit (ICU), and inquires into the positionings incurred in and around end-of-life care in one specific unit, with the aim of gauging the pertinence of heedful inter-relating to end-of-life care in ICU. The paper argues that while several commentators appear to be calling for enhanced heedful conduct in end-of-life care, ICU practices may not admit the kind of heedful inter-relating that is evident in high-reliability organisations such as nuclear aircraft carriers. We suggest it may be unwise to gauge intensive care units' complexity purely against the brief of realising cultural scripts of the dying, and that ICU in fact manifests a broader societal concern necessitating a more variegated composition: to devise multiple ways to contain the impression and impact of (the meaning) death for society (societies) generally.