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A qualitative study of expert and team cognition on complex patients in the pediatric intensive care unit*

Custer, Jason W. MD; White, Elizabeth RN; Fackler, James C. MD; Xiao, Yan PhD; Tien, Allen MD, MHS; Lehmann, Harold MD; Nichols, David G. MD

Pediatric Critical Care Medicine: May 2012 - Volume 13 - Issue 3 - p 278–284
doi: 10.1097/PCC.0b013e31822f1766
Feature Articles

Objectives: To understand expert and team cognition of complex patients in the pediatric intensive care unit through the use of cognitive task analysis.

Design: Qualitative study with semistructured interviews.

Setting: Academic medical center pediatric intensive care unit.

Participants: Physicians, nurses, and nurse practitioners.

Interventions: None.

Measurements and Main Results: Semistructured interviews were conducted with members of the critical care team involved with the care of seven complex patients. Interviews were transcribed and themes were identified based on grounded theory and further divided into categories. A focus group of critical care team members further refined and validated the findings. From the interviews, 177 verbal fragments were sorted into 11 themes. Four broad thematic categories were identified and a cognitive framework for the care of complex patients was formulated. We found that at the center of this framework, critical care teams attempt to create and share mental models of their patients. These mental models serve as the framework for delivery of longitudinal care across handovers and shift changes. The analysis revealed that this process is limited by a number of factors such that team members utilize a variety of techniques to overcome these limitations and develop more complete and shared mental models.

Conclusions: An inadequately developed or inadequately shared mental model is a substantial cognitive limitation for expert and team cognition in the complex environment of the pediatric intensive care unit. Providers utilize techniques that may avoid or decrease the variable interpretations of patient condition that would otherwise impair mental model formation and sharing. Future studies should be designed to enhance mental model formation and communication in the pediatric intensive care unit and other environments that deal with complex patients.

From the Department of Pediatrics (JWC), University of Maryland, Baltimore, MD; Departments of Anesthesia and Critical Care Medicine (EW, JCF, DGN) and Pediatrics (JCF, HL, DGN), Division of Health Science Informatics (AT), Johns Hopkins School of Medicine, Baltimore, MD; Office of Patient Safety (YX), Baylor Healthcare Systems, Dallas, TX; and Medical Decision Logic (AT), Baltimore, MD.

*See also p. 354.

The authors have not disclosed any potential conflicts of interest.

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©2012The Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies