The social context of crtical care clinical judgment

CLINICAL DECISION M A K I N G

The social c o n t e x t of critical care clinical j u d g m e n t

Susan K. Chase, EdD, RN, CS, Chestnut Hill, Mass B a c k g r o u n d : Clinical judgment in critical care is supported by a rich social network of care providers. The purpose of this study was to describe the social context in which the process of critical care clinical judgment occurs from the nurse's perspective, M e t h o d s : An ethnographic study was conducted that included interviews with 10 nurses and participant observation in an open heart surgery unit with 59 nurses and t w o surgical teams during a 2-year period. Results: Nurses and physicians were organized in hierarchies of nurse manager, resource nurse, charge nurse, and staff nurse or attending surgeon, fellow, chief resident, and resident. These parallel hierarchies allowed for checks on judgment both within and across professional lines. Rituals, such as nursing report, physician rounds, and flow sheet use, provided a context for a critique on judgment processes. Communication of judgment was frequently a casual, open conversation. At other times, differences in perspective could result in conflict. Communication between nurses and physicians has been associated with better patient outcomes. Critical care unit directors and managers can use an analysis of communication patterns to develop supports to clinical judgment. (HEART LUNG| 1995;24: 154-62)

Clinical judgment has been of interest to both clinicians and educators for many years. Most research into judgment processes has been approached from an individual perspective; that is, the process of interest has been the activity of the lone clinician responding to a case study or as observed in a clinical situation. In actual practice, however, clinical judgment almost always occurs in a group context. In critical care in particular, many persons contribute to developing the overall picture of patient status and the overall treatment plan. Accurate clinical judgments that lead to appropriate clinical interventions are essential to the survival of patients in the intensive care unit (ICU). Clinical judgment is the complex cognitive process by which a clinician interprets patient behaviors and builds a communicable description of the status of patients. Making a judgment involves making a decision about whether a patient needs the initiation or modification of treatment. In critical care, multiple clinicians are involved in deciFrom the Boston College School of Nursing, Chestnut Hill. Reprint requests: Susan K. Chase, EdD, RN, CS, Boston College School of Nursing, Chestnut Hill, MA 02176-3872. Copyright 9 1995 by Mosby-Year Book, Inc. 0147-9563/95/$3.00 + 0 2/1/62117

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sion making about patient care. Communication among all these persons is essential to optimal judgment by all care providers. In a study that examined outcomes of critical care, controlling for severity of illness, Knaus et al. 1 have shown that where communication between nursing staff and medical staff is good, patients have a lower than expected mortality rate. The study of Knaus et al. used a subjective rating of overall communication and did not attempt to describe how communication affected critical care judgment or care delivered. A critical care unit is more than a series of "private duty" rooms. The collection of skilled persons functioning in a tight social network makes judgments that are more than and different from the judgments made by persons working alone. The network provides a richer contact with the data on a minute-by-minute basis along with the expertise of care providers, who bring a higher level understanding of possible problems, interventions, and outcomes. An understanding of how judgment occurs can be useful for nurses, managers, physicians, and other care providers as they try to maximize the effectiveness of critical care units. Understanding the features of the judgment process, including its context, provides a means of developHEART & LUNG @ MARCH/APRIL 1995

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ing supports that optimize the judgment process. The purpose of this study was to describe the social context in which clinical judgment occurs, addressing the research question: how does the social context of critical care affect clinical judgment? REVIEW OF THE LITERATURE

In critical care, clinical judgments are concerned with questions of patient physiologic stability, psychologic stability, the need for the use of invasive technology, and the use of potent medications and mechanical support. Early problem recognition is supported by constant physiologic monitoring. Clinical judgments are supported by observing the trends in patient data over time. 2 The general process of clinical judgment has been reviewed by multiple authors. 26 Findings have shown that nurses and physicians gather information to use as cues in the judgment process. On the basis of these cues, experienced clinicians generate more hypotheses about the condition of patients than do inexperienced clinicians, and they do so earlier in the clinical encounter. 7m Further data are gathered to confirm or rule out the presence of suspected clinical problems, and data are evaluated as parts of patterns. Contexts and prior experience affect interpretation of cues. Relatively more cues are included by experienced clinicians than by students, 11, 12 and experts generate more complex hypotheses than clinicians with less experience. 13 Once clinical hypotheses have been validated, a judgment or diagnosis is established, and treatment options are considered. Clinical experience affects the judgment process by providing a rich repertoire of cases that can be used as examples of either possible problems or possible solutions. Experience is a basis for proposing most likely problems even when data are ambiguous or uncertain. The process of clinical judgment is not a simple selection from a list of possible diagnostic statements. Diagnostic reasoning errors can occur when a full range of diagnostic possibilities is not well understood, a problem common for novice practitioners. Another type of error occurs when the clinician jumps too soon to closure and fails to consider cues that do not fit the favored hypotheses, a problem more often experienced by the experienced than the novice clinician. 14 Mentoring by experienced clinicians helps novices to develop the judgment process. 15 In an hermeneutic study Benner et al. 16 described how nurses of varying levels of expertise actually perceive working in different clinical worlds. Qualitative research has described the social context of hospital settings. Bosk 17 described the HEART & LUNG|

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process of learning to become a surgeon, and Wolf18 described the context of nursing care on a general medical Unit. A study of clinical judgment in critical care described general processes of forming clinical judgments. 2 This study expands the understanding of critical care clinical judgment by describing both the process and the context of that judgment. METHODS

An ethnographic method was chosen to develop a rich description of the social context in which clinical judgments are made. The critical care unit can be seen as a "culture" in that it has members, roles, and rules. Field research enabled the researcher to become a part of the nursing subculture in a critical Care unit for the purpose of describing the meanings, behaviors, rituals, and communication of the unit. Some types of data that are of interest in this method are social roles, communication patterns, and gender influences on actions and speech. A strength of ethnographic research is that it supports the development of a rich description of a social process. The findings are setting and time specific)9723 Setting. A teaching hospital in the northeastern United States was chosen as the research site. The unit was open to a variety of technicians, students, and caregivers. The researcher's presence as observer was not as disruptive as it would have been on a more closed unit. The process of judgment was open to discussion, evaluation, and refinement because of the teaching focus of the unit. The primary unit studied was an 11-bed open heart surgical ICU. The population undergoing open heart surgery was relatively homogeneous and had repeatedly similar clinical problems. For comparison of judgment processes across units, observations were made for several months in a 10-bed general surgical ICU. The patients in this unit experienced trauma or abdominal, thoracic, vascular, or neurologic surgery. Field work. Approval for the study by the Department of Nursing and the Institutional Review Board at the hospital was obtained. Nurse managers granted access to the nursing units and individual nurses signed written consent forms to be interviewed or observed. Two nurses in the general surgical I C U declined to participate. No nurses in the open heart surgery I C U chose not to participate. T w o types of interviews were conducted. Individual interviews were conducted and audiotaped with 10 nurses in a private office. These interviews were open ended and changed during the research. One of the more general questions was, 155

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"Can you recall a time when you have been unsure what to do for a patient? What did you have to consider?" or "If you were orienting a new nurse, what would you make sure that they knew or could do?" A second type of "on-the-spot" interview was conducted with 20 additional nurses to learn why nurses had chosen to do certain things or what they might have done differently under different circumstances. Approximately 10 physicians were also interviewed casually to learn their perspective on the judgment process and how they viewed the nurse's role. All the informal interviews were hand recorded as part of the field notes. Participant observations were conducted approximately twice a week during a 2-year period. Subjects. The open heart unit had 59 full-time and regular part-time registered nurses as staff. The general surgical I C U had 38 full-time and regular part-time staff nurses. For the purposes of the study, 10 nurses were followed extensively in field research, and an additional six participated in tape-recorded interviews. In addition, approximately 20 staff nurses and 10 physicians were observed casually as part of field observations. Data analysis. Field notes were recorded daily. Field notes and other documents, such as communication books for the units, orientation materials, practice committee minutes, policy manuals, clinical flow sheets, and patient charts, were analyzed for themes. The Ethnograph 23 was used to code and sort data. Initial coding categories were based on themes described in the literature, such as sources of data, setting, roles, communication, and content of decisions. These categories shifted as analysis proceeded and eventually included formal organization, customs, and others. In addition to field notes, frequent methodologic and analytic memos were written to capture emerging patterns in data or to develop new understandings of observations. From these memos new approaches to data collection evolved. Focused observations were developed in response to initial observations about communication patterns. For example, a question of whether patient care protocols were more important to clinical judgment than individualized patient responses supported the choice to include a less protocol driven unit as part of the study. This led to observation of the general surgical unit. Information from the analytic memos was communicated back to nurses in the study. They could then accept or reject conclusions that were drawn about their practice. Finally, after analysis had been completed, formal meetings were held with the staff to share findings. Threats to validity. The researcher's back156

ground as a critical care nurse was clear to all participants and influenced data collection and interpretation. Identification with the study group could have made it harder to see limitations in the practice of nurses, but it allowed for discussions of critical care judgment using the language of the participants. Field notes were recorded as close as possible to observation. In addition, nurses were questioned on the spot to determine if data interpretation was accurate. The very nature of asking one to think or talk about one's thinking can change that thinking. Recall of events during an interview is also subject to selective memories. The description developed in this ethnographic analysis is from the viewpoint of the participants but as interpreted by the mind of the researcher. The multiple sources of data that were used in the analysis also support the validity of study conclusions. FINDINGS Social roles in critical care

Nursing hierarchy. Critical care nurses function in a hierarchy of roles. In this open heart surgical unit, the nurse manager "hires and fires" the nursing personnel. The nurse manager does not directly care for patients but follows the progress of unusual or long-term patients. On each shift a nurse assumes the role of "resource nurse." This person oversees the hour-by-hour functioning of the unit as a whole, such as considering expected admissions and discharges of patients, ascertaining that beds are available for patients in the operating room, and covering sick calls. Resource nurses also take a patient assignment. They are the most experienced of the staff nurses. The nurse clinician has a separate job description and provides for quality of care by orienting new staff, developing unit policies, and providing direct support where needed, such as assisting in emergency situations. The clinical nurse specialist in this unit is mostly involved with formal teaching in orienting new staff. The nurse manager, nurse clinician, and clinical nurse specialist are the designated "experts." They do not take patient assignments. The resource nurse is seen as both a caregiver and a resource to other caregivers. At the time of data collection, the unit had 36 full-time staff, 16 of whom worked between half and full time and seven of whom were "per diem." Staff nurses have a hierarchy of seniority. The scheduling sheet, both the handwritten one and the computer-generated sheet that was being phased in, listed staff by seniority and not alphabetically. Staff nurses are assigned to patients to provide HEART & LUNG@ MARCH/APRIL 1995

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all their nursing care. Stable patients might be "doubled," meaning that the nurse would care for two patients. Nurses refer to " m y " patient. This informal ownership is formalized by a large display board that lists each patient name, the nurse assigned, and the surgical team. This close attention to an individual patient is seen by the nurse as a way to "know the patient" that differs from the way the physician knows the patient. Nurses leave the unit only to transfer patients to different patient care areas, to have lunch, or to take a break. Any time the nurse is not physically on the unit~ "coverage" is arranged. The nurse might be as far away as the coffee room, but the patient is constantly in mind. Once while the researcher was interviewing a nurse in the coffee room across the hall from the patient unit, the nurse excused herself to check the patient because she thought, correctly so, that she heard a different pattern in monitor rhythm. Having a patient assignment means connection to the patient in a way that implies carrying a responsibility for knowing and caring. There is a blend of experienced and newer nurses in each shift. This layering of new with more experienced staff and with resource nurses and nurse clinicians provides available help to solve problems that might occur. Staff are expected to communicate their questions and concerns. When asked how a nurse might get in trouble, the nurse manager responded, "By not asking for help soon enough." The idea that "nurses help other nurses here" is supported by assigning two nurses to the admission of a new patient from the operating room. Nurse 1 "takes the patient" as an assignment. Nurse 2 provides technical support by connecting oxygen and suction lines, establishing drainage systems, and working with equipment. These responsibilities last only for the first hour of the admission. The nurse has additional assigned patients. This is a unique assignment system that clearly states that "we help each other here." Not all ICUs have this formalized means of support. In I C U admissions that occur multiple times each day, each member of this team plays his or her part and knows what to expect of others. The nurse who is admitting the patient obtains most of his or her information about patient status not from the operating room nurse but from the anesthesiologist. The concerns of anesthesiologists and I C U nurses are similar, including medication support levels, how the patient responds to medications, what level of medication has been necessary to anesthetize the patient, and the patient's temperature. Surgeons are more concerned with HEART & LUNG@ VOL.

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active bleeding and graft patency. Operating room nurses communicated more with the surgeons and with the nurse setting up mechanical systems than with the primary nurse. N u r s i n g report. T h r o u g h the ritual of nursing report, the staff accomplishes the handing over of responsibilities for the patient from one nurse to the next. A patient is never unassigned, that is, without a nurse. Unit standards state that shift to shift report will occur at the bedside. This allows for visual verification of data. The responsibility for accuracy in calibration of equipment: and drug administration rests with the nurse assuming responsibility for the patient. Nursing report serves 'other functions as well; it sets t h e stage for the judgment process. Critical care judgment involves evaluating trends in physiologic data. 2 Nursing report is a time for the offgoing nurse to leave a sense of trajectory for the incoming nurse so that the nurse's evaluation of even the first piece of data gathered has a context. Nurses fight any threat of changing report structure. They talk of needing a "good report" before they begin care and are annoyed with a report that is disorganized or incomplete. They report that subsequent to a disorganized report their judgment i s impeded. Medical hierarchy. The attending surgeon directs the actions of fellows and residents in the care of "his" operative patients. The research site has two teams of surgeons. The surgeon who performed the surgery is considered the "attending:" In addition, a unit director, is involved with general unit functioning more at a policy level than at an individual patient level. At no time during the study was the unit director observed in patientspecific dialogue with either nurses or physicians. Other physicians are fellows, chief residents, and other residents. A clear hierarchy exists among the physicians on the unit. Residents and even fellows are in a learning process. Residents are acquiring new skills whereas fellows are directing care, evaluating other residents, and Perfecting their techniques. Residents are usually in the operating room, but at all times one resident of the team is considered "out." It is that resident's responsibility to manage the care of patients not in the operating room. During attending rounds the unit resident summarizes and justifies actions taken on behalf of the patientl At other times senior residents or fellows ask for a brief description of patient status and offer suggestions for care. The unit residents are usually on the unit but are occasionally called to see a patient in another care area. These residents monitor patient progress by walking around the unit to check patient data and by 157

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talking to the nurses. The resident only occasionally enters the patient care area to deal directly with a patient. A ritual associated with physician hierarchy and clinical judgment is medical rounds. These are held each day, once in the morning before surgeries begin and once later in the day when surgeries are completed. Medical rounds are detailed examinations of each patient, with the resident presenting major events and the patient's status. This resident is questioned about data and asked to justify decisions in this public forum. This social ritual accomplishes a critique on judgment and an occasion for teaching. It differs from the nursing report in that it is more public, includes more of the hierarchy as audience, and has more of an evaluative tone than does the nursing report, which is done on a one-to-one basis. In nursing report there is a communication of whether the previous nurse has done all that needs to be done, as well as a report on patient status, but it is a more private evaluation than medical rounds. Nurse-physician communication

The clinical judgment process is experienced differently for the nurse and for the physician. These two groups have different points of view on the same patient problems. The nurse stands closer to the bedside literally and figuratively. The nurse has available more rich sensory data about the patient and a clearer focus on the idiosyncrasies of individual patients. This difference in perspective can lead to conflicts. For example, one such conflict occurred while extubating and transferring a patient who was a trauma victim. The nurse thought that the woman was ready to be transferred and felt some pressure to have a bed ready for a patient who was coming out of the operating room. The physician who was covering trauma patients was reluctant to move the patient out so quickly. He thought that observations would be less frequent by the floor nurses. "She's going to the Howard Johnson's out there. Anything could happen. She won't be seen for hours." The physician was not confident about the patient's ability to maintain spontaneous breathing and the monitoring in the unit to which the patient was to be discharged. Conflict is not always a negative experience. In this example the patient was extubated, progressed appropriately, and was transferred. The physician thought that the woman was sleepy, but the nurse's perspective was that she was lying still because of pain. The physician had not been in the room as much as the nurse, and he did not know her individual responses as well as the nurse. After some 158

more discussion at the desk, the physician returned to the room, smiling at the nurse with whom he had the disagreement and said, " H o w are you doing, Lisa?" There apparently was no resentment on either side as the conversation continued. The relationship between nurse and physician was strong enough that each could voice his or her position and work out a compromise on the amount of time the patient would stay in the unit before transfer. The resident Carries a different sense of responsibility for the patient and his or her judgments. As mentioned in relation to rounds, judgment must be accounted for in medical rounds twice a day. The resident managing patients in the unit must keep the priorities of 11 patients straight at one time. This taxes human memory and information processing capabilities. The nurse does not expect the physician to have the rich "feel" for the patient. When a patient is having difficulty and the attending physician comes in to make a decision, such as whether the patient needs to be returned to surgery because of heavy bleeding, the attending physician frequently asks for information directly from the nurse. He then directs the resident in what medical actions to take, such as repositioning or inserting chest tubes or changing medication or fluid management. This entire exchange provides recognition of the importance of the richness o f the data held by the nurse. Nurses know the individual patient's data the best, carrying at most two patients. Their grasp of details and also the nuances of the data makes the nurse a key player in data management and thereby in clinical judgment by the unit as a whole. The nurse's role on the team involves data generation, reporting early signs of patient deterioration, technology assessment and management, pulling together the plans of multiple members of the medical team, providing constant observation and connection with the patient, interpreting events to the family, reporting patient status at times of transfer to regular patient care areas, and prevention of complications. The physician depends on the nurse to generate data, maintain the database, and make the first pass at data evaluation. This data evaluation starts at the level of individual cue interpretation. One nurse provides an example of this evaluation in describing the process of deciding whether and how to supplement potassium. The data that comes in is prioritized, and then weighted as to consequence, acuity of the data, how powerful it is. If someone's K is 4.5 and the doctor wanted it 5.0, I might not act so quickly. If it's 3.2 or 3.3 and we're having eetopy, I'll do it (give potassium). If it's 4.5 and the doctor wanted it 4.5 and we're having ectopy, and I know there's

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a relation, I'll do it. Depends on the strength of the data coming in and what it might portend...On nights it's a lot different. You have to wonder. Is this really important enough to wake a guy up for? That's another confounding variable.

Clinical judgment in this situation begins with the nurse. Knowing how far to proceed in medication management is partly determined by actual written orders and partly by knowing the personalities and contexts of care. F l o w sheet entry. Completion of the flow sheet can be seen as a ritual act. Critical care nurses spend much of their time in data generation and management. Flow sheets that at the time were completed on paper stayed at the bedside. At a later time flow sheets were converted to a computerized system. This conversion process brought to the surface how important the flow sheet is to critical care judgment. Once when a resident took the flow sheet to the central station to discuss a case with the attending surgeon, the nurse laughed (seemingly at herself) and said, "I can't do anything without my flow sheet. I hope he hurries up and brings it back." The flow sheet contains physiologic data from the patient as well as treatment and support levels. In a way by completing the flow sheet, the nurse is assured that everything that needs to be done has been done. The flow sheet provides a structure for the complex activities of critical care from the nurses' standpoint. It holds the cues, supports seeing patterns in data, and allows a place to see the trends and rates of change in the data. Much as a symbol is a visible representation of an invisible reality, the flow sheet is symbolic of the data collection and management role of the critical care nurse. On this unit, which was developing a computer-based flow sheet, a policy was being developed that the only personnel who could access the flow sheet for data entry were the nurses and the unit physician directors. This policy decision refleets the respect for and reliance on the staff nurse as data collector and recorder for all the judgment processes in the unit. Casual conversation. Communication about patient data has a casual tone during most situations. The resident walks around the unit checking about once an hour on the data being generated. As long as everything is proceeding smoothly, treatment decisions a r e part of casual conversation. Face-to-face communication conveys information differently from written notes. A lot of times a report wasn't quite a report. We're just sitting around chatting about what's going on. You kind of throw up a case for discussion and a lot of things are handled that way.

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Another nurse explains: The flow sheet doesn't capture everything. Because if things are changing rapidly, there's not room on the flow sheet, number one, and lots of times that kind of stuffjust gets verbally communicated in shift reports and what not. I might click down a drip and see the pressure really take a drop, so I click it back up and I'm not going to record it all. Those are the kinds of things that you won't find written but verbally communicated. "I clicked down the drip a couple of drops and his pressure dropped so I went back up."

Casual conversation becomes part of thinking out loud as well as part of the process of reporting progress. Sometimes the data do not present a clear picture. One sleepy resident was observed looking at a flow sheet for a patient who was not responding in the expected way to the drugs being used. "Well, I don't know what to do about it, do you?" he asked the nurse. She responded that they would keep going as they were. Physicians frequently rely on nurses to suggest meanings in data or treatment approaches. When a nurse has a question about procedure, the nurse might casually go to the central station where the residents sit, take the flow sheet, and say, "You want to look at these numbers?," or "Could you come and look at this pacemaker?" One nurse described the following: The patient comes in, a nursing assessment is done, physical assessment data are collected, decisions are made about what the patient needs based on the data coming in. If the needs are within my control, I can just do them. If they required medical input, again, you build your case and present it to the does.

There is a sense that the assembly of the data before discussion with the physician is the nurse's responsibility. Another nurse describes how she learned the judgment process and how she used that process in conjunction with others. First I got all the information together. I put it in kind of a package and showed it to one of the more experienced nurses. At first I asked her what she thought about it. Later, she asked me. Then I would take the information to the resident and ask him. At first I went to get his judgment of what to do. Later, as I learned more, I would bejudging the resident. Was what he said to do the right thing? If not, I wouldn't do it.

Orders. There are judgments that nurses make independent of physicians. These include what and how to communicate with patients and families, how to care for patient skin, wounds, and lines, as well as patient comfort and activity issues. In other areas, such as the administration of a drug or changing a ventilator setting, a nurse by law and 159

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by policy must have a written order from a physician. This policy places even the most experienced nurse in a role dependent on a physician, even a junior one. The area of medical orders is the place in which the nurse is in a hierarchic position below the physician. However, this does not imply that the nursing hierarchy is entirely subject to the medical hierarchy. Nurses are answerable to nurses for nursing care. They are answerable to physicians for the medical care acts they carry out. Nurses provide evaluative information to the medical hierarchy regarding the actions of individual physicians. One way to learn about a situation is to examine the ways in which words assume unique meaning in that setting. "Orders" is a significant concept in critical care. One might expect that the order is a throw back to a military model where the physician in charge keeps the troops in line by telling them what to do. Orders here mean something different. In the nursing-medical world this is the officially recognized form of communication. When carrying out an act related to medical treatment, the nurse feels "covered" by the order and asks, coerces, or demands the physician to write it. In this way the order can b e seen more as a permission. The order symbolizes the result of the clinical judgment process that both nurse and physician develop. Orders can take different forms. Medications are often ordered with "parameters" That means that drugs are given to keep a blood pressure, a heart rate, or a urine output at a certain level. The nurse adjusts medication levels to achieve the appropriate readings on one or two physiologic parameters. Drug levels are also changed by nurses when the medications may no longer be needed. Because sudden discontinuation of these vasoactive drugs would be too drastic a change for the patient, the patient is "weaned off" of the drugs. The physician often gives a nonspecific verbal instruction to decrease medication. These medication level changes require a continual judgment process by the nurse. When asked a general question about what types of decisions critical care nurses make, one nurse responded: I guess one of the times, when they are on multiple drips, and the does say to wean them and then you kind of scratch your head a few minutes and say, "OK, which ones do they want weaned first ? Do I wean more than one at the same time? How fast do they want to go? [They don't say? Or do they sometimes give you some direction ?] If you go after them and say, "Give me a little more specifics," they are willing to do that. But very often they'll just say "wean them," or "wean nitro." Very

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rarely will they give parameters. In a lot of ICU's, I believe, they write very stringent parameters, but basically, here they just assume that the nurses are going to know, and they'll do it. [So how do the new nurses learn how to do that?] I can remember the first time I had a patient on several different drips, and I didn't know. And what you do is you go to the most experienced nurse who happens to be on and say, "Help me with this." And everybody works as a team here so it's really good for that. And when I got comfortable with something, I had no qualms about calling a physician and saying, "I need a little more guidance here as to what we're looking for."

This excerpt demonstrates that learning is done in a group context and that the nurse needed to feel that she was current in relation to expected nurses' knowledge and practice and that then she was comfortable pressing the physician for more detailed guidelines. The nurse still places this exchange in the group context and uses the collective "what we're looking for." The nurse hierarchy of nurse clinician, resource nurse, and senior nurses supports the judgment process of the less experienced nurse. Calling the attending. The ritual of '~calling the attending" can be seen as representing the location of ultimate responsibility for the patient. As previously discussed, nurses call for the resident to write orders that go beyond the unit protocols that determine how the nurse can manage a patient independently. Residents also have physicians above them on whom they can call when they are uncertain about managing patients. Deciding when to call for help is a judgment that residents must make. It is a decision usually made by the resident, but under unusual circumstances, it is made by the nurse. Sometimes a patient crisis is obvious and everyone knows it is time to call the attending physician for advice. At other times, the nurse initiates the process of obtaining help. This is a situation that many nurses call "rallying the troops." When a decline in physiologic stability is more subtle, inexperienced residents might not recognize the signs of impending patient deterioration. Nurses in this circumstance try various means to get what they think the patient needs. The first stage is often to present the data in such a way that any clinician would recognize what to do. If that fails, then the nurse might suggest that the chief or attending physician be called. If the resident does not act, the nurse might call in a more experienced nurse and use the strength of numbers. Failing this attempt, the nurse might "go over the resident's head" and call the attending physician independently. This is an act not taken lightly. It carries some threat to the HEART & LUNG @ MARCH/APRIL 1 9 9 5

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resident of revealing his limitation in judgment abilities, but the nurse is also at some risk. This is seen as a failure of the normal process because it breaks the normal "chain of command." T h e nurse recognizes that there might be verbal reprimand if her or his judgment was in error. T h e nurse risks being wrong about the severity of the patient's situation in a very public sense, but the nurse might feel that the risk is warranted if the patient's condition depends on it. One nurse told a story of being reprimanded for going over the head of a resident too soon. T h e attending physician told her the next morning that the resident needed to learn what he was doing wrong. T h e nurse's judgment was focused on her patient at the time. H e r closeness to the data and her experience gave her insights that were unavailable or unattended to by the less experienced resident. T h e ritual of the nurse "calling the attending" represents a check on the judgment abilities of residents in training. It is a place where the nurse can influence medical decision making and medical action. C o o r d i n a t i o n . Residents communicate with nurses, other residents, fellows, and attending physicians as problems arise. In addition, consulting physicians and pharmacists can be brought to the bedside to solve particularly difficult problems. W i t h this large network of specialists, the possibility of fragmentation exists. One of the main functions of the nurse is to gather, hold, and communicate information about the patient for the various constituencies of the unit. If one team's advice conflicts with that of another, the nurse has to juggle priorities. A simple question asked by a nurse, " W h e r e are we going with this?," prompts the team to consider more than the details but to keep in mind the "big picture." The majority of them comein and just want the basic facts and that's it. They don't want all the extraneous things that may have impacted on them like hemodynamics. They want to come in and say "OK, how much dobutamine is he on and what's the index?" And that?s basically it. They justzero in on that. (I: bottom line kind of stuff, not the whole picture?) Definitely not the whole picture. And if the vascular team comesaround, they just want to hear about pulses. They don't care about anything else. And if ortho comes around they just want to know about the bone, so it's very fragmented. The person who's got the most holistic view is the nurse. Definitely. Next, the resident does, currently much more so than the attending. At times physicians are captivated by the consideration of their own aspect of care. A resident visited a woman who had an apparent intraoperative cerebral vascular accident and who had not awakHEART & LUNG | VOL. 24, NO. 2

ened since the surgery the week before. H e was only concerned about her thyroid function. Once he determined that thyroid hormone levels were normal, his role was completed. T h e nurse stood by and shook her head. The resident had indeed carried out his responsibility related to the thyroid. T h e nurse was reacting to the inadequacy of his ability to see her picture of the patient. T h e nurses were the ones who took the calls from the woman's daughter asking if her mother had awakened. T h e physicians were telling her, " W e just have to wait and see." This was true, but the daughter was encouraged to hold (what the nurses thought was) false hope. CONCLUSIONS

An examination of the processes used to form clinical judgments in critical care allows unit leaders and clinicians to reflect on processes that otherwise might be invisible. This study has described the roles and communication patterns in two ICUs in one teaching hospital. T h e critical care group in the I C U is necessary to the complex care of the patient. No one person can see everything that needs to be seen in the complex clinical situation. T h e parallel hierarchies of nurses (staff nurses, resource nurses, nurse clinicians, and nurse manager) and physicians (resident, fellow, attending surgeon) provide a system of multiple checks that prevent lapses in judgment by either nurse or physician. Senior nurses and physicians monitor the judgment of the persons below them on the hierarchy. In addition, nurses and physicians monitor the judgments of each other. T h e social context of the critical care nurse ineludes both other nurses a n d physicians of various specialties. T h e nurse assembles data that allow assessment of the patient. T h e nurse also assembles data that allow assessment of the physician's ability to safely manage patient care. T h e social structure of the unit allows gradual assumption of responsibility and helps the new critical care nurse learn " w h e n she is in trouble" and that when new nurses judged themselves to be in trouble that they should bring their concerns to a more experienced nurse on the unit. Clearly the unit used for this study supports statements that reflect gaps in understanding. " N o t knowing" is something that is brought to the group for open or casual conversation around the nurses' station. Nurses and physicians were able to discuss disagreements, such as when is a patient ready for transfer out of the unit. Overall, this unit fosters trust and respect among individuals. T h e findings of this study can be used to predict 161

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the otherwise unanticipated effects of changes in practice patterns that might affect clinical judgment. For example, the introduction of critical care technicians to collect physiologic data on patients might decrease the nurse's contextual understanding of the patient's status. On the other hand, a computerized flow sheet might enhance unit clinical judgment by allowing for simultaneous analysis of data by more than one person. The findings of this study present one critical care culture. Staff in other units can use this description as a means of comparison with their own. Rituals of care such as nursing report and physician rounds can be examined for their effectiveness in any unit. Is essential information included? What other purposes do these rituals accomplish? Does the support for learning by novices and the continued development of experienced clinicians exist ? What is the tone of communication between different groups in the unit? Do experienced clinicians support the questions of less experienced personnel ? Do nurses and physicians at all levels have an opportunity to be heard? By understanding the different points of view that staff members in a critical care unit might hold, the opportunity exits for enhanced communication and understanding. Future research can be conducted that describes social context of other types of units. For example, is the culture of a medical unit different from that of a surgical unit? H o w do units compare in the freedom that nurses have to take medical action without a specific order? Other rituals also carry meanings for members. These could be examined to better understand the purpose each serves in the local context. Are there specific roles involved in a neonatal ICU? What role does the patient or family member play in the judgment process? H o w does orientation socialize members of units? If a unit chooSes to enhance its communication, how can that be measured and facilitated? Support for communication and the social context for clinical judgment affect the judgment process itself. The critical care unit provides a place in which the best thinking of multiple types of personnel is necessary to provide good judgment about care. By providing a place in which open communication, including respectful confrontation is allowed, supported, and celebrated, the context of the I C U becomes one of mutual respect and growth. Nurses and physicians have unique viewpoints that they bring to the clinical judgment pro-

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