Informatics methods to understand interdisciplinary communication related to common goals in the Intensive Care Unit

Background. In the clinical setting, ineffective communication is associated with an increased length of stay, increased patient harm, and increased resource utilization. Additionally, in the Intensive Care Unit (ICU) nurses' and physicians' patient care activities are interdependent, however, there is a lack of engagement in active and consistent collaboration between nurses and physicians This multi-method dissertation consists of four studies aimed at understanding the patterns of interdisciplinary communication of common goals in the Intensive Care Unit (ICU) and proposing an informatics solution to facilitate interdisciplinary communication of common goals.;Results. There is a division of labor within the ICU that allows for efficient task completion. However, registered nurses wanted information about physician order rationales to assess the safety and appropriateness of an order for a patient and medical residents wanted information about clinical domains, such as unfamiliar nursing interventions. During ICU interdisciplinary morning rounds the clinicians at this site had a high degree of common ground and the nurses, with the attending physician, jointly wrote the common goals (i.e., plan of care) on the computer-based Attending ICU note. In addition, clinicians perceived verbal communication as more efficient and accurate than retrieving information from electronic documentation. Overall, 75% of the common goals that were stated during ICU interdisciplinary morning rounds were evident in the electronic documentation (range of 14.28 to 100%); if a stated common goal was not documented it was 60% less likely that a goal-related action was documented. However, it was unclear if a goal was not documented because of a clinician's disagreement with the plan of care or inhibition to speak up due to the authority gradient. Furthermore, structured electronic nursing documentation did not reflect that the nursing activities performed were goal directed.;The common goals tool prototype that was developed included an 'online rounds' discussion board and an overview of the common goals for each patient. Clinicians found the prototype useful, easy to use and that the tool reflected patient care activities, but were concerned that the tool would increase the amount of documentation that they had to complete, instead of replacing some of their current documentation.;Conclusion. Clinicians in the NICU collaboratively discussed common goals; yet, 24.4% of these common goals were not documented in the CIS. This lack of documentation of the common goals plan of care may have patient safety implications such as delayed patient care and errors of omission. Furthermore, development of new nursing knowledge may be hindered by incomplete information in the CIS. Additionally, the clinical communication space theoretical model and Hazlehurst's properties of the ICU activity system and categories of information exchange may be expanded by including the concept that authority gradients in clinical care may impact clinician communication and that common ground may not always be attainable due to differences in clinical specialization or discipline. Informatics tools should aim to capture and facilitate the interdisciplinary communication that occurs within the ICU by moving beyond discipline specific documentation to provide patient centered documentation of common goals. Furthermore, within electronic documentation, nursing should increase evidence of their decision making and planning as it relates to the patient care activities that they perform.;Methods. This study used the distributed cognition and clinical communication space theoretical frameworks to understand information needs, communication patterns, common goals concordance and interdisciplinary collaboration. To describe these concepts and variables the Information Needs Events taxonomy, think aloud data, a satisfaction questionnaire, focus group data, interview data, observational data, comparison of verbal discussions and electronic documentation, and the ICU Interdisciplinary Collaboration survey were used. Additionally, a prototype of a computerized common goals tool was developed and nurses', physicians', and nurse practitioners' behavioral intention to use the common goals tool prototype was measured using the UTAUT survey.