Perceptions of risk and safety in the ICU: a qualitative study of cognitive processes relating to staffing

Objective: The aims of this study were to: i) examine individual professionals’ perceptions of staffing risks and safe staffing in intensive care; and ii) 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 1200-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 organisational) 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. Organisationally, 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 behaviours. 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 behaviour both within and beyond the unit.