Clinical Decision Making by Critical Care Mid-Level Practitioners Working within an Interdisciplinary Team: A Dissertation

Abstract

To improve patient safety a major change in health care reduced medical resident work hours to limit provider fatigue, in 2002 (Philibert, Friedmann, Williams, & Hours, 2002). This resulted in mid-level practitioners filling this provider void in health care teams, including critical care units (Buchanan, 1996; Christmas et al., 2005; Hoffman, Tasota, Scharfenberg, Zullo, & Donahoe, 2003; Hoffman, Tasota, Zullo, Scharfenberg, & Donahoe, 2005; Hooker & McCaig, 1996, 2001; Kaups, Parks, & Morris, 1998; Miller, Riehl, Napier, Barber, & Dabideen, 1998; Yeager, Shaw, Casavant, & Burns, 2006). In order to make appropriate clinical decisions for patients in critical care settings, mid-level practitioners are required to interpret data from multiple sources and to assimilate this information in a timely manner (Bernard, Corwin, & MacIntyre, 2000). Although these practitioners are actively involved in decision making individually and among interdisciplinary teams in critical care units, their decision making has not been described in the literature to date (Shortell et al., 1994). Therefore, the purpose of this qualitative study was to describe how critical care mid-level practitioners (N= 17) make decisions within an interdisciplinary team, undergirded by the cognitive continuum theory. A qualitative research design using focus groups guided by naturalistic inquiry enabled data collection. An interview guide, developed from the literature review and undergirded by the cognitive continuum theory, was used to structure discussion in the focus groups. Additionally, a demographic questionnaire and vignette were used to aid in description of findings. Data was managed by note based analysis and summarized on a Microsoft Excel document. Qualitative description was used to illustrate the findings. Prior to this study, there was a paucity of empirical literature describing the clinical decision making of critical care mid-level practitioners. The findings revealed a web of complexity in mid-level practitioner decision making on an interdisciplinary team. This included an overarching theme of quality of care, with central overlapping themes of judgment, resources, and negotiation interwoven with sub-themes of trust, communication, experience, and team structure. This study’s findings have direct implications for mid-level practitioner training courses, mid-level training, critical care orientation programs, theory development, and health policy.