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Sensemaking, Safety, and Cooperative Work in the Intensive Care Unit

  • Centre for Patient Safety, Tuscan Region
  • Adaptive Capacity Labs


Making sense of circumstances and situations is critical to coordinate cooperative work. Especially in process control domains, we may expect that effective and reliable organizations will possess processes that develop, maintain, distribute, and, when necessary, repair this social understanding (sensemaking). Our research has focused on collective sensemaking process in an intensive care unit (ICU). Thus, sensemaking is most likely to be visible to researchers in high tempo, high uncertainty work settings such as hospital ICU, where complexity, criticality, and uncertainty are the main characteristics of the working activities and making sense of what is happening is one of the most important challenge of the team of physicians working in this context. The research demonstrates how workers create and distribute sense within small work groups and also how they use the results of these efforts to coordinate ongoing work activities. Practitioners tradeoff the opportunity costs of formal, collective sensemaking (sensemaking at intervals) against the value that this preparation provides to sensemaking during high tempo work (sensemaking on-the-fly). Further study of this dynamic balance will provide insight about how practitioners construct platforms for action during future, uncertain, high stakes work.
Sensemaking, safety, and cooperative work in the intensive
care unit
Sara Albolino ÆRichard Cook ÆMichael O’Connor
Received: 1 October 2005 / Accepted: 1 October 2006 / Published online: 7 December 2006
ÓSpringer-Verlag London Limited 2006
Abstract Making sense of circumstances and situa-
tions is critical to coordinate cooperative work. Espe-
cially in process control domains, we may expect that
effective and reliable organizations will possess pro-
cesses that develop, maintain, distribute, and, when
necessary, repair this social understanding (sensemak-
ing). Our research has focused on collective sense-
making process in an intensive care unit (ICU). Thus,
sensemaking is most likely to be visible to researchers
in high tempo, high uncertainty work settings such as
hospital ICU, where complexity, criticality, and
uncertainty are the main characteristics of the working
activities and making sense of what is happening is one
of the most important challenge of the team of physi-
cians working in this context. The research demon-
strates how workers create and distribute sense within
small work groups and also how they use the results of
these efforts to coordinate ongoing work activities.
Practitioners tradeoff the opportunity costs of formal,
collective sensemaking (sensemaking at intervals)
against the value that this preparation provides to
sensemaking during high tempo work (sensemaking
on-the-fly). Further study of this dynamic balance will
provide insight about how practitioners construct
platforms for action during future, uncertain, high
stakes work.
Keywords Safety Collaborative sensemaking
Intensive care unit work
1 Sensemaking and cooperative work
Dramatic failures of sensemaking are the basis for
much of the research on sensemaking. Weick’s
re-analysis of the Mann Gulch disaster (Weick 1993)is
the archetypal case. While fighting a forest fire at
Mann Gulch, Montana, 13 men were burned to death
by a fire that overtook them as they ran up a steep
slope. Norman Maclean, an English professor at the
University of Chicago, wrote an account of the fire
(Maclean 1992) which shows that one firefighter com-
prehended the nature of the danger facing the team and
devised and used a solution successfully. The rest of the
team rejected the solution and tried to escape the fire,
all but two dying in the process. Such cases are useful as
a starting point for analysis of sensemaking in organi-
zations precisely because they combine what seems to
be a failure to make sense and graphic demonstration of
what seem to be consequences of this failure. But the
celebrated cases of sensemaking failures leave us to
wonder how it is that people are usually able to
make sense of the work world. What is the role of
S. Albolino (&)
Sociology and Social Research Department,
University of Milan Bicocca,
Via Bicocca Degli Archimboldi, Milano 8-20126, Italy
R. Cook
Cognitive Technologies Laboratory,
Department of Anesthesia and Intensive Care,
University of Chicago, 5841 S. Maryland Avenue,
MC4028, Chicago, IL 60637, USA
M. O’Connor
Section of Intensive Care, Department of Anesthesia
and Intensive Care, University of Chicago,
5841 S. Maryland Avenue, MC4028,
Chicago, IL 60637, USA
Cogn Tech Work (2007) 9:131–137
DOI 10.1007/s10111-006-0057-5
sensemaking in organizations? Is it only sometimes
required, e.g., when critical situations arise? Can
sensemaking itself be organized and modulated? More
particularly, is it a mechanism to coordinate individual
contribution in effective collective actions?
As Karl Weick stated (1995, p. 6) ‘‘Sensemaking is
about such things as placement of items into frame-
works, comprehending, redressing surprise, construct-
ing meaning, interacting in pursuit of mutual
understanding, and patterning.’’ Sensemaking is the
action that permits the passage from a non-sense situ-
ation to a situation that makes sense for all the persons
involved (R.I. Cook, personal communication). Be-
cause of its social nature, it is difficult to confine the
sensemaking process to a unique definition, so Weick
tries to clarify the concept by comparing it to others
which are similar and by underling the differences.
Sensemaking is more than interpretation, as interpre-
tation is about meaning, while sensemaking is also
about how the meaning is built and read. In addition,
social sensemaking does not include merely a shared
meaning; rather, it is possible to say that it is the
experience of the collective action that is shared. To
understand sensemaking is to pay attention to organi-
zational and social elements that guarantee the coor-
dination needed for action (R.I. Cook, personal
communication). Sensemaking keeps action and cog-
nition together.
In this paper we present a study of sensemaking in a
natural context, ‘‘in the wild’’ (Hutchins 1995) and
some consequences this inquiry may have for the
understanding of what sensemaking is and how it
contributes to the success of the cooperative work in
highly uncertain settings. We studied a busy intensive
care unit (ICU) in a large teaching hospital and the
function of what the workers here call ‘‘rounds.’’ The
study shows that sensemaking is a cooperative cogni-
tive activity that focuses sharply on the plans, uncer-
tainties, and possibilities of the near future.
2 The theoretical framework
We begin with apparently straightforward questions.
How do practitioners cope with the complexity and
uncertainty of the ICU? How do they manage to pro-
duce good results and avoid bad ones? Following Ras-
mussen in the analysis of natural contexts (Rasmussen
1995) we understand that safe systems are not neces-
sarily error-free. Safety is a dynamic rather than static
feature of systems (Cook and Rasmussen 2005). Safety
is an emergent property of the ways in which the dif-
ferent properties of the system (technical, individual,
organizational, economic) collaborate or clash (Reason
1997). It is the product system characteristics, including
sharp-end (Cook and Woods 1994) worker coping with
the various demands and possibilities that arise. Ulti-
mately, workers’ coping with complexity (Woods 1989)
is expressed in tradeoffs. For example, each ICU
attending physician must direct patient care (e.g.,
therapy, laboratory studies, investigations, procedures),
the organization of work (e.g., allocation of new
patients to residents, resident shift coordination),
learning activities (e.g., what to teach to residents, when
to do so). Devoting time and attention to one or another
activity takes that time and attention away from all the
others. These tradeoffs take place in a high hazard, time
pressured setting under uncertainty. All this coping
takes place in a notoriously ill-behaved domain. New
patients can appear with little warning, old patients may
suddenly deteriorate, and tempo of operations can go
from andante to allegretto with little warning.
It is likely that real world practitioners have tools
that allow them to make sense at a macro level of the
complexity and organize their coping with it. Sense-
making (Daft and Weick 1984; Weick 1995; Manning
1998) is a candidate concept for the analysis of social
coping under stress. The work of ICU teams involves
many patients and many different activities in parallel.
Work is distributed in ways that make it impossible for
any individual to sustain a complete understanding of
the situation. Although far from the dramatic situation
of the firefighters at Mann Gulch, the conditions in the
ICU must be challenging to workers and managers.
Sustaining coordinated, purposeful activity on multiple
fronts in a rapidly changing environment is unlikely to
happen simply by chance. Instead, it seems likely a
priori that some sort of ordinary sensemaking must be
present in the ICU.
3 Methods
This methods used are the hybrid socio-technical
approaches developed by Woods (1989) and Weick
(1995). With institutional human subjects review board
approval and consent of the workers, we examined
work-in-context in an busy, ICU in a large, tertiary
care, teaching hospital in the U.S. Field observations
were conducted so that we could participate in all the
unit activities and understand the complexity of the
work done. We conducted repeated observations over
10 weeks. The focus of the observation was the work
activities of physicians in the ICU unit. The ethno-
graphic study included a combination of observations
and interviews.
132 Cogn Tech Work (2007) 9:131–137
In addition to field notes, we recorded 300 h of
verbal communications that took place in the ICU and
analyzed 400 pages of transcriptions from those com-
munications. The field observations focused on the
work in the ICU, and particularly on moments where
interactions among the participants were visible. These
include the process of scheduled ‘‘rounds’’ (the term is
slang in this work domain that refers to any process
involving the sequential review of a group of patients
by workers). The observations are centered on the
medical team (residents and the attending) and on
their daily working tasks. A grid was used to organize
the field notes and tape recorded verbal communica-
tions. Portions of the recordings were transcribed to
provide illustrations of the main findings. The behav-
ioral protocol analysis method of Woods (1989) was
used to structure the field notes.
4 Making sense in the intensive care unit
In the ICU under study, a single attending physician
supervises a group of trainee physicians of varying
levels of experience. The makeup of the group varies
from day-to-day and week-to-week but attending staff
typically remain ‘‘on service’’ for up to 1 week at a
time. Other participants include fellows taking spe-
cialty training in intensive care, residents in surgery or
anesthesiology, and students in their third or fourth
year of medical school.
Morning rounds are variably formal. Presentations
from medical students, residents, and fellows are made
to the attending physician who interacts with the pre-
senter and others. The group walks from patient to
patient, stopping to conduct the formal portion of the
rounds. Often one or more nurses and one or more
pharmacists participate in some portion of the rounds.
When asked for a definition of the formal morning
round, one attending physician said, ‘‘a round is a
fundamental activity to point out what to do and to
build a common mental model of it.’’
Not surprisingly, the trainees view rounds somewhat
differently. A resident pointed out the importance of
round for identifying and sharing what matters for the
action: ‘‘(...) that’s sort of where the plans set, so when
you do it in the morning with everybody that kind of
gets everybody kind of on the same page, so we’re all
sort of aware of what’s happening with each patient...
It is clear that formal objective of morning rounds is
to develop and make explicit the plan for the day.
Practitioners’ tradition of rounds allows them to
collaborate in making sense of the ongoing processes
and to prepare for the need to manage unpredictable
but expected demands over time ranging from the next
few minutes to many hours. A round is one of the most
significant occasions where the clinicians develop a
collective sense of the situation they are working in.
And this sense is a precondition to accomplish of the
actions that follow.
5 Inside of ‘‘rounds’’: sensemaking at intervals
In the formal morning round, physicians present and
discuss the different patients (often referred to as
‘‘cases’’) sequentially. The case discussions have simi-
lar main moments that fit within a general scheme (see
Fig. 1).
5.1 Case presentation
In the ICU under study, each patient is assigned to a
trainee who is primarily responsible for that patient’s
care. On rounds, patients are discussed in sequence.
Trainees begin by presenting the case. The format for
presentation is more or less fixed but the content varies
with the characteristics of the patient’s condition. The
presentation of the patient makes the trainee’s sense of
Assessment and Plan
A resident describes
the patient in terms of:
clinical history, type of
intervention, last medical
procedures,current status
(vital signs, labs, exams),
medical prescriptions
The attending leads the
process of assessing the
case by identifying related
implications, possible
futures and planning
possible actions
The attending
summarizes the main
points related to the
case and the relat
actions to play during
the day
Moments of the case discussion:
Sensemaking dynamics:
Fig. 1 Sensemaking at intervals inside a ‘‘round’’
Cogn Tech Work (2007) 9:131–137 133
the case evident to the others who construct their own
understandings of the patient’s condition. Although all
the group members hear the presentation, the speech
utterances themselves are directed toward the attend-
Excerpt 1: Setting: Morning, 7.00 am, group gathered
outside of the patient n.1’s room
Dr C—Medical attending; Dr O—Male Medical
resident; Dr A—Female Medical resident; Nurse
1. Dr C (attending)—I can’t remember a thing
about Mr X. Where’s Dr O when you need him?
2. Dr O (resident)—I’m going to have to fill in I’m
sorry. So this is Mr. C, he is our 68 year old
gentleman who uhm is status post cabbage, like a
few months ago actually, he was admitted from
and outside hospital in cardiogenic shock and
respiratory failure who had a vegetation on his
mitral valve...
3. Dr O (resident)—Septic shock?
4. Dr C (attending)—septic shock, a he received a
new porcine mitral valve on the 4th, tricuspid
valve repair since then, he’s had a trach compli-
cated by a bleeder of his...
5. Dr O (resident)—tracheo-carotid fistula, tracheo-
thyroid fistula
6. Dr C (attending)—tracheo-thyroid artery fistula,
a and he now has a g-tube in place, this has all be
complicated by persistent a-flutter, uhm, so there
you but, that’s his story
7. (inaudible)
8. Dr O (resident)—um no I’m stumbling though yesterday he did a have his ultrasound,
ultrasound of his left upper extremity and bilat-
eral lower extremities (...) And overnight he re-
mained tacky sometimes up to the 130’s uh they
gave him, uh lets see 250 of albumin once and
then 50 of albumin twice,.... (...)
9. Dr C (attending)—is it working?
10. Dr O (resident)—I would say equivocal
11. Dr C (attending)—is this the longest he’s been off
vasopressants so far
12. Dr O (resident)—yes, but we’re also tolerating
lower blood pressures, but it could be, yea, I mean
13. Dr C (attending)—okay
14. Dr O (resident)—I don’t think its hurting
15. Dr C (attending)—-okay
16. Dr O (resident)—yea...uhm neurologically, he is
uhm.... you know sort of waxes and wanes I would
say, but he is interactive, uhm he’s able to move
all of his extremities however strength in the left
side is more like 4 out of 5 and the right side is
like 1 out of 5. uhm, he is able to communicate,
uhm not verbally, but you know he...he talks, he
requests cigarettes uhn. (...)
17. Dr C (attending)—great
18. Dr C (attending)—can’t wait
19. Dr C (attending)—I will fill this in (referring to
the plan)
In this instance, the patient is well known to the
group. Dr C moves the presentation forward to the
new information by quickly stating the history
(Excerpt 1, line 4), effectively encouraging the pre-
senter to get to the now-relevant details. The presenter
quickly focuses on the relevant information (Excerpt 1,
lines 8 and 16). Significantly, the attending physician is
engaged in the presentation, interrupting the presenter
and asking the presenter others questions. In this
phase, the attending has two objectives: creating and
reviewing his own understanding of the patient’s con-
dition and also understanding the presenter’s under-
standing of that same condition. The attending
physician is engaged in sensemaking about the patient
and also in making sense of the presenter’s own
5.2 Case assessment and plan
Following the presentation, the case discussion
undergoes a subtle change as attention shifts from
what has happened in the past to what is likely to
happen in the future and what actions need to be
Excerpt 2: Setting: Morning, 7.30 am—group gath-
ered outside of patient n.2’s room, after initial case
Dr C—Medical attending; Dr X—Male Medical
resident; Dr O—Female Medical resident; Nurse
1. Dr C (attending)—I’m not going to lie to you, but
I’m going to make you sweat it...go look at his
toes. Don’t we need a GI consult for his toes?
(background noise, talking)
2. (inaudible)
3. Dr C (attending)—Go look at his toes. Dr X, do
me a favor, go press on his left lower quadrant,
tell me what you think (background talking)
4. Dr C (attending)—What’d you think of his left
lower quadrant?
5. Dr X (resident)—No tenderness, not lesions, ...I
was not impressed. What did you think of it?
6. Dr C (attending)—It seemed a little tender to me
yesterday afternoon
7. Dr O (resident)—You’re worrying about diver-
ticulitis aren’t you?
134 Cogn Tech Work (2007) 9:131–137
8. Dr C (attending)—Does he have a lot of periph-
eral vascular disease in his feet bilaterally
9. Dr X (resident)—Yes, well, no, I mean, well
actually, no, no, no from (inaud) from his duplex,
um, he had some posterior tibial, but
10. Dr X (resident)—On the right side only
11. Dr.X (resident)—Yea, but, I mean, the perfera
and the toes are
12. Dr C (attending)—Toes are from a consequence
13. Dr C (attending)—Hypotension and shock
14. Dr C (attending)—Vaso constrictors...right
15. Dr C (attending)—And his
16. Dr C (attending)—Do you think there might be
other parts of his body that might look like that?
17. Dr O (resident)—Well, are you worrying about
his gut?
18. Dr C (attending)—So if he had an, a watershed
infarction and his colon looked like his toes, what
would he look like? He would look like a guy
whose on vanco, cipro, gents with a non recov-
ering renal failure, smouldering hypotension, um,
19. Dr X (resident)—You would think that he
wouldn’t be tolerating his tube feeds...he’d have
some, well I mean; he wasn’t tender at all today.
20. Dr C (attending)—So what should we do, should
we CT his abdomen? Get a GI consult? So I
mean, if his colon looks pink when they look, we
can be pretty confident. On the other hand if it
looks dusky or worse, then it’s a big change in
plan in him, right?
21. Dr O (resident)—True
22. Dr C (attending)—So take it out
Here the focus of attention is on the anomalies
rather than the consistencies and the plan emerges as
the various issues are brought forward and examined.
Questions are usually asked in order to be sure that the
plan will be executed in the form it has been conceived.
‘‘I need to make sure that everyone will do what we
decided to do. We need to get everyone on the same
page to make things work on safety,’’ a medical doctor
who covers the attending role said, pointing out that
questions are aimed at formulating the possible diag-
nosis and scenarios of evolution and the related
expectations for the future but they are also useful to
check once again the actions to take in terms of orders
to be written, procedures to be done, consultations to
be obtained. Significantly, some of the questions are
about the future. By asking these questions, the
attending is drawing attention to specific features of
the case (Excerpt 2, lines 4, 8, and 16). By emphasizing
which data matter and asking for their interpretation
the attending gives the trainees an opportunity to
construct their own sense of the case and anticipate the
5.3 Summary
The summary works to revise and confirm the shared
sense, incorporating the complex aspects into a single
narrative. The summary is usually brief and recounts
the relationship between the past data and the plans
for the future, especially the specific actions to be
taken by group members.
Excerpt 3: Setting: Morning, 10.00 am—Dr
C—Medical attending—a group discussing the possi-
bility to discharge patients
Dr C (attending)—So that, that’s important, you
need to understand that she’s going tic, tic, tic, tic, ti-
c...alright, so, do you want to write and order to start
heparin, starting at four or five PM. And lets start her
therosomide infusion at five and say at eleven or twelve.
If her blood pressure goes down, stop that, or actually, I
don’t care about her blood pressure, I care about her
mental status, if her mental status goes down, stop that
piece. Alright so neurologically, wake up exercise to
extubate, if she tolerates that well, we’ll probably start
turning down her nor epi and then her dobutimine,
those are park driving her afib, to it may be that she will,
be in sinus rhythm so we can get those guys off
Dr O (resident)—ok...all right...I will talk to a
physiotherapist right away
The sensemaking that occurs during rounds we may
call ‘‘sensemaking at intervals.’’ Its most salient char-
acteristic is that time is set aside for it and its conduct is
formalized in ways that are tailored to the need to
create shared sense amongst the participants to bring
together information, expectations, and plans in ways
that naturally result in coordinated assessments and
6 Outside of ‘‘rounds’’: sensemaking on-the-fly
In the ICU, while carrying out daily activities, the
moments dedicated to the discussion of what is going
on and to the decision making process for the patients’
care last few moments and seem more a review of the
sense built during rounds and other meeting rather
than a continuous creation of new interpretations,
decisions and related plans. Instead, clinicians con-
centrate on how to perform the decisions they have
already made. They dedicate to the technical content
of the work.
Cogn Tech Work (2007) 9:131–137 135
Excerpt 3: Setting: Morning, 7.30 am—Cardiac
surgery unit—out of the patient n.2’s room—Day of
observation 15
Doctor C—medical attending intensivist; doctor
O—resident anesthesiologist
1. Dr C (attending)—and then what you can do is
drape her with sterile towels and then when you’re
there, you’re going to numb her a up here (inaud)
2. Dr O (resident)—yea
3. Dr C (attending)—okay, wire in the sheath, pour
this out (inaud) glove, I’ll be helping
4. Dr O (resident)—okay, alright
5. Dr C (attending)—this is the first stuff I can (in-
6. Dr O (resident)—right
7. Dr C (attending)—P15 are you comfortable? So
what we’re going to be here, we’re going clean off
your neck with some cold wet stuff, okay (...)
8. (background noise)
9. Dr C (attending)—(addressing to the patient) He’s
(the resident) just going to clean that off...that’s all
Special soap, that’s all
Once rounds are complete, the remainder of the
work day is handled ‘‘on-the-fly’’ (see Fig. 2). Sense-
making in real time takes place in parallel with process
control activities, as practitioners work to keep pace
with the tempo of operations. This real time sense-
making draws on the results of rounds and the success
of rounds is measured, in part, by how well that
sensemaking at intervals anticipated the needs of
practitioners through the day.
While working on-the-fly, clinicians are more con-
centrated on the definition of how to perform the
decisions they have already taken. The focus is on the
action (see Excerpt 3). Being woven into the continual
work activities, most real time sensemaking is hidden
from view. The relationship between the round and the
work on-the-fly is not unidirectional. While performing
the daily activities, each operator gets new information
related to the ongoing situation. They review and
update the sense of the situation built during the round
according to this new information. The individual sense
will be shared again during the meeting in the after-
noon and the next round and will contribute to update
the social sense.
7 Sensemaking, cooperative work, and patient safety
High reliability organizations are marked by an accu-
rate, precise, and commonly held understanding about
current operations and the relationship between those
operations and potential accidents (Cook and Ras-
mussen 2005). A common understanding of the oper-
ating point produces effectiveness in coordination and
communication processes and safer performances. The
sensemaking processes create and nourish a common
understanding of the current situation among the
operators and support the cooperative work and suc-
cessful performances. Sensemaking on-the-fly lets each
actor maintain a view of how the situation is evolving
over the time. Sensemaking at intervals, here in the
form of the round, prepares the operators to cope with
potential risks. The close relationship between the
content of the round discussions and the workers sets
up what Rasmussen (1995) calls ‘‘cooperative condi-
tioning.’’ The combined attention increases the likeli-
hood that the shared understanding of the situation is
appropriate and accurate. This is one of the most
important conditions for the realization of patient
By preparing the conditions (knowledge and social
cohesion) needed for sensemaking on-the-fly, these
workers build a defense against future times, when
work pressures may limit the sensemaking at intervals
or when some members of the groups are no longer
present. The trade off here is between the work pres-
sures of today and investment in sensemaking that will
be needed tomorrow, next week or next year.
Close examination of the interplay between sense-
making at intervals and sensemaking in real time
can reveal domain features of interest. The balance
Building the sense:
Defining what to
do, why, and when
Doing the procedures
Working On the fly
Performing the sense:
discovering how to do it
Consulting other physicians
Monitoring and ordering labs
What to do,
why and when
What to do,
why and when
What to do,
why and when
Fig. 2 Sensemaking ‘‘on-the-fly’’
136 Cogn Tech Work (2007) 9:131–137
between these two types of sensemaking reflects,
among other things, the amount of irreducible uncer-
tainty in the workplace, the confidence of practitioners
in their ability to achieve shared, collective under-
standings, and the need to balance effort directed
toward immediate, short-, and long-term needs. These
relationships have central relevance for risk manage-
ment and patient safety (Laporte and Consolini 1994;
Weick and Sutcliffe 2001; Cook and Rasmussen 2005).
Acknowledgments Support for this work was provided by the
University of Chicago, Department of Anesthesia and Critical
Care. The authors thank Sandra Nunnally, Mark Nunnally,
M.D., Christopher Nemeth, Ph.D., and other practitioners who
contributed to the research.
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... The absence of a beginning (or end) in sense-making means that people may not always consciously make sense of things -they just do so, as events unfold within their experience (Weick et al., 2005). Dialogue and interaction are integral to collective sense-making (Maskiewicz & Winters, 2012;Weick et al., 2005), and serve as a springboard to action (Albolino et al., 2007). Weick et al (2005) identify features of sense-making as; noticing difference (resulting from, for example, feelings of uncertainty, that something is not quite right, new or abstract), followed by attempts at categorising and then labelling (naming) what is happening. ...
... As the examples illustrate, sense-making is not an individual activity happening solely in the minds of learners. It is apparent from the literature on sense-making and the data examined in this article that sense-making, is very much a social process, requiring access to opportunity to experiences that enable the use of all features of sense-making (Albolino et al., 2007;Malitis & Christianson, 2014;Weick et al., 2005). The previous sections have focused on learners' sense-making, this section attempts to summarize and visualize how the interplay of these contextual factors may exert impact on sense-making. ...
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The International Journal for Research in Vocational Education and Training (IJRVET) is a double blind peer-reviewed journal for VET-related research. All articles published in 2021 are included in this book. IJRVET is the official journal of VETNET (founded in 1996), the European Research Network in Vocational Education and Training (umbrella organisation: EERA European Educational Research Association), supported by CINTERFOR (founded in 1963), the Centro Interamericano para el Desarrollo del Conocimiento en la Formación Profesional / Inter-American Centre for Knowledge Development in Vocational Training (a technical service of OIT Organización International del Trabajo / ILO International Labour Organization).
... 19,20 Sensemaking theory has been used in healthcare research to provide an understanding of how healthcare providers turn complex and confusing circumstances into comprehendible situations. 21,22 Furthermore, sensemaking has been applied to organizational theory to examine risks, threats, and hazards in multiple industries, including healthcare. 23 For this study, sensemaking is understood to be (non)relevant pieces of information that emergency personnel must collectively synthesize to generate a shared understanding of a pre-hospital STEMI episode. ...
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Residents in rural communities have a higher incidence of cardiac death and risk factors associated with cardiac disease. Living in a rural region can add precious time that amplifies cardiac death during an ST-elevated myocardial infarction (STEMI) episode. The consensus is that improved efficiencies can increase myocardial salvage and decrease STEMI mortality rates. This article identifies issues that may impact pre-hospital STEMI triage of patients in a rural region of the United States (U.S.). A qualitative research design was chosen to gain insight into emergency personnel perceptions of pre-hospital STEMI triage. The participants (n = 18) were obtained from a convenience sample in rural Northeast Texas, U.S. Data were gathered by individual and group semi-structured interviews. Themes were identified, synthesized, and oriented to offer a basis for understanding opportunities to improve the delivery of rural STEMI care. This study demonstrated that quality improvement initiatives aimed at achieving pre-hospital STEMI triage efficiencies have dependencies on teamwork, technology, and training in the context of 3 stages (a) pre-transport, (b) door-to-door, and (c) post-transport. A pre-hospital STEMI triage model is offered based on the findings. By incorporating this model, emergency medical coordinators in rural communities have a better opportunity to facilitate timely reperfusion therapy for this high-risk population.
... Whether the user intends to draw on a notebook, sketch in the air, or have a discussion in front of a whiteboard, CollaboVR can instantly and seamlessly switch context to support the user arrangement and input mode of choice. Our main contributions are summarized as follows: 1 CollaboVR GitHub: column-sensitive content, such as text and maps then became incorrect. To solve this problem, FacingBoard selectively flipped the column-sensitive content individually and adjusted the content position. ...
Conference Paper
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Writing or sketching on whiteboards is an essential part of collaborative discussions in business meetings, reading groups, design sessions, and interviews. However, prior work in collaborative virtual reality (VR) systems has rarely explored the design space of multi-user layouts and interaction modes with virtual whiteboards. In this paper, we present CollaboVR, a reconfigurable framework for both co-located and geographically dispersed multi-user communication in VR. Our system unleashes users’ creativity by sharing freehand drawings, converting 2D sketches into 3D models, and generating procedural animations in real-time. To minimize the computational expense for VR clients, we leverage a cloud architecture in which the computational expensive application (Chalktalk) is hosted directly on the servers, with results being simultaneously streamed to clients. We have explored three custom layouts – integrated, mirrored, and projective – to reduce visual clutter, increase eye contact, or adapt different use cases. To evaluate CollaboVR, we conducted a within-subject user study with 12 participants. Our findings reveal that users appreciate the custom configurations and real-time interactions provided by CollaboVR. We have open sourced CollaboVR at to facilitate future research and development of natural user interfaces and real-time collaborative systems in virtual and augmented reality.
... General care units include non-specialty units such as medical, surgical, and "mixed" care units. Specifically, we focused on patient care rounds (i.e., a sequential review of a group of patients 16 ), as an important activity in the care delivery process for interpersonal and inter-professional communication. Physicians and nurses typically deliver care in parallel, asynchronous workflow Electronic supplementary material The online version of this article ( ...
Background: Poor communication between physicians and nurses is a significant contributor to adverse events for hospitalized patients. Overcoming communication difficulties requires examining communication practices to better understand some of the factors that affect the nurse-physician communication process. Objective: To develop a more detailed understanding of communication practices between nurses and physicians on general care units. We focused on patient care rounds as an important activity in the care delivery process for communication. Design: Qualitative study design PARTICIPANTS: A total of 163 physicians, registered nurses, and nurse practitioners who worked on pre-specified general care units in each of four hospitals in the Midwest. Approach: On each unit, data collection consisted of 2 weeks of observing and shadowing clinicians during rounds and at other times, as well as asking clinicians questions about rounds and communication during interviews and focus groups. A directed content analysis approach was used to code and analyze the data. Key results: Workflow differences contributed to organizational complexity, affecting rounds and subsequently communication practices, both across and within provider types. Nurse and patient participation during rounds appeared to reduce interruptions and hence cognitive load for physicians and nurses. Physicians adopted certain behaviors within the social context to improve communication, such as socializing and building relationships with the nurses, which contributed to nurse participation in rounds. When rapport was lacking, some nurses felt uncomfortable joining physicians during rounds unless they were explicitly invited. Conclusions: Improving communication requires bringing attention to three contextual dimensions of communication: organizational complexity, cognitive load, and the social context. Initiatives that seek to improve communication may be more successful if they acknowledge the complexity of communication and the context in which it occurs.
... Many previous works have researched sensemaking in different domains in HCI and computer-supported collaborative work (CSCW) area [1,4,27,40]. Given that sensemaking involves data analysis [61], different designs of 2D displays and digital tabletop are frequently discussed. ...
Despite various collaborative software that supports expressing ideas, people still largely prefer physical notebooks or whiteboards. The reason is that they provide free-form expressions, co-presence of all participants and easy collaboration. However, when working with remote participants, people often choose the convenience of video conferencing, perhaps with screen sharing. We propose CollaboVR, an open-source reconfigurable framework for distributed and co-located multi-user communication in Virtual Reality. We tested CollaboVR with an application that lets participants create freehand drawings and 3D objects, while allowing participants to adjust two key variables: (1) User arrangement (participants adjust the location of their views of other participants) and (2) Input orientation (participants adjust the input to be vertical or horizontal). Preliminary user studies show that CollaboVR is a useful collaborative tool. Users report that some user arrangements and input orientations work best for brainstorming, while others work best for presentation or collaborative refinement of designs.
... 31,33 Complexity science is a useful lens for studying relationships among primary care providers, 34,35 care improvement in nursing homes, 36 and collaboration in intensive care units. 37 In addition to its application in studying a diversity of health care delivery settings, complexity science has been useful in examining provider-level differences in health IT use, 31 clinic-level differences in the implementation of health IT for practice redesign, 38 and in the development of a sociotechnical model for studying health IT in health care systems. 32 Complexity science helped us evaluate secure messaging interactions between patients and their outpatient care team as a system of relationships 39 sometimes characterized by high complexity (contexts that cannot be fully understood simply by analyzing individual components of the system) 27 and uncertainty (an inevitable and natural part of complex systems that cannot be avoided, eliminated, or controlled) . ...
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Background: The value of secure messaging in streamlining routine patient care activities is generally agreed upon. However, the differences in how patients use secure messaging, including for communicating both routine and nonroutine issues, and the implications of these differences in use are less well understood. Objective: The purpose of this study was to examine secure messaging use to extend current knowledge of how this tool is being used in outpatient care settings and generate new research questions to improve our understanding of the role of secure messaging in the patient-provider communication toolbox. Methods: We conducted an in-depth qualitative analysis of secure message threads in 12 US Department of Veterans Affairs outpatient clinics in south Texas. We analyzed 70 secure message threads with a total of 179 unique communications between patients and their outpatient teams for patterns in communication and secure message content. We used theories from information systems and complexity science in organizations to explain our observations. Results: Analysis identified content relating to 3 main themes: (1) information management, (2) uncertainty management, and (3) patient safety and engagement risks and opportunities. Within these themes, we identified 2 subcategories of information management (information exchange and problem solving), 2 subcategories of uncertainty management (relationship building and sensemaking), and 3 subcategories of patient safety and engagement risks and opportunities (unresolved issues, tone mismatch, and urgent medical issues). Secure messages were most often used to communicate routine issues (eg, information exchange and problem solving). However, the presence of subcategories pertaining to nonroutine issues (eg, relationship building, sensemaking, tone mismatch, urgent issues, and unresolved issues) requires attention, particularly for improving opportunities in outpatient care settings using secure messaging. Conclusions: Patients use secure messaging for both routine and nonroutine purposes. Our analysis sheds light on potentially new patient safety concerns, particularly when using secure messaging to address some of the more complex issues patients are communicating with providers. Secure messaging is an asynchronous communication information system operated by patients and providers who are often characterized as having significant differences in knowledge, experience and expectations. As such, justification for its use beyond routine purposes is limited-yet this occurs, presenting a multifaceted dilemma for health care organizations. Secure messaging use in outpatient care settings may be more nuanced, and thus more challenging to understand and manage than previously recognized. New information system designs that acknowledge the use of secure messaging for nonroutine and complex health topics are needed.
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Several professionals or teams, such as physicians, rescue teams, air traffic controllers and others, work in shifts systems to ensure the continuity of the services they offer. The shifts systems lead to a continuous asynchronous collaboration, which professionals get together, most of the time, on the shifts change (handoff). In order to guarantee the quality and success in the execution of services, it is important to pay special attention to the obtaining, maintaining and availability of pertinent information to enable the asynchronous collaboration of the groups and professionals involved. Usually, the information to be transferred is recorded near to the end of the shift. The shift reports are delivered and explained orally in a short period when the shifts intersect during the handoff. In environments which require the constant readiness of the agents in order to offer the services, e.g. Intensive Care Units (ICU), the absence of key information used to provide the understanding of a situation and to ensure proper decision making could put in danger the continuity of the services and lead to error situations with indirect or direct negative impacts to the staff and patients. Miscommunication can be related somehow with up to 91% of the cases of errors and adverse events in medical and hospital environments, about half of that total is originated from unsuccessful handoffs. An unsuccessful handoff occurs when key information is not appropriately kept and transferred. This dissertation presents a Proposed Model of medical handoff for ICU environments with the aim of assist in the transfer, maintenance and access of the key information through shifts, and also decrease the frequency and the negative impacts of unsuccessful handoffs by assisting the sensemaking and emphasizing the asynchronous collaboration. The starting point to the elaboration of the Proposed Model was a Descriptive Model of medical handoff originated from an ethnographic study conducted at the Pediatric ICU of the Hospital Federal da Lagoa (HFL). The features obtained with the Descriptive Model along with the scientific literature related to collaborative systems, medical sensemaking and handoff were the base for the three objectives of the Proposed Model: the maximization of the Information Access, the decrease of the Information Volatility and the assurance of the Information Completeness. The Proposed Model has been tested at the adult ICU of HFL through the implementation of a collaborative system (the Sistema de Apoio ao Handoff Médico: SAHM) developed during this research together with a touchscreen monitor installation and a tablet distribution to the staff. This experiment allowed us to perform initial assessments of the Proposed Model by means of case studies. The qualitative analysis of the data collected during the case studies led us to encouraging results which demonstrate strong evidence of the effectiveness of the Proposed Model.
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A comparative model of organizations as interpretation systems is proposed. The model describes four interpretation modes: enacting, discovering, undirected viewing, and conditioned viewing. Each mode is determined by (1) management's beliefs about the environment and (2) organizational intrusiveness. Interpretation modes are hypothesized to be associated with organizational differences in environmental scanning, equivocality reduction, strategy, and decision making.
A comparative model of organizations as interpretation systems is proposed. The model describes four interpretation modes: enacting, discovering, undirected viewing, and conditioned viewing. Each mode is determined by (1) management's beliefs about the environment and (2) organizational intrusiveness. Interpretation modes are hypothesized to be associated with organizational differences in environmental scanning, equivocality reduction, strategy, and decision making.