How to improve sense-making in the Emergency Department (ED). Sense-making series 2

Today I am sharing my interpretation of a sensemaking study published in 2019. Prof Christianson has expertise in organisational behaviour, and the focus of her study was on the role of trajectory management when updating sense-making (i.e. re-making sense).

A brief reminder – sense-making starts with a cue i.e. a signal, variance or occurrence that stands out as different to the expected. Once noticed, the cue is justified or rationalized, for example the information can be rechecked, ignored, or questioned. Often, seemingly disparate cues may be patched together, and a pattern may be observed, implying keeping an open mind to update sensemaking and to stay vigilant for other cues.

The ability to pattern-match, yet simultaneously re-check and update sense-making is especially crucial in complex environments, like the ED. With an influx of new information or cues that could be clinical or operational, EDs are interrupt-driven, and tasks are often interrupted, increasing the cognitive density of decision-making, and making it tricky to keep track of the influx of cues. Individual team members can’t monitor and respond to all the cues; thus, they respond to selected cues, that they deem notice-worthy.

Study method:

The study took place at a simulation laboratory with participants from a facility routinely ranked as a top Paediatric hospital in the USA. Participants were randomly assigned to a multidisciplinary team, which included doctors, nurses, paramedics, respiratory technicians, etc. They fulfilled their usual professional role during the simulation. Peadiatric Advanced Life Support (PALS) certification is a job requirement, this practical course is designed to enhance skills in evaluation and management of paediatric patients with respiratory or cardiac compromise. It can thus be assumed that all participants were familiar with this type of scenario as well as simulation-based training.

The simulation lasted 20 minutes and everyone received the same scenario: A small boy known with asthma presented at the ED with difficulty in breathing. His breathing deteriorates, and he eventually stops breathing. If the underlying issue is not picked up, he deteriorates further and eventually requiring CPR.

The underlying issue or event is an equipment failure – a faulty bag-vale-mask (BVM) used to support breathing. If teams did not pick up on this early, they were reminded of a commonly taught mnemonic to check potential failures when ventilating, which includes rechecking equipment as faulty equipment is not unimaginable.

Analysis:

The simulations were video recorded and used a micro-ethnographic approach followed to perform moment-to-moment analysis of the data. This included extensive mapping of when and who noticed cues, what cues were noticed, what they said and what they did/the action taken.

Findings:

19 teams participated.

Note that more than 5 minutes is a long time in this type of patient presentation, and that the majority of teams (11 out of 19) took longer than 5 minutes, with some (5 teams) unable to update their sensemaking.

Breakdown of teams	What happened	Timeframe
8 teams	Quickly made sense in the short time frame	5 minutes or less
6 teams	Ran into problems with updating, missing cues, misinterpreting cues and not searching for explanations, but eventually made sense.	5-20 minutes
5 teams	Unable to update within the 20 minutes.	No updated sense-making in 20 minutes.

The difference between the teams:

Effective teams continuously monitored for cues, when sensing cues, they rapidly investigated and interpreted it, continuously adjusting their sensemaking. Effective teams shared their thoughts and worked together bouncing ideas, checking each other, and tracking changes in the patient condition over time.

On average, effective teams had one more expert on the team, however the equipment failure was more likely to be detected by a novice. It is unclear how experts and novices were defined.

Ineffective teams were less likely to continuously monitor for cues, and experienced delays in sensing change. They seemed unable to recover from interruptions and were sidetracked i.e. not returning to the interrupted task. There appeared to be a mismatch between the cues that the ineffective teams sensed versus the cues that would be the most useful in the situation.

Ineffective teams narrated only the tasks they were undertaking. Further, the longer they took to update their sensemaking, the higher the workload became e.g. instead of ‘only’ sorting out a breathing problem, they now had to perform CPR. Combined with their inability to recover from interruptions, they were unable to make sense of what was going on.

What this means:

Catastrophic breakdowns of sense-making are well-described in literature; this study adds to the conversation by demonstrating how a failure to update sensemaking could be due to multiple small interruptions. These small interruptions can build up to a point of no-return and a complete loss of sensemaking.

In the simulation, the teams that were effective in updating their sensemaking were continuously monitoring the situation for cues, they acted quickly to test plausible explanations (e.g. check the BVM), and they narrated their findings – thus the team could make collectively interpret, update knowledge and take further action. With those that could not update their sense-making there was a noticeable delay between cues, action, and interpretation, furthermore the cues they selected were not the best matched for the situation.

There is an obvious link between sense-making and teamwork, and specifically interprofessional teamwork. Salas has made extensive contributions to this field, including work with ED teams. He found a distinct difference in the communication and coordination strategies of teams in high stress situations. The teams that deteriorated in high stress situations were more likely to shift to an individual focus when stressed, resulting in a decrease in sharing explicit information. In Christianson’s study the effective teams shared more information, whereas the ineffective teams only shared the tasks they were performing. It appears that as the sense-making faltered and stress increased, the ineffective teams become focused on individual tasks and lost their ability to triangulate meaningful cues and collectively make sense.

Mental frame also comes to play here, and the data-frame model provides an analytical framework considering the cognitive structures of sense-making. In short when new data/cues emerge, the current mental frame can be questioned, reframed, more information could be sought to update the mental frame, or it could be preserved i.e. ignore the incoming cues and stick to the current trajectory. This is not always conscious (dual-processing theories), it is mostly automated. Yet, the frame adopted will determine what happens next. And one way to improve collective sense-making is to narrate interpretation as it allows the frame to be questioned by others that may have a different perspective or may have picked up on other cues, this is especially important when the situation is dynamic.

How to improve sensemaking in the ED:

There are various practical ways how sense-making in the ED (and other dynamic settings) can be improved. To mention a few:

• Prework briefings seems to be more effective than post event debriefs and can included as brief interprofessional huddles at the start of a shift. Debriefs are valuable though and can be further optimised by focusing on team learning.  
• Increase or introduce team-based simulation training. Obviously, skills-based training during these sessions are important, but attention should be given to communication, coordination and what is narrated and what not.
• Sense-making literature argues that gaps in information are filled with assumptions, when the assumptions are shared, they can be tested faster. This is tricky as there can be too much narration in dynamic situations which adds to the noise, and perhaps the balance required in a team can be experimented with during simulation training.
• Often the short skills-based courses are attended by individuals, but patient treatment is a team effort, and the benefit of sending a team/shift together cannot be overstated. I know this is complicated by the nature of high turnover rates, teams that are not static etc. but it is worth considering.
• Effective teamwork can reduce medical error by as much as 20%. Teamwork is linked to collective sensemaking. Sense-making is strengthened by strong social networks, which in turn is strengthened by regular interactions. Salas has found that firefighters that have meals together outperform those who don’t. Perhaps ED teams can ‘break bread together’ on regular basis, or leadership can enable more opportunities for social connection between professions e.g. 5 minutes of social connection during meetings, sharing tearooms etc.
• Experts on the team are invaluable, but the rest of the team needs to feel psychologically safe enough to speak up and be heard. This might sound far easier to operationalise than what it is, as it implies addressing deeply entrenched patterns of behaviour.

Summary

Sense-making is embedded in space and time, and in dynamic environments it is not static nor linear, in these situations sensemaking needs to be constantly updated. Knowledge and sense-making is created between sensing cues, interpretation and action and it can be strengthened by maximising collective or team sense-making.

Sense-making is intimately interwoven in other fields of study, including but not limited to, teamwork, psychological safety, communication, and decision-making. In my opinion, sense-making is a neglected part of the curriculums of emergency medical care and response and research.

I use this study often, and it is always met with disbelief. I’m not sure if it is a cognitive bias, but it raises the question: if we repeated this study in a lower resource setting would the teams pick up on the failed equipment within 5 minutes and without prompts? The assumption is that in lower resource settings there is a high rate of equipment failure, and it would be an early check. This could point to the contextuality of sense-making and I’m keen to hear your thoughts.

Read the case presentation

Christianson MK. More and less effective updating: The role of trajectory management in making sense again. Administrative Science Quarterly. 2019 Mar;64(1):45-86.

References

Brown AD, Colville I, Pye A. Making sense of sensemaking in organization studies. Organization studies. 2015 Feb;36(2):265-77.

Klein G, Moon B, Hoffman RR. Making sense of sensemaking 2: A macrocognitive model. IEEE Intelligent systems. 2006 Oct 2;21(5):88-92.

Klein G, Moon B, Hoffman RR. Making sense of sensemaking 2: A macrocognitive model. IEEE Intelligent systems. 2006 Oct 2;21(5):88-92.

Salas E, Cannon-Bowers JA, Johnston JH. How can you turn a team of experts into an expert team?: Emerging training strategies. Naturalistic decision making. 1997;1:359-70.

Salas E, Rosen MA, King H. Managing teams managing crises: principles of teamwork to improve patient safety in the emergency room and beyond. Theoretical Issues in Ergonomics Science. 2007 Sep 1;8(5):381-94.