Orienting frames and private routines: the role of cultural process in critical care safety.

BACKGROUND: Being a nurse in the ICU requires extensive clinical knowledge as well as great skill in making stressful decisions and acting decisively while maintaining close working relationships with team members and other hospital staff. Nurses in the ICU draw on social, cognitive, and technological resources to accomplish tasks and achieve goals. Culture is a process that creates and makes available these resources through the situated activities of ICU actors. AIM: To understand the means by which cultural process enhances patient safety by establishing and maintaining barriers to adverse events.
METHODS: During the final month of a year-long ethnographic study of patient safety in an ICU, we interviewed nine staff nurses of the unit, and asked them to talk about the details of their work routines. From this talk, and drawing upon our field notes, we identified shared "orienting frames" which are used by nurses to organize, prioritize, conduct, and evaluate their work.
RESULTS: We report on three orienting frames commonly articulated by interviewees. "Being organized" creates the means for streamlining work in a way that makes it efficient and robust to expected challenges. "Being prepared for emergencies" creates means for effectively coping with the inevitable crises. Finally, "Being responsible and accountable" creates means for nurses to demand resources and to act decisively when they otherwise might not be granted the authority to do so.
CONCLUSIONS: To understand safety in health care, we must go beyond investigating adverse events that arise due to insufficient safety barriers, and study how cultural process creates and maintains these barriers. Understanding cultural process would help improve design and implementation of safety-enhancing interventions and technologies in the ICU.