The impact of cognitive load on clinical practice in AEC - can team working mitigate the effects?

Problem

AEC (Ambulatory Emergency Care) provides acute assessment and treatment in the community with patients staying in their own homes or care homes overnight (or in between visits). This ethnography aimed to understand the cognitive work of the senior clinicians in the AEC environment.

Approach

Three AEC sites were purposively sampled to recruit twelve clinicians with backgrounds in Geriatrics, General Practice, Emergency and Acute Medicine. This qualitative investigation used focused ethnography within a case study approach to understand the decision-making processes in the context of the AEC environment. Observation during an AEC shift was complemented by informant interviews. A framework approach to thematic analysis used a priori and data derived codes to develop explanatory themes. Ethnographic principles of constant comparison and cognitive task analysis were used to evaluate the clinicians’ decision-making processes for index patient cases.

Findings

This ethnography established three environmental factors in AEC that increased cognitive load; high demand, low time and disruptions. AEC clinicians described their experiences of working under cognitive load as fear of forgetting, frustration and anxiety about the potential for error. Clinicians managed cognitive load caused by their environment by varying the work task, the duration of the task, the way they enact the task and the team members involved in the task. Cognitive load affected decision making through altered task time, referral thresholds, clinical behaviours and team working. Task time altered in response to environmental pressures, particularly disruption and high demand. Clinicians controlled AEC demand by altering their referral thresholds; reducing patient acceptance rates when demand was high or actively seeking patients when AEC had capacity. Clinical roles were altered under cognitive load with shared responsibility and mutual support enabling cohesive teamwork.

Consequences

The impact of teamwork on mitigating environmental pressures in urgent care is a new insight gained from interpretation of the ethnographic data in this study. Further research is needed on team-based decision-making in urgent care setting including urgent primary care. It is hoped this work will inform the development of generalist curriculum for future interdisciplinary teams working in urgent primary care.