The components of the core task are the characteristics of work, the objective of work and other external influences. In order to understand organizational culture, the structure of work (including tools, technologies and other artefacts), the organizational climate, and conceptions about work demands must be identified. The collective components of the core task provide the structure for sense making (i.e., internal understanding of core processes). The components of organizational culture provide the foundation for responses to the task at hand. Using this model, the relationship between the core task and organizational culture can be used to model dynamic clinical activities and to understand inherent social constructs.
Applying sociotechnical theory to the problem of antimicrobial resistance can facilitate an understanding of where and when technology can be used to support antibiotic prescribing decision making. The problem of antimicrobial resistance is growing in the acute care setting. Because of potentially lethal sequelae, babies in neonatal intensive care units (NICUs) who are suspected of having an infection are aggressively treated with antibiotics, often despite incomplete clinical information to guide a decision . Several groups have encouraged efforts to promote practices that will decrease antimicrobial resistance; however, adherence to these guidelines has been documented to be inconsistent. The use of decision support for guidelines related to antibiotic prescribing has been examined by several researchers, however none of the studies to date have examined the NICU setting . To date, high level studies reporting on decision support in the NICU have been limited to those examining trans parenteral nutrition (TPN) and physiologic monitoring . Researchers have examined clinical decision support and computerized provider order entry systems on the management of antibiotic prescribing, however, such systems are not ubiquitous .
4. Materials and Methods
This study was conducted in two NICUs in an academic medical center in a large metropolitan city in northeastern United States. Both NICUs are situated in quaternary care centers and thus receive patients from lower level local and regional care centers. Both units are affiliated with medical and nursing schools where medical interns, medical residents, neonatology fellows, nurses and nurse practitioners receive their training. Both units have nurse practitioner teams. A team of neonatologists function as the physician in charge and are responsible for overseeing the day-to-day care of all patients in the unit.
4.1. Data Collection and Analysis
We conducted focus groups and key informant interviews with medical residents, pharmacists, nurses, nurse practitioners, neonatology fellows and neonatal attending physicians. IRB approval was received and informed consent was obtained prior to all interviews. Data were collected between January and June 2008. Focus groups and key
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informant interview lasted approximately one hour each and were audio recorded. Audio recordings were transcribed by a professional transcription service and were verified by the researchers. Data were analyzed for themes related to organizational core task and organizational culture.
Thirty-three clinicians participated in the focus groups and key informant interviews. Fourty-eight hours of ethnographic observations were carried out at varying time points during the day. Using the Rieman and Oedewald framework, the following characteristics of the NICU environment were identified. Figure 1 shows the sociotechnical model with factors contributing to the core task and factors contributing to organizational culture.
Figure 1. Culture Task Continuum in the Neonatal ICU
5.1. Organizational Core Task
Factors contributing to the organizational core task were the objective of work, characteristics of work, and external influences. The objective of work involves the saving baby while, if possible, preventing morbidity. If a baby was stable, the objective of the work was for the babies to ‘feed and grow.’ These themes were identified across focus groups and interviews. The characteristics of the work are that the babies are complex, their presentation with infection is vague and the overall work is variable. The theme of managing antibiotics in the face of vague signs and symptoms was evident across provider groups. The following quote from a seasoned nurse practitioner captures the organizational core task:
“If you’ve ever seen a preterm infant die of gram negative sepsis where in two hours they go from being fine, eating, looking around, active and within, dead within hours. It’s really, really horrendous. So any time these kids do anything, they don’t run fevers the way pediatric patients do. They don’t give you a clear sense that they’re septic. Sepsis looks like NEC looks like, whatever they’re doing, it all presents the same way.”
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5.2. Collective Sense Making
According to Reiman & Oedewald, the organizational core task ‘creates constraints and requirements for activities’  such that the activities will make sense to the clinicians during their work process. Policies and procedures were verbalized by all participants reflecting their mental model of the processes associated with achieving the core task. For example, when asked about types of technologies that might support decision making around antibiotic prescribing, this attending neonatologist replied as follows:
“This is a fairly conservative unit. I think we’re fairly minimal in the antibiotics that we are using in our population. I think, you’re sort of looking for an algorithm of approach which we sort of drilled into our residents already. I’m not sure if they actually need it written down.”
5.3. Organizational Culture
The components of organizational culture included multidisciplinary rounds with multiple interruptions using highly technical tools. Other artefacts included paper copies of policies related to treating neonatal sepsis, paper copies of the neonatal medication ‘bible’ Neofax and managing information related to different technologies. The organizational climate components included mentoring and education as well as collaboration. Clinicians from both NICUs expressed a certain pride in practice in describing the uniqueness of the NICU clinical environment. The following quote from a neonatology fellow exemplifies the conception about the work and work demands:
“….we’re very conservative here…… the population we deal with tend to be infection prone, tend to have lines following preop time, tend to need long-term TPN, tend to be with us for months and are considered immunosuppressed when they are premature.”
5.4. Ways of Responding to Tasks
According to sociotechnical theory, the core task, mental model and organizational climate will create clinician behaviours. Several examples of this process were present in our data. For example, the following statement from a medical resident (low man on the totem pole), was in response to the question “How do you decide which antibiotics to prescribe?”
“Usually we do the ordering, the actual eclipsys ordering and figuring out which dose to use based on usually Neofax, but most of the time the decision of which antibiotic we use comes from a higher level.”
We conducted a sociotechnical analysis of a neonatal intensive care unit and found that the core task was to save the baby in the face of vague symptoms, complex problems and the use of multiple technologies. This core task was present in the focus group and interview data from all participant groups which is consistent with Reiman and Oedewald’s posit that cultures are socially constructed. The core task was the primary driver for all protocols and plans of care that were described by our participants. Thus, the clinicians were making sense of their activities and building mental models about their work activities. The characteristics of organizational culture included teaching and learning, multitasking, and adapting based on the ‘higher level’ decision makers. The latter is important to understand since decision support via CPOE targets the order