Cardiopulmonary resuscitation decisions in the emergency department: An ethnography of tacit knowledge in practice

Abstract

A note on versions:The version presented here may differ from the published version or from the version of record. If you wish to cite this item you are advised to consult the publisher's version. Please see the repository url above for details on accessing the published version and note that access may require a subscription. AbstractDespite media images to the contrary, cardiopulmonary resuscitation in emergency departments is often unsuccessful. The purpose of this ethnographic study was to explore how health care professionals working in two emergency departments in the UK, make decisions to commence, continue or stop resuscitation. Data collection involved participant observation of resuscitation attempts and in-depth interviews with nurses, medical staff and paramedics who had taken part in the attempts. Detailed case examples were constructed for comparative analysis. Findings show that emergency department staff use experience and acquired tacit knowledge to construct a typology of cardiac arrest categories that help them navigate decision making. Categorisation is based on `less is more' heuristics which combine explicit and tacit knowledge to facilitate rapid decisions. Staff then work as a team to rapidly assimilate and interpret information drawn from observations of the patient's body and from technical, biomedical monitoring data. The meaning of technical data is negotiated during staff interaction. This analysis was informed by a theory of `bodily' and `technical' trajectory alignment that was first developed from an ethnography of death and dying in intensive care units. The categorisation of cardiac arrest situations and trajectory alignment are the means by which staff achieve consensus decisions and determine the point at which an attempt should be withdrawn. This enables them to construct an acceptable death in highly challenging circumstances.2

Knowledge and expertise in care practices: the role of the peer worker in mental health teams

“…We note that healthcare professionals acquire tacit knowledge and expertise through practice as well as formal education (Lave and Wenger ) – learning what works well in healthcare practice – and that this informal, perhaps more intuitive knowledge complements their formally acquired expertise (Brummell et al . , Greenhalgh et al . ).…”

“…practice that worked with similar types of patient in the past (Brummell et al . , Greenhalgh et al . ).…”

“…We acknowledge that mental healthcare professionals exercise knowledge that is derived from their experiences of delivering care in practice; i.e. practice that worked with similar types of patient in the past (Brummell et al 2016, Greenhalgh et al 2008. However, the objective knowledge that governs healthcare practice also aims to remove the disorder of context and life from what is considered the actual illness (Abbott 1981, Timmermans andBerg 2003), leaving the relevant psychiatric problems professionally defined (Quinlan 2009).…”

“…Thus, healthcare professionals working in Emergency Departments in the UK have been shown to use both their experiential, tacit knowledge (about ‘types’ of cases) and technical knowledge (biometrics) when making rapid decisions during resuscitation procedures (Brummell et al . ), while clinicians making care decisions in a neuro‐rehabilitation team in the UK were shown to complement the codified knowledge offered by routine use of standardised clinical measurement tools with their intuitive, experience‐based (tacit) knowledge of patients (Greenhalgh et al . ).…”

“…These forms of knowing arise from engaging with an object of study while being temporally and physically immersed in the specialist culture of the practice in question (Emirbayer andMische 1998, Lave andWenger 1991). Thus, healthcare professionals working in Emergency Departments in the UK have been shown to use both their experiential, tacit knowledge (about 'types' of cases) and technical knowledge (biometrics) when making rapid decisions during resuscitation procedures (Brummell et al 2016), while clinicians making care decisions in a neuro-rehabilitation team in the UK were shown to complement the codified knowledge offered by routine use of standardised clinical measurement tools with their intuitive, experience-based (tacit) knowledge of patients (Greenhalgh et al 2008). It is also argued that tacit knowledge (about health and health care) can be derived from aspects of selfhood that are beyond the experience of clinical practice (Kontos and Naglie 2009).…”