Table 2.

Dimensions of Barriers and Facilitators

Dimension	Definition	Work System Elements						Examples
		Person	Task	T/T1	O2	PE3	EE4
Anticipation	How clinicians’ and staff members’ ability to foresee and address in advance the needs related to care of the pediatric trauma patient is impacted (increased or decreased).		X		X			• ED nurse giving situation, background, assessment and recommendation (SBAR) report to PICU nurse lets them anticipate what care will be needed for that patient when they get to PICU from OR. • Time to prepare before patient arrives to ED makes transitions, care smoother. • By policy, PICU nurses cannot look at patient record until patient is in unit which hinders preparation to receive the patient. • Knowing the patient’s condition before surgery and how the patient responded to surgery helps the PICU team care for the patient and ensure nothing is missed (either by going to ED and/or OR or reviewing patient information in advance).
ED decision making	Factors that influence how decisions about patient care after the ED are made and how that decision impacts further patient care (beyond simply where the patient goes after the ED)	X	X		X			• Clear, strong leader is needed to provide direction and facilitate agreement about disposition, which improves care and family experience. • Quick decision and agreement between doctors about disposition, i.e. what’s next for the patient, is needed for care to be provided in a timely manner. • PICU clinicians present in ED makes it easier to communicate and have everyone on the same page; if they are not there, there is more communication work when information is given serially.
Interacting with family	Factors that impact how clinicians and staff interact with family/caregivers and vice versa.		X		X			• Having a role dedicated to interacting with patient, family face-to-face can ease family concerns during care and facilitate communication. • Parents may be left in OR waiting room or forgotten, and not talked to anyone even though patient is in PICU for two hours. • Someone moving family to PICU waiting room lets PICU nurses settle, begin caring for patient uninterrupted.
Physical environment	How the physical environment impacts the care and transitions of pediatric trauma patients					X		• Too many people in the ED can make it difficult to do procedures, provide care. • The team uses the public (e) elevator to move the patient, which can create delays during transport. • Activity during the handoff can create distractions and hinder communication; hard stops during handoff would help avoid those distractions.
Role ambiguity	Factors that cause and/or the impact of clinicians and staff being (un)clear about roles and expectations				X			• Pediatric team going to adult OR can be difficult, even if better for patient care (do not know who to get information from, nurses less comfortable, surgical team does not know charge nurse, etc.). • Surgical attire can make it hard to identify the role of individuals in the OR, and make it difficult to identify who should be given information. • Having defined roles in the care transition makes it smoother because no one is fighting for roles and wondering how to manage fluid/ambiguous roles to provide the best care.
Staffing/resources	How available staff and other resources impact the ability of clinicians and staff to care for the pediatric trauma patient				X			• Having enough nurses in trauma bay lets one nurse prepare to move patient (document, coordinate, gather supplies) without delay or compromising patient care. • A new anesthesiologist who replaced the anesthesiologist mostly involved in the surgery can lead to loss of information because they were not there for more than the last 15–30 minutes or so. • Delays in being able to handoff to the receiving clinician can result in the trauma chief being unable to handoff at all, e.g., if they have to put an emergent chest tube in another patient. • An oversupply of nursing staff when the patient arrives can help with the transition to get things done (e.g. changing the patient, moving them and starting the IV).
Team cognition	Factors that cause and the impact of team cognition (i.e., planning, decision making, problem solving and problem assessment at the team level), which occurs in communication interactions between care team members.		X		X			• Team familiarity (or lack thereof) can make communication and collaboration more difficult; fewer interactions between ED and OR units does not help to build rapport. • Communication between team can ensure everyone knows what to do to care for patient and any special requests to respect (e.g., no female providers). • The transition from surgical team to medical team can require different language, information, more time because they may be less familiar with complex surgical care and are a completely new care team. • Interprofessional handoff at bedside allows all involved clinicians receive the same information, preventing errors and giving better overall picture, if they go to the handoff (e.g., may not know they will be caring for patient or may not want to go). • Incomplete handoff (due to communication mode and/or difference in expectation between sender and receiver), or missing handoff to key groups, results in more time calling to get information and/or delayed feedback; conversely, clear communication with written plans to refer to help the PICU team care for the patient.
Technology	Work system barriers and facilitators caused by characteristics, usability and/or usefulness of the technology they use			X				• EHR is not useful because of high time pressure and it may not match verbal information. • Communication tools used by nurses are important for coordination/anticipation/preparation, and some tools (e.g., smart phones) are more useful than others (e.g., pagers, Vocera) because of functionality (reception issues) and features (stored numbers, group text). • Bed assignment system may not be updated, so assigned room number may not work in system (e.g., if room is/is not clean).
Characteristic of trauma care	Inherent properties of caring for trauma patients that impact how clinicians and staff can provide care.	X						• Trauma care transitions (especially for very unstable patients) are high time pressure, which impacts communication and planning; having a concise plan helps. • When people are rushed, the transition can go poorly (inaccurately estimating patient trajectory, delaying calling PICU, etc.). • Having an accurate assessment of the patient and their trajectory is key for a good transition.

Notes:

X in a work system element column indicates that element is proximally (i.e., closely) involved in creating a barrier/facilitator of that dimension.

¹T/T = tools and technology

²O = organization

³PE = physical environment

⁴EE = external environment