Clinical decision-making process of healthcare workers when feeding critically ill adults in public sector ICUs in South Africa.

Background: Feeding critically ill patients is a complex process because swallowing is heterogeneous, and dysphagia in critically ill patients can have multiple causes. Decisions regarding dysphagia in the critically ill need to be made as a team with all possible outcomes and factors taken into account to ensure the best possible outcomes for patients. However, research has shown that in South Africa (SA), the multidisciplinary team (MDT) approach is not generally used when making decisions around feeding. Objectives: To explore the clinical decision-making (CDM) factors in feeding practices in adults of the MDT in public healthcare intensive care units (ICUs) in Johannesburg, SA. Methods: A qualitative design with non-probability purposive sampling was used. There were 15 MDT participants across two tertiary hospitals. Data were derived from observations, focus groups, and individual interviews and analysed using a reflective thematic approach. Results: Three themes were reported on, namely decision-making factors in the ICU by the MDT, non-patient-related factors and the meaning and misconception of the word 'tolerance'. There are no protocols followed in the ICU and decisions are made on an individual basis. Non-patient related factors impact the decisions and when the MDT collaborates, it positively influences the CDM process. Different MDT members use the word 'tolerance' differently in dysphagia, which needs to be considered. Conclusion: Clinical factors were the primary consideration for all MDT members when selecting a feeding method for critically ill patients. Environmental factors were also considered when adaptations were necessary owing to contextual constraints. The findings indicate that a multidisciplinary approach to feeding is not consistently practised in SA public sector ICUs, and there is no standardised feeding protocol in place. This was evident from the infrequent communication and collaboration among MDT members. Improved interdisciplinary co-ordination is needed. Additionally, inconsistent use of medical terminology among team members may affect patient care. Clear communication of terminology is essential to ensure mutual understanding of clinical decisions. Contribution of the study: This study contributes to the understanding of feeding practices for critically ill patients in South African public sector intensive care units (ICUs) by highlighting the absence of standardised feeding protocols and the inconsistent application of a multidisciplinary team (MDT) approach. It highlights how clinical decision-making is influenced not only by patient-related factors but also by environmental and contextual constraints. Importantly, the research draws attention to the impact of inconsistent terminology, such as varied interpretations of 'tolerance', on patient care and team collaboration. By documenting these challenges, the study provides evidence for the urgent need to strengthen interdisciplinary communication, establish clear protocols, and promote coordinated MDT practices to improve patient outcomes in ICU feeding decisions.