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systems in other New Zealand hospitals were also interviewed [18]. This was because of potential implementation at the primary study hospital. The remainder of this section is an explanation of DCMT [18] as displayed in Figure 1 below. Factors affecting the junior doctor’s response on whether to communicate to others are shown below in Figure 1. Escalation is defined here as communication specifically to senior doctors. DCMT starts with the sender’s interpretation of the clinical situation and its setting. For instance, a sender may consider a patient-related task request to be routine. The sender’s perception of context determines which communication system is used, i.e. the combination of the physical means of communication and mode options. Once a message is received, the recipient then interprets and acts upon it, forming a judgement about clinical risk for the patient, and personal risk for him or herself e.g. criticism by other clinicians. Communication senders select the ICT system on the basis of their interpretation of usage context, e.g. patient acuity and personal work load. As in Figure 1, the clinical ICT system used then determines the ICT reliability and efficiency of communication receipt. For instance, live video communication may facilitate quick acknowledgement of communication and be faster than describing complex problems. However, it may be less technically reliable than asynchronous text-based systems. Also, recipients may view synchronous communication as disruptive for their own workflow regardless of advantages for senders [23]. ICT reliability also facilitates, but does not obligate, ICT efficiency for both the sender and receiver. An example is that locators may reliably and quickly send protocolised messages for unidirectional emergency group communication to multiple recipients. However, this system may be inefficient in other contexts where bidirectional, rich communication is desirable e.g. evolving situations. Ease of use is an important part of ICT efficiency. Other factors which contribute to ICT efficiency are ICT accessibility (the ability for a user to see the status of other users via the ICT system), and bidirectionality. ICT accessibility and bidirectionality contribute to ICT efficiency although they are features used after or separate to communication receipt, rather than accompanying it. Some features may contribute to ICT efficiency inconsistently e.g. ICT technical design. Whilst increased mobile phone screen size should improve readability, this would be irrelevant if message clarity was inadequate or the message was not received in the first place. Whatever the communication system combination is as in Figure 1, junior doctors ultimately prefer it to deliver maximal ICT reliability, then efficiency. Any other features (e.g. smart mobile phone applications) are secondary considerations. Communication systems also shape communication content, e.g. locator messages are constrained by character length and type. It is easier to structure and standardise text messaging platforms, which may lead to improved quality of information transfer [34]. Smart mobile phone messages can include photos, improving the efficiency of information transfer. Depending on the situational context, communication content and quality afforded by the communication system may be of low relevance. If a recipient junior doctor had pre-existing awareness of a patient’s issues, he or she may require minimal message content to act. Alternatively, doctors may not alter RRS triggering parameters to prevent unnecessary nurse escalation, merely accepting the additional messages [35]. Senders may deliberately vary communication quality according to the intended recipient [12], so that quality is not wholly determined by technological limitations. Junior doctors are seldom free agents in determining which ICT system is used to initiate communication to them and cannot enforce their preferred communication content, shape or timing. They can vary their response, e.g. senders may J.Liangetal. / JuniorDoctorCommunicationSystemsand theDCMT126