Physicians and nurses often state the importance of collaboration, communication, and cooperation in delivery of clinical care. Until recently, however, there has been little evidence as to how each of the professions defines these key components of the practice environment. In a 2009 study, health professionals indicated understanding and appreciation of professional roles and responsibilities, and communicating effectively to be two core competencies necessary for patient-centered collaborative practice [29]. Studies where both physicians and nurses were queried about collaboration and communication in their specific units suggest that their perspectives are often far apart. Using the Safety Attitude Questionnaire, Sexton and colleagues found that nurses’ and anesthesiologists’ perceptions of teamwork in the operating room were significantly lower than that reported by surgeons in the same area [30]. One study measuring communication in four ICUs in the United Kingdom noted that, while a majority of senior physicians reported a highly positive open communication style between nurses and physicians, only one third of nurses reported the same [31]. Thomas et al. investigated critical care nurses and physicians’ attitudes about teamwork in eight ICUs in six hospitals. Findings of the 320 subjects suggested that while over 70% of physicians viewed collaboration as very high, only one third of the nurses felt the same [32]. These studies indicate that the two professions experience the organizational climate very differently. This begs the question, what underlies these varying perceptions, given that those surveyed were working together in the same units?

A review of the various codes of ethics for the professions of nursing, pharmacy, medicine, occupational therapy, social work, physical therapy, respiratory care, and chaplaincy indicate that the levels of ethical responsibility associated with interprofessional practice fall into five categories: professional conduct (citizenship), acknowledgement of others, cooperation, collaboration, and conflict engagement. The categories reflect a progression in depth of professional engagement and they provide a glimpse into the perceptions each profession acquires regarding interprofessional practice [33]. The discrepancy highlighted in the studies above suggests that differing approaches found in the professional codes of ethics may impact the way in which each profession is defining and perceiving collaboration. This idea proves likely based on the results of a 2006 survey measuring teamwork among nurses and physicians in the OR (operating room) setting. Discussions with survey respondents indicated that, “nurses often described good collaboration as ‘having their input respected,’ whereas physicians often described good collaboration as having nurses, ‘who anticipate their needs and follow instructions’ [30].” Research into effective teamwork indicates that having shared mental models and a common language are key for working well together. A good starting point for enhancing collaboration is the joint development of shared models for collaboration that provide a common language for working together.

Research that examines the impact of interprofessional teams on patient safety is limited. Most reports either are anecdotal
or include a limited description of the methods used to measure team effects [16]. A 2009 Cochrane review of clinical trials measuring the impact of interprofessional collaboration practice-based interventions designed to improve the work interactions or processes among various types of health professionals yielded five studies that fit the review criteria [4]. The five studies evaluated the effects of interprofessional rounds, interprofessional meetings, and an externally facilitated interprofessional audit. Three of the studies found that the interventions led to improvements in patient care, such as drug use, length of hospital stay and total hospital charges, while one study showed no impact, and one study showed mixed outcomes. The results of other studies suggest a positive correlation between interprofessional practice and clinical outcomes. Recent studies looking at the impact of teams in critical care and primary care have linked teamwork to increased survival to discharge, decreased readmission to the intensive care unit (ICU), fewer adverse events, shorter lengths of stay, and decreased mortality rates following surgical interventions [34]. Research assessing system failures in ORs and ICUs found that positive perceptions of team coordination among ICU staff were associated with lower error rates, that is, when the staff perceived timely transfer of information, role clarity, and awareness of team member activities [35]. Thomas et al. assessed the relationship between teamwork and noncompliance with neonatal resuscitation standards in 132 videotaped resuscitations and found a weak correlation between team behaviors (information sharing, inquiry, treatment planning, and leadership) and compliance [36]. There is also evidence that good team behaviors are linked to decreased turnover among nursing staff in the OR [30] and survey research has shown a link between high levels of cooperation between ICU nurses and physicians and reports of staff burnout [37]. Greater perceived relational coordination has been associated with patient perceptions of higher quality of care, less postoperative pain, greater postoperative functioning, and shorter length of stay [16].

The 2004 Institute of Medicine report, Keeping Patients Safe, addresses the work environment of nurses and its impact on patient safety. The report provides an extensive review of the literature on interprofessional collaboration in its Appendix B: Interdisciplinary Collaboration, Team Functioning, and Patient Safety [16]. Additional research is needed to differentiate the impact of team behaviors, organizational context, team composition, and team stability on clinical outcomes. In addition, the next phase of research should further elaborate strategies for cultivating team effectiveness [34].

End-of-life care in the ICU is a complex and oftentimes an emotion-filled, process. Much work has been done to examine how to improve end-of-life care. In a 2005 special report from the Hastings Center, three areas were identified as needing greater attention to improve end-of-life care. The authors suggested a rethinking of assumptions related to (i) the end-of-life care delivery system, (ii) the approach to advance directives and surrogate decision making, and (iii) how to manage conflict and disagreement [38]. Each of these has implications for collaborative practice among ICU team members. Difficulties for clinicians in providing end-of-life care include: variability in practice, poor communication among providers, lack of consensus regarding plan of care, incomplete documentation, and differences of opinion regarding the definition of futility [39]. According to a statement released from the Consensus Conference in Critical Care, “The principles of shared end-of-life decision making between patients, family members, and clinicians can be achieved only through full participation of all ICU healthcare professionals in the communication and decision-making process [40].”

Critical care nurses have consistently described one of the greatest stressors in their work to be related to decision-making regarding futile treatment [41]. The most important factor enabling nurses to move from cure to comfort-oriented care is developing a consensus about the treatment plan. A survey of 864 critical care nurses revealed barriers to good end-of-life care as being disagreement about the direction of the dying patient’s care, actions that prolonged a patient’s suffering, and physicians who were evasive and avoided talking with patient’s families [42]. When nurses believe that they are powerless to impact decisions related to a course of treatment they perceive to be unethical or harmful to the patient, it leads to moral distress [43]. According to the American Association of Critical Care Nurses, moral distress has a significant impact on the clinical work environment. Studies indicate that one in three nurses experiences moral distress and in one study, nearly half of the nurses surveyed left their unit, and for some their profession, as a result of moral distress [44]. Incorporation of shared goal setting, protocols for managing end of life care, collaborative decision-making processes, and interprofessional dialogue related to complex cases can alleviate some of the stress experienced by all clinicians in the critical care environment and improve care for patients and their families at a very difficult time in their lives.