Interprofessional Collaboration Among Critical Care Team Members



Interprofessional Collaboration Among Critical Care Team Members


Debra Gerardi

Dorrie K. Fontaine




“In the ICU, nurses and physicians stand at a patient’s bedside initially as strangers, thrown together by a combination of choice and circumstance. With each interaction, they assess one another’s knowledge, openness to suggestion, and commitment to patient care. They learn each other’s strengths and weaknesses and, over time, forge relationships that become the bedrock of effective collaboration. They communicate, negotiate, and compromise [1].”


Interprofessional Collaboration in Critical Care

Collaboration among critical care professionals is essential to the provision of safe and effective care in the Intensive Care Unit (ICU). Outcomes associated with effective collaboration include patient safety, improved quality indicators, retention of healthcare providers, and patient and family satisfaction with care. In 1994, a joint position statement was issued by the Society of Critical Care Medicine (SCCM) and the American Association of Critical Care Nurses (AACN) promoting a multidisciplinary approach for managing and providing intensive care services as the preferred model of care [2]. Since that time, an increasing number of mandates and standards issued from national organizations reinforce interprofessional collaboration as a necessary component of care delivery in complex clinical environments.

This chapter describes the principles and importance of interprofessional collaboration, the integration of teamwork as a means of achieving collaborative outcomes, and strategies for cultivating environments in which collaborative delivery of safe patient care can flourish.


Defining Collaboration

Collaboration is the process of working together toward common goals through joint communication and joint decision-making [3]. Collaboration is both a process and a style that blends high levels of assertiveness and cooperation. Interprofessional collaboration is defined as the process in which different professional groups work together to positively impact health care and relies on negotiated agreements to bring the valued and unique contributions of experts to patient care. Interprofessional collaboration involves understanding what enables effective collaboration as well as understanding barriers to collaboration including: unhealthy power dynamics, poor communication patterns, lack of understanding of one’s own and others’ roles and responsibilities, and conflicts due to varied approaches to patient care that are inherent within diverse clinical teams [4]. Collaboration is vital, difficult, and learnable [5]. True collaboration is relational and requires skilled communication, trust, knowledge, shared responsibility, mutual respect, optimism, and coordination [6].


Collaboration As A Core Competency for Health Professionals

Health professionals are required to possess core competencies (knowledge, skills, and attitudes) associated with interprofessional collaboration including communication, negotiation, and conflict resolution as a component of academic training
and professional practice [7,8,9]. The Accreditation Council for Graduate Medical Education and the Association for American Medical Colleges include aspects of communication, coordination, and collaboration among the required physician competencies [10]. Explicit guidelines for collaboration are embedded in professional codes of ethics for nurses and physicians [11,12]. Understanding of and respect for the professional contributions of colleagues across the professions is a necessary precursor to effective collaboration. Slow progress is being made to incorporate these competencies into curricula across the health professions to better teach the concepts of collaboration that support patient safety and improved care coordination [9,13].


Mandates for Interprofessional Collaboration

The need for improved interprofessional collaboration has been discussed for decades among professional associations—particularly among critical care associations. The past decade has seen a shift from discussion to concerted action, as multiple calls for improvement in care delivery from the Institute of Medicine (IOM) have emerged, resulting from data linking poor clinical outcomes to ineffective teamwork and inadequate care coordination [14,15,16]. There is substantial evidence that the leading contributors to medical errors and unsafe care are breakdowns in teamwork, communication, and the overriding culture of health care itself [17,18]. Hundreds of billions of dollars are wasted on medical errors and ineffective care coordination each year [19]. In addition to poor patient outcomes, ineffective collaboration has been linked to perceptions of hostile work environments [20], low morale, and job stress among health professionals [21], increased turnover of clinical staff [22], and moral distress [23]. As such, new mandates are emerging to focus attention within healthcare organizations on strategies for developing interprofessional collaboration as a component of safe patient care.

The National Quality Forum (NQF) added teamwork training and interventions to their 2006 consensus report, Safe Practices for Better Healthcare, which are now represented in the 2009 Report as Safe Practice #3—Teamwork Training and Skill Building [24]. The Joint Commission, through their Patient Safety Goals [25], their sentinel event alerts [17], and their accreditation standards, requires improved teamwork, collaboration, and conflict management across the healthcare organization. Calls for conversation and dialogue to begin to address the challenges to working together are growing [26,27,28]. With this increased interest comes a growing database of empirical evidence associated with teamwork, collaboration, and improved conflict management in the clinical setting. This culture shift creates a golden opportunity for researchers interested in elucidating the impact of professional subcultures, human factors, team training, and conflict dynamics on the effectiveness of interprofessional collaboration and its impact on clinical outcomes, quality of work environments, and the resilience of health professionals.


Interprofessional Collaboration—Emerging Research

The complexity of delivering critical care services requires ongoing integration of skills and knowledge from multiple professions. Emerging research highlights several areas including: perceptions of health professionals; the impact of collaboration and teamwork on clinical outcomes, quality indicators, retention of health professionals, patient satisfaction, and the quality of the work environment; characteristics of effective teams; and the influence of conflict on team effectiveness. Much of the research is based on self-reports combined with only a few observational or controlled trials. Several key studies will be reported here that serve as the foundation for future strategies.


Perceptions of Health Professionals

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.


Impact on Quality, Safety, and Retention

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].


Interprofessional Collaboration and End-of-Life Care

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.


Strategies for Advancing Interprofessional Collaboration

There can be no assurance of safe, effective, quality care without collaboration that begins with a trusting, respectful relationship. Addressing what some consider these “soft” issues may in reality be the solution to many of the hardest challenges in critical care settings. In the complex environment of the ICU, the challenge to focus full attention on the patient experience and create systems of care where clear communication from respectful collaboration is the norm is crucial [45]. The history of critical care in the United States is replete with the concept of teams and reliance on expertise from many professionals—the hallmark of the ICU [46]. Relationship-centered care, where the primacy of relationship of patient and healthcare provider exists, cannot occur without skilled partnerships of all members of the healthcare team, especially physicians and nurses [47].

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Sep 5, 2016 | Posted by in CRITICAL CARE | Comments Off on Interprofessional Collaboration Among Critical Care Team Members

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