EVALUATION Interprofessional collaboration in the ICU: how to define?* Louise Rose ABSTRACT The intensive care unit (ICU) is a dynamic, complex and, at times, highly stressful work environment that involves ongoing exposure to the complexities of interprofessional team functioning. Failures of communication, considered examples of poor collaboration among health care professionals, are the leading cause of inadvertent harm across all health care settings. Evidence suggests effective interprofessional collaboration results in improved outcomes for critically ill patients. One recent study demonstrated a link between low standardized mortality ratios and self-identified levels of collaboration. The aim of this paper is to discuss determinants and complexities of interprofessional collaboration, the evidence supporting its impact on outcomes in the ICU, and interventions designed to foster better interprofessional team functioning. Elements of effective interprofessional collaboration include shared goals and partnerships including explicit, complementary and interdependent roles; mutual respect; and power sharing. In the ICU setting, teams continually alter due to large staff numbers, shift work and staff rotations through the institution. Therefore, the ideal ‘unified’ team working together to provide better care and improve patient outcomes may be difficult to sustain. Power sharing is one of the most complex aspects of interprofessional collaboration. Ownership of specialized knowledge, technical skills, clinical territory, or even the patient, may produce interprofessional conflict when ownership is not acknowledged. Collaboration by definition implies interdependency as opposed to autonomy. Yet, much nursing literature focuses on achievement of autonomy in clinical decision-making, cited to improve job satisfaction, retention and patient outcomes. Autonomy of health care professionals may be an inappropriate goal when striving to foster interprofessional collaboration. Tools such as checklists, guidelines and protocols are advocated, by some, as ways for nurses to gain influence and autonomy in clinical decision-making. Protocols to guide ICU practices such as sedation and weaning reduce the duration of mechanical ventilation in some studies, while others have failed to demonstrate this advantage. Existing organizational strategies that facilitate effective collaboration between health care professionals may contribute to this lack of effect. Key words: Collaboration • Intensive care unit • Interdisciplinary • International • Nurses’ role INTRODUCTION Due to increased patient acuity and throughput, most hospital environments but particularly intensive care units (ICUs) have become complex, dynamic, stressful and time pressured (Donchin and Seagull, 2002). These characteristics necessitate a team approach to care delivery that encourages effective interprofessional communication and collaboration. Interprofessional collaboration promotes and optimizes active participation of all health care professions in clinical ∗ Paper was presented at the BACCN International Conference 2009, Belfast, Northern Ireland. Author: L. Rose PhD, MN, RN, Lawrence S. Bloomberg Professor in Critical Care Nursing, Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada Address for correspondence: Lawrence S. Bloomberg Professor in Critical Care Nursing, Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, 155 College St, Toronto, Ontario, Canada M5T IP8 E-mail: [email protected] decision-making focused on patient needs while ensuring respect for team member contributions (Herbert, 2005). The expertise and particular contributions of all health care professionals are acknowledged in this process (Zwarenstein & Reeves, 2006), resulting in improved quality of care, patient safety and outcomes. Unfortunately poor communication, teamwork and problem solving have been noted in ICUs, indicating interprofessional collaboration is inconsistent and suboptimal (Sexton, 2002; Garland, 2005). Team membership within ICUs is not constant due to shiftwork, educational rotations and staff attrition as well as dynamic changes in the needs of individual patients (Hawryluck et al., 2002). Notably, when asked to evaluate interprofessional collaboration, nurses consistently rate it lower than doctors, suggesting discipline-specific perspectives on the nature of collaboration (Baggs et al., 1997; Miller, 2001; Sexton, 2002). Senior and junior staff also rate interprofessional © 2011 The Author. Nursing in Critical Care © 2011 British Association of Critical Care Nurses • Vol 16 No 1 5 Interprofessional collaboration in the ICU: how to define? communication differently (Reader et al., 2007). While doctors and nurses are not the only members of the interdisciplinary team, the status of medicine and the sheer size of the nursing profession means effective collaboration of these two disciplines modulates successful service delivery (Reeves et al., 2008). This paper discusses determinants and complexities of interprofessional collaboration, evidence supporting its impact on outcomes in the ICU, and interventions designed to foster better interprofessional team functioning. Determinants of interprofessional collaboration Collaboration implies sharing, partnership, interdependency, but also power (D’Amour et al., 2005). Many barriers to successful interprofessional collaboration exist, including problematic power dynamics, poor communication patterns, poor understanding of roles and responsibilities resulting in boundary infringements, and conflict due to differences in approaches to patient care (Sheehan et al., 2007; Delva et al., 2008; Kvarnstrom, 2008; Miller et al., 2008; Suter et al., 2009). Issues of power, control, knowledge and status have dominated professional practice for many decades (McCallin, 2001). Using ethnographic observation in a single ICU, Hawryluck and colleagues (Hawryluck et al., 2002) identified six key catalysts influencing the balance between collaboration and conflict, both within the core ICU team and other consulting specialties contributing to patient care such as neurosurgery or orthopaedics. These catalysts included authority, education, patient needs, knowledge, resources and time. Authority was a positive influence on collaboration if the interprofessional team endorsed the team member assuming the leadership role. Conflict occurred when leadership and therefore decision-making responsibility was not universally accepted. Education may engender shared team goals, yet conflict occurred when educational needs were not met due to other constraints. Focusing on patient needs has the capacity to bring the team together but conflict may happen when disparate views exist regarding the nature of patient needs and strategies to meet them. Possession of knowledge within the team may foster collaboration, whereas lack of knowledge may be exclusionary. Constraints in resources and time, conditions prevalent in the majority of ICUs internationally, may have variable influence on team functioning. Some teams may function more collaboratively in times of constraint; alternatively tensions arising from limited resources may negatively impact team communication and function. 6 In a subsequent focus group study by the same investigators, the six catalysts were found to be influenced by two concepts: the perception of ownership and the process of trade (Lingard et al., 2004). Ownership of elements such as specialized knowledge, technical skills, and clinical territory including the patient, produced interprofessional conflict if not acknowledged by team members. Trading of owned commodities could be used to facilitate collaborative team function, but also emphasised power relationships within the team. Determinants of interprofessional collaboration not only include interactional features as described above but also organizational and systemic factors (San Martin Rodriguez et al., 2005). Systemic factors creating power differences that potentially influence interprofessional collaboration include social, cultural, professional and educational systems. Gender, cultural and social stereotypes that influence power relationships continue to exist. Professionalization by definition creates an independent framework focused on autonomy and control. Professionals with high levels of autonomy frequently work in a parallel fashion that is not conducive to team functioning (Satin, 1994). Collaborative team members have less individual autonomy, yet the team is more autonomous with members better integrated (Ivey et al., 1987; Satin, 1994). Interprofessional collaboration requires interdependent as opposed to autonomous practice and decision-making based on the premise that health professionals want to work together to provide optimalpatient care (Pike et al., 1993; Evans, 1994). Despite this collective goal, team members may continue to have their own interests to secure necessitating a certain amount of autonomy or independence (D’Amour et al., 2008). Baggs et al. (1997) noted power disparity was a principal barrier to interprofessional collaboration. For true collaboration to occur, all disciplines within the health care team must be considered equal partners. Yet, health professionals are socialized during their education towards a discipline-specific framework that shapes how patients and clinical environments are perceived as well as clinical knowledge, skills and communication styles (D’Amour et al., 2005). This means interprofessional teams consist of individuals with distinct professional identities that have different and sometimes opposing priorities or agendas. Despite recent advances in interprofessional education, for the most part, health professionals are educated separately with limited access to the other discipline’s-specific knowledge. Flat as opposed to hierarchical organizational structures promote interprofessional collaboration. © 2011 The Author. Nursing in Critical Care © 2011 British Association of Critical Care Nurses Interprofessional collaboration in the ICU: how to define? Communication failures can occur when hierarchical organizational models cause junior team members to be hesitant to communicate with senior colleagues due to fear of reprisal, embarrassment or appearing incompetent (Edmondson, 1999). Other influential organizational factors include a philosophy that promotes collaboration, availability of administrative support enabling effective coordination and communication mechanisms, and team resources in terms of meeting space and time for collaborative discussion, information sharing, debriefing and relationship building (San Martin Rodriguez et al., 2005). Interprofessional collaboration and outcomes Performance of individual ICUs can be assessed in terms of medical, economic, psychological and institutional outcomes (Garland, 2005). Medical outcomes are measured by variables such as patient survival, complication rates, adverse events and symptom control. Economic outcomes refer to resource consumption and cost-effectiveness of care. Measurable psychological outcomes include long-term recovery and quality of life, as well as patient and family satisfaction. Institutional outcomes refer to measures of staff satisfaction and turnover, ICU bed utilization, efficiency of ICU services and satisfaction by other hospital departments with these services (Garland, 2005). Empirical studies linking interprofessional collaboration to improved medical outcomes for critically ill patients are limited, yet evidence is accumulating, indicating interprofessional collaboration is an important consideration (Zwarenstein & Reeves, 2006). In the much cited study by Knaus and colleagues (Knaus et al., 1986), those ICUs reporting high rates of interprofessional collaboration demonstrated lower actual mortality rates than predicted. More recently, Wheelan and colleagues established a link between a low standardized mortality ratio and high scores of teamwork in 17 ICUs in the United States (Wheelan et al., 2003). Lower rates of ICU readmission and mortality following ICU discharge have been demonstrated on wards with high levels of interprofessional collaboration (Baggs et al., 1992; Baggs et al., 1999). Using a cross-sectional survey design, Manojlovich et al. (2009) evaluated team communication and demonstrated associations between: (1) variability in communication and development of ventilator associated pneumonia and (2) timeliness of communication and presence of pressure ulcers. Ineffective interprofessional collaboration may also negatively influence collective outcomes such as team function and morale (Baggs et al., 1997) and ethical decision-making (Baggs, 1993). Interventions to promote interprofessional collaboration There is no doubt that communication failure as the result of poor interprofessional collaboration results in increased patient harm, increased ICU and hospital length of stay, increased resource use and increased caregiver dissatisfaction and turnover (Baggs et al., 1999; Sexton, 2002; Zwarenstein and Reeves, 2002; Reader et al., 2007). Several quality improvement interventions that may promote interprofessional teamwork have received recent attention. These tools designed to encourage explicit and inclusive communication include checklists, daily goal sheets, interdisciplinary rounds and protocols. Quality improvement checklists are cognitive tools that can improve interprofessional collaboration while optimizing care and securing patient safety. Patient or procedural checklists originated from the aviation industry where checklists are routinely used for various tasks to ensure safety (Simpson et al., 2007). Checklists are designed to standardize processes, thus reducing variability and improving performance (Winters et al., 2009). Checklists are frequently implemented with other communication interventions designed to foster interdisciplinary collaboration. In one of the most publicized studies demonstrating the efficacy of checklists, Pronovost and colleagues (Pronovost et al., 2006) implemented a central line insertion checklist with other safety initiatives including a designated central line cart, a daily goals sheet, clinician education and monthly feedback. This strategy resulted in a reduction in the incidence of catheter-related bloodstream infections from 2·7 per 1000 catheter days to zero; a reduction that was maintained for 18 months. Understanding the daily goals of care including required tasks, the care plan with designated responsibilities and a plan for interdisciplinary communication seems like a basic premise of ICU management. However, previous work suggests few staff may be aware of patient goals (Pronovost et al., 2003). Implementation of a daily goals sheet in a single US ICU improved awareness from 10% to 95% with an associated 50% reduction in ICU length of stay (Pronovost et al., 2003). Nurses in the participating unit perceived themselves as more active within the team through partnering with physicians to achieve a common goal. Commentary on this study emphasized the importance of interdisciplinary communication derived from the tool as opposed to specific tasks. Daily ICU goals sheets have now demonstrated improved interprofessional collaboration in numerous settings (Narasimhan et al., 2006; Agarwal et al., 2008). © 2011 The Author. Nursing in Critical Care © 2011 British Association of Critical Care Nurses 7 Interprofessional collaboration in the ICU: how to define? Few empirical guidelines exist to inform the development of checklists or daily goals sheets (Winters et al., 2009). Key considerations and questions for institutions include: • Who is responsible for development, implementation, and ongoing review of the tool and what resources are available to them? • What incentives are needed to facilitate engagement of the interdisciplinary team? • What, if any, are the consequences to the individual of non-compliance? To be effective, checklists should be developed, implemented and evaluated by interdisciplinary team members with participation from change agents and role models. Traditionally doctors have viewed checklists, guidelines and protocols as insults to their intelligence and professional autonomy (Kingston, 2000). However, the mounting complexity of critical care as well as evidence of the effectiveness of checklists (Pronovost et al., 2006) has led to increasing adoption for a number of complex interventions. Audit and feedback may create reputational and social incentives that facilitate engagement. Yet, there is a potential for interdisciplinary conflict to occur if one discipline is given the responsibility for monitoring compliance of another discipline. Protocols may include checklists but extend to provide sequential steps with alternative options for clinical interventions dependent on patient response. Over the past two decades, much attention has been paid to protocols that guide ventilator weaning and sedation management in the ICU. Studies of nurse or respiratory therapist-led weaning protocols from the US found clinically and statistically significant reductions in the duration of ventilation and ICU stay compared with existing practice (Ely et al., 1996; Kollef et al., 1997; Marelich et al., 2000). Nurse-led sedation protocols also have been shown to reduce the overall duration of ventilation and ICU stay (Brook et al., 1999). Protocols are viewed by some as tools that reduce practice variability, ensure timely and appropriate decision-making and thereby result in improved patient outcomes (Saura et al., 1996). However, conflicting evidence on the efficacy of protocols for weaning and sedation management exists. The only rigorous study of weaning protocols conducted in the United Kingdom found increased durations of weaning and ICU stay (Blackwood et al., 2006). Similarly, implementation of a computerized weaning protocol in a single Australian ICU did not demonstrate a reduction in weaning duration (Rose et al., 2008). Sedation protocols 8 similarly have demonstrated substantial reductions in the duration of ventilation and length of ICU stay in North America (Brook et al., 1999), a finding that could not be replicated in the Australian context (Bucknall et al., 2008). These conflicting results are attributed to existent clinical practices and organizational structures including closed ICUs, high staffing levels, frequent patient evaluation by medical and nursing staff and good interprofessional collaboration (Blackwood et al., 2006; Bucknall et al., 2008; Rose et al., 2008). Consequently, protocols may be considered to aid interprofessional communication and collaboration when these elements are lacking but may be redundant in units in which high levels of interprofessional collaboration already exist. Interdisciplinary rounds are another strategy that can improve communication, collaboration and professionalism as well as patient outcomes (Halm et al., 2003; Vazirani et al., 2005; Kerfoot et al., 2006). The premise of interdisciplinary rounds is not the composition of health disciplines physically in attendance, but rather the interdisciplinary communication, shared planning and decision-making that should occur. Key elements for successful interdisciplinary rounds include collegiality, respect and trust in a supportive, education focused environment (Falise, 2007). When evaluating the current structure of rounds within individual units, it is important to observe and critique interprofessional communication exchanges. Counting the number of disciplines attending rounds may not accurately reflect the level of interprofessional collaboration. CONCLUSION In reviewing the evidence, there is little doubt that promoting interprofessional communication and collaboration within individual ICUs is a positive strategy that will result in improved quality of care, patient safety and outcomes. Presuming a negative impact from improved collaboration is counterintuitive. Organizations must focus on strategies that create the structures required for interprofessional collaboration. Individual health care professionals need to seek out the skills and knowledge that enable them to function effectively within an interdisciplinary team. Sharing of care planning, decision-making responsibility, goals, values, patients, clinical territory and data should be the rule as opposed to the exception. Quality improvement strategies such as checklists, daily goal sheets, protocols and interdisciplinary rounds are additional tools that may serve to improve interprofessional communication and collaboration for some ICUs. © 2011 The Author. Nursing in Critical Care © 2011 British Association of Critical Care Nurses Interprofessional collaboration in the ICU: how to define? WHAT IS KNOWN ABOUT THIS TOPIC • Systemic, organizational and interactional determinants influence interprofessional collaboration. • Quality improvement tools and processes may improve interprofessional collaboration resulting in better outcomes in units with inconsistent and suboptimal communication, teamwork and problem solving. WHAT THIS PAPER ADDS • This paper provides commentary on the theoretical constructs underlying interprofessional collaboration as well as some strategies that can enhance teamwork in the critical care environment. • Emphasis is made of the importance of contextual elements that potentially influence effective collaboration between health care professionals and the success of these strategies. REFERENCES Agarwal S, Frankel L, Tourner S, Mcmillan A, Sharek P. (2008). 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