Interprofessional collaboration in the ICU: how to define?* Louise Rose

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: louise.rose@utoronto.ca
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.
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