Collaborative Practice in Critical Care Settings

A Workbook

Scott Reeves, Janet Alexanian, Deborah Kendall-Gallagher, Todd Dorman, Simon Kitto

• Publisher: Routledge
• Year: 2018
• ISBN:
  9781351798679
• Edition: 1
• Topic: Médecine
• Subtopic: Médecine d'urgence et soins intensifs

This practical and evidence-based workbook offers a series of assessment, implementation and evaluation activities for professionals working in critical care contexts. Designed to improve the quality of care delivery, it looks both at collaboration between professionals and between patients and/or family members.

Collaborative Practice in Critical Care Settings:

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• identifies the issues relating to the "current state" of collaboration in critical care through a series of assessment activities;

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• provides a series of interventional activities which can address shortfalls of collaboration previously identified; and

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• offers advice on generating evidence for the effects of any interventions implemented.

The activities presented in this book are based on extensive empirical research, ensuring this book takes into account the everyday work environment of professionals in critical care units. It is suitable for practitioners and educators, as well as patient safety leads and managers.

Chapter 1
Examining effective collaboration in critical care settings

Introduction

In this chapter we provide an overview of the literature related to effective collaboration among critical care professionals and between patient/family members. Following an extensive literature search we found that four central themes were key to developing and sustaining these differing forms of collaboration.

Background

Interprofessional collaboration provides the foundation for delivering safe, efficient, patient-centred care. Effective collaborative practice engages different healthcare providers, patients and their family members. Collaborative practice is seen as a key mechanism for achieving the end goal of improving patient outcomes (Lutfiyya et al. 2016a). However, limited teamwork, poor coordination and ineffectual communication are regularly cited as precursors to preventable healthcare-related adverse outcomes (e.g. Reeves et al. 2017a). In addition to harm caused to patients, adverse events are expensive. Van Den Bos et al. (2011), for instance, estimated that in the USA in 2008, the annual cost of measurable clinical error resulting in harm was $17.1 billion.

Effective interprofessional collaboration is essential in critical care settings due to the clinical vulnerability of the patient population, many of whom may not be able to give voice to their concerns (e.g. Happ, 2000), and the complexity of technology in these environments. According to Dietz et al. (2014), the combination of clinical vulnerability and technological complexity means that “the margin of error is thin, and the consequences of errors are profound” (p. 912).

Critical care patients’ lives depend on the ability of their healthcare providers to problem-solve quickly, collaboratively and effectively to give them the best outcome possible (Kendall-Gallagher et al. 2016; Manthous et al. 2011). Learning to function effectively together as a team in critical care is a skill developed over time through evidence-informed, mentored practice (Manthous et al. 2011). A growing body of evidence suggests a multitude of interrelated factors influence the quality of effective interprofessional collaboration (Courtenay et al. 2013; Dietz et al. 2014; Manthous et al. 2011; Paradis et al. 2014; Reeves et al. 2015a; 2017a).

Family members are increasingly being recognised as having an important role on the critical care healthcare team (Davidson et al. 2017; Olding et al. 2016). Greater engagement of patients’ family members during a critical care admission benefits both patient and family – reported benefits include a decrease in family member psychological stress associated with their loved one’s critical care stay and an increase in family members’ effectiveness when caring for the patient (e.g. Gerritsen et al. 2017).

Key Themes from the Literature

As noted above, our review of the literature revealed the following four key themes related to collaboration within a critical care context:

• building the infrastructure to support sustainable improvement;
• understanding how local context impacts collaboration;
• creating psychologically safe environments;
• giving patients and their families a voice.

Below we describe and discuss each of these areas to help provide an insight into some of the issues affecting collaboration between critical care professionals, patients and their families.

Building the Infrastructure to Support Sustainable Improvement

Critical care units vary considerably in size, structure, model of care, outcomes, and cost (Fanelli & Zangrandi, 2017; Prin & Wunsch, 2012; Vincent et al. 2014). In the United States, for example, the annual cost of critical care has been estimated to be in the range of $80 billion (Halpern & Pastores, 2015; Kahn & Rubenfeld, 2015). Numerous strategies have been introduced to improve patient outcomes and reduce costs including use of intensivists (Valentin et al. 2011; Weled et al. 2015), evidence-based protocols (Pronovost et al. 2010), and interprofessional daily rounds (Kim et al. 2010). However, use of these strategies, either individually or collectively, has produced mixed improvements in quality (Dixon-Woods et al. 2013; Kerlin et al. 2017).

Quantitative research findings suggest interprofessional collaborative models of care may be an effective framework for achieving overall improvement in critical care outcomes (Checkly et al. 2014). For example, Kim et al. (2010) used multivariate logistic regression to determine if interprofessional care teams had an independent effect on 30-day mortality in a risk-adjusted sample of 107, 324 adult ICU patients across 112 hospitals by linking patient-level discharge data with data from a multi-centre, hospital-level organisational survey. The independent variable was the presence or absence of interprofessional rounds (Kim et al. p. 370). These authors found that the odds of death were significantly lower with use of interprofessional teams, noting that “survival benefit of intensivist physician staffing is in part explained by the presence of multidisciplinary teams in high-intensity staffed ICUs” (Kim et al. p. 369). In contrast, a study by Costa et al. (2015) involving fourty-nine ICUs across twenty-five hospitals which aimed to explore the impact of daytime intensivist physician staffing on risk-adjusted ICU adult patient in-hospital mortality. Controlling for interprofessional rounds and clinical protocols, the authors found no significant association between daytime intensivists and reduced odds of mortality. More recently, the American Thoracic Society published a systematic review (eighteen studies) and meta-analysis (four studies) examining adjusted effects of night-time intensivists on adult ICU patient mortality and ICU length of stay (Kerlin et al. 2017). The authors found that night-time intensivist staffing was not significantly associated with either mortality (odds ratio, 0.99; 95% confidence interval, 0.75–1.29) or patient length of stay and concluded that other types of ICU staffing models such as “interprofessional care delivery models” may need to be considered as a pathway for improving ICU outcomes (Kerlin et al. p. 390).

Qualitative studies exploring interprofessional collaboration teamwork across critical care settings provide a window for understanding why efforts to improve critical care outcomes through introduction of quality improvement (QI) interventions, such as clinical protocols and presence of intensivists, produce inconsistent results (Dixon-Woods et al. 2013; Reeves et al. 2017b). In particular, a growing body of qualitative data suggests that failure to understand the underlying “social processes and mechanisms that produced the outcomes” impedes meaningful and sustainable improvements in quality (Dixon-Woods et al. 2011, p. 168). For example, Costa and colleagues (2014) interviewed sixty-four ICU clinicians composed of clinical pharmacists, dieticians, nurses, nurse managers, physicians and respiratory therapists across seven ICUs to identify factors that facilitated their collaborative efforts. Two types of facilitating factors emerged from the data – cultural and structural – with each factor working independently, as well as interdependently, to facilitate interprofessional collaboration. Structural factors were seen as tools that improved the efficiency and effectiveness of communication among ICU clinicians such as checklists, clinical protocols and daily rounds; whereas cultural factors addressed modifiable, non-technical factors related to team member accessibility, trust, value and leadership (Costa et al. 2014).

As a number of studies have indicated, building an effective interprofessional team within critical care requires forethought regarding fostering positive interactions that create an environment of trust, respect, and psychological safety (e.g. Manthous & Hollingshead, 2011; Paradis et al. 2014; Reeves et al. 2015a). However, as Manthous & Hollingshead, (2011) note, a “team approach [. . .] does not arise by accident or spontaneous generation but rather through cultivation of principles and practices rooted in the social and behavioural sciences” (p.17). In addition, effective leadership across the team is also required (Caldwell et al. 2008).

Importantly, findings from recent reviews examining interprofessional teamwork and collaboration have indicated that failure to address the underlying social context of care that drives clinician, managerial and organisational behaviours is one of the most significant impediments to achieving meaningful and sustainable improvements in quality and safety (Dixon-Woods et al. 2011; Paradis et al. 2014; Reeves et al. 2017b).

Understanding how Local Context Impacts Collaboration

Across the globe, limited progress with enhancements in patient safety, combined with inconsistent results from interprofessional QI initiatives (Austin & Provonost, 2015; Centers for Disease Control and Prevention, 2016; Organisation for Economic Co-operation and Development, 2016) is driving interest in greater examination of how local context influences the success or failure of these activities.

Kaplan and colleagues’ (2011) seminal article related to quality, includes an evidence-based conceptual model, known as the Model for Understanding Success in Quality (MUSIQ), that explicates twenty-five contextual factors thought to impact QI intervention success. MUSIQ categorises factors based on their level of operation within the healthcare delivery system and focuses on the following: external environment; organisation; microsystem and team (Kaplan et al. 2011). Examples of the factors at each level include regulatory requirements and competition (external environment), leadership and resource avail ability (organisation), unit culture and motivation to change (microsystem), and leadership and decision-making process (team). Kaplan et al. (2011) go on to hypothesise that team-based factors (e.g. clinician team leadership behaviour needed to successfully implement improvements at the bedside) directly influence the outcome of collaborative QI projects, whereas other factors (e.g. organisational support), exert an indirect influence on team behaviour.

Kringos et al. (2015) used MUSIQ to frame a systematic review of the literature that explored evidence-based associations between contextual factors and QI intervention success. Further, Kaplan et al. (2013) conducted a cross-sectional survey of participants involved in QI interventions (n = 74) to quantitatively test interrelationships among the twenty-five contextual factors. Findings from this review and other studies discussed suggest that team leadership, team skills, and organisational resource support play important roles in the success of quality-focused interprofessional interventions (Kringos et al. 2015).

In the specific context of interprofessional teamwork, Reeves et al. (2010) identified four domains, and associated domain-specific sub-factors, known to influence the quality of collaborative teamwork: relational, processual, organisational, and contextual (Figure 0.1). Viewed collectively, the sub-factors are all interprofessional issues critical care team members may experience daily in delivering care (Reeves et al. 2016). Sub-factors may be overt, such as the presence or absence of daily interprofessional rounds, or subtle, such as workload issues that prevent nurses from being able to participate in interprofessional rounds within a critical care context (Kendall-Gallagher et al. 2016).

QI interventions can be designed to incorporate important social contextual factors known to impact critical care outcomes. For example, Dixon-Woods et al. (2011) provided a detailed analysis of how an evidenced-based clinical protocol designed to reduce central venous catheter blood stream infections (CVC-BSI) can be developed purposively to address social contextual factors that potentially enhance the opportunity for successful and sustainable improvement. The QI intervention, known as the Michigan Keystone Project that involved 103 ICUs (Pronovost et al. 2006, 2010), facilitated clinician behaviour change through a combination of a structured protocol that included empowering nurses to stop catheter insertion if the clinical protocol was not being followed. It also reframed CVC-BSI as a social problem that could be improved through “human action and behaviour” rather than as “a problem with a simple technical fix” (Dixon-Woods et al. 2011, p. 183).

Bion and colleagues (2012) attempted to replicate the success of the Michigan CVC-BSI initiative in a government-initiated patient safety intervention in over 200 ICUs in England. Results from this study indicated a substantial reduction in reported CVC-BSI in adult ICUs (Bion et al. 2012). However, a more detailed review of study data suggested that “concurrent and preceding improvement efforts” rather than the safety intervention may have accounted for the results (Bion et al. 2012, p. 8). Findings from a related ethnographic study by Dixon-Wood et al. (2013) of seventeen of the participating ICUs in the Bion et al. (2012) study suggested that differences in context play a pivotal role in program outcomes. Identified differences in context included a local peer-driven versus government-driven program, lack of participant engagement due to previous experience with other initiatives and availability of high quality data collection systems (Dixon-Woods et al. 2013).

Collectively, the critical care literature effectively demonstrates that local context (and local cultures) need to be paid close and detailed attention to when studying collaboration or intervening to improve the delivery of interprofessional care.

Creating Psychologically Safe Environments

Psychological safety is about interpersonal risk-taking in the workplace (Edmondson, 1999). In a critical care context, Manthous & Hollingshead (2011) describe psychological safety as “a culture in which it is safe for all members to offer their observations and opinions, especially when germane to the quality of delivered care and patient safety” (p. 19). Lack of psychological safety can lead to missed information that can trigger erroneous decision-making and increased risk of patient harm (Manthous & Hollingshead, 2011). Psychological safety can impact quality of care on multiple levels, including provider behaviour related to reporting of adverse events (Appellebaum et al. 2016) and “engagement in quality improvement work” (Nembhard & Edmondson, 2006, p. 941).

The hierarchical status difference among the health professions frequently impedes positive interprofessional interactions and can undermine psychological safety (e.g. Siedlecki & Hixson, 2015). Quality of communication between nurses and physicians continues to present patient safety concerns (Johnson, 2009). It has been argued that notwithstanding the professional hierarchical issues, interprofessional leaders can create an environment of psychological safety (Manthous & Hollingshead, 2011) and facilitate team learning by modelling leader inclusiveness, defined as the “words and deeds by a leader or leaders that indicate an invitation or appreciation for others’ contributions” (Nembhard & Edmondson, 2006, p. 947).

Nembhard and Edmondson (2006) explored how leader inclusiveness of team members could “overcome the inhibiting effects of status differences” (p. 941) in twenty-three neonatal ICUs and found that in interprofessional teams, positive associations existed between the following factors: higher profes sional status and greater psychological safety; leadership inclusiveness and psychological safety; and psychological safety and engagement in quality improvement, respectively. These authors also found that leader inclusiveness moderated the association between professional status and psychological safety (Nembhard & Edmondson, 2006).

Manthous & Hollingshead (2011) for example advocate that improving patient outcomes in critical care settings will require that interprofessional team leaders, inclusive of nurse managers and attending (senior) physicians, practice three behaviours: cultivate psychological safety for all team members; develop the team’s transactive memory capability that allows professions to function cohesively and effectively together overtime in an interdependent and interconnected manner; and demonstrate leadership skills that empower team members, particularly during interprofessional rounds.

While this emerging body of research helpfully elucidates the positive effects of leadership on safety and interprofessional collaboration, additional research is needed to better understand how psychological safety moves from concept to practice within an interprofessional team (Edmondson & Lei, 2014).

Giving Patients and their Families Voice

Effective collaboration engages patients and their families (Robert Wood Johnson Foundation, 2015). From a conceptual perspective, patient-centred care makes intuitive sense; however, from an operational perspective, the concept is challenging to implement, particularly in the critical care environment where “the nature and extent of patient/family involvement can be fraught with tension” (Olding et al. 2016, p. 1184).

The US Society of Critical Care Medicine recently published its new Guidelines for Family-Centred Care that “represent the current state of international science in family-centred care and family support for family members of critically ill patients across the lifespan” (Davidson et al. 2017, p. 104). Family-centred care is defined as “an approach to healthcare that is respectful of and responsive to individual families’ needs and values” (Davidson et al. 2017, p. 106). The methods used for guideline development included both scoping and systematic reviews. The scoping review allowed for exploration of the qualitative literature in the context of family-centred care within the critical care setting, while the systematic review provided the quantitative foundation and grading of evidence related to practice recom mendations (Davidson et al. 2017). These authors found that the quality of evidence for family-centred care ranged from very low to moderate and covered five topics, “communication with family members, family presence, family support, consultations and ICU team members, and operational and environmental issues” (p. 104). Building on this work Gerritsen et al. (2017) argue for a concerted effort to develop a more robust family-centred evidence base in addition to improving the quality of clinicians’ communication with family members. The stress associated with having a family member admitted to a critical care unit is common with an estimated “one-quarter to half of family members of critically ill experiencing significant psychological symptoms . . .” (Gerritsen et al. 2017, p. 550). Quality of communication between healthcare providers and the family combined with inclusion of family members in care and decision-making contribute to better family member outcomes (Davidson et al. 2012).

In a recently published scoping review of the literature related to patient and family involvement in adult critical and intensive care settings, Olding and colleagues (2016) found that much of the literature focused on family involvement as passive recipients of care rather than as active partners. The literature fails to explore professional as well as socio-cultural factors that may enhance or...

Table of contents

• Cover
• Title
• Copyright
• Contents
• About the authors
• Dedication to Scott Reeves
• Acknowledgements
• Introduction
• 1 Examining effective collaboration in critical care settings
• 2 Assessing and addressing collaborative practice issues
• 3 Collaboration with patients and family members
• 4 Collaboratively identifying and addressing critical care delivery issues
• 5 Developing and undertaking effective evaluation
• 6 Concluding comments
• Appendix 1: An overview of the study which informed this workbook and underpinned the development of its activities and tools
• Appendix 2: Ideas for combining the activities presented in this book (Chapters 3, 4 and 5) with other critical care interventions
• Appendix 3: Methodological and practical guidance on interviewing critical care staff to support the data collection activities in Chapter 2
• Appendix 4: Methodological and practical advice for gathering observational data to support the activities in Chapter 2
• Appendix 5: Guidance for facilitating the initial staff workshop as described in Chapter 2
• Appendix 6: Guidance for facilitating the family involvement workshop as described in Chapter 3
• Appendix 7: Guidance for facilitating the collaborative critical care workshop as detailed in Chapter 4
• Appendix 8: Checklists recording interprofessional and patient/family issues as described in Chapters 2 and 3
• Appendix 9: General advice on facilitating workshop activities described in Chapters 2, 3 and 4
• Appendix 10: A possible evaluation form that could be used in any of the workshop activities detailed in Chapters 2, 3 and 4
• Appendix 11: A selection of organisations that promote interprofessional collaboration and patient- and family-centred care
• Appendix 12: Further reading on collaboration between critical care professionals, patients, and families
• Glossary
• References
• Index