Current Climate of Teamwork in Critical Care

Hospitals have traditionally been places where departments of professionals have protected their own ways of practicing, frequently in isolated silos without the understanding or cooperation of other departments. Historically, each profession has developed its own body of research, sets of standards, and practice agendas. In critical care, the urgency, complexity, and chaos of the environment makes teamwork even more important, and yet even harder to achieve than in most other areas.

Several factors can hamper the achievement of good teamwork in the ICU. Patients admitted to the hospital today have a higher severity of illness, yet they are being cared for with shorter lengths of stays. Patients discharged from ICUs today are often at the same acuity level as patients admitted to the ICU in the 1990s. While the current emphasis on evidence-based practice is bringing research to the bedside faster, growth in the volume of critical care research makes keeping up with best practices difficult. We practice in an environment of constant change in numbers of patients, in individual patient status, in participating team members, and available resources. Constant change can breed chaos. Increased oversight by regulators and third-party payers has affected bedside decision making as caregivers struggle to observe fiscal restraint without compromising quality of care.

In addition, clinicians are challenged to balance many things. We must distinguish patient needs from family needs, saving lives from prolonging death, patient versus societal needs, and following rules versus individualizing care. Scarce resources often necessitate rationing our time, expert personnel, and beds. These factors can breed stress, distress, or conflict. Moral distress, posttraumatic stress symptoms, depression, and burnout are all commonly found in critical care clinicians.¹

In the past 40 years, agencies, commissions, and professional organizations have promoted improving teamwork. Regulatory and accrediting agencies, including The Joint Commission (TJC), have increased their emphasis on the importance of collaboration to obtain quality outcomes of care. The Society of Critical Care Medicine (SCCM) has focused on delivering the right care, right now. They advocate delivery of care by an integrated team of dedicated experts who learn it, implement it, measure it, and improve it.

Attitudes and perceptions of the quality of teamwork vary widely between institutions, units, individuals, clinicians, and professions. Nurses may perceive teamwork as good when physicians ask for and listen to their input. Physicians may perceive teamwork as good when nurses follow their instructions well. Surveys have shown that while the minority of nurses describe their unit’s teamwork as good, the majority of the unit’s physicians describe it that way.^2,³ Clinicians and managers are becoming more aware that organizational structures and processes affect patient care outcomes. Leaders at the unit, facility, state, and national level understand the importance of expert teams. They are promoting the creation of systems that allow teams to function at the highest level. More and more, change is being driven from the top down. Leaders are spreading the word that improved care delivery teams and systems can reduce costs and improve patient outcomes. It is widely believed that the only hospitals that will succeed in the future are those that can attract, train, and retain expert team members. To do this, hospitals will have to create a culture that demands top-notch teamwork and that will not tolerate poor performance.

Components of Effective Teamwork

In the broadest sense, teamwork is defined as working well together. Important components include communication, competence, trust, cooperation, coordination, respect, accountability, conflict resolution, and shared decision making.

The development of teamwork using these essential factors has a natural history. It begins with the movement away from practice in isolation toward practice in concert with other healthcare providers. Increasing contact can automatically lead to greater collaboration and communications whether or not they are consciously pursued. Collaboration and communication are much more likely to be optimal, however, when they reflect a deliberate effort to identify and clarify goals and to focus efforts on patient outcomes. Through the exchange of ideas and expertise, practitioners become familiar with the nature and scope of one another’s practice. In this way each practitioner is better able to assess individual competence. Once clinical expertise is demonstrated, trust can be established, and negotiation of new roles for all care team members in the critical care environment is possible.

In critical care, each profession has dependent, independent, and interdependent roles. In addition, doctors and nurses often use different methods to resolve conflict. When resolving differences, physicians tend to bargain or negotiate and nurses avoid, accommodate, or compete. Focusing on the common goal of providing the best possible care for patients and their families is key to reducing team conflict.^2,^4,⁵

Over time, trust and open communication promotes respect. Team members begin to appreciate each other’s skills, knowledge, and judgment. In collaborative practice, responsibility is shared, so that goal setting and decision-making occur jointly. Team leadership moves quickly and frequently from team member to team member depending on the issue at hand. To ensure every team member makes their optimal contribution, each must have the confidence to speak up whenever their input could be helpful and to be good listeners when others offer their input. This leads to more flexibility and creativity in problem solving or decision making.

SCCM’s guideline for critical care delivery describes five general characteristics of the multidisciplinary team ⁶:

1 Medical and nursing directors with authority and co-responsibility for ICU management

2 Nursing, respiratory therapy, and pharmacy collaboration with medical staff in a team approach

3 Use of standards, protocols, and guidelines to ensure a consistent approach to medical, nursing, and technical issues

4 Dedication to coordination and communication for all aspects of ICU management

5 Emphasis on practitioner certification, research, education, ethical issues, and patient advocacy

More recently, Reader et al.³ have reviewed the body of research on teamwork in intensive care. They discuss input, process, and output variables. Input variables are the characteristics of team members, the tasks, and leadership. Process variables are team communication, leadership, and coordination. Output variables can be related to the patient or the team.

Another way of approaching it is to review what is known about team leadership. Good leaders are said to be able to generate two-way trust, respect, and communication. They have vision, self-confidence, enthusiasm, tolerance, and a commitment to excellence. They are organized and prepared, fulfill commitments, inspire shared missions, grow new leaders, model the way, challenge processes, tolerate ambiguity, and remain calm. It can be said that to have high-quality ICU teamwork, each team member should possess the same characteristics.

Although patients and families are important members of the ICU team, they are exempt from any of these expectations. We accept them as they are: in crisis, under stress, confused by the situation, and possibly in conflict. Yet we need their input for a better understanding of the patient’s values and wishes and to tend to the family’s own needs.

A team is not just as weak as the weakest link, but it is a balance of strong and weak members. Each individual team member, then, has the responsibility to make their strongest contribution. To do this, each of us must develop our listening skills, learn to speak up to make our observations and opinions known, ask for help when we need it, reinforce and praise the contributions of others, model behavior we expect, take time to think before we act, think out loud to help novices develop, and use positive professional communication.

Creating an environment within the healthcare system to ensure the safest collaborative care model and highly effective teamwork is the responsibility of everyone involved in the care of the critically ill and their families. It requires our focus, commitment, time, and energy.

Impact of Teamwork on Outcomes

Despite the support for teamwork and development of an interdisciplinary team model for the care of critically ill patients, research on the relationship to outcomes is limited.⁷ A literature review on the effectiveness of patient care teams in a variety of healthcare settings found limited effect on patient outcomes, and the added value of coordination of care was unclear.⁸ However, reports from some recent studies in critical care have demonstrated positive effects. The following section summarizes the current literature on teamwork and outcomes.

Teamwork and Care Delivery

In 2005, the Institute of Healthcare Improvement (IHI) began a 1-year nationwide initiative called The 100,000 Lives Campaign to reduce morbidity and mortality in American health care (http://www.ihi.org/IHI/Programs/Campaign/100kCampaignOverviewArchive.htm). They invited hospitals to join by agreeing to address six areas requiring process improvement. Four of these (ventilator associated pneumonia, catheter-related bloodstream infections, surgical site infections, and rapid response teams) involve critical care teamwork. Approximately 2800 hospitals joined the campaign, which resulted in saving more lives than predicted.

Patients in ICUs are frequently exposed to and vulnerable to medical errors. The severity of illness, complexity and number of interventions, pervasiveness of invasive catheters and equipment, and length of stay in the ICU put critically ill patients at higher risk of adverse events and errors.⁹^–¹² One comprehensive review of the literature on critical incidents in intensive care showed an increased incidence of adverse events when there was a deficit in nontechnical skills, including elements of teamwork.¹³

Ineffective communication and poor teamwork have been identified as significant contributors to patient errors and critical incidents in the ICU.^12,^14,¹⁵ Improvements in processes for communication have the potential to reduce such adverse events and errors.¹⁵^–¹⁶ In medicine, the focus has been on what should be done without enough attention to execution or planning how to get it done.¹⁰ To effectively carry out any plan of care in the ICU, coordination of care between disciplines and departments with clear, specific communication about the treatment plan is needed. One initiative to improve teamwork in the ICU involved establishing physician-led multidisciplinary rounds, assessing bed availability daily, using “bundles” of evidence-based practice care, and making efforts to change culture. The result was a significant reduction in nosocomial infections (ventilator-associated pneumonia, bloodstream and urinary tract infections), adverse events, and costs of care.¹⁷ This approach also led to improved communication among providers, enhanced team knowledge, and better coordination of care. Implementing a team decision-making culture placed responsibility on the team rather than on the physician and resulted in empowered team members.

The Veterans Administration has reported improvements in team communication and the quality of care after implementing a medical team training program to enhance team performance, satisfaction, and patient outcomes.¹⁴ They credited their debriefing training and process with the avoidance of potential adverse events in surgical patients, such as performing a procedure on the incorrect site or performing the wrong procedure. This also led to improvements in surgical efficiency, management of fatigue, more active collaboration between disciplines, increased nurse job satisfaction and morale, and reduced errors.

Teamwork and Patient Outcomes

Intensivist-led multidisciplinary teams have been espoused as an ideal model for critical care. However, there are insufficient numbers of trained intensivists to meet current or future demands, and only a minority of ICUs have implemented intensivist staffing.^7,¹⁸ Further, results from outcomes studies on intensivist-led care demonstrate mixed findings.¹⁸^–¹⁹ One recent study from a large cohort of patients examined mortality outcomes from hospitals with daily rounds by multidisciplinary teams with and without intensivist models compared to those without this structure.⁷ They found that hospitals with multidisciplinary team care were associated with 16% lower odds for mortality, and those with high intensivist staffing and multidisciplinary team care were associated with the most significantly reduced odds ratio of death. Interestingly, hospitals with a multidisciplinary team approach but low physician staffing also had a significant reduction in mortality. This reinforces the idea that patients do benefit when cared for by a multidisciplinary team. However, the most benefit comes when that team is led by a trained intensivist. In another study, mortality was significantly reduced in patients with acute lung injury (ALI) who were cared for by multidisciplinary teams led by fulltime critical care physicians.²⁰ The use of the intensivist-led team model also led to significantly reduced mortality, duration of mechanical ventilation, and rates for ventilator-associated pneumonia (VAP) in a military setting.²¹ In a literature review, Durbin also found that the team model for ICU care delivery was associated with reduced mortality, ICU and hospital length of stay, and costs of care.²²

One hospital in Illinois achieved several improved outcomes by implementing evidenced-based bundles of care and a multidisciplinary daily goals rounding tool. They found decreased ICU lengths of stay, improved compliance with care protocols, reduced VAP and bloodstream infections, and fewer falls and pressure ulcers in surgical ICU patients.²³ Cheung et al.²⁴ did not find improved outcomes, however, when the team met on a weekly basis and decided that the meetings were too infrequent to impact patient outcomes. Research has shown that teamwork can also influence the discharge process from the ICU²⁵ through coordination of efforts.

The ability to achieve patient goals in the ICU is also impacted by team leadership and management skills of attending physicians.²⁶ Developing written daily goals in the ICU improves communication between caregivers about expectations for care and follow-through on treatment plans. Failure to complete treatment plans has been recognized as a key factor leading to errors in the ICU.^10,²⁶ Fostering teamwork to accomplish daily goals can improve care effectiveness and patient safety.

Multidisciplinary teams developed to respond to shock in nontrauma patients resulted in decreased time to treatment, intensivist arrival, and admission to the ICU.²⁷ This resulted in a significant reduction in mortality as well as an increased likelihood of good patient outcomes.

Teamwork and Team Outcomes

Communication, a key component of teamwork, has been associated with job satisfaction. Recent studies have shown a difference in perception about communication among practice disciplines in critical care.^2,^15,²⁸^–³⁰ Nurses report lower quality of communication with physicians than those physicians report. In one survey, 33% of critical care nurses ranked the quality of collaboration and communication with physicians highly as compared to 73% of physicians.^2,¹⁵ The degree of open communication among ICU team members correlated with better understanding of patient care goals.

Differing perceptions between nurses and physicians also exist regarding the care of dying patients in the ICU.²⁹ Nurses reported more moral distress and lower collaboration than their physician counterparts. Nurses perceived the ethical environment as more negative and were less satisfied with the quality of care of those patients than were attending physicians. Their evaluation of the quality of care was strongly related to the perception of collaboration between disciplines. A study by Huang³⁰ found that physicians, leadership, and nursing directors tended to overestimate nurses’ attitudes on teamwork climate and working conditions. Weinberg³¹ found the quality of medical resident communication with nurses was dependent on a nurse’s degree of cooperation and congeniality with them. Their level of trust in information communicated also was dependent on their perception of nurse competence and their ability to relay relevant information in a timely manner. Although nearly all physicians reported instances of poor communication with nurses, they did not see it as a threat to patient care, because they thought the nurses’ role was to simply follow orders. This indicates that these medical residents did not necessarily view nurses as colleagues and collaborators. In critical care, the multidisciplinary team members are dependent on each other to accomplish the complex needs of patients, and all are accountable for the outcomes achieved.

When teamwork increases efficiencies of care, an increased sense of accomplishment can occur.^32,³³ Research has shown that nurses preferred communicating with attending physicians over first-year residents and valued shared understanding and open, accurate communication.³⁴ In addition, the more experience nurses had, the more they required effective communication with experienced physicians. Another study by the same researcher showed that nurse-to-physician communication was a significant predictor of nurse job satisfaction and the quality of the practice environment.³⁵ The degree of workplace empowerment and perceived quality of the environment was significantly related to communication between nurses and physicians.³⁶^–³⁷ When a higher level of nurse-physician communication was reported, medication errors were reduced.³⁶ When timeliness of communication improved, there was a decrease in the prevalence of pressure ulcers.³⁷