Pulling Together and Pushing Apart

Balancing interdisciplinary differences and coping with the strain of limited resources, intensive care unit (ICU) teams face the physical and psychological stress of caring for the critically ill. Differences in knowledge and skill, gender, and care models are organized by a complex hierarchical structure that does not always adequately account for these differences. Thus, ICU teams not only face the challenge of working efficiently in a highly stressful acute care environment, they also confront the complexities of interprofessional communication and collaboration. Multifaceted interprofessional relationships must be established and re-established as individual providers continuously rotate to and from the unit. These characteristics provide the context for potentially divisive team communication and pose significant challenges to team collaboration.1,2,3,4,5,6,7,8 Problems in team communication and collaboration may have significant impact on administrative, social, clinical, and educational outcomes in the ICU.1,2,3,4 Previous studies have highlighted the importance of collaboration in improving patient outcomes,1,2,3,4,5,6,7,8,9 in decision making around ethical issues2 and in improving the team's morale.9 Other studies have focused on physician—nurse interactions and describe inadequate communication of treatment goals and a lack of collaboration,3,4,8 as well as a lack of understanding and frank disputes over roles and responsibilities.1,2,3,8,9,13 This study examines communication patterns in the context of this continuously shifting interprofessional team. Further, it explores the implications of these patterns for the education and socialization of critical care trainees as they negotiate professional roles and relationships within the hidden curriculum of critical care medicine. Method Data collection. Over a four-month period in the winter of 2001–2002, 144 hours of ICU team interactions were captured during 36 observation sessions at two urban teaching hospitals. These hospitals were selected for two reasons: (1) residents and faculty divide their time equally between these two intensive care units; and (2) differences between the units (i.e., case types and caseloads, nurse staffing patterns, hospital cultures) might affect team collaboration and communication. Approval for the study was obtained from the University of Toronto Research Ethics Board and informed consent was obtained from all research subjects. A theoretical sampling approach was used to determine sample size.14 Using this approach, observations were conducted at the first site alongside a continuous analysis of emerging themes until saturation of recurrent themes was achieved (24 sessions). At this point, observations moved to the second ICU site with two objectives: (1) to confirm the recurrence of similar themes, and (2) to explore new themes not evident in the previous observations. Twelve observation sessions were conducted at the second site. The sample was designed to yield data regarding the range of communicative and collaborative patterns in the ICU setting, rather than a detailed analysis of the communicative styles of particular individuals. Therefore, a large sample population with limited observations per individual was sought. Three observers attended ICU activities ranging from formal rounds, technical procedures, and discussions between residents and nurses, to informal gatherings on the unit. Subjects observed during these activities included staff intensivists (n = 7), fellows (n = 4), residents (n = 21), ICU nurses (n = 90), and nursing trainees (n = 2). Observers independently recorded communication-related activities using standard ethnographic written field note techniques15 and occasionally conducted brief unstructured interviews that solicited subjects' opinions of the representative nature of the observed activity. Mechanisms to minimize observer or Hawthorne effect16 included observation length (three to five hours for most sessions), observation duration (at least two months per ICU unit), and strategic integration into the context. For instance, early observations focused on formal group activities (e.g., morning rounds) where the observer could be less obtrusive; later sessions, when participants were more accustomed to the observer's presence, captured one-on-one conversations and more casual exchanges among nurses and residents. Data analysis. The 36 observation sessions yielded 716 pages of field-note text for analysis. Field notes were analyzed for emergent themes using a constant comparative approach.17 Following this standard procedure for inductive analysis, the group of researchers individually read and annotated the field-note data to represent recurring themes. Discrepancies were negotiated by referral to the field notes and by discussion among research team members. Once key thematic categories had been confirmed through this process, each was defined, anchored with an illustrative example from the data set, and arranged into a coding structure that represented relationships among central categories and subcategories. Three research assistants coded overlapping samples of the data set using this coding structure. To ensure the authenticity of this final coding process, the principal investigators reviewed random sections of the coded data at regular intervals and discrepancies were resolved via group discussion. Results Analysis of field notes revealed three key findings regarding collaboration in the ICU setting. These were (1) the expanding and contracting nature of the team, (2) the degrees of collaboration and conflict on the team, and (3) the catalysts underlying fluctuations in collaboration. The Expanding and Contracting Nature of the Team Our analysis offered insights into the nature of the team, particularly its size, (in)stability, and internal relationships. We found the team to be a more complex and fluid entity than the term itself belies, and we have characterized this fluidity as a range from “core” to increasingly “expanded” team. The “core” ICU team more closely reflects the traditional notion of team, but our data suggest that “core” is a flexible entity. The core team can be as small as the two to four individuals directly involved in caring for the patient at the bedside (e.g., nursing, respiratory therapy, and medicine). For example, in the early morning before patient rounds, a resident and nurse may share information regarding overnight issues, questions, or the plan for the day. The core team is also evident in situations where a larger number of people are present, and involvement is defined by professional and their immediate roles. Commonly, only a subset of the individuals is directly involved in the “core” at any given time, and this restricted involvement is continuously negotiated. For instance, during morning rounds, the sharing of relevant information is orchestrated by the team leader: Staff to nurse: “Blood pressure? Heart rate?” Nurse begins to give respiratory data. Staff interrupts: “That's okay, the RT will give us that.” RT commences her report. Dec. 7 In response to the leader's signals, team members take turns stepping forward to offer patient data from their domains and stepping back, often into conversations tangential to the core discourse: Staff: “Who has this patient?” Nurse: “I do.” Staff: “Are you able to join us?” Nurse: “Yep.” A second nurse enters the room, singing: “Should I stay or should I go?” Jan. 23 Each role on the team has an implicitly designated understudy in the event of an absence. For example, if the bedside nurse cannot participate in rounds due to a patient crisis, a resident may provide the nurse's patient assessment; similarly, if the attending is called away, the fellow takes over the “leader/teacher” role: Nurse reporting to staff during rounds: “I'm sorry, I forgot to mention one other thing….” (reports hemoglobin) Phone rings: staff is called to the phone in the room. Fellow takes over: “So what's the plan for him?” Jan. 15 In many instances, the core team expands to encompass a variety of health care professionals, services, and systems. This expansion is temporary and subject to negotiation. For instance, while a patient is in the ICU, consulting teams are layered onto the core team and their needs, goals, and values are negotiated with core members: Resident: “I don't think it would hurt, but I don't want to ‘d/c’ their neurology's order.” Fellow: “I'd be biased in the opposite direction… We're co-managing patients and we don't want to make enemies, but if doctor neurologist saw it and he didn't see any issues….” Jan. 4 The expanded team can further inflate, such as when a patient is transferred in or out of the unit. In these situations, the expanded team includes members of the receiving medical team, consultant teams, and nursing staff on the receiving ward. Degrees of Collaboration and Conflict Along the continuum of core and expanded team described above, significant fluctuations were evident in the cohesion among team members. These fluctuations can be understood as degrees of collaboration or conflict within the core and expanded teams, as illustrated in the following representative excerpts from the fieldnotes. Core Team Collaboration. Nurse reports patient's feeding tube is stuck. Staff looks curious: “Not that I don't believe you but….” Goes over and tries unsuccessfully to pull it out. Fellow: “How much tube is left inside patient?” Nurse: “Not much.”… Someone jokes about pulling harder. Staff smiles: “Well, I could pull harder, but….” Nurse: “Sometimes they get stuck because they're not being used, and when you pull it out, you end up tearing tissue, too.” Staff: “These shouldn't get stuck. An endoscopy might have to be done.” Jan. 15 Conflict. The team moves to the next bed during rounds. Staff turns to bed 2 to ask: “Is there is a nurse for this patient.” Nurse: Muffled “yea” response Staff: “Don't snarl. We just want to know if there is a nurse available.” Dec. 7 Expanded Team Collaboration. Resident: “So the pain service saw him, and when they saw him he was complaining of pain. But the nurse also said he was complaining of spasm. They'll reassess next week. And the other thing is for PT to see him.” Fellow: “And we were talking about the spine X-rays, and the spine fellow looked at them and there is no problems. So we need to document that.” Resident: “Right.” And flips chart pages to write it down. Nov. 6 Conflict. Staff: “Practically at the bedside we will lower pressure support and pay attention to rate. Rates I like at about 25 or less. His tidal volumes are enormous… blood gases are the last thing. Transplant people want the patient quite dry and we are in conflict and we need to advocate for the other systems. Our job is balance that in the ICU. They want to save the graft, understandably.” Nov. 23 Catalysts of Collaborative Fluctuations Analysis of changes in collaborative activity yielded insight into the catalysts that recurrently provoke collaborative fluctuation (increases or decreases). Six such catalysts are evident in the data: authority, education, patient needs, knowledge, resources, and time. Each of these is defined below, with a representative excerpt from the data set. Authority. Authority can increase collaboration when the team agrees upon leadership and decision making in a situation; however, authority can also be the source of conflict, if team members disagree about who has the right to make decisions. Nurse: “What's the deal with this leg thing? Is it staying in until it falls out or something?” Fellow: “We need to call Orthopedics in—they want to lead it.” Nov. 23 Education. Education can be a source of collaboration in that instruction can foster a sense of shared goals and values between team members and trainees. It can be a source of conflict if patient needs and time compete for instructors' and trainees' attention. Staff: “If anybody asks you ‘Why's he hypoxic?’ just say, ‘because he had a shunt.’ That's it. You can't argue with that. ‘Why did he have a shunt?’ that's the next question—that's the next thing you go to.” Nov. 6 Patient needs. Patient needs can catalyze collaboration when team members work together to establish accurate patient histories, and to adjust treatments and medications accordingly. Conflicts can result if the team disagrees about the patient's needs or how best to meet them. Staff: “The reason I'm asking is I'm wondering if we're giving him too much valium. There's no reason why he the patient should be so…” (imitates doziness) Resident: “I can decrease it.” (starts to write order) Other resident: “Put him on a standing once-a-day.” Staff: “He doesn't need all that much.” Dec. 20 Knowledge. Knowledge can be a catalyst to collaboration or conflict when core and expanded teams lay claim to (or deny responsibility for) spheres of knowledge. Resident: “I wonder why she's on all these drugs, but she's not on drug.” Nurse (exasperated): “Don't ask me. I don't know.” Resident: “I know, I know… I don't know either….” Jan. 4 Resources. Competition for limited resources influences collaboration in the core and expanded team. This influence may be positive, when resources are requested and received, or negative, when resources are the site of competition. Nurse: “Our other oscillator is at St. Mike's, in use. We're just checking with Mt. Sinai.” Staff: “How long have they had our oscillator?” Nurse: “I don't know. Seems like it might have been before Christmas.” Staff: “Tell them to get their own damn oscillator.” Jan. 15 Time. Time governs many variables in the ICU, including the nature of team collaboration. For instance: Fellow: “Okay, we have seven patients left to see in 40 minutes.” Feb. 20 These six catalysts can also be understood as challenges the team (in its core and expanded groupings) recurrently faced—sometimes with cohesion and unity, other times with disagreement and discord. These catalysts can also trigger collaboration between team members that provides a space for collegial discussion of differing points of view, such as in the “Patient Needs” example above. Discussion While the importance of teamwork and respect for professional roles may be taught, undergraduate medical education does little to prepare trainees for the practicalities of working on a team. The skills necessary to an effective team member are instead acquired through experience, role modeling, and performance evaluations. As a result, learning to collaborate is an important component of the hidden curriculum of postgraduate medical education. This study, by helping to elucidate how the ICU team communicates and collaborates, has practical implications for the future of medical education and research. The finding that ICU teams are not rigidly defined but are continually shifting entities provoked by recurrent and interrelated catalysts is crucial for trainees to grasp. They need to decode the implicit membership of the team: who is “us” and who is “them” (membership negotiated for finite periods of time or individuals viewed as opponents). Failure to accurately and continuously decode team membership may result in trainees' finding themselves aligned with the wrong “side”: Discussion about the resident's having removed a chest tube without consulting Thoracic Surgery—the team who inserted it. Resident: “They were very upset.” Staff: “That's completely understandable.” Dec. 20 The trainee has assumed that Thoracic Surgery is “them.” However, this assumption fails to take into account the implicit rule: The team that inserts the tube is the one to decide when to remove it. Breaking this rule puts the trainee in the position of “them,” and the staff is aligned with the Thoracic Surgery team as “us.” This dynamic increases team tension and may result in unexpected reprimands. “Us” or “them” alignment is initially determined by professional role, immediate needs, and tacit rules of play. These alignments are dynamic, as seen in the pattern of stepping forward and stepping back to offer information from professional perspectives on rounds. Complementary perspectives ensure issues are fully appreciated and a level of redundancy ensures patient safety. An implicitly designated understudy is available in the event of an absence. While practical, this also has implications for the educational curriculum. When the understudy role is not explicitly explained, it may convey the erroneous message that some roles and professions are easily replaced. Moreover, while roles can overlap, there are some activities that cannot be traded off: Staff: “You cannot transcribe the nursing assessment as your medical notes.” (loudly and obviously upset) “The important thing is that these are dynamic patients and you may have to identify important issues. Pay attention and be vigilant.” Resident: That's my fault. Staff: “I'm not asking for blame They are your patients and you examine them with your input…. See the patients, write your orders and commit yourself to a treatment plan…. think about the case independently and synthesize issues.” Feb. 13 This trainee assumed that his responsibilities could be merged with those of the nurse; however, his decision neglected the unique responsibilities of his professional role. While the trainee is explicitly told to conduct his own patient assessment, there is no discussion of the tacit rules of teamwork that disallow this kind of overlap of information and labor. Learning the balance between and collaborative responsibilities is of professional and the shifting on the team. of “us” and “them,” and of responsibilities as and collaborative team members an important role in trainee While such can pull the team they also members and conflict and the of patient Our study catalysts that result in shifting of “us” and “them.” of these catalysts are highly entities and of tension and in In the explicitly teaching trainees to decode their responsibilities who is “us” and who is “them” and the catalysts for in these could their learning by the of their being by the teaching of their being aligned with “them.” Our study is limited in that it ICU teams and these teams may not be representative of the catalysts were of tension in a previous study the that they represent they are issues, it is not that they are and have to be continuously negotiated within a group of working all trainees rotate through acute care these studies are relevant for all postgraduate medical education research is to explore other teams in less acute care have the of and catalysts to the socialization in these performance and this component of the postgraduate curriculum out of making it will result in education, and patient