The rules of the game: interprofessional collaboration on the intensive care unit team

BACKGROUND: The intensive care unit (ICU) is a nexus for interspecialty and interdisciplinary tensions because of its pivotal role in the care of the hospital's most critically ill patients and in the management of critical care resources. In an environment charged with temporal, financial and professional tensions, learning how to get results collaboratively is a critical aspect of professional competence. This study explored how team members in the ICU interact to achieve daily clinical goals, delineate professional boundaries and negotiate complex systems issues. METHODS: Seven 1-hour focus groups were conducted with ICU team members in two hospitals. Participants consisted of four nursing groups (n = 27), two resident groups (n = 6) and one intensivist group (n = 4). Interviews were audio-recorded, anonymized and transcribed. With the use of a standard qualitative approach, transcripts were analyzed iteratively for recurrent themes by four researchers. RESULTS: Team members articulated their perceptions of the mechanisms by which team collaboration was achieved or undermined in a complex and high-pressure context. Two mechanisms were recurrently described: the perception of 'ownership' and the process of 'trade'. Analysis of these mechanisms reveals how power is commodified, possessed and exchanged as team members negotiate their daily needs and goals with one another. CONCLUSION: Our data provide a non-idealized depiction of how health care professionals function on a team so as to meet both individual and collective goals. We contend that the concept of 'team' must move beyond the rhetoric of 'cooperation' and towards a more authentic depiction of the skills and strategies required to function in the competitive setting of the interprofessional health care team.