The role of teams in resolving moral distress in intensive care unit decision-making

Conflicts arise within teams and with family members in end-of-life decision-making in critical care. This creates unnecessary discomfort for all involved, including the patient. Treatment plans driven by crisis open the team up to conflict, fragmented care and a lack of focus on the patient's wishes and realistic medical outcomes. Methods to resolve these issues involve planned ethical reviews and team meetings where open communication, clear plans and involvement in decision-making for all stakeholders occur. In spite of available literature supporting the value of these techniques, patient care teams and families continue to find themselves involved in spiraling conflict, pitting one team against another, placing blame on family members for not accepting decisions made by the team and creating moral conflict for interdisciplinary team members. Through a case presentation, we review processes available to help resolve conflict and to improve outcome.     

The role of teams in resolving moral distress in intensive care unit decision-making

Conflicts arise within teams and with family members in end-of-life decision-making in critical care. This creates unnecessary discomfort for all involved, including the patient. Treatment plans driven by crisis open the team up to conflict, fragmented care and a lack of focus on the patient's wishes and realistic medical outcomes. Methods to resolve these issues involve planned ethical reviews and team meetings where open communication, clear plans and involvement in decision-making for all stakeholders occur. In spite of available literature supporting the value of these techniques, patient care teams and families continue to find themselves involved in spiraling conflict, pitting one team against another, placing blame on family members for not accepting decisions made by the team and creating moral conflict for interdisciplinary team members. Through a case presentation, we review processes available to help resolve conflict and to improve outcome.     

The patient and the primary care team: a small-scale critical theory

The patient and the primary care team: a small-scale critical theory For increasing the understanding of team-based delivery of primary care, ratings of care satisfaction and stimulated-recall interviews were used to compose a small-scale critical theory. Three teams and 24 patients at a community health care centre participated in the study. It was found that the multiprofessional team was vulnerable to discrepancies between the health service policy and the available care resources. If pre-paid patients arrive with too high expectations and demands on the service, a significant part of the team's attention is used for economizing with care procedures. When health and economics are entangled for the team, the patients are not invited to share decisions about their health. The patients' concerns are instead turned to the social arena, which is separated by language and context from the health analysis. Simultaneously, when the teams are led to solve the health problems without involving the patients in the process, the team members convert these to their own personal distress when they fail. The conclusion is that the discrepancy between care policy and factual resources is an important cause of imbalance in patient-primary care team interaction. If service strategy and team organization and resources are not continuously adjusted to each other, the effects will continue to obstruct communication during consultations.     

Can staff attitudes to team working in stroke care be improved?

BACKGROUND: Teamwork is regarded as the cornerstone of rehabilitation. It is recognized that the skills of a multiprofessional team are required to provide the care and interventions necessary to maximize the patient's potential to recover from his/her stroke. LITERATURE REVIEW: Critical evaluation of team working is lacking in the literature. Indeed, there is no consensus on a precise definition of teamwork or on the best way of implementing it, beyond a general exhortation to members to work to the same therapeutic plan in a cohesive manner. The literature has highlighted many problems in team working, including petty jealousies, ignorance and a perceived loss of autonomy and threat to professional status. AIM: To determine if the use of team co-ordinated approaches to stroke care and rehabilitation would improve staff attitudes to team working. METHOD: A pre-post design was adopted using 'The Team Climate Inventory' to explore attitudes to team working before and after introducing the interventions. Local Research Ethics Committee approval was obtained. RESULTS: Improvements in attitudes towards team working suggest that the introduction of team co-ordinated approaches (integrated care pathways and team notes) did not result in greater team working. LIMITATIONS: The introduction of an integrated care pathway and team notes is based on an assumption that they would enhance team working. CONCLUSIONS: The results suggest that the introduction of team co-ordinated approaches (team notes and care pathways) do not improve attitudes to team working, teams appear to take a long time to establish cohesion and develop shared values.     

Discursive patterns in multiprofessional healthcare teams

AIM: The aim of this paper is to report a study exploring how members of multiprofessional healthcare teams talk about their team. Specifically, the team members' talk was analysed to explore the discursive patterns that emerged and their functions. BACKGROUND: Over recent decades there has been an increasing demand in Western countries to change care organizations and to coordinate resources and professional competencies to meet the needs of patients/service users better. Because society promotes this kind of work, it may be valuable to explore the self-presentations of a multiprofessional healthcare team. METHODS: A discourse analysis was carried out on existing empirical data from focus group interviews with a member-identified category sample comprising 32 healthcare professionals in six authentic multiprofessional teams in south-east Sweden. The analysis focused on the participants' discursive constructions of multiprofessional teamwork, on the way they talked about their group, and, in particular, on their use of the pronouns we, they and I. FINDINGS: The constructions of 'we' by multiprofessional healthcare teams showed discursive patterns that are here referred to as knowledge synergy and trusting support, which included factors such as cross-learning and personal chemistry. The pronoun we was also used as a flexible resource to manage expertise, power and leadership within the teams, and it might also function to ease the pressure for consensus. CONCLUSION: These discursive patterns provided powerful rhetorical resources for team members, both to affirm their choice of membership and to claim superiority in relations with the surrounding community (the others) by linking to a societal discourse that promotes collaboration.     

Team supervision in multiprofessional teams: team members' descriptions of the effects as highlighted by group interviews

The aim of the study was to describe the effects of team supervision in multiprofessional teams as perceived by team members. The literature describes team supervision as a way to develop collaboration in multiprofessional teams. However, little empirical research into the effects of team supervision is available. A research project was undertaken on five units of a university hospital between 1995 and 1998. Data were collected using group interviews with 62 interviewees and were analysed using qualitative content analysis. Team members' perceptions of the feeling of togetherness varied. Communication had become more open in the teams, but the frankness of expression varied: communication had generally become more tactful, whereas in one of the teams frankness offended some members. Team members had learned to know each other. This had improved mutual understanding, but also increased tension. Teams' working methods had changed. Joint decision making had developed, but conflicts had also emerged. Motivation for work had improved as a result of the awareness of shared problems. However, motivation had been lessened by frustration caused by slow progress in the team. Perceptions of the effects of team supervision in the multiprofessional teams varied by units and teams. The study showed that team supervision is a challenge to supervisors.     

Cognitive continuum theory in interprofessional healthcare: A critical analysis

Effective clinical decision making is among the most important skills required by healthcare practitioners. Making sound decisions while working collaboratively in interprofessional healthcare teams is essential for modern healthcare planning, successful interventions, and patient care. The cognitive continuum theory (CCT) is a model of human judgement and decision making aimed at orienting decision-making processes. CCT has the potential to improve both individual health practitioner, and interprofessional team understanding about, and communication of, clinical decision-making processes. Examination of the current application of CCT indicates that this theory could strengthen interprofessional team clinical decision making (CDM). However, further research is needed before extending the use of this theoretical framework to a wider range of interprofessional healthcare team processes. Implications for research, education, practice, and policy are addressed.     

A comparison between the ethics of justice and the ethics of care

The parameters of the problem within which the principal aim of the present article will be addressed can be described as follows. When making ethical decisions there are different perspectives that health care professionals may use. This may lead to conflict and insufficient co-operation between the members of the health team. Two of these perspectives are the ethics of justice and the ethics of care. The ethics of justice constitutes an ethical perspective in terms of which ethical decisions are made on the basis of universal principles and rules, and in an impartial and verifiable manner with a view to ensuring the fair and equitable treatment of all people. The ethics of care, on the other hand, constitutes an ethical approach in terms of which involvement, harmonious relations and the needs of others play an important part in ethical decision-making in each ethical situation. To seek some sort of way of avoiding conflict and promoting a mutual understanding about ethical decisions in the health team, there is a need to examine the ethics of justice and ethics of care. In order to understand the ethics of justice and ethics of care, the purpose of this article is to compare the two ethical perspectives. It is argued that the ethics of justice and the ethics of care represent opposite poles. If the members of the health team were to use only one of these two perspectives in their ethical decision-making, certain ethical dilemmas would almost certainly remain unresolved. Both the fair and equitable treatment of all people (from the ethics of justice) and the holistic, contextual and need-centred nature of such treatment (from the ethics of care), ought therefore to be retained in the integrated application of the ethics of justice and the ethics of care.     

Perceptions regarding the use of physical restraints with elderly persons: comparison of Israeli health care nurses and social workers

In view of the difficulty involved in decision-making regarding the use or removal of physical restraints and the recent pattern encouraging the use of interdisciplinary teams for elder care issues, the present study compared the perceptions of Israeli nurses and social workers in health care settings regarding the use of physical restraints. Data were collected from a convenience sample of 50 nurses and 69 social workers working in long-term and acute care settings. The findings indicated that participants in all professions attributed moderate to low importance towards the use of physical restraints. Social workers' perceptions were similar to those of nurses in psychiatric hospitals and slightly more favourable to the use of physical restraints than those of nurses in nursing homes. Patients' safety (as reflected in the scores of the items related to protecting an older person from falling and protecting an older person from pulling out a catheter) was the most important reason for using physical restraints for both groups. Increased attention should be given to the role of social workers as team members in the process of decision-making regarding the use or removal of physical restraints, especially as mediators between the elderly person, family members and staff members.     

Designing an interprofessional training program for shared decision making

For implementation of patient-centered treatment in interprofessional health care units, such as rehabilitation teams, external participation (interaction between patient and health care professionals) and internal participation (communication, coordination and cooperation in the interprofessional team) need to be considered. The aim of this study is to identify the preferences of patients and health care professionals concerning internal and external participation in rehabilitation clinics, in order to develop an interprofessional shared decision-making (SDM) training program for health care professionals to enhance both types of participation. Therefore, a cross-sectional mixed-methods study was implemented in four rehabilitation clinics. The study consists of two parts: focus groups with patients and a survey of experts (senior health care professionals from medicine, psychotherapy, physical therapy and nursing). More time, more respect from the health care professionals and the desire for more participation in decision-making processes were mentioned most frequently by patients (n = 36) in the focus groups. The health care professionals (n = 32) saw most deficits in internal participation, e.g. management of feedback, talking with difficult team members and moderate conflict discussion. The results of both assessments have been used to develop an interprofessional SDM training program for implementing internal and external participation in interprofessional teams in medical rehabilitation.     

Implementation of an electronic health records system within an interprofessional model of care

Abstract

Implementation of electronic health records (EHR) systems is challenging even in traditional healthcare settings, where administrative and clinical roles and responsibilities are clearly defined. However, even in these traditional settings the conflicting needs of stakeholders can trigger hierarchical decision-making processes that reflect the traditional power structures in healthcare today. These traditional processes are not structured to allow for incorporation of new patient-care models such as patient-centered care and interprofessional teams. New processes for EHR implementation and evaluation will be required as healthcare shifts to a patient-centered model that includes patients, families, multiple agencies, and interprofessional teams in short- and long-term clinical decision-making. This new model will be enabled by healthcare information technology and defined by information flow, workflow, and communication needs. We describe a model in development for the configuration and implementation of an EHR system in an interprofessional, interagency, free-clinic setting. The model uses a formative evaluation process that is rooted in usability to configure the EHR to fully support the needs of the variety of providers working as an interprofessional team. For this model to succeed, it must include informaticists as equal and essential members of the healthcare team.     

An integrated approach to ethical decision-making in the health team

When making ethical decisions there are different perspectives that health care professionals may use. This may lead to conflict and insufficient co-operation between the members of the health team. Two of these perspectives are the ethics of justice and the ethics of care. In a bid to gain a better understanding of the nature of ethical decision-making in the health team, a comparison was drawn between the ethics of justice and the ethics of care. The investigation into and comparison between the ethics of justice and the ethics of care revealed that the deficiencies in each of the two perspectives in isolation, in fact, necessitate the application of a combination of both perspectives. The aim of the article is to describe how the members of the health team can, in an integrated manner, apply both the ethics of justice and the ethics of care in their ethical decision-making. The central argument of the article is based on the following premises: (1) the inadequacy of the ethics of justice and the ethics of care in isolation necessitates that both these perspectives be applied; (2) the application of both these perspectives again requires an extended rationality and discourse and (3) discourse, in its turn, requires that the emphasis falls on a specific telos and that the participants in the discourse be endowed with certain virtues in order to abide by the rules of discourse.     

Achieving teamwork in stroke units: The contribution of opportunistic dialogue

Collaborative interdisciplinary working is central to contemporary health policy. The specialized and co-ordinated multidisciplinary care provided in stroke units is considered to contribute to improved patient outcomes in such units. However, how stroke unit teams co-ordinate their work is not clearly understood. This paper reports on a grounded theory study which explains how health professionals in two stroke units in northern England achieved teamwork. Data were generated through 220 hours of participant observation and 34 semi-structured interviews. Interviews were undertaken during and following participant observations. A basic social process common to teamworking in both units was identified; this was termed “opportunistic dialogue”. The division of labour in respect of rehabilitation activities was negotiated through this interactional process. Co-location of most team members led to repeated engagement in sharing patient information and in exploring different perspectives. Opportunistic dialoguing contributed to mutual learning and explained the shift in thinking and team culture as team members moved from concern with discrete disciplinary actions to dialogue and negotiations focused on meeting patients' needs. The findings indicate that routinely incorporating periods of joint working in which team members articulate the reasoning for their decisions and interventions, contributes to achieving interdisciplinary teamworking in rehabilitation settings.     

A network model of communication in an interprofessional team of healthcare professionals: A cross-sectional study of a burn unit

Healthcare teams consist of individuals communicating with one another during patient care delivery. Coordination of multiple specialties is critical for patients with complex health conditions, and requires interprofessional and intraprofessional communication. We examined a communication network of 71 health professionals in four professional roles: physician, nurse, health management, and support personnel (dietitian, pharmacist, or social worker), or other health professionals (including physical, respiratory, and occupational therapists, and medical students) working in a burn unit. Data for this cross-sectional study were collected by surveying members of a healthcare team. Ties were defined by asking team members whom they discussed patient care matters with on the shift. We built an exponential random graph model to determine: (1) does professional role influence the likelihood of a tie; (2) are ties more likely between team members from different professions compared to between team members from the same profession; and (3) which professions are more likely to form interprofessional ties. Health management and support personnel ties were 94% interprofessional while ties among nurses were 60% interprofessional. Nurses and other health professionals were significantly less likely than physicians to form ties. Nurses were 1.64 times more likely to communicate with nurses than non-nurses (OR = 1.64, 95% CI: 1.01–2.66); there was no significant role homophily for physicians, other health professionals, or health management and support personnel. Understanding communication networks in healthcare teams is an early step in understanding how teams work together to provide care; future work should evaluate the types and quality of interactions between members of interprofessional healthcare teams.     

Consumers and carers as partners in mental health research: reflections on the experience of two project teams in Victoria, Australia

A successful working partnership in research between a consumer project team from the Victorian Mental Illness Awareness Council and a carer project team from the Victorian Mental Health Carers Network was forged during their collaborative involvement in an innovative 2-year pilot project funded by the Victorian Government of Australia. This project trialled new ways of capturing consumer and carer experiences of mental health services, and that feedback was integrated into service quality improvement. Towards the end of the project, an external facilitator was used to enable the two teams to reflect on their experience of working together so that their joint story could be shared with others and used to promote further use of this approach in the mental health field. Main findings included the importance of having strong support and belief at leadership levels, opportunities to build the relationship and develop mutual trust and respect, a common vision and a clearly articulated set of values, targeted training appropriate to the needs of the team members, independent work bases, and mutual support to overcome challenges encountered during the project. The experience forged a close working relationship between the two teams and has set the scene for further participation of consumers and carers in research and innovative quality-improvement processes in the mental health field.     

Comparison of language used and patterns of communication in interprofessional and multidisciplinary teams

Can the language used and the patterns of communication differentiate a multidisciplinary team from an interprofessional team? This research question arose from an unexpected outcome of a study that investigated clinical reasoning of health professional team members in the elder care wards of two different hospitals. The issue at stake was the apparent disparity in the way in which the two teams communicated. To further explore this, the original transcribed interview data was analysed from a symbolic interactionist perspective in order that the language and communication patterns between the two teams could be identified and compared. Differences appeared to parallel the distinctions between multidisciplinary and interprofessional teams as reported in the literature. Our observations were that an interprofessional team was characterized by its use of inclusive language, continual sharing of information between team members and a collaborative working approach. In the multidisciplinary team, the members worked in parallel, drawing information from one another but did not have a common understanding of issues that could influence intervention. The implications of these communication differences for team members, team leaders and future research are then discussed.     

The district nurse and the district physician in health care teams. An analysis of the content of primary health care

An assessment of community nursing in relation to physician care has been made in a Swedish primary care district. The staff was organized in health care teams. A totally integrated, comprehensive care service for everyone in the geographically defined district was made possible, as all members of the team used the same medical records. Visits in district care (district nurse, practical nurse) amounted to more than 50% of the visits to the teams. The visiting pattern in district care was dominated by the young and the old, the ages below 5 years of age making 3.7 visits per year, and the ages above 75 years making 10.0 visits. Health care was an important task among the children, while chronic ulcer of skin, senile dementia and diabetes were the most common diagnoses among the elderly. Every third visit in district care was a home visit. In almost 50% of the visits no appointment had been made in advance, which demonstrates a high accessibility to the district nurse. The distribution of diagnoses presented several social problems. Diagnoses like neuroses, alcoholism, and senile dementia produced many visits by few patients. Compared to physician visits, the district nurse made more home visits, had more visits among the young and the old, and had a different distribution of diagnoses. Regardless of, or despite, their different ways of working, the district nurse and the district physician complemented each other in the team co-operation. Besides her role as a health professional concerned about health care and medical treatment, the district nurse is an important social contact for many individuals living in her district.     

Exploring the importance of team psychological safety in the development of two interprofessional teams

It has been previously demonstrated that interactions within interprofessional teams are characterised by effective communication, shared decision-making, and knowledge sharing. This article outlines aspects of an action research study examining the emergence of these characteristics within change management teams made up of nurses, general practitioners, physiotherapists, care assistants, a health and safety officer, and a client at two residential care facilities for older people in Ireland. The theoretical concept of team psychological safety (TPS) is utilised in presenting these characteristics. TPS has been defined as an atmosphere within a team where individuals feel comfortable engaging in discussion and reflection without fear of censure. Study results suggest that TPS was an important catalyst in enhancing understanding and power sharing across professional boundaries and thus in the development of interprofessional teamwork. There were differences between the teams. In one facility, the team developed many characteristics of interprofessional teamwork while at the other there was only a limited shift. Stability in team membership and organisational norms relating to shared decision-making emerged as particularly important in accounting for differences in the development of TPS and interprofessional teamwork.     

The impact on work-related stress of mental health teams following team-based learning on clinical risk management

Risk management is viewed as a systematic process based on multiprofessional and multi-agency decision-making. A learning pack was developed as part of a team-based learning project aiming to encourage and develop collaborative working practice. This brought different professionals and agencies working in mental health together to learn. There is little doubt that mental health practice is a source of stress for practitioners. Apart from the stress associated with managing 'risky' situations, risk management is also a relatively new concept. This can increase stress around ability to cope, both on an individual practitioner level and in teams. This article reports the impact that the learning pack had on team members' stress, specifically work-related stress. A range of scales were used to measure change in stress and results demonstrated reduced work-related pressure in a number of areas following the learning. The implications for team learning in relation to clinical risk management are discussed in light of the findings.