Exploring the nature of interprofessional collaboration and family member involvement in an intensive care context

Abstract

Little is known about the nature of interprofessional collaboration on intensive care units (ICUs), despite its recognition as a key component of patient safety and quality improvement initiatives. This comparative ethnographic study addresses this gap in knowledge and explores the different factors that influence collaborative work in the ICU. It aims to develop an empirically grounded team diagnostic tool, and associated interventions to strengthen team-based care and patient family involvement. This iterative study is comprised of three phases: a scoping review, a multi-site ethnographic study in eight ICUs over 2 years; and the development of a diagnostic tool and associated interprofessional intervention-development. This study’s multi-site design and the richness and breadth of its data maximize its potential to improve clinical outcomes through an enhanced understanding of interprofessional dynamics and how patient family members in ICU settings are best included in care processes. Our research dissemination strategy, as well as the diagnostic tool and associated educational interventions developed from this study will help transfer the study’s findings to other settings.     

Identification of core ethical topics for interprofessional education in the intensive care unit: a thematic analysis

ABSTRACT

Medical educators have not identified effective approaches for interprofessional ethics education of clinicians who work in intensive care units (ICUs), in spite of the fact that ICUs have a high incidence of ethical conflicts. As a first step in designing an interprofessional ethics education initiative tailored to the needs of ICU team members, we interviewed 12 professionals from the medical and surgical ICUs of a tertiary care academic medical center to understand what they know about medical ethics. Respondents were interviewed between November 2016 and February 2017. We used the ‘think aloud’ approach and realist thematic analysis of the sessions to evaluate the extent and content of interprofessional team members’ knowledge of medical ethics. We found wide variation in their knowledge of and facility in applying the principles and concepts of biomedical ethics and ways of resolving ethical conflicts. Ethics education tailored to these areas will help equip critical care professionals with the necessary knowledge and skills to discuss and address ethical conflicts encountered in the ICU. Preventive ethics rounds are one approach for providing real-time, embedded interprofessional ethics education in the clinical setting.     

Examining the implementation of collaborative competencies in a critical care setting: Key challenges for enacting competency-based education

Interprofessional collaboration is recognised as an important factor in improving patient care in intensive care units (ICUs). Competency frameworks, and more specifically interprofessional competency frameworks, are a key strategy being used to support the development of attitudes, knowledge, skills, and behaviours needed for an interprofessional approach to care. However, evidence for the application of competencies is limited. This study aimed to extend our empirically based understanding of the significance of interprofessional competencies to actual clinical practice in an ICU. An ethnographic approach was employed to obtain an in-depth insight into healthcare providers’ perspectives, behaviours, and interactions of interprofessional collaboration in a medical surgical ICU in a community teaching hospital in Canada. Approximately 160 hours of observations were undertaken and 24 semi-structured interviews with healthcare workers were conducted over a period of 6 months. Data were analysed using a directed content approach where two national competency frameworks were used to help generate an understanding of the practice of interprofessional collaboration. Healthcare professionals demonstrated numerous instances of interprofessional communication, role understandings, and teamwork in the ICU setting, which supported a number of key collaborative competencies. However, organisational factors such as pressures for discharge and patient flow, staffing, and lack of prioritisation for interprofessional learning undermined competencies designed to improve collaboration and teamwork. The findings demonstrate that interprofessional competencies can play an important role in promoting knowledge, attitudes, skills, and behaviours needed. However, competencies that promote interprofessional collaboration are dependent on a range of contextual factors that enable (or impede) individuals to actually enact these competencies.     

The use and usefulness of ICU diaries to support family members of critically ill patients

PurposeTo analyze and describe the use and usefulness of the ICU diary to support family members of critically ill patients.Materials and methodsA socio-technical systems model (SEIPS 2.0) guided data collection and analysis in this study aimed to gain a holistic understanding of factors that shape ICU diary processes and family requirements for support. Triangulated data sources, including interviews, observations, and photographs, were content analyzed for person, task, tool, and context attributes determining the use and usefulness of ICU diaries. Researchers recruited family members of critically ill patients admitted to ICUs in two hospitals (urban, rural) in the southeastern United States.ResultsNineteen female (100%) family members participated in this study. ICU diaries were used and adapted by family members to cope with the ICU experience in multiple ways. Results indicate that staff support, easy access, embedded instructional format, early initiation, and family ownership facilitated ICU diary use by family members. The ICU diary was useful as a medium to process emotions and gain insights, reduce stress, track information, and communicate with the staff and the patient.ConclusionsThe ICU diary is useful to family members as a stress reduction, information management, and communication tool. The design of ICU diary implementations must address system factors to assure family members receive benefits from diary use. Further research is needed to expand our understanding of the optimal structure, process, and content of ICU diary implementations.     

Family participation in care to the critically ill: opinions of families and staff

Background Allowing family members to participate in the care of patients in intensive care units (ICUs) may improve the quality of their experience. No previous study has investigated opinions about family participation in ICUs.Methods Prospective multicenter survey in 78 ICUs (1,184 beds) in France involving 2,754 ICU caregivers and 544 family members of 357 consecutive patients. We determined opinions and experience about family participation in care; comprehension (of diagnosis, prognosis, and treatment) and satisfaction (Critical Care Family Needs Inventory) scores to assess the effectiveness of information to families and the Hospital Anxiety and Depression score for family members.Results Among caregivers 88.2% felt that participation in care should be offered to families. Only 33.4% of family members wanted to participate in care. Independent predictors of this desire fell into three groups: patient-related (SAPS II at ICU admission, OR 0.984); ICU stay length, OR 1.021), family-related (family member age, OR 0.97/year); family not of European descent, OR 0.294); previous ICU experience in the family, OR 1.59), and those related to emotional burden and effectiveness of information provided to family members (symptoms of depression in family members, OR 1.58); more time wanted for information, OR 1.06).Conclusions Most ICU caregivers are willing to invite family members to participate in patient care, but most family members would decline.Supported by a grant (AOR1004) from the Assistance Publique des Hôpitaux de Paris and the Direction Régionale de la Recherche Clinique. Affiliations of the authors are listed in the Appendix     

Interprofessional care review with medical residents: lessons learned, tensions aired--a pilot study

Integrated interprofessional care teams are the focus of Canadian and American recommendations about the future of health care. Keeping with this, a family medicine teaching site developed an educational initiative to expose trainees to interprofessional care processes and learning (Interprofessional Care Review; IPC). A formative evaluation pilot study was completed using one-on-one interviews and a focus group (n = 6) with family medicine residents. A semi-structured guide was utilized regarding: knowledge, skills and attitudes related to interprofessional care; their experience of the processes utilized in IPC. Data were analyzed using content analysis. Residents' perspectives on their learning revolved around four themes: changes to understanding and practice of interprofessional care; personal impact of IPC; learning about other health professionals; tension and challenges of IPC learning and clinical implementation. Residents valued the educational experience, but identified that faculty supervisors provided "mixed messages" in the value of collaborating with other health professionals. Implications regarding future educational and research opportunities are discussed.     

Important clinician information needs about family members in the intensive care unit

PurposeClinicians often lack key information regarding intensive care unit (ICU) families. Our objective was to identify (1) important information for clinicians to know about ICU families when making decisions and (2) important information for families to know about patients from clinicians.Materials and methodsWe identified important information items through a literature review and semistructured interviews. A separate cohort of family members, nurses, and physicians from 2 ICUs in a single institution were asked to prioritize the identified information as necessary for decision making.ResultsWe identified 21 items important for clinicians to know about families and 32 items important for families to know about patients from clinicians. Themes important for clinicians to know about family members included family background, questions, understanding, goals, concerns, well-being, and requests for additional help. Themes important for families to know about the patient included diagnosis, treatments, prognosis, clinical status, schedule, comfort, goals of care, medical team, and family participation.ConclusionsThrough qualitative and quantitative analysis, we identified important information for ICU clinicians to know about family members and for family members to know about patients. The identified information can be used to guide strategies and tools to improve assessment of and communication with families.     

Interprofessional care review with medical residents: Lessons learned,tensions aired – A pilot study

Integrated interprofessional care teams are the focus of Canadian and American recommendations about the future of health care. Keeping with this, a family medicine teaching site developed an educational initiative to expose trainees to interprofessional care processes and learning (Interprofessional Care Review; IPC). A formative evaluation pilot study was completed using one-on-one interviews and a focus group (n?=?6) with family medicine residents. A semi-structured guide was utilized regarding: knowledge, skills and attitudes related to interprofessional care; their experience of the processes utilized in IPC. Data were analyzed using content analysis. Residents' perspectives on their learning revolved around four themes: changes to understanding and practice of interprofessional care; personal impact of IPC; learning about other health professionals; tension and challenges of IPC learning and clinical implementation. Residents valued the educational experience, but identified that faculty supervisors provided “mixed messages” in the value of collaborating with other health professionals. Implications regarding future educational and research opportunities are discussed.     

Factors associated with family satisfaction in the adult intensive care unit: A literature review

ObjectiveThe objective of this study was to identify and summarise factors associated with family satisfaction among family members of adult intensive care unit (ICU) patients.Review methods/data sourcesA search was conducted from inception to October 2020 in the following databases: PubMed, Scopus, EMBASE, CINAHL Plus, ProQuest Health Management, PsycINFO, LILACS, and SciELO. Studies reporting the questionnaire's items or dimensions as family satisfaction factors, studies dichotomising family satisfaction outcome, and those involving family members of neonatal, paediatric, palliative, and end-of-life patients were excluded. Quality of the studies was examined through a modified approach to the Consolidated Standards for Reporting Trials (CONSORT). Reported factors were classified as family member, patient, or provider/organisation related.ResultsThe search yielded 26 articles reporting factors associated with family satisfaction in the ICU. Regarding study quality, 19.2% were classified as high-quality studies. Family member–related variables such as educational level, gender, and kinship to the patient showed divergent associations with family satisfaction. Within patient-related variables, the severity of illness was positively associated with family satisfaction. Factors related to healthcare providers and organisations were reported only in 26.9% of the studies.ConclusionsA broad number of factors associated with family satisfaction in the ICU were found in this review. However, few nonmodifiable factors related to the family members and the patient showed a significant and consistent association with family satisfaction. Evidence on factors related to healthcare providers was scarce. Gaps in knowledge regarding family satisfaction in the ICU, including methodological issues that impair the validity of the findings, were identified. Future studies should address these limitations to accurately identify factors that impact family satisfaction in the ICU.     

A family intervention to reduce delirium in hospitalised ICU patients: A feasibility randomised controlled trial

BackgroundFamily members could play an important role in preventing and reducing the development of delirium in Intensive Care Units (ICU) patients. This study sought to assess the feasibility of design and recruitment, and acceptability for family members and nurses of a family delivered intervention to reduce delirium in ICU patients.MethodA single centre randomised controlled trial in an Australian medical/surgical ICU was conducted. Sixty-one family members were randomised (29 in intervention and 32 in non-intervention group). Following instructions, the intervention comprised the family members providing orientation or memory clues (family photographs, orientation to surroundings) to their relative each day. In addition, family members conducted sensory checks (vision and hearing with glasses and hearing aids); and therapeutic or cognitive stimulation (discussing family life, reminiscing) daily. Eleven ICU nurses were interviewed to gain insight into the feasibility and acceptability of implementing the intervention from their perspective.ResultsRecruitment rate was 28% of eligible patients (recruited n = 90, attrition n = 1). Following instruction by the research nurse the family member delivered the intervention which was assessed to be feasible and acceptable by family members and nurses. Protocol adherence could be improved with alternative data collection methods. Nurses considered the activities acceptable.ConclusionThe study was able to recruit, randomise and retain family member participants. Further strategies are required to assess intervention fidelity and improve data collection.     

The relationship between team climate and interprofessional collaboration: Preliminary results of a mixed methods study

ABSTRACT

Relational and organisational factors are key elements of interprofessional collaboration (IPC) and team climate. Few studies have explored the relationship between IPC and team climate. This article presents a study that aimed to explore IPC in primary healthcare teams and understand how the assessment of team climate may provide insights into IPC. A mixed methods study design was adopted. In Stage 1 of the study, team climate was assessed using the Team Climate Inventory with 159 professionals in 18 interprofessional teams based in São Paulo, Brazil. In Stage 2, data were collected through in-depth interviews with a sample of team members who participated in the first stage of the study. Results from Stage 1 provided an overview of factors relevant to teamwork, which in turn informed our exploration of the relationship between team climate and IPC. Preliminary findings from Stage 2 indicated that teams with a more positive team climate (in particular, greater participative safety) also reported more effective communication and mutual support. In conclusion, team climate provided insights into IPC, especially regarding aspects of communication and interaction in teams. Further research will provide a better understanding of differences and areas of overlap between team climate and IPC. It will potentially contribute for an innovative theoretical approach to explore interprofessional work in primary care settings.     

Developing the family support tool: An interactive,web-based tool to help families navigate the complexities of surrogate decision making in ICUs

IntroductionAlthough family members of incapacitated, critically ill patients often struggle in the role of surrogate decision maker, there are no low-cost, easily-scaled interventions to address this problem.Aim of the studyTo develop and pilot-test the Family Support Tool, an interactive, web-based tool to help individuals navigate the complexities of surrogate decision making in ICUs.Material and methodsWe used a mixed methods, user-centered process to create the Family Support Tool, including: 1) creation of a preliminary design by an expert panel; 2) engagement of a key stakeholder panel to iteratively refine the preliminary design; 3) user testing of a low-fidelity prototype of the tool by 6 former ICU surrogates; 4) creation of a web-based prototype; and 5) user testing of the web-based prototype with 14 surrogates and ICU physicians, including semi-structured interviews and quantitative measurement of usability, acceptability, and perceived effectiveness.ResultsThe initial design contained a collection of videos and exercises designed to help individuals understand the surrogate's role and think through the patient's values and preferences. Based on family stakeholders' feedback about the emotional overwhelm they experience early in an ICU stay, we redesigned the tool to be viewed in sections, with the first section focused on decreasing surrogates' emotional distress, and later sections focused on helping surrogates prepare for family meetings. Surrogates actively making decisions in the ICU judged the final tool to be highly usable (mean summary score 83.5, correlating to 95th percentile when normalized to devices of its type), acceptable (mean 4.2 +/− 0.5 out of 5), and effective (mean 4.3 +/− 0.6 out of 5). All surrogates reported the tool helped them consider goals of care and all indicated they would recommend the tool to a friend.ConclusionsWe successfully developed a web-based tool to help individuals navigate the complexities of surrogate decision making in ICUs that has high potential for scalability. Surrogates judged the tool to be usable, acceptable, and effective. These data support proceeding to test the tool in a pilot randomized clinical trial.     

Family visitation policies,facilities, and support in Australia and New Zealand intensive care units: A multicentre,registry-linked survey

ObjectiveThe objective of this study was to describe family visitation policies, facilities, and support in Australia and New Zealand (ANZ) intensive care units (ICUs).MethodsA survey was distributed to all Australian and New Zealand ICUs reporting to the Australian and New Zealand Intensive Care Society Centre for Outcomes and Resources Evaluation Critical Care Resources (CCR) Registry in 2018. Data were obtained from the survey and from data reported to the CCR Registry. For this study, open visiting (OV) was defined as allowing visitors for more than 14 h per day.Setting and participantsThis study included all Australian and New Zealand ICUs reporting to CCR in 2018.Main outcome measuresThe main outcome measures were family access to the ICU and visiting hours, characteristics of the ICU waiting area, and information provided to and collected from the relatives.FindingsFifty-six percent (95/170) of ICUs contributing to CCR responded, representing 44% of ANZ ICUs and a range of rural, metropolitan, tertiary, and private ICUs. Visiting hours ranged from 1.5 to 24 h per day, with 68 (72%) respondent ICUs reporting an OV policy, of which 64 (67%) ICUs were open to visitors 24 h a day. A waiting room was part of the ICU for 77 (81%) respondent ICUs, 74 (78%) reported a separate dedicated room for family meetings, and 83 (87%) reported available social worker services. Most ICUs reported facilities for sleeping within or near the hospital. An information booklet was provided by 64 (67%) ICUs. Only six (6%) ICUs required personal protective equipment for all visitors, and 76 (80%) required personal protective equipment for patients with airborne precautions.ConclusionsIn 2018, the majority of ANZ ICUs reported liberal visiting policies, with substantial facilities and family support.     

A 6-y retrospective cohort study of family satisfaction with critical care and decision-making in an Australian intensive care unit

BackgroundPartnering with patients and families to make decisions about care needs is a safety and quality standard in Australian health services that is often not assessed systematically.ObjectiveThe objective of this study was to retrospectively evaluate satisfaction with care and involvement in decision-making among family members of patients admitted to the intensive care unit (ICU).MethodsA retrospective cohort analysis of a satisfaction survey administered to family members of patients admitted to an ICU in an Australian metropolitan tertiary care hospital from 2014 to 2019 was conducted. The Family Satisfaction in the Intensive Care Unit questionnaire (FSICU) questionnaire was used to assess overall satisfaction, satisfaction with care, and satisfaction with decision-making on a scale from “poor” (0) to “excellent” (100).ResultsIn total, 1322 family members fully completed the survey. Respondents were typically direct relatives of ICU patients (94.2%) with an average age of 52.6 years. Most patients had an ICU length of stay <7 d (56.8%), with most patients being discharged to the ward (96.8%). The overall mean satisfaction score was high among respondents (90.26%). Similarly, mean satisfaction with care (93.06%) and decision-making (89.71%) scores were high. Satisfaction with decision-making scores remained lower than satisfaction with care scores. Multivariable modeling indicated that those younger than 50 years reported higher satisfaction scores (p = 0.006) and those with prolonged lengths of stay in the ICU were associated with lower overall satisfaction scores (p = 0.039). Despite some criticism of waiting times and noise levels, responses showed sincere gratitude for patients’ treatment in the ICU and appreciation for the care, skill, and professionalism of the staff.ConclusionVery high satisfaction levels were reported by family members during this study. Routine, prospective evaluations of family member satisfaction with ICU experiences are feasible and can be leveraged to provide insight for clinicians and administrators seeking to improve family satisfaction with decision-making and care in ICU settings and meet national standards.     

Criteria deemed important by the relatives for designating a reference person for patients hospitalized in ICU

PurposeWe investigated the criteria that patients' relatives deem important for choosing, among themselves, the person best qualified to interact with the caregiving staff.MethodsExploratory, observational, prospective, multicentre study between 1st March and 31st October 2018 in 2 intensive care units (ICUs). A 12-item questionnaire was completed anonymously by family members of patients hospitalized in the ICU 3 and 5 days after the patient's admission. Relatives were eligible if they understood French and if no surrogate had been appointed by the patient prior to ICU admission. More than one relative per patient could participate.ResultsIn total, 87 relatives of 73 patients completed the questionnaire, average age of relatives was 58 ± 15 years, 46% were the spouse, 30% were children/grandchildren. Items classed as being the most important attributes for a reference person were: good knowledge of the patient's wishes and values; an emotional attachment to the patient; being a family member; and having an adequate understanding of the clinical status and clinical history.ConclusionThis study identifies the attributes considered by relatives to be most important for designating, among themselves, a reference person for a patient hospitalized in the ICU.