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

Finally, daily multidisciplinary rounds led by a hospitalist medical director paired with a nurse practitioner resulted in improved physician-to-nurse collaboration, particularly with residents. In this model, the nurse practitioner was able to facilitate coordination of patient care and communication between nurses and physicians.³⁸

Barriers to Team Performance

Implementing teamwork strategies within acute health care has its benefits and challenges. Barriers to implementing a team model in critical care can include local customs, hospital patterns, and reluctance to change despite proven benefit.²² Implementation requires a cultural shift. The existence of hierarchical and status differences in acute care can present a barrier to team function and the ability of team members to openly contribute to the plan of care.^28,42 Team members may not be convinced that their input is important or needed to make decisions about patient care.

Another barrier to the intensivist-led team in the ICU is the lack of an adequate number of qualified physicians who are trained in critical care.¹⁸ The ability to recruit medical residents into critical care fellowships is challenging, particularly with concerns about financial compensation and hectic lifestyle. Additionally, there are costs associated with implementation of the intensivist model.^18,22 Without strong leadership at the bedside, it is more difficult to implement team models of care. However, even without a designated intensivist, establishing a multidisciplinary team in the ICU improves outcomes.⁷

Another obstacle is that working as a team requires some team members to forfeit their autonomy in practice.²² This may be difficult when team leaders hold high value in their ability to orchestrate things without the aid of others. The physician leader must be willing to engage members of the team and establish respect and trust for their contribution to discussion and decision making.

Many practitioners in the ICU have not been trained in teamwork activities and are not prepared with the skills required. While teamwork is not related to technical expertise, it is a nontechnical skill necessary for patient safety.¹³ Each member’s knowledge, skill, and personality characteristics have an important influence on the effectiveness of patient care teams.⁸ One qualitative study showed that emotional distress individual members experienced during medical crises impacts the function of the entire team through contagion of anxiety.¹ Another study on team interactions during crises found that in the post-crisis period, nurses were left with significant questions and emotions about the event compared to other members of the team.⁴⁴ Potential solutions to these barriers are to hold interdisciplinary team debriefings and feedback sessions immediately after crises, assess for gaps in teamwork competencies, and determine opportunities for team training. Team leaders need to assess anxiety among team members during crises and help defuse potential emotional breakdowns during critical interventions. Team training may also help prepare members emotionally for real events and enable them to gain experience in safer settings.

Programs Used to Develop Teamwork in the Icu

Programs designed to improve team core competencies and communication skills may improve team performance through experiential team learning. A successful pediatric critical care unit provided an interdisciplinary experiential learning day-long program (Program to Enhance Relational and Communication Skills [PERCS]) to improve communication skills and relational abilities when having difficult conversations with family members. The training included video case scenarios and debriefing feedback sessions and shared communication about experiences with difficult conversations with families. This approach resulted in improved communication skills, confidence, and perceptions of preparation. Anxiety was reduced and then sustained.³²

Teamwork skills can be developed to improve communication between physicians and nurses that improves care at the end of life (EOL).⁴⁵ Studies have shown that nurses and physicians differ in perspectives and burdens felt as the result of decisions made at the end of life. Strategies to improve communication between caregivers include joint grand rounds, patient care seminars, and interprofessional dialogue about EOL care. Using tools such as daily rounds forms, communication training, and a collaborative practice model are other mechanisms that may improve physician-nurse communication and EOL care.

Teamwork can also be enhanced when multidisciplinary expertise is focused on key patient outcomes. One example of a successful program was a critical care team that examined its practice to determine factors that interfered with mobility in mechanically ventilated patients.³³ The ICU staff developed a team strategy to improve their culture to focus on improving early mobility in ventilated patients and a process to evaluate the effectiveness on patient outcomes. This initiative enabled the team to improve patients’ functional abilities and long-term outcomes.

In one study, a Delphi method was used to identify key components needed for crew resource management training in the hospital environment. Five areas were identified: communication, task management, situational awareness, decision making and leadership.⁴³ Programs to improve patient safety and collaboration in the ICU have been developed using a crew resource management (CRM) approach.⁴² Team members are taught to promote safety by changing attitudes and behaviors. Tools used are team training in interpersonal communication, conflict resolution, and nonthreatening evaluation of critique of team performance. Education may include methods to improve system processes for care, including the use of checklists and standardizing handoffs to relate key information. Additionally, CRM training can be used to teach methods to counter patient care errors such as debriefings, cross-checking, and review of patient care plans. Team members can learn how to actively participate in decision making and how to question actions and decisions among team members in a constructive manner. This allows for open communication and the ability to speak up about concerns or recommendations for patient care.

Team Training Using Simulation

Currently, more organizations are using simulation as a means to educate and train members of teams to function under specific circumstances. Members of the interdisciplinary team use simulation to learn and practice roles in various clinical situations and to evaluate communication and team effectiveness. Team learning in simulation exercises allows professionals to learn and practice safely under circumstances outside of stressful clinical settings. Team members learn their roles and contributions in key clinical scenarios.

Simulation can be used to train teams to manage septic shock by creating an ICU environment and using a high-fidelity patient simulator (mannequin).⁴⁶ In one study, residents participated in exercises in a simulated environment during their ICU rotations. A mannequin was programmed to give complaints and responses to questions using a standardized scenario. Participants had access to vital signs and could ask questions about the patient’s condition. These were video recorded for later review and debriefing with the residents and other members of the team after performance scoring by senior faculty. Both technical and nontechnical (teamwork) functions were evaluated. They found this method to be an effective tool to test and teach knowledge, clinical application, and teamwork principles, and to evaluate the quality of performance in simulations of septic shock.

Handoff of a patient from one professional to another or transfer to other areas within a hospital creates an opportunity for miscommunication to occur. This is particularly true of nurse-to-nurse communication at shift change and patient transfer to other units. The use of standardized communication tools such as SBAR (Situation, Background, Assessment, Recommendation) can be instrumental in conveying important information between shifts, departments, nurses, and physicians. Berkenstadt et al.⁴⁷ used a 6-hour simulation-based training workshop to improve nurse teamwork and communication. In this program, nurses viewed videos on demonstration of relevant handoff tasks followed by debriefing sessions and discussion. This resulted in a significant increase in communication of crucial information and treatment goals during handoffs between nurses. This use of simulation may be an effective means to train any caregiver on handoff communication.

Simulation has also been used to train healthcare workers on CRM as a means to improve teamwork competencies. One example is a comprehensive Medical Team Training (MTT) full-day interactive program. The aim was to improve patient outcomes and enhance job satisfaction among the interdisciplinary team in the Veterans Administration’s Employee Education Service. Their program was facilitated by a physician-nurse pair. The faculty came from multiple disciplines and professions to model collaboration and teamwork. This program includes rules of conduct, communication principles, tools, and techniques, debriefing processes, and processes for safe handoffs. Multiple modes of education were used to reinforce material over the one-day seminar, including simulation, interaction, discussion, and videos to demonstrate and model teamwork behaviors. Participation in this program resulted in improvements in communication and the quality of care.¹⁴

High-fidelity simulation can be used to evaluate team performance in resuscitation of the critically ill. In a pilot study by Kim et al.,⁴⁸ a high-fidelity simulation of recreated emergencies encountered in acute care was used to teach and evaluate crisis resource management skills in first- and third-year residents. In their study, they included a simulated ICU environment and other team members (nurse and respiratory therapist) to further augment the simulated sessions. They were able to use this model to represent clinical scenarios of the management of acute respiratory failure, airway management, myocardial ischemia, trauma, and shock occurring in the ICU, postanesthesia care unit, and emergency room. The scenarios used were originated from real-life cases encountered in their hospital. They were able to validate their tool for assessment for crisis resource management. They support this model as a means of evaluating team leadership and decision-making skills in critical events encountered in acute care.

Resources Available

There are resources made available for critical care teambuilding by various organizations. The American Association of Critical Care Nurses has made a commitment to their initiative to promote a healthy work environment. Their website has many tools for evaluating and promoting teamwork (aacn.org). The IHI is dedicated to quality improvement processes. Since team work is key to most of their initiatives, their website (ihi.org) has many useful tools for teambuilding. The Agency for Healthcare Research and Quality (AHRQ) and the Veterans Administration (VA) are collaborating on the STEPPS project: Strategies and Tools to Enhance Performance and Patient Safety. Information on this program with teambuilding at its core can be found on their website (teamstepps.ahrq.gov).

Collaborative Practice Teams

Collaborative practice teams (CPTs) are groups that are assembled for a particular population to address issues related to clinical practice and outcomes. These teams are multiprofessional and interdisciplinary in scope and function. They design initiatives to drive evidence-based practice and improve quality of care. The team composition usually consists of representative practitioners directly involved in the care of patients. In critical care this could include intensivists and other physicians, nurses, respiratory therapists, pharmacists, nutritionists, social workers, clergy, administrators, risk managers, infection control, safety officers, and quality improvement personnel. The goal is to capture expertise from multiple disciplines to improve delivery of care. The actual composition of CPTs depends on the nature of the ICU and patient population and should be individualized to each facility. Examples of CPT initiatives are the development of disease-specific protocols, care “bundles,” order sets, and performance improvement campaigns.

Daily Multidisciplinary Rounds With the Interdisciplinary Team and Daily Goals

The use of multidisciplinary rounds on patients every day in the ICU enhances patient care.²² When caregivers meet as a team to discuss and plan for patient care and use evidence-based protocols and care bundles, the opportunity for teamwork, team planning, and team accountability exists. Daily rounds also provide opportunities to augment efforts and initiatives by the CPT. Communication about the plan of care by the team can be facilitated by using a daily goals checklist during daily rounds.⁴⁹ Caregivers are tasked with specific functions and assignments that are reviewed for completion at the end of the day. Team goals improve accountability for patient care and momentum for progress. This approach has been demonstrated to improve team and patient outcomes.^26,49,50 Siegele described the impact of implementing daily team goals for patients in a surgical ICU.²³ A daily goals tool with patient-centric goals to improve communication, collaboration, and coordination of care was established for the multidisciplinary team. Evidence-based practices and care bundles were used. These tools can be adapted for many practice areas or groups of disciplines that work together for common patient goals. Several days to 1 week can be placed on one tool. They can be used for follow-up to make sure goals were met and to determine next steps.

Krimsky et al. developed a model to increase implementation of measures to prevent venous thrombosis, VAP, and stress ulcers in ICU patients.⁵¹ Their systematic approach integrated evidence-based strategies, a tool to develop team communication and team building, daily prompts in ICU progress notes to assess these complications, and real-time feedback of performance measures to correct behaviors. This model allowed incorporation of these evidence-based practices using a team-based culture of patient safety.

Teams With Specific Clinical Focus

Some teams are formed to manage care for particular situations or patient types. One example is the use of multidisciplinary medical emergency response teams to respond to calls about acute changes in patient condition. These teams facilitate timely assessment and treatment of patients to reduce the development of further complications or cardiopulmonary arrest. Other specialty teams can be developed to assess and manage urgent clinical conditions such as stroke, sepsis,⁴⁶ and shock.²⁷ Team training and evidence-based practice tools can be developed for these teams to assist them in efficient and effective practice.