Conflicts and communication gaps in the intensive care unit

Challenging behaviours in interprofessional teamwork in the intensive care unit: a qualitative content analysis of focus group interviews

OBJECTIVES

To explore interprofessional team members' experiences of teamwork at an intensive care unit.

DESIGN

Qualitative content analysis of focus group interviews with members from the intensive care teams.

SETTING

University hospital in Sweden.

PARTICIPANTS

In total, 31 participants were interviewed. Enrolled nurses (n=7), critical care registered nurses (n=16), and intensive care physicians (n=8) employed at an intensive care unit were divided into nine focus groups organised according to the profession.

RESULTS

The overall theme, Balancing behaviour and knowledge in teamwork, emerged from the two categories of creating a safe atmosphere when working in an unknown environment and counteracting and mitigating destructive team dynamics. The theme captures how well-functioning teamwork must take into account members not acting as team players while also building a secure environment when working in new surroundings outside the intensive care unit. The categories describe how mutual respect, effective teamwork and a safe atmosphere were fostered through support without taking over tasks and countering power structures.

CONCLUSIONS

Navigating teamwork during critical situations is inherently complex, making it essential to understand team interactions and factors influencing individual behaviour. To ensure patient safety, the interprofessional team must recognise, understand and manage diverse behaviours and knowledge in dynamic settings. This research contributes to existing knowledge on teamwork in the intensive care context by providing insights into how knowledge and behaviour in teamwork can be optimised to enhance patient safety.

Pediatric Intensive Care Unit Conflict Management Perspectives Among Physician and Nurse Leaders

Importance

Decision-making conflict is common in the pediatric intensive care unit (PICU) and associated with negative outcomes for patients, families, and teams. Disparities in conflict outcomes are reported, yet no studies have explored conflict management approaches.

Objective

To understand approaches to conflict mediation and escalation in the PICU.

Design, Setting, and Participants

This national, multicenter, prospective, mixed-methods survey study recruited PICU physician and nursing directors from February to April 2023.

Exposure

PICU size, conflict policy, behavior contract tracking.

Main Outcomes and Measures

Closed- and open-ended survey questions were used to collect information on hospital policies, general conflict approaches, and specific approaches to scenarios.

Results

The overall response rate was 57% (68 of 120 surveys, with 60 complete enough for analysis). Overall, 30 of 51 respondents (59%) identified as female, with a wide distribution of reported years in current role and percentage of time spent in clinical care. Institution regions varied, with an even distribution among institutions with different PICU sizes. Conflict strategies were used variably across institutions. Approximately 65% (32 of 49) reported policies for conflict management. Only 23% (10 of 43) tracked conflicts and their outcomes. Few institutions trained staff in conflict management techniques. Compared with institutions that did not track behavior contracts, those that did were more likely to call ethics consults for conflict management (3 of 12 [25%] vs 0 of 20; P = .04) and to implement behavior contracts for more objective reasons (8 of 11 [73%] vs 4 of 16 [25%]; P = .02). Leaders offered ideas for multipronged conflict prevention and response based on strategies implemented at their institutions but also highlighted needs and concerns with existing approaches.

Conclusions and Relevance

In this mixed-methods survey study of PICU physician and nurse leaders, tracking and internal reporting of conflicts and outcomes were associated with more objectively applied interventions. The wide-ranging approaches and thresholds for escalation voiced by our respondents indicate a need to develop standardized and evidence-based processes to ensure greater effectiveness by clinical teams and leaders in addressing conflict and reduce potential disparities in outcomes. Respondents shared ideas for preventive and responsive processes that could be implemented and tested in the future. Learning from existing management approaches may help develop standardized, generalizable interventions to reduce conflict, improve interventions, and reduce subjectivity in the application of interventions.

A Survey of Surrogates and Health Care Professionals Indicates Support of Cognitive Motor Dissociation-Assisted Prognostication

BACKGROUND

Prognostication of patients with acute disorders of consciousness is imprecise but more accurate technology-supported predictions, such as cognitive motor dissociation (CMD), are emerging. CMD refers to the detection of willful brain activation following motor commands using functional magnetic resonance imaging or machine learning-supported analysis of the electroencephalogram in clinically unresponsive patients. CMD is associated with long-term recovery, but acceptance by surrogates and health care professionals is uncertain. The objective of this study was to determine receptiveness for CMD to inform goals of care (GoC) decisions and research participation among health care professionals and surrogates of behaviorally unresponsive patients.

METHODS

This was a two-center study of surrogates of and health care professionals caring for unconscious patients with severe neurological injury who were enrolled in two prospective US-based studies. Participants completed a 13-item survey to assess demographics, religiosity, minimal acceptable level of recovery, enthusiasm for research participation, and receptiveness for CMD to support GoC decisions.

RESULTS

Completed surveys were obtained from 196 participants (133 health care professionals and 63 surrogates). Across all respondents, 93% indicated that they would want their loved one or the patient they cared for to participate in a research study that supports recovery of consciousness if CMD were detected, compared to 58% if CMD were not detected. Health care professionals were more likely than surrogates to change GoC with a positive (78% vs. 59%, p = 0.005) or negative (83% vs. 59%, p = 0.0002) CMD result. Participants who reported religion was the most important part of their life were least likely to change GoC with or without CMD. Participants who identified as Black (odds ratio [OR] 0.12, 95% confidence interval [CI] 0.04-0.36) or Hispanic/Latino (OR 0.39, 95% CI 0.2-0.75) and those for whom religion was the most important part of their life (OR 0.18, 95% CI 0.05-0.64) were more likely to accept a lower minimum level of recovery.

CONCLUSIONS

Technology-supported prognostication and enthusiasm for clinical trial participation was supported across a diverse spectrum of health care professionals and surrogate decision-makers. Education for surrogates and health care professionals should accompany integration of technology-supported prognostication.

Best Case/Worst Case-ICU: protocol for a multisite, stepped-wedge, randomised clinical trial of scenario planning to improve communication in the ICU in US trauma centres for older adults with serious injury

INTRODUCTION

Poor communication about serious injury in older adults can lead to treatment that is inconsistent with patient preferences, create conflict and strain healthcare resources. We developed a communication intervention called Best Case/Worst Case-intensive care unit (ICU) that uses daily scenario planning, that is, a narrative description of plausible futures, to support prognostication and facilitate dialogue among patients, their families and the trauma ICU team. This article describes a protocol for a multisite, randomised, stepped-wedge study to test the effectiveness of the intervention on the quality of communication (QOC) in the ICU.

METHODS AND ANALYSIS

We will follow all patients aged 50 and older admitted to the trauma ICU for 3 or more days after a serious injury at eight high-volume level 1 trauma centres. We aim to survey one family or 'like family' member per eligible patient 5-7 days following their loved ones' admission and clinicians providing care in the trauma ICU. Using a stepped-wedge design, we will use permuted block randomisation to assign the timing for each site to begin implementation of the intervention and routine use of the Best Case/Worst Case-ICU tool. We will use a linear mixed-effects model to test the effect of the tool on family-reported QOC (using the QOC scale) as compared with usual care. Secondary outcomes include the effect of the tool on reducing clinician moral distress (using the Measure of Moral Distress for Healthcare Professionals scale) and patients' length of stay in the ICU.

ETHICS AND DISSEMINATION

Institutional review board (IRB) approval was granted at the University of Wisconsin, and all study sites ceded review to the primary IRB. We plan to report results in peer-reviewed publications and national meetings.

TRIAL REGISTRATION NUMBER

NCT05780918.

Learning to Communicate: A Photovoice Study With Intensive Care Residents During Night Shifts in the Intensive Care Unit

This study explored the learning experiences of intensive care residents in an intensive care unit (ICU) during night shifts and the development of communication skills in this community of practice. This action research qualitative study used the photovoice method in four workshops. A group of nine residents shared their learning experiences and collectively analyzed, built, and presented proposals to improve residents' communication skills in the community of practice in which they become intensivists. Participatory thematic analysis was conducted. Students concluded that night shifts in the ICU offered a perfect situational learning environment for communication with one-on-one resident-teacher relationships, less administrative work, and more resident responsibility, improving intensivist identity. Role models, reflective thinking, and teamwork are essential for fostering communication skills among intensivist community members and are all trainable. The results and student suggestions were presented to teachers and decision-makers in the clinic. These photovoice strategies developed students' abilities to share their critical views and suggestions with decision-makers for subsequent implementation, enhancing their confidence in their learning process, strengthening trust-based relationships with teachers, and improving future intensivists' practice communities.

Family centeredness of care: a cross-sectional study in intensive care units part of the European society of intensive care medicine

PURPOSE

To identify key components and variations in family-centered care practices.

METHODS

A cross-sectional study, conducted across ESICM members. Participating ICUs completed a questionnaire covering general ICU characteristics, visitation policies, team-family interactions, and end-of-life decision-making. The primary outcome, self-rated family-centeredness, was assessed using a visual analog scale. Additionally, respondents completed the Maslach Burnout Inventory and the Ethical Decision Making Climate Questionnaire to capture burnout dimensions and assess the ethical decision-making climate.

RESULTS

The response rate was 53% (respondents from 359/683 invited ICUs who actually open the email); participating healthcare professionals (HCPs) were from Europe (62%), Asia (9%), South America (6%), North America (5%), Middle East (4%), and Australia/New Zealand (4%). The importance of family-centeredness was ranked high, median 7 (IQR 6-8) of 10 on VAS. Significant differences were observed across quartiles of family centeredness, including in visitation policies availability of a waiting rooms, family rooms, family information leaflet, visiting hours, night visits, sleep in the ICU, and in team-family interactions, including daily information, routine day-3 conference, and willingness to empower nurses and relatives. Higher family centeredness correlated with family involvement in rounds, participation in patient care and end-of-life practices. Burnout symptoms (41% of respondents) were negatively associated with family-centeredness. Ethical climate and willingness to empower nurses were independent predictors of family centeredness.

CONCLUSIONS

This study emphasizes the need to prioritize healthcare providers' mental health for enhanced family-centered care. Further research is warranted to assess the impact of improving the ethical climate on family-centeredness.

Communication strategies for expressing empathy during family-clinician conversations in the intensive care unit: A mixed methods study

OBJECTIVES

To explore communication strategies intensive care clinicians and patients' family members prefer for expressing empathy during family-clinician conversations.

RESEARCH METHODOLOGY/DESIGN

Mixed-methods survey study.

SETTING

Two medical ICUs of a German academic tertiary care hospital.

MAIN OUTCOME MEASURES

Using a self-developed online survey with closed and open-ended questions with free-text options, the participants' preferences of communication strategies for expressing empathy were investigated. Quantifiable similarities and differences were determined by statistical analysis. Qualitative themes were derived at by directed content analysis.

FINDINGS

The responses of 94 family members, 42 nurses, and 28 physicians were analysed (response rate: 45.3 %). Four communication strategies were deduced: (1) reassuring the families that the intensive care unit team will not abandon neither them nor the patient, (2) acknowledging emotions and offering support, (3) saying that the families are welcome and cared for in the intensive care unit, (4) providing understandable information. In comparison, the families considered an expression of nonabandonment as more empathic than the physicians did (p =.031,r = 0.240), and those expressions focussing solely on the family members' well-being (p =.012,r = 0.228) or comprising evaluative wording ("good", "normal") (p =.017,r = 0.242) as less empathic than the nurses did. Unanimously advocated nonverbal communication strategies included to listen attentively and to avoid interrupting as well as being approachable and honest.

CONCLUSION

The participants' preferences supported expert recommendations and highlighted that it is not only important what the clinicians say but also how they say it. Further research is needed to elucidate ways of successfully expressing empathy during family-clinician conversations in the intensive care unit.

IMPLICATIONS FOR CLINICAL PRACTICE

Intensive care unit clinicians are encouraged to practice active listening and to express their caring and nonabandonment. It is further suggested to reflect on and adjust pertinent nonverbal behaviours and relational aspects of their communication, as applicable.

Can mediation avoid litigation in conflicts about medical treatment for children? An analysis of previous litigation in England and Wales

OBJECTIVE

To investigate the reasons why parents disagree with their clinicians in cases reaching the court and to estimate the number of cases in which mediation might have avoided litigation.

DESIGN

Analysis of 83 published cases regarding medical treatment decisions for children initiated either by an NHS Trust or Local Authority between 1990 and 1 July 2022.

RESULTS

The analysis found that the main areas of contention are different value judgements, different interpretations of observable events such as the health of the child, their quality of life or burden of treatment and relational issues (ie, loss of trust). More than half of the cases are estimated not to have been preventable by mediation because either no conflict existed (n=13) or the parental decision was based on strongly held, mostly faith-based, views unlikely to be open for discussion (n=31).

CONCLUSION

The potential of mediation to avoid future litigation may be more limited than hoped for.

How to communicate with family members of the critically ill in the intensive care unit: A scoping review

OBJECTIVE

To map the existing approaches to communication with family members of the critically ill in the intensive care unit and the corresponding implementation requirements and benefits.

METHODS

We conducted a scoping review in February 2022 by searching PubMed, CINAHL, APA PsycINFO, and Cochrane Library for articles published between 2000 and 2022. We included records of all designs that met our inclusion criteria and applied frequency counts and qualitative coding.

RESULTS

The search yielded 3749 records, 63 met inclusion criteria. The included records were of an interventional (43 %) or observational (14 %) study design or review articles (43 %), and provided information in three categories: communication platforms, strategies, and tools. For implementation in the intensive care unit, the approaches required investing time and resources. Their reported benefits were an increased quality of communication and satisfaction among all parties involved, improved psychological outcome among family members, and reduced intensive care unit length of stay and costs.

CONCLUSION

The current approaches to communication with patients' family members offer insights for the development and implementation of communication pathways in the intensive care unit of which the benefits seem to outweigh the efforts. Structured interprofessional frameworks with standardised tools based on empathic communication strategies are encouraged.

Interprofessional care for the ICU patient's family: solitary teamwork

The aim of this study was to explore how interprofessional family care by ICU teams was reflected in their daily work. Data were collected from four ICUs in Norway. Fieldwork and focus groups with ICU nurses and physicians were conducted in addition to dyadic and individual interviews of surgeons and internists. In line with a constructivist grounded theory approach, the core category "solitary teamworking" was constructed. Together with three sub-categories, proximity and distance, silent interprofessional work and a connecting link, this core category conceptualizes interprofessional family care as a form of contradictory cooperation where physicians and nurses alternate between working alone and as a team. The sub-categories reveal three notable characteristics of interprofessional family care: (1) it is emotionally challenging, affected by proximity and distance to the families and between the clinicians, (2) it is silent, at a strategic and organizational level, and (3) nurses and family members have an essential role as a connecting link in the ICU team. Interprofessional family care needs strong involvement by an organization that supports and prioritizes family care, includes family members as an active part of the ICU team and emphasizes interprofessional dialogue.

Interpersonal Conflict between Clinicians in the Delivery of Palliative and End-of-Life Care for Critically Ill Patients: A Secondary Qualitative Analysis

Background: Conflict between clinicians is prevalent within intensive care units (ICUs) and may hinder optimal delivery of care. However, little is known about the sources of interpersonal conflict and how it manifests within the context of palliative and end-of-life care delivery in ICUs. Objective: To characterize interpersonal conflict in the delivery of palliative care within ICUs. Design: Secondary thematic analysis using a deductive-inductive approach. We analyzed existing qualitative data that conducted semistructured interviews to examine factors associated with variable adoption of specialty palliative care in ICUs. Settings/Subjects: In the parent study, 36 participants were recruited from two urban academic medical centers in the United States, including ICU attendings (n = 17), ICU nurses (n = 11), ICU social workers (n = 1), and palliative care providers (n = 7). Measurements: Coders applied an existing framework of interpersonal conflict to guide initial coding and analysis, combined with a flexible inductive approach allowing new codes to emerge. Results: We characterized three properties of interpersonal conflict: disagreement, interference, and negative emotion. In the context of delivering palliative and end-of-life care for critically ill patients, "disagreement" centered around whether patients were appropriate for palliative care, which care plans should be prioritized, and how care should be delivered. "Interference" involved preventing palliative care consultation or goals-of-care discussions and hindering patient care. "Negative emotion" included occurrences of silencing or scolding, rudeness, anger, regret, ethical conflict, and grief. Conclusions: Our findings provide an in-depth understanding of interpersonal conflict within palliative and end-of-life care for critically ill patients. Further study is needed to understand how to prevent and resolve such conflicts.

Improving Safety and Quality During Interhospital Transfer of Patients With Nontraumatic Intracranial Hemorrhage: A Simulation-Based Pilot Program

BACKGROUND

The presentation of critically ill patients to emergency departments often necessitates interhospital transfer (IHT) to a tertiary care center for specialized neurocritical care. Patients with nontraumatic intracranial hemorrhage represent a critically ill population subject to high rates of IHT and who is thus an important target for research and quality improvement of IHT. We describe the use of an innovative simulation methodology engaging transfer staff, clinicians, and stakeholders to refine and facilitate the adoption of a standardized IHT protocol for transferring patients with neurovascular emergencies.

METHODS

This was a qualitative study using a phenomenological approach. Participants consisted of IHT call center staff members, neurointensivists, neurosurgeons, and emergency physicians. We conducted a standardized telephone-based simulation case to prime participants for feedback on their experiences with IHT for intracranial hemorrhage patients. Facilitators conducted focus groups immediately after the simulation to identify process improvement opportunities. A structured thematic analysis identified overarching concepts from the data.

RESULTS

We achieved data saturation with 7 simulations and a total of 24 participants. Thematic analysis identified 3 IHT-specific themes: (1) challenges unique to multispecialty critical illness, (2) interdisciplinary relationships and dynamics, and (3) communication and information processing for IHT. Three quality improvement initiatives emerged from the debriefings: standardized communication checklist, early acceptance protocol, and structure for telephone-based care handoffs.

CONCLUSIONS

We demonstrate the use of telephone-based simulation technology to identify potential pitfalls and accelerate the adoption of a new IHT protocol for patients with nontraumatic intracranial hemorrhage. New quality improvement strategies can organically result through interprofessional debriefings for patients with potentially complex handoffs between hospitals.

Caught between ideals and reality: Phenomenological-hermeneutic study of healthcare providers' experiences while interacting with mechanically ventilated patients

This study aimed to explore healthcare providers' experiences of their communication and interaction with conscious patients on mechanical ventilation in intensive care. Nurses, physicians, and physiotherapists were interviewed after they had been video recorded in naturally occurring interactions with patients. The interviews were analyzed using a phenomenological-hermeneutical approach. Three themes were identified: The willingness to engage and understand the mechanically ventilated patient, the potential risk of neglecting the patient in the encounters, and provider interdependence as the core of intensive care. The themes elicited how providers handled the dissonance between their own personal ideals of care and their real-world encounters with patients and other professionals. The healthcare providers were aware of how easily patients could be neglected while being non-vocal, and therefore invested time and effort communicating with the patients. Based on their personal ideals of patient participation and autonomy, it was difficult to perform procedures, such as weaning off the ventilator or mobilization, to which the patient was opposed. Interprofessional collaboration was valued by the providers in such situations. The study revealed that providers need to consider the communication barriers that exist on the individual and team levels when interacting with patients on mechanical ventilation.

Exploring medical students' perceptions of the challenges and benefits of volunteering in the intensive care unit during the COVID-19 pandemic: a qualitative study

OBJECTIVES

In March 2020, the WHO declared SARS-CoV-2 a pandemic. Hospitals across the world faced staff, bed and supply shortages, with some European hospitals calling on medical students to fill the staffing gaps. This study aimed to document the impact of volunteering during the COVID-19 pandemic on students' professional development, resilience and future perceived career choices.

DESIGN

This is a retrospective, qualitative study of student reflections, using purposive sampling.The Royal College of Surgeons in Ireland (RCSI) University of Medicine and Health Sciences recruited 26 medical student volunteers to assist in pronation and supination of ventilated patients affected by SARS-CoV-2. These students were invited to complete an anonymous survey based on their experiences as volunteers. Thematic analysis was performed on these written reflections.

RESULTS

The results showed that volunteering during the COVID-19 pandemic developed key skills from RCSI's medical curriculum, significantly fostered medical students' resilience and guided their career choices. Major areas of development included communication, teamwork, compassion and altruism, which are not easily developed through the formal curriculum. A further area that was highlighted was the importance of evidence-based health in a pandemic. Finally, our respondents were early stage medical students with limited clinical exposure. Some found the experience difficult to cope with and therefore supports should be established for students volunteering in such a crisis.

CONCLUSION

These results suggest that clinical exposure is an important driver in developing students' resilience and that volunteering during a pandemic has multiple benefits to students' professional development and professional identity formation.

Changes in communication of end-of-life decisions in European ICUs from 1999 to 2016 (Ethicus-2) - a prospective observational study

PURPOSE

We investigated changes in communication practice about end-of-life decisions in European ICUs over 16 years.

MATERIALS AND METHODS

This prospectively planned secondary analysis of two observational studies in 22 European ICUs in 1999-2000 (Ethicus-1) and 2015-16 (Ethicus-2) included consecutive patients who died or with limitation of life-sustaining therapy. ICUs were grouped into North, Central and South European regions.

RESULTS

A total 4592 patients were included in 1999-2000 (n = 2807) and 2015-16 (n = 1785). Information about patient wishes increased overall (from 25.4% [570] to 51.1% [840]) and in all regions (42% to 61% [North], 22% to 56% [Central] and 20% to 32% [South], all p < 0.001). Discussions of treatment limitations with patients or families increased overall (66.0% to 76.1%) and in Northern and Central Europe (87% to 94% and 75% to 82.2%, respectively, all p < 0.001) but not in the South. Strongest predictor for discussions was the region (North>Central>South) followed by patient decision-making capacity.

CONCLUSION

End-of-life decisions are increasingly discussed but communication practices vary by region and follow a North-South gradient. Despite increased availability of information, patient preferences still remain unknown in every second patient. This calls for increased efforts to assess patient preference in advance and make them known to ICU clinicians.

Disconnection in Information Exchange During Pediatric Trauma Transfers: A Qualitative Study

Pediatric patients experiencing an emergency department (ED) visit for a traumatic injury often transfer from the referring ED to a pediatric trauma center. This qualitative study sought to evaluate the experience of information exchange during pediatric trauma visits to referring EDs from the perspectives of parents and referring and accepting clinicians through semi-structured interviews. Twenty-five interviews were conducted (10 parents and 15 clinicians) and analyzed through qualitative thematic analysis. A 4-person team collaboratively identified codes, wrote memos, developed major themes, and discussed theoretical concepts. Three interdependent themes emerged: (1) Parents’ and clinicians’ distinct experiences result in a disconnect of information exchange needs; (2) systems factors inhibit effective information exchange and amplify the disconnect; and (3) situational context disrupts the flow of information contributing to the disconnect. Individual-, situational-, and systems-level factors contribute to disconnects in the information exchanged between parents and clinicians. Understanding how these factors’ influence information disconnect may offer avenues for improving patient–clinician communication in trauma transfers.

Perceptions of quality of communication in family interactions in neurocritical care

OBJECTIVE

Given the challenges of patient-provider communication in neurocritical care lacking robust decision-making tools on prognostication, we investigated concordance in perceptions of communication among participants in family discussions and assess the different domains of communication that affect these perceptions.

METHODS

Prospective observational study conducted over 4 months in a tertiary-level academic medical center neurocritical care unit. Our study involved family discussions regarding plan of care for admitted patients observed by a neutral observer. All participants completed a survey. The first four questions rated the understanding of the discussion and general satisfaction; the remaining questions were open-ended to assess the quality of communication by the physician leading the discussion. Responses were scored and compared among participants using a Likert scale. A difference of < 1 in scores among participants was rated as concordance, whereas that of > 1 was designated as discordance. All open-ended responses were classified into six domains.

RESULTS

We observed 35 family discussions. Questions 1 to 3 inquiring on general satisfaction, impact, and understanding of treatment options yielded 99 cross-comparisons per question (297 compared responses). Most responses were either "Strongly Agree" or "Agree," with "Neutral" or "Disagree" responses being more prevalent in Question 2 regarding the impact of the conversation. Overall concordance of responses between participants was 88% with a lower rate of concordance (72%) on Q2. Further open-ended questions queried observers on specific physician-spoken content, and answers were analyzed to identify domains that affected the perception of quality of communication. Education was the most frequently cited domain of communication in response to open-ended questions. Among family and neutral observers, empathy was frequently listed, whereas providers more often listed family engagement.

CONCLUSION

Overall, satisfaction was high among providers, families, and the observer regarding the quality of communication during family discussions in the unit. Perceptual differences emerged over whether this communication impacted healthcare decision-making during that encounter.

Fluctuating Code Status: Strategies to Minimize End-of-Life Conflict in the Neurocritical Care Setting

BACKGROUND

There are multiple factors that may cause end-of-life conflict in the critical care setting. These include severe illness, family distress, lack of awareness about a patient's wishes, prognostic uncertainty, and the participation of multiple providers in goals-of-care discussions.

METHODS

Case report and discussion of the associated ethical issues.

RESULTS

We present a case of a patient with a pontine stroke, in which the family struggled with decision-making about goals-of-care, leading to fluctuation in code status from Full Code to Do Not Resuscitate-Comfort Care, then back to Full Code, and finally to Do Not Resuscitate-Do Not Intubate. We discuss factors that contributed to this situation and methods to avoid conflict. Additionally, we review the effects of discord at the end-of-life on patients, families, and the healthcare team.

CONCLUSION

It is imperative that healthcare teams proactively collaborate with families to minimize end-of-life conflict by emphasizing decision-making that prioritizes the best interest and autonomy of the patient.

COVID-19: lessons for junior doctors redeployed to critical care

Approximately 4% of patients with coronavirus disease 2019 (COVID-19) will require admission to an intensive care unit (ICU). Governments have cancelled elective procedures, ordered new ventilators and built new hospitals to meet this unprecedented challenge. However, intensive care ultimately relies on human resources. To enhance surge capacity, many junior doctors have been redeployed to ICU despite a relative lack of training and experience. The COVID-19 pandemic poses additional challenges to new ICU recruits, from the practicalities of using personal protective equipment to higher risks of burnout and moral injury. In this article, we describe lessons for junior doctors responsible for managing patients who are critically ill with COVID-19 based on our experiences at an urban teaching hospital.

Humanizing Intensive Care: From Theory to Practice

The International Research Project for the Humanization of Intensive Care Units (Proyecto HU-CI) was initiated in 2014. The aim of this project is to change the current paradigm toward a human-centered care model. Patients, families, and professionals (everyday stakeholders) were asked to describe their ideal intensive care unit (ICU). Using their opinions, 8 fields of research to improve the management of ICUs and change the reality of care throughout the world were designed. This replicable tested model to humanize the ICU care delivery model is presented.

The hard talk: Managing conflict in the cardiac intensive care unit

Conflict between parents and providers is common in the cardiac intensive care setting, particularly in patients with prolonged length of stay. Poor communication is the most commonly cited reason for conflict and is exacerbated when providers and families cannot find common ground and develop mutual trust. It is critically important that healthcare providers learn strategies to better partner with families in order to optimize patient medical and psychosocial outcomes. This requires providers to avoid falling prey to their own implicit (or unconscious) biases, including those towards families labeled as “difficult”. Building a healthy family-provider relationship is part of a healthcare provider's duty to treat, has a measurable effect on patient outcomes, and sets up a foundation for the provider-family dyad to more easily navigate any conflicts that do develop. Once a relationship is built, providers and families can talk through their conflicts. They are more likely to have open and transparent communication and are more able to give each other the benefit of the doubt when navigating difficult situations and/or behaviors, rather than labeling each other as intrinsically “difficult” people.

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The healthcare team is designed to work together like chess pieces on a chess boardParents supporting critically ill hospitalized children may feel more like metaphorical checkers – isolated and out of place.

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The everyday stresses of living in the cardiac intensive care unit frequently lead to parent-provider conflict.

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Conflict occurs on a foundation of previous experiences of both parent and provider; these associated biases contribute to conflict escalation.

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Avoiding labels and approaching difficult situations with empathy and self-reflection helps arrest the cycle of conflict and build mutual trust.

Ethical, legal, and communication challenges in managing goals-of-care discussions in chronically critically ill patients

Clinicians should expect controversial goals of care discussions in the surgical intensive care from time to time. Differing opinions about the likelihood of meaningful recovery in patients with chronic critical illness often exist between intensive care unit providers of different disciplines. Outcome predictions presented by health-care providers are often reflections of their own point of view that is influenced by provider experience, profession, and personal values, rather than the consequence of reliable scientific evaluation. In addition, family members of intensive care unit patients often develop acute cognitive, psychologic, and physical challenges. Providers in the surgical intensive care unit should approach goals-of-care discussions in a structured and interprofessional manner. This best practice paper highlights medical, legal and ethical implications of changing goals of care from prioritizing cure to prioritizing comfort and provides tools that help physicians become effective leaders in the multi-disciplinary management of patients with challenging prognostication.

Developing Strategy: A Guide For Nurse Managers to Manage Nursing Staff's Work-related Problems

PURPOSE

The purpose of this study was to assess nursing staff's work-related problems as perceived by their managers and thereafter develop strategies that would serve as a guide for nurse managers to manage these problems.

METHODS

A descriptive research design was used. The participants included in the study consisted of the following two groups: Group 1-a convenience sample of 150 first-line managers working at three different hospitals; and Group 2-a panel of experts for the Delphi technique, selected using the Snowball sampling technique. Tools for data collection included the following: Tool 1-questionnaire about nursing staff's problems; Tool 2-Delphi technique to develop strategies for managing nursing staff's problems; and Tool 3-opinionnaire format.

RESULTS

The recruited first nurse managers were of the opinion that job stress, work overload, conflict, workplace violence, poor performance, staff turnover, demotivation, lack of empowerment, and staff absenteeism were among the common problems faced by staff nurses at work.

CONCLUSION

From the expert panelists' perspectives, the newly developed strategy in this study was considered valid; the researchers recommend the strategy developed in this study to be universalized in different health care settings and used as a guide for nurse managers.

Effects of a person-centred care intervention in an intensive care unit: Using mixed methods to examine nurses' perspectives

AIM

We identified nurses' experiences and changes in person- and family-centred care (PFCC) after applying a family-visiting programme in an intensive care unit (ICU).

BACKGROUND

Critical care provision is shifting to include communication among patients, families and health care providers.

METHODS

We used mixed methodology and a group pre- and post-test design. In 2019, 30 ICU nurses completed an 8-week programme, including keeping a diary and completing fundamental care activities. A survey of PFCC nursing performance was completed pre- and post-programme, and 15 nurses were interviewed post-programme. Performance differences were examined through paired t tests; qualitative data were analysed by thematic analysis.

RESULTS

The pre- and post-scores were 3.06 ± 0.34 and 4.00 ± 0.29, respectively (t = 17.38, p =.000), and five main themes and 13 subtopics were revealed. Most nurses 'discovered the importance of nursing through a truthful relationship with ICU patients' families'.

CONCLUSION

For effective PFCC, changes in nurses' perceptions and hospital organisation are required, such as improving the ICU working environment, assigning suitable health care personnel to provide care and implementing open-visit programmes.

IMPLICATIONS FOR NURSING MANAGEMENT

Hospital policymakers and nurse managers should take care to provide staff support and high-quality patient care to realize effective PFCC.

Hard Enough to Manage My Emotions: How Hardiness Moderates the Relationship Between Emotional Demands and Exhaustion

The frequency of conflicts with patients' families is one of the main contributors to the amount of emotional demands that healthcare professionals must tackle to prevent the occurrence of burnout symptoms. On the other hand, research evidence suggests that hardiness could enable healthcare professionals to handle their responsibilities and problems effectively. Based on the health impairment process of the Job Demands-Resources model, the main goal of this study was to delve deeper into the relationship between conflict with patients' families, emotional demands, and exhaustion, as well as to test the buffering role of hardiness. Data were collected from a sample of N = 295 healthcare professionals working in a private hospital in Northern Italy. Most of them were women (78.6%) with a mean age of 40.62 years (SD = 9.50). The mediation of emotional demands within the association between conflict with families and emotional exhaustion and the moderating role of hardiness was tested using a bootstrapping approach. In the current sample, emotional demands mediated the association between conflict with families and exhaustion among healthcare professionals. Moreover, this relationship decreased among individuals with higher levels of hardiness. These findings contribute to the current understanding of the negative impact played by conflict with families on healthcare professionals' psychological well-being. Furthermore, they corroborated the role of hardiness as a personal resource that could prevent the occurrence of burnout symptoms. In addition to manage-and decrease-episodes of conflict with patients and their families, organizations in the healthcare sector should develop interventions aimed at fostering employees' hardiness and, consequently, tackle job demands ingrained in their profession (i.e., emotional demands).

Creating Healthful Work Environments to Deliver on the Quadruple Aim: A Call to Action

Nurses face workplace stressors that contribute to job dissatisfaction, burnout, and turnover, impacting not only patient safety but the nurses' physical and emotional well-being. At the 2018 American Academy of Nursing conference, a policy dialogue "Creating Healthy Work Environments to Address the Quadruple Aim" was convened focusing on creating healthy work environments by addressing stressors such as violence and bullying. That discussion is encapsulated in this article, providing proven and practical strategies for reducing risk.

Interprofessional Shared Decision-Making in the ICU: A Systematic Review and Recommendations From an Expert Panel

OBJECTIVES

There is growing recognition that high-quality care for patients and families in the ICU requires exemplary interprofessional collaboration and communication. One important aspect is how the ICU team makes complex decisions. However, no recommendations have been published on interprofessional shared decision-making. The aim of this project is to use systematic review and normative analysis by experts to examine existing evidence regarding interprofessional shared decision-making, describe its principles and provide ICU clinicians with recommendations regarding its implementation.

DATA SOURCES

We conducted a systematic review using MEDLINE, Cumulative Index to Nursing and Allied Health Literature, and Cochrane databases and used normative analyses to formulate recommendations regarding interprofessional shared decision-making.

STUDY SELECTION

Three authors screened titles and abstracts in duplicate.

DATA SYNTHESIS

Four papers assessing the effect of interprofessional shared decision-making on quality of care were identified, suggesting that interprofessional shared decision-making is associated with improved processes and outcomes. Five recommendations, largely based on expert opinion, were developed: 1) interprofessional shared decision-making is a collaborative process among clinicians that allows for shared decisions regarding important treatment questions; 2) clinicians should consider engaging in interprofessional shared decision-making to promote the most appropriate and balanced decisions; 3) clinicians and hospitals should implement strategies to foster an ICU climate oriented toward interprofessional shared decision-making; 4) clinicians implementing interprofessional shared decision-making should consider incorporating a structured approach; and 5) further studies are needed to evaluate and improve the quality of interprofessional shared decision-making in ICUs.

CONCLUSIONS

Clinicians should consider an interprofessional shared decision-making model that allows for the exchange of information, deliberation, and joint attainment of important treatment decisions.

Scales Used to Measure Job Stressors in Intensive Care Units: Are They Relevant and Reliable? A Systematic Review

Background: Many studies have been conducted in intensive care units (ICUs) to identify the stress factors involved in the health of professionals and the quality and safety of care. The objectives are to identify the psychometric scales used in these studies to measure stressors and to assess their relevance and validity/reliability. Methods: All peer-reviewed full-text articles published in English between 1997 and 2016 and focusing on an empirical quantitative study of job stressors were identified through searches on seven databases and editorial portals. Results: From the 102 studies analyzed, we identified 59 different scales: 17 "all settings scales" (16 validated scales), 20 "healthcare settings scales" (13 validated scales), and 22 "ICU settings scales" (two validated scales). All these scales used measured stressors from at least one of the following eight broad categories: High job demands, Problematic relationships with other professionals, Lack of control over work situations and career, Lack of organizational resources, Problematic situations with users and relatives, Dealing with ethical- and moral-related situations, Risk management issues, and Disadvantages in comparison to other occupational situations. The "all settings scales" and "healthcare settings scales," the most often validated, did not measure, or only slightly measured, the stressors most specific to ICUs. Where these were taken into account, the authors were forced to develop their own tools or modify existing scales without testing the validity of the tool used. Conclusions: This review highlights the lack of a tool that meets both the criteria of validity and relevance with regard to the specificity of work in ICUs. Future research must focus on developing reliable/valid tools covering all types of relevant stressors to ensure the quality of the studies carried out in this field.

Resilience or detachment? Coping strategies among termination of pregnancy health care providers in two South African provinces

There is global recognition that competent and willing health care providers remain the most important determinant of safe abortion or termination of pregnancy services. The psychosocial well-being of providers is critical to the provision of responsive termination of pregnancy services. In light of the dearth of scholarly attention on termination of pregnancy providers' coping strategies in low- and middle-income countries, this paper explores coping strategies among these providers in the urban Gauteng and the mixed rural-urban North West provinces of South Africa. During 2015, in-depth interviews were conducted with 30 termination of pregnancy providers working at abortion facilities in these provinces. Questions focused on providers' lived experiences of abortion service provision, the meanings they attached to their work and their reported coping strategies. Interpretative phenomenological analysis was used to analyse the interviews. Interviewees' mean age was 45.8 years, all were professional nurses and the majority were female (82%), working for an average of 3.6 years in abortion services. Four overlapping themes emerged in relation to reported coping strategies: silence and concealing emotions; seeking support; detachment or disengagement; and belief systems. Study findings point to the need for effective, sustainable employee wellness programmes, within an overall context of positive practice environments.

Interpersonal Communication among Critical Care Nurses: an Ethnographic Study

Introduction: Interpersonal communication in critical care units is one of the most important factors due to complicated and critical conditions of patients. Nurses’ confrontation with ethical distresses and conflict resolution techniques are often influenced by the culture governing these units. This study aimed to explore interpersonal communication culture among critical care nurses.

Methods: A focused ethnographic approach was used to conduct study in Iran. The research method was based on the research evolutionary cycle model recommended by Spradley (1980). Data were collected over six months through purposeful sampling and semi structured interviews (n=18) and participation observation (n=43). The data were obtained over six months of observation and interview with participants. Data analysis was done by Spradley method and was interpreted to discover the meaning units from the obtained themes. MAXQDA10 was used to manage data.

Results: Five major domains of observations and high-level consensus were extracted in this study, including grouping, work-life interaction, professionalism, organizational atmosphere and experience.

Conclusion: Development of interpersonal communication culture is influenced by various factors. Besides, the working models and nurses’ use of workspace are indispensable components of effective communication at workplace. The findings of this study can be helpful in determining appropriate strategies and practices to resolve communication problems among nurses by specifying challenges, thereby leading to proper communication among nurses, promoting this communication and finally providing high quality and more effective care.

The differing perspectives of doctors and nurses in end-of-life decisions in the intensive care unit: A qualitative study

BACKGROUND

End-of-life (EOL) decision-making in the intensive care unit (ICU) can be emotionally challenging for both doctors and nurses, who are sometimes placed in difficult positions where they are required to make decisions on behalf of patients. With an ageing population and advances in medical technology, there is an increase in such decisions being made in ICUs.

OBJECTIVES

The objective of this study was to explore the perspectives of doctors and nurses involved in the EOL decision-making process in an ICU.

METHODS

This study used a qualitative methodology based on naturalistic inquiry. Intensive care nurses and doctors from a large Sydney metropolitan public hospital were purposively selected, and data saturation was reached after a total of eight nurses and four doctors were interviewed. Data were collected through semistructured interviews, either face-to-face or over the telephone. Interviews were then transcribed verbatim, and themes were identified and coded through a line-by-line analysis of each transcript (manual thematic analysis).

FINDINGS

The findings revealed two main themes: 'Doctors' and nurses' roles in decision-making' and 'Managing family expectations'. These themes highlighted key differences in decision-making processes, in that doctors tended to aim to meet the family's needs, while the nurses tended to advocate on behalf of the patient and what they interpreted as the patient's best interests. Furthermore, nurses tended to feel undervalued in decision-making during family conferences, when in reality, the doctors were making decisions based on all information obtained, primarily from nursing staff.

CONCLUSIONS

EOL decision-making is complex and affects doctors and nurses involved in different ways. More emphasis on interprofessional education and collaboration between the two disciplines may enhance future decision-making processes.

Preventing Conflicts Between Nurses and Families of a Multi-ethnic Patient Population During Critical Medical Situations in a Hospital

Introduction: Little is known about how to avoid intercultural nurse–family conflicts in critical care settings. In this article, strategies are discussed that may be useful to prevent or mitigate intercultural nurse–family conflicts during critical medical situations in hospital. Method: Strategies are based on an ethnographic study by Van Keer et al., other literature, and expert opinion. Results: Sufficient structural measures are needed. First, institutions must create appropriate ward policies, such as including nurses in end-of-life communication. Second, nurses should be coached in the workplace. Third, institutions must provide adapted, visual, ward information to families. Additionally, education and research are needed. These measures should be actively stimulated by nurse managers and reflect a multicultural program supported by the hospital. Discussion: Intercultural nurse–family conflict prevention or mitigation should take into account organizational aspects, on hospital units and in hospital as a whole, and the crucial role of education and research.

We don't need unilateral DNRs: taking informed non-dissent one step further

Although shared decision-making is a standard in medical care, unilateral decisions through process-based conflict resolution policies have been defended in certain cases. In patients who do not stand to receive proportional clinical benefits, the harms involved in interventions such as cardiopulmonary resuscitation seem to run contrary to the principle of non-maleficence, and provision of such interventions may cause clinicians significant moral distress. However, because the application of these policies involves taking choices out of the domain of shared decision-making, they face important ethical and legal problems, including a recent challenge to their constitutionality. In light of these concerns, we suggest a re-conceptualization of informed non-dissent as an alternative approach in cases where the application of process-based policies is being considered. This clinician-directed communication model still preserves what is valuable in such policies and salvages professional integrity, while minimising ethical and legal challenges.

When Team Conflicts Threaten Quality of Care: A Study of Health Care Professionals' Experiences and Perceptions

OBJECTIVES

To explore professionals' experiences and perceptions of whether, how, and what types of conflicts affected the quality of patient care.

PATIENTS AND METHODS

We conducted 82 semistructured interviews with randomly selected health care professionals in a Swiss teaching hospital (October 2014 and March 2016). Participants related stories of team conflicts (intra-/interprofessional, among protagonists at the same or different hierarchical levels) and the perceived consequences for patient care. We analyzed quality of care using the dimensions of care proposed by the Institute of Medicine Committee on Quality of Health Care in America (safety, effectiveness, patient-centeredness, timeliness, efficiency, and equity).

RESULTS

Seventy-seven of 130 conflicts had no perceived consequences for patient care. Of the 53 conflicts (41%) with potential perceived consequences, the most common were care not provided in a timely manner to patients (delays, longer hospitalization), care not being patient-centered, and less efficient care. Intraprofessional conflicts were linked with less patient-centered care, whereas interprofessional conflicts were linked with less timely care. Conflicts among protagonists at the same hierarchical level were linked with less timely care and less patient-centered care. In some situations, perceived unsatisfactory quality of care generated team conflicts.

CONCLUSION

Based on participants' assessments, 4 of 10 conflict stories had potential consequences for the quality of patient care. The most common consequences were failure to provide timely, patient-centered, and efficient care. Management of hospitals should consider team conflicts as a potential threat to quality of care and support conflict management programs.

Nonbeneficial Intensive Care: Misalignments Between Provider Assessments of Benefit and Use of Invasive Treatments

BACKGROUND

The purpose of this study was to examine how frequently invasive intensive care unit (ICU) treatments are delivered to critically ill patients despite clinicians' impressions that ICU care may be nonbeneficial.

METHODS

Patients admitted to the medical ICU of an academic public hospital were prospectively categorized according to guidelines from the Society of Critical Care Medicine which classifies patients based on severity of illness and likelihood of recovery (categories 1-4). Clinical data and use of ICU treatments in patients with high (category 1) and low (category 3) likelihoods of benefit were collected by chart review. Multivariable regression analyses examined associations between use of invasive treatments and patient categories, and clinical factors associated with receiving invasive ICU treatments despite low likelihood of benefit.

RESULTS

There were 533 patients (369 in category 1 and 164 in category 3) in the study. A total of 19.8%, 29.9%, and 28.9% of patient-days on mechanical ventilation, vasopressors, and renal replacement therapy, respectively, were delivered to patients who were considered unlikely to benefit from ICU treatments (category 3) and ultimately did not survive hospitalization. These patients also received 35.2% of cardiopulmonary resuscitation attempts and 22.6% of central venous catheter placements. Clinicians' impressions of likelihood of benefit (category 1 vs 3) were not associated with odds of receiving invasive ICU treatments. Clinical characteristics associated with greater odds of receiving potentially nonbeneficial treatments included older age, presence of dementia or malignancy, and higher Acute Physiologic Assessment and Chronic Health Evaluation score.

CONCLUSIONS

Invasive ICU treatments are frequently delivered to patients who are not expected to benefit from ICU care and die during hospitalization. These findings highlight the need to improve utilization of ICU services among patients with advanced medical illnesses.

Ceilings of treatment: a qualitative study in the emergency department

Background

Decision-making concerning the limitation of potentially life-prolonging treatments is often challenging, particularly in the Emergency Department (ED). Current literature in this area of Emergency Medicine is limited and heterogeneous. We seek to determine the factors that influence ceiling of treatment institution in the ED.

Methods

We conducted a phenomenological qualitative study employing semi-structured interviews. Emergency Medicine Consultants were recruited via a sample of convenience from 5 hospitals in the West of Scotland. Data saturation was achieved after 15 interviews. Interviews were recorded, anonymised, transcribed, coded, and an iterative thematic analysis was carried out.

Results

A model was created to illustrate the identified themes. Patient wishes are central to decision-making. Acute clinical factors and patient-specific factors lay the foundations of ceiling of treatment decisions. This is heavily contextualised by family input, collateral information, anticipated outcome, and whether the patient is accepted for higher care. This decision-making process flows through a ‘filter’ of cultural and environmental factors. The overarching nature of patient benefit was found to be of key importance, framing all aspects of ceiling of treatment institution. Ultimately, all ceiling of treatment decisions result in one of three common patient pathways: full escalation, limited escalation, and maintenance of current care with the option of palliative care initiation.

Conclusions

We present a conceptual model composed of 10 major thematic factors that influence Consultant ceiling of treatment decision-making in the ED. Clinicians should be cognizant of influential factors and associated biases when making these important and challenging decisions.

Electronic supplementary material

The online version of this article (10.1186/s12873-019-0225-6) contains supplementary material, which is available to authorized users.

The perceived and experienced role of the nurse unit manager in supporting the wellbeing of intensive care unit nurses: An integrative literature review

INTRODUCTION

The number of patients requiring admission into intensive care units (ICUs) is increasing worldwide. Concurrently, recruitment and retention of the ICU nursing workforce is becoming a major challenge due to the high intensity environment, heavy workloads, and decreasing nurse wellbeing. Nurse unit managers play a vital role in promoting and supporting ICU nurse wellbeing, yet little is known about perceptions and experiences of this role.

OBJECTIVES

To examine the perceived and experienced role of the nurse unit manager in supporting the wellbeing of ICU nurses.

REVIEW METHODS

A comprehensive review of the literature was undertaken using Whittemore and Knafl's five stage approach: (i) problem identification, (ii) literature search, (iii) quality appraisal, (iv) data analysis, and (v) presentation of findings.

DATA SOURCES

The following databases were searched for literature published between January 2007 and December 2017: Cumulative Index to Nursing and Allied Health Literature, Cochrane, Informit, Joanna Briggs Institute Library of Systematic Review, ProQuest, PubMed, Scopus, and Wiley online library digital databases. Variations and synonyms of key words included: nurse unit manager, ICU, compassion fatigue, burnout, stress, job satisfaction, bullying, wellbeing, and work environment.

RESULTS

Rigour and trustworthiness of the included studies were assessed using the Critical Appraisal Skills Program qualitative research checklist,⁷¹ a modified Critical Appraisal Skills Program Cohort study checklist for quantitative research,⁷² and the Mixed Methods Appraisal Tool for mixed-method studies.⁷³ The critical review guidelines by Shenton⁷⁴ and Polit and Beck⁷⁵ were also used to make judgements about the worth of the evidence. All of the 11 qualitative studies provided moderate to strong evidence. The overall quality of the quantitative studies was lower, with three of seven studies providing only adequate evidence. The majority of the 19 included studies represented the voices of ICU nurses. Three major themes emerged from the analysis; '1) building professional relationships', '2) leading the way' and '3) satisfying the needs of ICU nurses'.

CONCLUSION

Nurse unit manager behaviours clearly affect the wellbeing of ICU nurses. However, the role of supporting ICU nurses is complex and challenging. More research is needed to investigate the needs of ICU nurses and the facilitators and barriers nurse unit managers face when supporting the wellbeing of nurses in their unit.

The relationship between ethical conflict and nurses' personal and organisational characteristics

INTRODUCTION

Critical care nurses work in a complex and stressful environment with diverse norms, values, interactions, and relationships. Therefore, they inevitably experience some levels of ethical conflict.

AIM

The aim of this study is to analyze the relationship of ethical conflict with personal and organizational characteristics among critical care nurses.

METHODS

This descriptive-correlational study was conducted in 2017 on a random sample of 216 critical care nurses. Participants were recruited through stratified random sampling. Data collection tools were a demographic and professional characteristics questionnaire, the Ethical Conflict in Nursing Questionnaire-Critical Care Version, and the Organizational and Managerial Factors Questionnaire. The data were analyzed using the SPSS software (v. 22.0).

ETHICAL CONSIDERATIONS

All participants were informed about the study's aim and were assured that participation in and withdrawal from the study would be voluntary.

FINDINGS

The mean score of exposure to ethical conflict was 201.91 ± 80.38. The highest-scored conflict-inducing clinical situation was "working with professionally incompetent nurses or nurse assistants." Married nurses, nurses with official employment, nurses with master's degree, and nurses with the history of attending ethics education programs had significantly higher exposure to ethical conflict than the other nurses (p < 0.05). The significant predictors of exposure to ethical conflict were marital status, educational status, reward system, organizational culture, manager's conduct, and organizational structure and regulations (p < 0.05). These predictors accounted for 37.2% of the total variance of exposure to ethical conflict.

CONCLUSION

Critical care nurses experience moderate levels of exposure to ethical conflict. A wide range of personal and organizational factors can contribute to such exposure, the most significant of which is the professional incompetence of nursing colleagues, nurse assistants, and physicians. Therefore, many improvements at personal and organizational levels are needed to reduce critical care nurses' exposure to ethical conflict.

Internists' and intensivists' roles in intensive care admission decisions: a qualitative study

BACKGROUND

Intensive care Unit (ICU) admission decisions involve collaboration between internists and intensivists. Clear perception of each other's roles is a prerequisite for good collaboration. The objective was to explore how internists and intensivists perceive their roles during admission decisions.

METHODS

Individual in-depth interviews with 12 intensivists and 12 internists working at a Swiss teaching hospital. Interviews were analyzed using a thematic approach.

RESULTS

Roles could be divided into practical roles and identity roles. Internist and intensivists had the same perception of each other's practical roles. Internists' practical roles were: recognizing signs of severity when the patient becomes acutely ill, calling the intensivist at the right moment, having the relevant information about the patient and having determined the goals of care. Intensivists' practical roles were: assessing the patient on the ward, giving expert advice, making quick decisions, managing access to the ICU, having the final decision power and, sometimes, deciding whether or not to limit treatment. In complex situations, perceived flaws in performing practical roles could create tensions between the doctors. Intensivists' identity roles included those of leader, gatekeeper, life-death decision maker, and supporting colleague doctors (consultant, senior and helper). These roles could be perceived as emotionally burdensome. Internists' identity roles were those of leader and partner.

CONCLUSIONS

Despite a common perception of each other's practical roles, tensions can arise between internists and intensivists in complex situations of ICU admission decisions. Training in communication skills and interprofessional education interventions aimed at a better understanding of each other roles would improve collaboration.

"It's better to have three brains working instead of one": a qualitative study of building therapeutic alliance with family members of critically ill patients

Background

Studies in the intensive care unit (ICU) suggest that better communication between families of critically ill patients and healthcare providers is needed; however, most randomized trials targeting interventions to improve communication have failed to achieve family-centered outcomes. We aim to offer a novel analysis of the complexities involved in building positive family-provider relationships in the ICU through the consideration of not only communication but other important aspects of family-provider interactions, including family integration, collaboration, and empowerment. Our goal is to explore family members’ perspectives on the enablers and challenges to establishing therapeutic alliance with ICU physicians and nurses.

Methods

We used the concept of therapeutic alliance as an organizational and analytic tool to conduct an interview-based qualitative study in a 20-bed adult medical-surgical ICU in an academic hospital in Toronto, Canada. Nineteen family members of critically ill patients who acted as substitute decision-makers and/or regularly interacted with ICU providers were interviewed. Participants were sampled purposefully to ensure maximum variation along predetermined criteria. A hybrid inductive-deductive approach to analysis was used.

Results

Participating family members highlighted the complementary roles and practices of ICU nurses and physicians in building therapeutic alliance. They reported how both provider groups had profession specific and shared contributions to foster family communication, integration, and collaboration, while physicians played a key role in family empowerment. Families’ lack of familiarity with ICU personnel and processes, physicians’ sporadic availability and use of medical jargon during rounds, however, reinforced long established power differences between lay families and expert physicians and challenged family integration. Family members also identified informal interactions as missed opportunities for relationship-building with physicians. While informal interactions with nurses at the bedside facilitated therapeutic alliance, inconsistent and ad-hoc interactions related to routine decision-making hindered family empowerment.

Conclusions

Multiple opportunities exist to improve family-provider relationships in the ICU.

The four dimensions of therapeutic alliance prove analytically useful to highlight those aspects that work well and need improvement, such as in the areas of family integration and empowerment.

Electronic supplementary material

The online version of this article (10.1186/s12913-018-3341-1) contains supplementary material, which is available to authorized users.

Acceptability and feasibility of an interprofessional end-of-life/palliative care educational intervention in the intensive care unit: A mixed-methods study

OBJECTIVES

This study aimed to describe a seven hour End-of-Life/Palliative Care educational intervention including online content related to symptom management, communication and decision-making capacity and an in-person group integration activity, from the perspective of the interprofessional team in terms of its acceptability and feasibility.

RESEARCH DESIGN

A mixed-methods study design was used.

SETTING AND SAMPLE

The study was conducted in a medical-surgical Intensive Care Unit in Montreal, Canada. The sample consisted of 27 clinicians of the Intensive Care Unit interprofessional team who completed the End-of-Life/Palliative Care educational intervention, and participated in focus groups and completed a self-administered questionnaire.

MAIN OUTCOME MEASURES

The main outcomes were the acceptability and feasibility of the educational intervention.

FINDINGS

The intervention was perceived to be appropriate and suitable in providing clinicians with knowledge and skills in symptom management and communication through self-reflection and self-evaluation, provision of assessment tools and promotion of interprofessional teamwork. The online format was more feasible, but the in-person group activity was key for the integration of knowledge and the promotion of interprofessional discussions.

CONCLUSION

Findings suggest that an interprofessional educational intervention integrating on-line content with in-person training has the potential to support clinicians in providing quality End-of-Life/Palliative Care in the Intensive Care Unit.