Transforming Team Culture: A Case Study From Critical Care

Interprofessional team conflict amplifies division and impedes patient care. Normal differences of opinion escalate to frank conflicts when members respond with indignation or resentment. These behaviors engender a workplace culture that degrades collaborative clinical management and patient safety. We describe the impacts of dysfunctional team culture along with interventions that can lead to more productive teams. In our case study, an interprofessional group of critical care clinicians recognized that their interactions impaired collaborative care and requested support. Two experts, a nurse and a physician, facilitated two 2-h workshops with 18 critical care physicians, nurses, and fellows to begin transforming their dysfunctional unit culture. After establishing psychological safety, facilitators introduced the learning pathways grid to explore (1) how faulty assumptions lead to dysfunctional interactions and suboptimal results and (2) how new assumptions informed by new insights enable teams to redesign their interactions. Through reflection and analysis, clinicians concluded that understanding other clinicians' goals and perspectives benefits patients and families, helps clinicians feel valued, and fosters mutual trust. This exercise supports interprofessional teams to transform dysfunctional interactions by helping team members to develop a mindset of humility and inquiry and to remind themselves about the good intentions in others. To address conflict, we offer a conversational approach grounded in curiosity, respect, and transparency. Ultimately, the most important communication strategy for effective critical care is caring about the perspectives and experiences of other members of the interprofessional team.

Communication as a High-Stakes Clinical Skill: "Just-in-Time" Simulation and Vicarious Observational Learning to Promote Patient- and Family-Centered Care and to Improve Trainee Skill

Patient-provider communication is a hallmark of high-quality care and patient safety; however, the pace and increasingly complex challenges that face overextended teams strain even the most dedicated clinicians. The COVID-19 pandemic has further disrupted communication between clinicians and their patients and families. The dependence on phone communication and the physical barriers of protective gear limit nonverbal communication and diminish clinicians' ability to recognize and respond to emotion. Developing new approaches to teach communication skills to trainees who are often responsible for communicating with patients and their families is challenging, especially during a pandemic or other crisis. "Just-in-time" simulation-simulation-based training immediately before an intervention-provides the scaffolding and support trainees need for conducting difficult conversations, and it enhances patients' and families' experiences. Using a realistic scenario, the author illustrates key steps for effectively using just-in-time simulation-based communication training: assessing the learner's understanding of the situation; determining what aspects of the encounter may prove most challenging; providing a script as a cognitive aid; refreshing or teaching a specific skill; preparing learners emotionally through reflection and mental rehearsal; coaching on the approach, pace, and tone for a delivery that conveys empathy and meaning; and providing specific, honest, and curious feedback to close a performance gap. Additionally, the author acknowledges that clinical conditions sometimes require learning by observing rather than doing and has thus provided guidance for making the most of vicarious observational learning: identify potential challenges in the encounter and explicitly connect them to trainee learning goals, explain why a more advanced member of the team is conducting the conversation, ask the trainee to observe and prepare feedback, choose the location carefully, identify everyone's role at the beginning of the conversation, debrief, share reactions, and thank the trainee for their feedback and observations.

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.

Understanding Palliative Care and Hospice: A Review for Primary Care Providers

Palliative care provides invaluable clinical management and support for patients and their families. For most people, palliative care is not provided by hospice and palliative medicine specialists, but rather by their primary care providers. The recognition of hospice and palliative medicine as its own medical subspecialty in 2006 highlighted the importance of palliative care to the practice of medicine, yet many health care professionals harbor misconceptions about palliative care, which may be a barrier to ensuring that the palliative care needs of their patients are identified and met in a timely fashion. When physicians discuss end-of-life concerns proactively, many patients choose more comfort-focused care and receive care more aligned with their values and goals. This article defines palliative care, describes how it differs from hospice, debunks some common myths associated with hospice and palliative care, and offers suggestions on how primary care providers can integrate palliative care into their practice.