Association between nurse-physician collaboration and patient outcomes in three intensive care units.

OBJECTIVE: To investigate the association of collaboration between intensive care unit (ICU) physicians and nurses and patient outcome. DESIGN: Prospective, descriptive, correlational study using self-report instruments. SETTINGS: A community teaching hospital medical ICU, a university teaching hospital surgical ICU, and a community non-teaching hospital mixed ICU, all in upstate New York. SUBJECTS: Ninety-seven attending physicians, 63 resident physicians, and 162 staff nurses. PROCEDURE: When patients were ready for transfer from the ICU to an area of less intensive care, questionnaires were used to assess care providers' reports of collaboration in making the transfer decision. After controlling for severity of illness, the association between interprofessional collaboration and patient outcome was assessed. Unit-level organizational collaboration and patient outcomes were ranked. MEASURES: Healthcare providers' reported levels of collaboration, patient severity of illness and individual risk, patient outcomes of death or readmission to the ICU, unit-level collaboration, and unit patient risk of negative outcome. MAIN RESULTS: Medical ICU nurses' reports of collaboration were associated positively with patient outcomes. No other associations between individual reports of collaboration and patient outcome were found. There was a perfect rank order correlation between unit-level organizational collaboration and patient outcomes across the three units. CONCLUSIONS: The study offered some support for the importance of physician-nurse collaboration in ICU care delivery, a variable susceptible to intervention and further study.

Nurse-physician collaboration and satisfaction with the decision-making process in three critical care units.

OBJECTIVE: To assess and compare levels of nurse-physician collaboration and satisfaction with the decision-making process as reported by critical care nurses, resident physicians (residents), and attending physicians (attendings) in making decisions to transfer individual patients out of the critical care unit, and to assess if satisfaction predicts nurse retention. DESIGN: Longitudinal descriptive correlational study using self-reporting instruments. SETTINGS: A university hospital's surgical ICU, a community teaching hospital's medical ICU, and a community hospital's mixed ICU. SUBJECTS: Eighty-one nurses, 23 residents, and 37 attendings from the surgical ICU; 44 nurses and 51 residents from the medical ICU; 25 nurses and 45 attendings from the community hospital's ICU, reporting on the transfers of 473, 465, and 494 patients, respectively. MAIN OUTCOME MEASURES: Healthcare providers' reported levels of collaboration and satisfaction with the decision-making process, the correlations between collaboration and satisfaction, and nurse retention. RESULTS: Nurses and physicians within sites (except attendings from the surgical ICU) reported similarly moderate amounts of collaboration, but nurses reported less satisfaction with decision making than did physicians in all sites. Collaboration was related to satisfaction with decision making for all providers, but more strongly for nurses. The strength of the relationship for nurses was similar in all sites. Nurses' satisfaction with decision making did not predict their retention. CONCLUSIONS: Collaboration between nurses and physicians is a more important component of satisfaction with decision making for nurses than for physicians. Any interventions to change the amount of collaboration in practice must take account of this difference.

Rooming-in for elderly surgical patients.

Elderly patients are at risk for developing acute confusion during hospitalization. Rooming-in, an intervention frequently used for pediatric patients, was compared to usual care in a sample of 24 elderly patients hospitalized for orthopedic surgery. Although confusion during hospitalization, complicate rate, and length of stay did not differ between patients who did and did not have rooming-in, the family members and friends who roomed in were very satisfied with the experience. These findings suggest that rooming-in is feasible and highly satisfactory to the patient's family and/or friends.

Nurses' and resident physicians' perceptions of the process of collaboration in an MICU.

Ten intensive care unit nurses and 10 medical resident physicians were interviewed to compare their perceptions of the process of nurse-physician collaboration. The grounded theory method for concept development recommended by Strauss and Corbin (1990) was used. The core of the process of collaboration for both groups was working together. Two major antecedent conditions were found: being available, which included being in the right place, having time, and having appropriate knowledge; and being receptive, which included being interested in collaboration and having respect and trust for the other profession. The major outcomes of working together were described as improving patient care, feeling better in the job, and controlling costs. The findings of the study pull together disparate concepts associated with collaborative practice and provide direction for future research.

Intensive care decisions about level of aggressiveness of care.

Questionnaires were used to assess (a) the factors intensive care unit resident physicians (N = 33) and nurses (N = 57) perceived as influential in making decisions about level of aggressiveness of patient care (LAC), (b) who residents and nurses believed should be involved versus who was involved in decision making, and (c) the amount of collaboration they perceived in their practices. Questionnaires then were used to assess decision making about 314 patients. All providers agreed that patient request influenced their LAC decisions, with possibility of benefit and diagnosis ranked second and third. Although both nurses and residents believed capable patients should be making LAC decisions, providers identified attending physicians as the most common participants in decision making for specific patients. Residents were more satisfied with the decision making process than nurses, t = 2.05 (88), p = .04. There was no relationship between perceptions of nurse-resident collaboration and providers' inclusion of others in the LAC decision process.

Development of an instrument to measure collaboration and satisfaction about care decisions.

The psychometric assessment of a new instrument for measurement of the construct of nurse-physician collaboration in making specific patient care decisions. Collaboration and Satisfaction About Care Decisions (CSACD), is reported. Content validity for the tool was supported by literature review, nurse and physician experts, and potential subjects. In a pilot study 58 neonatal intensive care nurses' and resident physicians' responses showed variance; alpha reliability of the collaboration questions was 0.95. Construct validity of the collaboration questions was supported by finding expected correlational patterns and by factor analysis revealing a single factor that explained 75% of the variance in collaboration. Further psychometric testing of the instrument is proposed, particularly in the context of substantive studies that would allow investigation of its association with patient outcomes.

A survey of practicing nurses' research interests and activities.

We conducted a survey of 279 practicing nurses' research attitudes, past and current research activities, and research resources. Levels of practice included staff nurses, nurse managers, and advanced practice nurses. Three factors were identified from a 15-item research attitudes scale: research value, confidence, and perceived support. Significant differences were found for research value and confidence among three levels of clinical practice. Advanced practice nurses reported higher research value and confidence than did staff nurses and nurse managers. Most respondents reported using research findings in practice, but only a small percentage were conducting research. Factors related to research conduct and use differed. Suggestions are offered for methods to increase the value of research by practicing nurses.

Two instruments to measure interdisciplinary bioethical decision making.

OBJECTIVE: To develop and test two instruments measuring decision making about level of aggressiveness of intensive care unit (ICU) patient care. Decisions about Aggressiveness of Patient Care (DAC) measures care providers' general perceptions about decision making. Decisions about Aggressiveness of Patient Care for Specific Patients (DAC[SP]) measures perceptions in specific situations. DESIGN: Two-phase psychometric instrument evaluation. SETTING: Phase I, nationally mailed questionnaire. Phase II, northeastern medical center medical ICU. SUBJECTS: Phase I, 22 ICU nurse and physician experts. Phase II, 35 medical ICU staff nurses and eight medical resident physicians. OUTCOME MEASURE: Psychometric properties of instruments. RESULTS: Content validity of both tools was supported by their development from the literature and by the experts. Face validity was supported by the experts, staff nurses, and medical resident physicians. Both instruments had variance in responses, internal consistency reliability (r = 0.53, r = 0.73) and, test-retest reliability (r = 0.73). CONCLUSION: These instruments may enrich our understanding of how care providers make bioethical decisions for ICU patients. Such understanding could assist with development of interventions to increase collaborative interdisciplinary decision making, leading to increased care provider satisfaction and better patient outcomes.

Collaborative interdisciplinary bioethical decision making in intensive care units.

There is strong support in the literature for involvement of nurses with patients and physicians in bioethical decision making about patient care. There are indications that nurses and physicians have different beliefs about decisions made and about the decision-making processes, such as who should be involved and what factors should influence such decisions. The literature also demonstrates that nurses often disagree with physicians or are not involved in ethical decision making or both. Interdisciplinary collaboration has been proposed to improve decision making and recommended for health care giving generally. There is research support for the benefit of collaboration in care giving. Ethical principles also support collaborative decision making, involving nurses, as well as physicians, patients, and family. With collaboration there is sharing of information and perspectives, respect for patient and family autonomy, and disclosure. More studies of interdisciplinary bioethical decision making are needed, measuring both professions' perceptions of their roles in ethical decision making, as well as examining the effects of collaboration on care outcomes.

The association between interdisciplinary collaboration and patient outcomes in a medical intensive care unit.

We prospectively studied the relationship between interdisciplinary collaboration and patient outcomes in the medical intensive care unit (MICU) using nurses' and residents' reports of amount of collaboration involved in making decisions about transferring patients from the MICU to a unit with a less intense level of care. Either readmission to the MICU or death was considered a negative patient outcome. Nurses' reports of collaboration were significantly (p = 0.02) and positively associated with patient outcome, controlling for severity of illness. Patient predicted risk of negative outcome decreased from 16%, when the nurse reported no collaboration in decision making, to 5% when the process was fully collaborative. There was an interaction of collaboration with availability of alternative choices in the transfer decision-making situation. When alternatives were available, collaboration was more strongly associated with patient outcome. There was no significant relationship between residents' reports of collaboration and patient outcomes. The correlation between amount of collaboration reported by nurses and residents about the same decisions was quite low (r = 0.10).

ICU nurse-physician collaboration & nursing satisfaction.

ICU nurses who are satisfied with their work are more likely to be retained, leading to institutional cost savings. In this study, higher levels of nurse-physician collaboration in making decisions about patient care were found to be very important to nurses' satisfaction.