Unclear role definitions were amplified during patient care decision-making

The open model structure of the SICU fostered a culture of shared responsibility between the interdisciplinary care teams that comanaged patient care. Unclear, diffuse responsibility blurred boundaries between the critical care team and consulting services. As one faculty surgeon noted, the complex patient care problems can overlap, making critical care management ‘…a lot greyer about, ‘what am I handling and what are [the consultants] handling?’ The diffusion of responsibility was met with tension over who was responsible for different aspects of the patients’ care.

The ICU is…a juggernaut with lots of people that work in it…because of the nebulous reporting structure there, it could be a little challenging sometimes to figure out who is the decision maker, or who do I speak to about this or that? Faculty Surgeon

Participants noted that ambiguity around roles and responsibilities inhibited care team members from making care decisions and escalating communication. Participants shared that this led to delays in care. Non-physician team members spent extra time seeking advice from colleagues and searching through patient charts to find who might be overseeing a patient. Even when there was a call number in the patient notes, it would sometimes be an incorrectly listed. As one nurse said:

In the [Epic] summary page, there is a section that shows you who is ‘primary’…but that doesn't necessarily mean that’s who you're supposed to page. Bedside ICU Nurse

Participants indicated that designating responsibility for specific aspects of patient care to each interdisciplinary care team, creating shared mental models around team boundaries, and establishing points of contact (and appropriate back-up contacts) could aid efficient team communication around patient care.

Formal processes for interdisciplinary care team communication were underused

The formal mechanisms around interdisciplinary care team communication included daily team meetings, multidisciplinary rounds, and patient admissions and handoffs. The implementation of multidisciplinary rounds received positive feedback from interdisciplinary clinicians for providing a platform for different roles to converge on patient care. Many surgical teams sent representative team members, such as APPs, to the critical care team morning multidisciplinary rounds or invited the critical care team to their own team’s morning rounds.

Participants reported that the effectiveness of communication during these formal processes varied by the lead faculty surgeon and their team culture. Rounds were enacted differently depending on the faculty surgeon’s preferences and priorities. As one nurse stated:

…regarding rounds, I think it’s very much faculty surgeon-specific and driven. So, there’s some faculty surgeons that value the interdisciplinary…and they take the time to make sure everyone’s included and everyone understands what’s going on. And then there’s other faculty surgeons who that’s not a priority for them… So I think that can delay care, and that’s when communication breaks happen. Bedside ICU Nurse

Participants indicated that more standardised communication during formal processes could promote knowledge sharing. One nurse reported how a lack of standardised handoff procedures can lead to unintentionally sharing ‘half the story’.

They give you sign out, but… and you get half the story. Then there you are, the primary nurse with the ICU physician-in-training overnight, trying to figure out the plan of care for this patient until the day team comes to see them. Bedside ICU Nurse

Current organisational dynamics promoted informal communication pathways

Participants noted that team members often relied on informal communication pathways because formal processes were lacking. Informal communication pathways included texting, paging, unplanned visits to the OR, unplanned visits to the critical care offices and hallway conversations. They allowed for rapid updating and information exchange outside of formal processes. Informal communication pathways seemed important given the emergent issues that arise and necessitate quick decision-making.

[Faculty surgeon] and I will use a lot of cell phone or texting and [Faculty surgeon] will even come down to the OR. Or he’ll know I’m actually stuck in the OR for six hours. They’ll need to get some message to us, and text just isn’t good enough, so he’ll walk down to the operating room. Faculty surgeon

While there are benefits to informal communication pathways (such as getting immediate, relevant patient updates outside of designated meeting times), participants reported that having an abundance of informal communication led to an ‘overcommunication’ problem. Participants explained that constant communication between multiple types and levels of providers in the SICU did not always equate to an efficient sharing of knowledge. Additionally, informal communication pathways in the complex SICU environment were not always structured for following-up on information.

It varies from month to month, and it depends on the day and what’s going on. But I have witnessed a lot of delays in patient care, and a lot of delays in patient throughput, because there hasn’t been follow-up, or those ‘checking back in with each other’ type communication. Nurse clinical coordinator

Informal communication pathways were influenced by physical proximity (accessibility) and relationships with clinicians. If an answer was needed quickly, clinicians would consult the critical care team members nearby on the floor and/or clinicians with whom they had established rapport. Participants underscored how face-to-face communication and physical accessibility were valued. The availability of clinicians on the floor, such as APPs, made their role in care decisions more clinically relevant.

I think the ICU team sometimes is more in communication with the nurses because they are literally on our unit so that we are able to voice our concerns immediately because they sit right there and we’re right there, too. Bedside ICU Nurse

As a workaround for approval on patient care decisions, participants stated that they can get a quick, or potentially more favourable, response by seeking permission or advice from people they know. While informal communication pathways was an effective tool, communication issues arose when team members used the pathways to circumvent appropriate approval. Participants reported that this often occurs when team members are navigating disagreements between the SICU and primary teams.

‘If Mom says no, go to Dad’, and that’s what they'll do…you know how little kids do that. Sometimes people in the ICU will do that if they hear “no” from one person, they'll go to a different person. Physician-in-training

Hierarchy influenced the communication practices of physicians-in-training

Both formal processes and informal communication pathways were subject to cognitive biases that influenced communication behaviours. Participants reported that the negative expressions of cognitive biases, such as overvaluing voices of authority in hierarchical systems, could diminish team members empowerment, especially in non-physicians.

As the main figures of authority, faculty surgeons were reported to have the strongest influence and felt to be responsible for teaching physicians-in-training ‘how to work with others’. Participants, including physicians-in-training, noted that as part of the physician-in-training learning process, physicians-in-training adopted faculty surgeons’ styles during their rotation. Physicians-in-training tended to model behaviours more from their team’s faculty surgeons than from faculty surgeons on other teams or from non-faculty surgeon team members. However, participants were uncertain whether faculty surgeons were fully aware of their influence on interdisciplinary care team communication.

It was just that it was not paid attention to…depending on who the faculty surgeon is in the ICU, it can be run very differently. As is on our service, depending which faculty surgeon is currently on for that week, it can be run very differently. APP

Participants reported that when communicating with non-physicians, physicians-in-training would mirror their faculty surgeon’s practices for creating (or reducing) psychological safety and minimising (or increasing) the presence of hierarchy. As nurses noted:

Some physicians-in-training are great with it, some have no desire to speak with nurses. They're going to speak only to the doctor and the nurse can figure it out later. My point is that it also comes from the faculty surgeons. There’s some faculty surgeons that have no desire to communicate with the nurse…well, of course that behavior then is demonstrated to the physicians-in-training who follow the same behavior. Nurse clinical coordinator

Team cultures and practices that inhibit the non-physician voice block an optimal exchange of information, weakening effective interdisciplinary care team communication. When the hierarchy was flatter, trusting relationships between physicians-in-training and nurses could greatly facilitate interdisciplinary communication. Physicians-in-training and nurses (both within and across teams) built trusting relationships through patterns of interactions where they saw each other work with patients, took feedback and achieved consensus. The relationship between nurses and each individual physician-in-training had to be established anew every month because SICU physicians-in-training changed monthly. Physicians-in-training earned the trust of bedside SICU nurses when they made informal visits before and after morning rounds to check on the patients and get updates from the nurses. This demonstrated respect for the nurses, valuing their perspective and flattening the interdisciplinary hierarchy.

During rounds, [the physician-in-training] had an excellent presentation, they asked us what we thought was going on…and then they'll circle back, talk to families, and just stuff like that… this person wants to be here. Then the trust comes in too. If I come to someone and I'm like, “this patient, this is what happened and I'm concerned.” And they are like, “okay,” and then they come with me and they assess the patient too… seeing that stuff from physicians-in-training helps build trust. Bedside ICU Nurse

Conversely, nurses earned the trust of the physicians-in-training when they would speak up to educate the physician-in-training, providing rationale to guide care based on their critical care experience and knowledge.

It’s their first time putting in orders…it’s a matter of us being like ‘hey, you put this in and that’s not safe,’ or, ‘you have to change it to this because,’ for X, Y, Z reasons. That helps them trust us because we're not going to do things that will harm the patient, and we're going to help them figure out what needs to be done. Bedside ICU Nurse

Standardised practices supported the development of psychological safety and interdisciplinary team engagement

A high level of psychological safety sets the stage for participants to engage meaningfully and earn team members’ trust. Participants, particularly non-physician team members such as APPs and nurses, expressed a desire to feel more engaged and psychologically safe in team-level patient decision-making. These participants stated that they were more likely to speak up and share their perspective in team discussions when they felt encouraged by high-status team members (ie, faculty surgeons) to provide input on the care plan. Support from high-status team members was demonstrated by direct invitation (eg, asking team members to attend the meeting or to speak during rounds), mindful presence (eg, allowing team members to finish speaking, not interrupting them or walking away), and validation (eg, acknowledging and acting on what team members communicate).

It’s just a nice invitation to bring up additional issues. Sometimes there’s nothing additional…it’s just nice to be offered that opportunity. Clinical provider

However, routines supporting psychological safety varied by faculty surgeons. While many faculty surgeons welcomed the input of non-physician team members, some either rejected non-physician team input or bypassed them during rounds completely. One non-physician participant pointed out that faculty surgeons can use physical cues to show physicians-in-training and other team members that the non-physician’s input is valued. Otherwise, ‘you feel you have to interject or catch if the team starts to walk away while you’re mid-sentence’. Participants reported that can be impacted by how faculty surgeons and higher-level team members demonstrate respect and trust to non-physician team members outside rounds as well.

…the faculty surgeon [physician] made a comment to their team about not listening to the non-physician and making sure that they take things to a more higher-level and I couldn’t have helped feeling insulted….I understand that I am definitely a lower-level staff member, but at the same time this is coming from a higher-level person who’s telling me to carry out these plans. APP