Professionalism, Teamwork and Regulation in the Intensive Care Unit

Abstract

In this chapter, we discuss the concepts of professionalism in relation to intensive care medicine. The intensive care management of patients represents the sharp edge of every speciality and the potential for miscommunication, conflict, psychological overload and burnout is large. The presence of a culture of trust between patients and staff, and between staff members is a major factor in patient outcome, staff recruitment, staff retention and motivation. As critical care morbidity and mortality rates improve, patient and staff expectations of an acceptable short-term and long-term outcome increase. To reach these expectations, healthcare professionals need to operate in high performing teams, with defined standards and objectives. We focus on key aspects of good professional behaviour, high-performance healthcare teams and the regulatory aspects of care in the high technology, critical care environment.

1. Introduction

Critical care medicine offers many challenges for staff and patients. When admitted to the Intensive Care Unit (ICU) patients are critically ill and require life-saving intervention with the aim of disease treatment and maximising organ support and recovery. If the patient survives, there may be a prolonged period of rehabilitation. This level of medical intervention is usually coordinated by a specialist in critical care medicine and delivered by a multidisciplinary team of health professionals.

The range of disciplines that now contribute to the outcome of the patient has grown and includes clinical psychology, speech and language therapy, bioengineering and clinical pharmacy. As care has become more complex, the need for experienced professionals has increased, with a worldwide shortage of intensive care staff. Recruitment, training and retention of valuable ICU staff are important. Understanding what makes team members satisfied with their job is vital in keeping good staff, reducing disruptive staff turnover and improved continuity of high-quality care to patients. Emphasis on a healthy professional culture within the ICU can be helpful in encouraging personal and professional development, and positive interactions between staff and patients.

2. Professionalism

The term professionalism describes the attributes of a skilled competent practitioner. These qualities reassure the patient and their family that they can trust healthcare staff to do their best for them, be honest in their interactions and speak up when needed. Professionalism also encompasses an acceptance that a clinician participates in ongoing training and education, reflective practice, audit and assessment. Within its scope is a code of conduct which always prioritises the dignity and safety of the patient.

3. Teamwork

As we have moved from parallel practice to the concept of integrative multidisciplinary care, the intensive care team has evolved to include many physicians and healthcare professionals who share the common goal of delivering high quality, coordinated patient-centred care. Team members are highly skilled professionals who contribute from their diverse knowledge and experiences to improve patient care.

The structure of the team can vary depending on the needs of the patient and the availability of staff. During a typical admission to the intensive care unit (ICU) a patient can expect to receive care from the following team members; ICU doctor, ICU nurse, medical/surgical doctor, physiotherapist, dietician, occupational therapist, speech and language therapist, pharmacist, psychologist and social worker. The delivery of patient care is the result of a highly coordinated effort from each of these professionals. Many critical care units will be in teaching hospitals, so there will be students and trainees in each discipline present and participating in the team. With healthcare staff delivering care over 24-hour periods, there is a handover of patient information across shifts. This means relatively large numbers of trained staff are required to maintain safe care. To operate a large team in a cohesive fashion takes attention and a proactive approach to resolving differences in opinion. Excellent communication assists greatly in keeping a team together, with the common aim of giving good patient care.

3.1 High performance teams in the intensive care unit

There is an emerging body of research, which suggests that high-performance teams lead to improved outcomes in healthcare. Initially coined in the 1950s and adopted as a concept within organisation development, a high-performance team consist of a group of skilled individuals with a shared goal. The analogy has been drawn from Formula 1 motor racing and nuclear energy production. All high-performance teams are under pressure to deliver consistently high-quality results in a climate of significant risk. Through open communication, role expectations and group operating procedures, the high-performance team collaborate to produce reliable superior results.

Considering the wide variety of expertise amongst professionals involved in delivering critical care, the concept of a high-performance team seems appropriate to adopt. In this section, we discuss the essential components of high-performance teamwork and the potential barriers faced in the busy intensive care environment.

3.1.1 Fundamental elements of high-performance teamwork in the intensive care unit

3.1.1.1 Common goals

The ICU team must agree upon short- and long-term goals of care for each patient. These goals are individualised and reflect the priorities of the patient and their family. All team members, including the family, should be involved in the initial setting of goals of care. Ideally, these goals should be written down and be easily accessible to all team members. There should be regular and routine evaluation of progress and all team members must agree on amendment of processes if goals are not sufficiently reached.

3.1.1.2 Clear roles and responsibilities

Each member of the ICU team must have individual, discipline-specific roles, and responsibilities. It is important that team members are aware of each other’s functions, so each has a clear understanding of both individual and team obligations. Labour should be divided according to the expertise available to enhance team efficiency in realising common goals. Holding information in separate silos across the ICU team may cause difficulties in communication, especially out of usual working hours. For this reason, it is preferable if clinical records are contributed to and maintained centrally. This is easy to achieve when an electronic record is used.

3.1.1.3 Accountability

High-performance teams must demonstrate individual and shared accountability. Individual accountability is dependent upon the personal values of each team member. It may be encouraged by setting personal goals for team members and regular feedback to the individual. Shared accountability can be achieved by agreeing upon group-wide operating rules and standards. Regular review and reinforcement of standards will encourage mutual accountability amongst the team. Open discussion of risk, adverse events and error is a key element in producing accountability: if critical care staff feel that they work in a climate of compassionate understanding of adverse events, they are more likely to be comfortable managing their personal responsibility for patient care.

3.1.1.4 Leadership

Effective teams require a team leader who is responsible for overseeing group performance. The team leader should ensure provision of a cohesive and supportive team environment. Although traditionally the physician would be the team lead in ICU, the lead in any given scenario may be determined by the needs and experience of the team at that time, rather than in a hierarchical manner. Shared decision making is fundamental to a high-performance team. The team leader should abolish the top-down leadership style and encourage every team member to have a voice, regardless of their position. The value of this approach becomes clear as the team develops and leads to richer interaction. When a critical incident occurs that requires flat lines of communication and prompt action, prior investment of time and effort in professionalism development across the team delivers excellent results in terms of patient care and how team members feel after the event. If there is a poor outcome, follow up between the team leader and team members is important to support staff and extract learnings that can be shared with the aim of improving care.

3.1.1.5 Continual enhancement of skills

Team members must commit to continual enhancement of their individual skills. This may involve participation in courses or further academic endeavours. The high performing team will encourage each member to enhance their skills and provide adequate time and support for such activities. Team-based education and simulation sessions can facilitate learning in an environment with considerable risk of serious adverse events [1, 2, 3]. Interdisciplinary education may also improve team bonding and communication [4].

3.1.1.6 Wellbeing

Individual and team wellbeing must be acknowledged by the institution. High personal and collective morale may enhance job satisfaction. This can in turn improve collaborative processes, productivity, and staff retention.

3.1.1.7 Psychological safety

To function at a high level, trust between team members is imperative. Psychological safety is the belief that one will not be punished or humiliated for making suggestions or admitting to error. This encourages transparency amongst team members. A no-blame culture is fostered where active participation and critical thinking can flourish, allowing the team to discuss and learn from their mistakes [5]. This collaborative approach will address deficits in the team’s processes to improve the safety of patient care. Maintaining the dignity of a patient in the critical care unit is central to good care. Placing an emphasis on the dignity of staff is important to staff psychological safety and retention. Each unit needs to have active measures in place to tackle bullying. Bullying is extremely damaging and contributes to high staff turnover, which impacts patient care. Focus on upstream measures is most effective—creating a positive culture of support for each other at a fundamental human level exposes those who begin to engage in bullying as being out of step with the ‘norm’ for this unit. This approach includes coaching and mentoring through addressing errors, and remediation to keep staff working safely. All team members should be encouraged to care for themselves emotionally and physically, with institutional promotion of self-care, good mental health and collegial conduct.

3.1.1.8 Conflict management

Open communication is essential for high-performing teams. A diverse multidisciplinary team may have conflicting individual ideas or priorities at times. Team members must feel comfortable and supported to communicate their concerns about team processes and direction of patient care. The team must have consistent channels for communication, ideally with regularly scheduled meetings. Conflicting ideas must be identified and discussed early. It is important for the team leader to embrace but depersonalise diverse views. They will manage relationships amongst the team members and address any obstacles that may hinder group performance. Professionalism supports should be funded and made available including specific training courses, facilitated debriefing, mentoring and referral to counselling. These measures may be co-facilitated by the human resources department in the hospital, as there may be overlap with employment issues.

3.1.1.9 Outcome measurement

Any high-performance team should have a measurement system in place to determine their success. This allows for timely and reliable feedback to the team regarding their successes and failures. Local metrics foster an environment of continual improvement and learning. Most intensive care units collect a vast amount of data on patient admissions, and this contributes to audits. Intensive care units may collaborate and combine their audit information to produce more robust targets and standards e.g., Paediatric Intensive Care Audit Network (PicaNet) in the United Kingdom and Ireland. This means that measurable patient care processes can be audited against the group’s agreed standards and amendments made to local processes based upon results. An example of this is the assessment of an unplanned extubation event. Using data from a number of ICUs and from a number of years, it is possible to produce a standardised rate and compare individual units performance each year against this rate. Ideally, outcomes would be validated and internationally recognised to allow the team to compare themselves with similar units in other jurisdictions [6]. Patient’s outcomes can be tracked over time and communicated back to the team. Satisfaction of patients, their families and team members can also be measured and followed over time. Staff resigning from work should be offered a confidential interview to ascertain information which might assist in improving team-working and patient care.

3.1.1.10 Appraisal of team members

Feedback to individuals and the team reinforces positive behaviours and allows for continual development of the team. It also provides an opportunity for deficits to be identified and remediated. A 360-evaluation process may be utilised whereby many colleagues, regardless of discipline or seniority, will provide evaluation for a team member [7]. Interpersonal skills and professionalism are the core emphasis of this approach.

3.1.1.11 Research

ICU team members must keep up to date with the latest emerging evidence in their respective fields. Critical care medicine is a technology-dependent speciality which is rapidly evolving. Specific assessment of new techniques, medications and equipment should be incorporated into a local coordinated research agenda. This is necessary to achieve continuously improving, team-based healthcare. Team members must be provided with sufficient time and resources to engage in relevant research, and feedback their results into clinical practice.

3.1.1.12 The patient and family as team members

Vital to a high-performing ICU team is the inclusion of the patient and their family as integral members of the team. This concept of shared decision-making is gradually replacing a more paternalistic style of directing care [8]. It is important to involve the family in clinical decision making and to allocate sufficient time to meet with them. The patient’s needs and expectations are the driving force for the team’s efforts, and some neonatal and paediatric intensive care units now facilitate unrestricted family visiting and limited participation in medical rounds.

3.1.2 Barriers to high-performance teamwork in the intensive care unit

3.1.2.1 The changing team

As staff change from day to night shift and junior doctors rotate through training posts, the multidisciplinary ICU team is continually changing. Although some team members will be a constant presence, the changing nature of the team can threaten its performance [9]. It may be difficult for new team members to join a well-established and experienced team and it takes time and effort for team members to build a trusting relationship with each other. The rotation of care providers may also influence the continuity of care delivered to the patient. This highlights the importance of having established written goals for patient care.

3.1.2.2 Interpersonal relationships

With the amalgamation of many personalities and healthcare specialities, it is inevitable that conflict may occur within the ICU team. Tension may arise due to the existence of differing priorities or perspectives of team members [10]. Occasionally, the priorities of the team may not align with those of the patient or family. The relationship between team members and the patient and family is important in the overall delivery of care, job satisfaction and incidence of compassion fatigue. Tensions can be exacerbated by inefficient or infrequent communication between team members—this contributes to disharmony in the patient’s bedspace, especially if conflicting pieces of information and opinions are being passed onto the patient and their family. Although reaching an agreement between all team members is challenging, it can be facilitated with early and open communication. Senior team members must oversee conflict resolution with maturity and compassion [11, 12].

3.1.2.3 Psychological stress

The ICU can be a demanding work environment which poses several challenges to team members. Caring for a critically unwell child and their family can be distressing. Team members are often faced with stressful resuscitations, emergencies, and death. Ethical dilemmas are often encountered and can have a psychological impact on the staff involved. A supportive environment is essential to allow staff members to manage these stressors and continue to function as a high-performing team. Debriefing should be used after critical incidents and staff should have access to a counselling service.

3.1.2.4 Resource limitations

Whilst dependent largely upon the collaborative efforts of individual team members, a high-performance healthcare team does require organisational support to function maximally. Adequate resources must be in place to support the work of the team. Health informatics and technological resources should facilitate seamless communication between team members. Financial support should be in place to allow for education and research. Appropriate facilities should be provided for team meetings, education sessions and simulation. Medical equipment should meet minimum standards to deliver care. Team members should be provided with adequate time for completion of clinical duties, continual professional development, and rest.

3.2 Regulatory aspects of medical care in the intensive care unit

Regulation of medical practice in any speciality should focus on ‘right touch’. This is a balance between onerous rules which may lead to defensive practice and light-touch regulation which may not be sufficient to guide good practice. Moving the emphasis of regulation upstream, to the issues which can positively impact a physician’s professionalism will potentially reduce the number and significance of breaches of conduct and competence. Many regulatory bodies around the world now use this ‘right touch’ approach to medical regulation. There has been a move away from self-regulation in many jurisdictions, with the establishment of statutory bodies with a non-medical majority. This is a deliberate action to give reassurance to patients that public protection is the key remit of regulation.

In consultation with the public and the profession, high standards of education and practice are developed. These high standards of medical undergraduate and postgraduate education, postgraduate and speciality training, medical ethics and communication are then applied to educational institutions and individual doctors. Following assessment, recommendations for domains of improvement are made by the regulatory authority and followed up in a cycle of appropriate, targeted regulation. Tailored guides to specific areas of medical practice may be produced by a medical regulator to inform doctors and the public of the standards expected e.g., Telemedicine. A regulator will usually maintain a register of doctors who are qualified in that profession. That register is open to the public for inspection and assurance.

The Intensive Care Unit is a key part of a hospital environment. Intensive or critical care medicine has expanded over the last 2 decades to include premature neonates (Neonatology), infants and children (Paediatric Intensive Care) and adults (Adult ICU). Most ICUs will provide education and training to medical practitioners as part of structured training programs. The curriculum and formal assessment of the training program are decided by the certifying professional body e.g., European Society of Intensive Care Medicine (ESICM). A hospital and its medical staff will have a relationship with a medical regulatory body to ensure that there is protection of the public interest in its interactions with doctors employed within the hospital. All doctors must demonstrate their licence or registration with their regulatory body as part of their terms of employment. This provides the public with confidence that their doctor has the necessary medical qualifications to provide medical services.

3.2.1 Education and training

Regulation extends into education and training with the setting of standards and the periodic evaluation of these standards by the regulatory body. In the ICU, all doctors are expected to meet a basic standard of medical practice and conduct, in addition to demonstrating ongoing learning. There may be overlap with individual training programs and a sharing of compliance data. Accreditation of training bodies by the regulator may be a feature of some healthcare systems, but the principles are the same. A doctor may be asked to demonstrate fitness to practice through a process of investigation if there is a significant complaint made against the doctor. Management of a complaint against a professional is outlined below in Section 2.7.

3.2.2 Continued professional development

Each doctor working in the critical care environment has a professional and ethical obligation to keep up to date with clinical developments. Each year specific training courses may be mandated e.g., resuscitation procedures and algorithms. Professional competencies in communication are important in the ICU where giving patients and families bad news is a vital part of the senior medical role. Miscommunication is a common area of complaint where families have a grievance around how important information was imparted by a doctor. There are simulation modules and training drills in communication skills available.

3.2.3 Supervision and revalidation

All doctors in training programs must be supervised by a doctor senior in experience. Supervision is a skilled intervention, providing oversight of clinical activity, guidance and the capacity for feedback and debriefing. Doctors of all training levels and ability should have access to a supervisor. As critical care medicine is an acute speciality where patients’ clinical status can deteriorate rapidly, supervision should be accessible 24/7. Doctors returning to clinical practice in the ICU following a significant period of absence should be asked to work within a structured program of revalidation to ensure that the doctor is ready to return to full practice and deliver safe patient care. This revalidation program may be sourced from within larger intensive care units, or from the doctor’s professional body.

3.2.4 Mentoring

A mentor can have the capacity to listen and support a colleague and is a formal professionalism arrangement. Informal collegial behaviour is important but not guaranteed, so developing a mentoring relationship over time can assist a physician who needs career advice or advice on managing conflict or clinically challenging situations. Training programs frequently assign a formal mentor to new entrants, however comfortable mentoring relationships often grow organically.

3.2.5 Duty of Candour

In some countries or states, doctors have a legal obligation to disclose details of adverse clinical events to patients and their families. In most areas of clinical practice, there is an ethical duty on the physician to openly discuss significant events or information which could impact patient care. Doctors in the ICU are supported in disclosing information with the support of senior hospital management. Meetings with patients where such matters are disclosed should be documented clearly in the patient’s medical record. The patient should be offered psychological support and follow up after any adverse event.

3.2.6 Raising concerns

All doctors have an ethical duty to document and voice concerns, with regard to clinical resources, patient care and community care of the patient. Safeguarding of patients involves a legal mandate in many countries to formally report a concern that a vulnerable patient is being subjected to abuse. Patients in ICU are vulnerable because of their critical illness and sedation levels which will generally compromise their capacity to advocate for themselves. If a doctor feels that they do not have access to the resources to safely care for their patients, they should clearly articulate this deficit in writing to senior management within their institution. Risk to patient’s care is an important issue in the critical care environment. There are many publications cataloguing incidences of preventable patient harm, and it is a significant cost to the healthcare system in terms of litigation.

3.2.7 Managing a complaint

Patients in ICU and their families may make a complaint about the care that they have received, or their outcome. Sometimes disagreements about direction of care or interventions can occur and it is wise to invest time into resolving potential disputes as soon as they arise. There are a small number of situations that will result in a formal complaint to hospital management even in the context of good quality patient care. Learning the tools to respond compassionately to a complaint, answer questions and give further information is vital to the doctor working in the high-pressure ICU environment. Having access to specific institutional supports is useful if they exist—some hospitals will have a Patient Support Unit or Complaints Department that can assist in open communication with patients and their families. When a complaint is received it is crucial to take adequate time to review the patient’s medical information and clinical course in ICU before responding. A calm response with an expression of empathy is essential. If possible, offer to meet the complainant to discuss the issue to their satisfaction. Both parties should have an accompanying support person, and the meeting should be documented. Open disclosure of facts is expected by complainants and their right to information must be respected. If there has been a poor outcome, this should be acknowledged, and further support offered.

3.2.8 Preparation of reports

Patients who have been in the ICU occasionally warrant a report on their course in ICU. This may be requested by insurance companies, legal representatives or the Coroner. Reports should be prepared by the senior critical care physician involved in the admission of the patient to the ICU. Adequate time should be assigned to the task, with full access to clinical records. It is wise for the report to confine itself to the facts of the case and refrain from opinion unless specifically asked for. Preparation of a report may elicit a request to attend a court hearing to present the information, and this should be allowed as part of the duties of a senior doctor working in ICU.

4. Conclusions

1. Professionalism and effective teamworking are key features of high-quality critical care medicine and contribute to improved patient care.

2. Understanding the regulation of educational and training standards in the intensive care unit is important to ensure that medical care is delivered in an environment which is routinely inspected and accredited.

Acknowledgments

No external funds were sought or obtained for the preparation of this manuscript.

Conflict of interest

The authors declare no conflict of interest.