Using Self-Efficacy and Transformative Learning Theories to Examine Interprofessional Collaborative Practice at End-of-Life in the ICU between Nurses and Physicians

Background:  Research has documented that the health care system provides inadequate care for the dying patient at end of life (Papadimos et al., 2011).  In order to provide appropriate end-of-life care for the patient it is imperative that the nurse be able to recognize that the patient is dying, communicate that assessment to the health care team and contribute to the plan of care by way of interprofessional communication and interprofessional collaborative practice (IPCP).  Efforts to change and improve the effectiveness of collaboration and communication between nurses and physicians are evident on an international scale according to Institute of Medicine (2001) and the National Patient Safety Goals Hospital Program (2008).  The Accreditation Council for Graduate Medical Education recognized the importance of nurse-physician relationships and has designated team functioning as a competency area to be addressed by residency programs (Baldwin, 2010).  The Joint Commission for the Accreditation of Healthcare Organizations recognized communication as important to patient safety and set improved effectiveness of communication among care givers as a safety goal (2009).  The Joint Commission identified the need to improve the timeliness of communication between care givers suggesting that this too may further improve patient safety (Manojlovich & Antonakdos, 2008). Effective team work requires mutual respect among members, effective communication, and shared participation and responsibility in the decision making process which are the foundations of the core competencies of IPCP (Interprofessional Education Collaborative Expert Panel, 2011). 

Qualitative research suggests intensive care settings that have higher levels of interprofessional collaboration have lower mortality, shorter length of stays, lower intensive care readmission rate, less nurse-physician conflict, and lower job related stress for nurses (Curtis & Shannon, 2006).  A practice setting that favors nurse-physician communication and collaboration is strongly related to better nurse and physician job satisfaction and even more importantly better end-of-life care for patients.  Better communication between nurses and physicians leads to better satisfaction and positive outcomes for dying patients and their families (Puntillo & McAdam, 2006).  Decision making is a major function and responsibility associated with end-of-life care practice.  Florin, Ehrenberg & Ehnfors, (2006) conducted a study that investigated nurses’ perceptions of the decision making.  They found that nurses and physicians involved in the patients care reported that patients and their surrogates noted they would like to have more conversations with the nurses and have them provide more information.  Researchers Tan, Lee, O’Connor, Peters & Komesaroff, (2013) reported findings from a six month study that end of life decisions were made 24 hours before death. However, when the decision making process actively involved healthcare professionals, the patient and family, for patients who were seriously ill and near end of life, the patient’s wishes were identified and there was less risk of delaying end of life discussions in the illness trajectory.  Active involvement in the decision making process about the treatment plan can set the foundation for increasing understanding and respect of team members feelings, knowledge, and desire to participate more fully in end-of-life care and the decision making process (Yaguchi et al., 2005). 

Purpose:  The study will use the principles of Self-Efficacy Theory and Transformative Learning Theory as theoretical frameworks to explore nurses and physicians perceptions about IPCP in end-of-life care situations and examine factors associated with IPCP. 

Methods:  A cross-sectional, survey design will be used. The setting for this study will be multiple hospital intensive care units (ICUs, ie. step down ICU, MICU, SICU, CCU) in public and private hospitals that have the similar patient populations, including patients requiring prolonged mechanical ventilation (PMV). From the chosen intensive care units, a convenience sample of nurses and physicians who volunteer will be the participants for the research study.  Inclusion criteria will be all full and part-time (at least 20 hours per week) registered staff nurses that provide bedside care and physicians who are responsible for managing the care of patients in the intensive care unit.  Licensed practical nurses certified medical assistants, nursing assistants and technicians, social workers, nurse practitioners, and physician’s assistants will be excluded from the study.  This study is interested in the collaborative practices between the bedside staff nurse and the physicians treating these patients.  Per diem status nurses and non-active physicians on the medical service of the unit will also be excluded.  For this research study, a minimum of 110 participants with complete surveys will be needed for the study’s
sample. 

A 87 item likert-like scale, internet web-based survey will be used to collect data. This study will use separate surveys for nurses and physicians.  Quantitative data will be collected by using existing validated and reliable instruments that measure four independent and one dependent variable. The independent variables to be measured are professional valuing, attitudes toward collaboration, communication, and decision making. Self-reported independent variables that will be included are professional education and training and years of ICU experience.  The dependent variable to be measured is interprofessional collaboration.

Data Analysis: Descriptive and inferential statistics will be used to analyze the data. Descriptive statistics will used to describe demographic characteristics of study participants. A score will be generated for each independent variable and dependent variable.  These scores will be examined for central tendency and distributions for the total sample and for nurses and physicians separately including amount of professional education and training and years of ICU experience.  For continuous variables, the mean and standard deviation will be reported.  An independent t-test analysis will be conducted to test differences in satisfaction with professional valuing, attitude towards collaboration, communication, decision making, and interprofessional collaboration between physicians and nurses.  Pearson’s correlation will be used to test the relationship between demographic characteristics, amount of professional education, years of ICU experience, professional valuing, attitude towards collaboration, communication and decision-making.  Multiple regression analysis will be used to identify significant factors associated with IPCP.

Possible Implications:  The results of this research can be used to determine problematic areas that impede IPCP and identify how nursing research, practice and education can impact and facilitate change in academic preparation of nurses and physicians and improve clinical practice for care of the dying patient.  The core competencies identified for interprofessional education and collaborative practice as educational program objectives can be integrated into a health science curriculum for implementation into didactic and clinical content as well as continuing education for professionals. The evaluation of achievement of these core competencies would include the use of validated and reliable outcome measurements in a structured didactic learning environment.  Implementation and evaluation of achievement of outcomes can be measured in simulated and clinical patient care settings which should include collaboration with nursing and medical disciplines.  The goal of this research is to add to the body of knowledge about educational and practice measures that could be implemented into a health science curriculum to improve how professionals engage in IPCP as well as utilizing IPCP as a foundation to improving knowledge and care of the dying patient.