Interprofessional, Interdisciplinary, or Multidisciplinary?

As a longtime researcher in interprofessional collaborative care and deputy editor-in-chief of the Journal of Interprofessional Care, I was dismayed by the imprecise use of language in the article by Colbenson et al.1 The title says "interprofessional," the first sentence of the abstract says "interdisciplinary," and the abstract also uses the word "multidisciplinary." These words have different meanings and are not interchangeable. The first implies collaborative interactions, the second is often used by physicians to imply physicians with different specialties interacting (eg, oncologist and pathologist), and the third simply means that persons from different professions are in the same space per- haps working in parallel, perhaps sequentially. Another term the authors use, "ICU [intensive care unit] teams," may or may not actually be working as teams, but the terms are not defined. The theme "interdisciplinary dynamics" is really about multidisciplinary interactions and is minimally described. If nurses feel devalued and not involved in decision-making, the dynamics are not interprofessional or even interdisciplinary.

Association of changes in nursing work environment, non-professional tasks, and nursing care left undone with nurse job outcomes and quality of care: A panel study.

BACKGROUND: Strengthening quality of care without compromising nurse job outcomes by building a safer health care system is a common concern worldwide including in China. Most of the current evidence comes from cross-sectional studies conducted in western countries, which limits inferences of causality and generalization. OBJECTIVE: The objectives of this longitudinal study were to compare changes in quality of care, nurse job outcomes, nursing work environment, non-professional tasks, and nursing care left undone in acute hospitals in China between 2014 and 2018. Secondly, we wanted to determine the association of changes in nursing work environment, non-professional tasks, and nursing care left undone with nurse job outcomes and quality of care. DESIGN, SETTINGS, AND PARTICIPANTS: A prospective two-stage panel study conducted in 108 adult medical and surgical units from 23 hospitals in Guangdong province, China in 2014 and repeated in 2018. METHODS: Work environment was measured by the Practice Environment Scale of the Nursing Work Index. Non-professional tasks were measured with a seven-item scale surveying the performance of and time spent on non-professional tasks. Nursing care left undone was measured by 12 items addressing necessary nursing activities. Nurse job outcomes included burnout, dissatisfaction, and retention. Quality of care was measured by four items indicating overall quality of care as assessed by nurses (three items) and patients (one item). Generalized estimating equations with linear regression were employed to analyze data. RESULTS: In 2018, compared with 2014, the nursing work environment had improved, and non-professional workloads had decreased minimally. The average number of the 12 nursing care tasks left undone had increased to 6.5 from 5.6 in 2014. Fewer nurses reported job dissatisfaction or intention to leave. Quality of care was improved slightly as assessed by nurses and patients. As for the changes of hospital organizational factors on quality of care, a better nursing work environment was related to better nurse job outcomes and quality of care. More non-professional tasks were related to higher levels of nurse job burnout. Less nursing care left undone was associated with better nurse-assessed quality of care. Units with more nurses experiencing job burnout and dissatisfaction were likely to have poorer nurse-assessed quality of care. CONCLUSIONS: Improving nursing work environment and supporting nurses to engage in professional and direct patient care as opposed to non-professional work may be beneficial to nurse job outcomes and promote quality of care.

Feasibility of an Intervention Study to Support Families When Their Loved One Has Life-sustaining Therapy Withdrawn.

This investigation addressed family member perceptions of preparation for withdrawal of life-sustaining treatment in the intensive care unit. These families are at a high risk for psychosocial and physical sequelae. The quantitative results of this mixed methods study are reported. A control group received usual care and an educational booklet component of the intervention. The experimental group received the above plus exposure to comfort cart items and additional psychological support. Twenty-eight family members enrolled over a 13-month period. Sixty-one percent (10 intervention, 7 control) completed the follow-up. Fourteen family members (82%) recalled the booklet. Some family members reported moderate to severe depression (12.5%), anxiety (12.5%), and stress (12.6%). Satisfaction with care (83.7%-85.2%) and family member well-being (44.1) were within the norm. Short Form-36 physical component score was higher than the norm, and the mental component score was lower than the norm. This study demonstrated feasibility and acceptability of the interventions and follow-up questionnaires when families make the difficult decision to withdraw treatment. Strategies are suggested to strengthen statistical power.

Hospital nursing organizational factors, nursing care left undone, and nurse burnout as predictors of patient safety: A structural equation modeling analysis.

BACKGROUND: Promotion of patient safety is among the most important goals and challenges of healthcare systems worldwide in countries including China. Donabedian's Structure-Process-Outcome model implies that patient safety is affected by hospital nursing organizational factors and nursing care process. However, studies are imperative for a clear understanding about the mechanisms by which patient safety is affected to guide practice. OBJECTIVE: The objective of this study was to explore the impact of hospital nursing work environment, workload, nursing care left undone, and nurse burnout on patient safety. DESIGN: This was a cross-sectional study conducted in 23 hospitals in Guangdong province, China in 2014. Data from nurses (n = 1542) responsible for direct care on 111 randomly sampled medical and surgical units were analyzed. METHODS: Work environment was measured by the Practice Environment Scale of Nursing Work Index. Workload was measured by day shift unit patient-nurse ratio and non-professional tasks conducted by nurses. Nursing care left undone was measured by 12 items addressing necessary nursing activities. Nurse burnout was measured by the emotional exhaustion subscale of the Maslach Burnout Inventory-Human Services Survey. Patient safety was measured by three items indicating nurses' perception of overall patient safety and nine items addressing patient adverse events. Structural equation modeling was used to examine a hypothesized model that supposed work environment and workload have both direct and indirect effects on patient safety through nursing care left undone and nurse burnout. RESULTS: The findings generally supported the hypothesized model. Better work environment was associated with better patient safety both directly and indirectly. Lower workload primarily indirectly related to better patient safety. Nursing care left undone and nurse burnout were mediators negatively associated with patient safety. CONCLUSIONS: Improving work environment, increasing nurse staffing levels, and providing sufficient support for nurses to spend more time on direct patient care would be beneficial to patient safety improvement.

Life-sustaining treatment decisions in the ICU for patients with ESLD: a prospective investigation.

We conducted a prospective study in the ICU of life-sustaining treatment and comfort care decisions over time in patients with end-stage liver disease (ESLD) from the perspectives of patients, family members, and healthcare professionals. Six patients with ESLD, 19 family members, and 122 professionals participated. The overarching theme describing the decision-making process was "on the train." Four sub-themes positioned patients and family members as passengers with limited control, unable to fully understand the decision-making process. Findings suggest that including patients and family members in non-immediate life-saving decisions and verifying early on their understanding may help to improve the decision-making process.

Who is attending? End-of-life decision making in the intensive care unit.

PURPOSE: Traditional expectations of the single attending physician who manages a patient's care do not apply in today's intensive care units (ICUs). Although many physicians and other professionals have adapted to the complexity of multiple attendings, ICU patients and families often expect the traditional, single physician model, particularly at the time of end-of-life decision making (EOLDM). Our purpose was to examine the role of ICU attending physicians in different types of ICUs and the consequences of that role for clinicians, patients, and families in the context of EOLDM. METHODS: Prospective ethnographic study in a university hospital, tertiary care center. We conducted 7 months of observations including 157 interviews in each of four adult critical care units. RESULTS: The term "attending physician" was understood by most patients and families to signify an individual accountable person. In practice, "the attending physician" was an ICU role, filled by multiple physicians on a rotating basis or by multiple physicians simultaneously. Clinicians noted that management of EOLDM varied in relation to these multiple and shifting attending responsibilities. The attending physician role in this practice context and in the EOLDM process created confusion for families and for some clinicians about who was making patient care decisions and with whom they should confer. CONCLUSIONS: Any intervention to improve the process of EOLDM in ICUs needs to reflect system changes that address clinician and patient/family confusion about EOLDM roles of the various attending physicians encountered in the ICU.

Family members' informal roles in end-of-life decision making in adult intensive care units.

BACKGROUND: To support the process of effective family decision making, it is important to recognize and understand informal roles that various family members may play in the end-of-life decision-making process. OBJECTIVE: To describe some informal roles consistently enacted by family members involved in the process of end-of-life decision making in intensive care units. METHODS: Ethnographic study. Data were collected via participant observation with field notes and semistructured interviews on 4 intensive care units in an academic health center in the mid-Atlantic United States from 2001 to 2004. The units studied were a medical, a surgical, a burn and trauma, and a cardiovascular intensive care unit. PARTICIPANTS: Health care clinicians, patients, and family members. RESULTS: Informal roles for family members consistently observed were primary caregiver, primary decision maker, family spokesperson, out-of-towner, patient's wishes expert, protector, vulnerable member, and health care expert. The identified informal roles were part of families' decision-making processes, and each role was part of a potentially complicated family dynamic for end-of-life decision making within the family system and between the family and health care domains. CONCLUSIONS: These informal roles reflect the diverse responses to demands for family decision making in what is usually a novel and stressful situation. Identification and description of these informal roles of family members can help clinicians recognize and understand the functions of these roles in families' decision making at the end of life and guide development of strategies to support and facilitate increased effectiveness of family discussions and decision-making processes.

Online survey of nursing journal peer reviewers: indicators of quality in manuscripts.

Nursing journal peer reviewers (N = 1,675) completed a 69-item online survey that assessed their views on manuscripts' contributions to nursing, priorities in writing reviews, use of journal impact factor, and other areas related to indicators of quality. They reported using contribution to knowledge or research evidence, topic of current interest, and newly emerging area as indicators of a manuscript's contribution to nursing. In writing their reviews, research rigor and clinical relevance of the manuscript were high priorities. Those familiar with the concept of impact factor were significantly more often not nurses; not United States residents; involved in research; and most often reviewed for journals that published only research or a scholarly mix of research, reviews, policy, and theory. When judging a paper's contribution, nursing journal peer reviewers weigh both research and clinical interests. Most reviewers do not use impact factors and place clinical considerations ahead of impact factors.

Peer reviewer training and editor support: results from an international survey of nursing peer reviewers.

TOPIC: Nursing journals depend on the services of peer reviewers for their expertise in research and clinical practice. Although some research has been done with peer reviewers of biomedical journals, to date, our knowledge about reviewers of nursing journals is minimal. METHODS: In this international survey of 1,675 reviewers for 41 nursing journals, reviewers were asked 69 questions about their experiences reviewing for professional nursing journals. This article examines their answers to the survey questions about training to become reviewers and the support they receive from editors. RESULTS: Results showed that 65% wanted formal training, although only about 30% received such training in the form of orientation, manuals, practice reviews, or workshops. For most peer reviewers, it took one to five reviews before they felt comfortable with the process, although some commented that, "I still question my reviews" and "It took a few years." In this sample, 31% reported getting feedback from editors about their reviews, but 87% wanted feedback. Most (80%) wanted to see the other reviews of the manuscripts they reviewed, although only about 45% actually saw them. Reviewers reported that the editor had been helpful to them by providing feedback, demonstrating appreciation of their efforts, mentoring, and being available. CONCLUSIONS: We concluded from this research that many reviewers' needs for training and support are not being met and that both reviewers and nursing editors could profit from a better understanding of the process. Editors could consider instituting programs of orientation, training, and support such as feedback on reviews, making other reviews available, and feedback on final disposition of manuscripts. Reviewers should consider discussing these issues with editors to make their needs for feedback and training known. Intervention studies to examine the effects of such programs on reviewer satisfaction could ultimately strengthen the nursing literature.

Blinding in peer review: the preferences of reviewers for nursing journals.

AIM: This paper is a report of a study to assess the beliefs and preferences of reviewers for nursing journals about blinding of authors to reviewers, reviewers to authors, neither or both. BACKGROUND: Blinding of author and reviewer names in the manuscript review process has been of interest to nursing editors, but reports that are based on data rather than simply opinion concern the editorial practices of biomedical rather than nursing journals. There has been no study of nursing journal reviewer beliefs and preferences related to blinding. METHOD: A descriptive web-based survey was conducted. The sample included 1675 anonymous reviewers, recruited through 52 editors of nursing journals from their review panels. Data were collected in 2007. FINDINGS: Double-blinding of reviews was the most common method reported. Ninety per cent of respondents reported that the papers they received to review did not include author names. When author names were blinded, 62% of reviewers could not identify the authors of papers; another 17% could identify authors < or =10% of the time. Double-blinding was the method preferred by 93.6% of reviewers, although some identified some advantages to an unblinded open review process. CONCLUSION: Nursing journal reviewers are generally very satisfied with double-blinding and believe it contributes to the quality of papers published. Editors or editorial boards interested in a more open review process could consider alternatives such as offering authors and reviewers the option to unblind themselves. Simply announcing that the review process will henceforth be unblinded would probably lead to loss of reviewers.

Challenges in conducting end-of-life research in critical care.

Critical care units present some unique challenges to the researcher, especially when the research topic of interest is related to end-of-life care. The purpose of this article is to address some of the methodological and practical issues related to conducting end-of-life research in the critical care setting. Recruitment barriers include gaining access to a clinical site, gaining access to patients, and prognostic uncertainty. Additional barriers include challenges related to informed consent, data collection, the research team, and ethical considerations. Strategies are described that can be used to guide researchers to conduct end-of-life research successfully in critical care.

Intensive care unit cultures and end-of-life decision making.

PURPOSE: Prior researchers studying end-of-life decision making (EOLDM) in intensive care units (ICUs) often have collected data retrospectively and aggregated data across units. There has been little research, however, about how cultures differ among ICUs. This research was designed to study limitation of treatment decision making in real time and to evaluate similarities and differences in the cultural contexts of 4 ICUs and the relationship of those contexts to EOLDM. MATERIALS AND METHODS: Ethnographic field work took place in 4 adult ICUs in a tertiary care hospital. Participants were health care providers (eg, physicians, nurses, and social workers), patients, and their family members. Participant observation and interviews took place 5 days a week for 7 months in each unit. RESULTS: The ICUs were not monolithic. There were similarities, but important differences in EOLDM were identified in formal and informal rules, meaning and uses of technology, physician roles and relationships, processes such as unit rounds, and timing of initiation of EOLDM. CONCLUSIONS: As interventions to improve EOLDM are developed, it will be important to understand how they may interact with unit cultures. Attempting to develop one intervention to be used in all ICUs is unlikely to be successful.