Team management is important in running an ICU. Team members have little faith that conflicts can be dealt with effect. In this article indicators of (impending) conflicts are provided. Patient-centred team meetings are powerful tool to deal with these conflicts, for which a model is presented.
There is general awareness amongst intensivists that good management of the ICU team is of vital importance to the quality of care that can be delivered, and it is also true that working with people who are satisfied in their jobs results in a good atmosphere, in which people enjoy working. To create these circumstances, we need to understand which items are important for ICU staff and, practically, which interventions have a high payoff. In general, for people working in a team, things that matter include: worthwhile work, participation in goal achievement, offering and receiving interpersonal support, and leadership delivered with respect and responsible authority, rather than power. We also know from a Canadian study, that for workers in an ICU there is another important item: faith that conflicts can be dealt with effectively (Ohlinger et al. 2003).
A recent study by Studdart et al. (2003) shows that conflicts in the ICU frequently occur over long-term patients. In a group of 656 patients exceeding the 85th percentile of length of stay, a total of 248 conflicts were found for 209 patients. These conflicts were classified as between the team and family, intra team and intra family (Studdert et al. 2003).
Knowing that conflicts occur frequently and that resolving them is
important for ICU workers, gives us the opportunity to improve communication
and team work. The first thing, therefore, is to recognize a conflict. Also from
the work of Studdart and colleagues, we know that nurses and doctors hold
discordant views about whether a conflict exists. In Studdart’s study,
consensus was reached for only one-quarter of the conflicts researched. Nurses
are more likely to identify conflicts, regardless of their type or source.
How to Recognize a Conflict: Indicators of Trouble
Over the years, we have identified a set of circumstances that may indicate that a conflict is present or impending. I present these circumstances here, in more or less random order:
- A patient with no plan or progress
- A situation where many specialists are involved
- Short, or even worse, no contact time at the bed of the patient during rounds
- Different approaches during different shifts/supervision periods
- Nurses seeking external opinions
- Nurses wanting you to talk more often than usual to the family
- Discussion at the bedside
- Discussions about the patient taking place outside the regular moments/places (especially at night between nurses and residents)
- Doctors growing irritated when the case is brought up
- Residents minimising care
- Individual nurses starting to avoid caring for a patient
- Separate coffee breaks (doctors and nurses) behind closed doors
- And the worst one: “if it was my husband/ father/mother…….”
What Can We Do?
The earlier a conflict is detected and handled, the better. The longer you wait, the more difficult it will be to deal with. Also, clearly stating that there is a conflict acts as a signal to the team that the problem is taken seriously, and provides an opening for it to be dealt with.
Over the years these meetings have acquired the name, “lange
ligger bespreking” or in English, “long-stayer meetings”. The goal of these
meetings is to provide the whole team with the same information, agree upon a plan
of action, and set goals to be reached for the patient by targeted times.
How Do We Do It?
The first thing is to act fast: if a problem is identified, a meeting is organized the same day or the day after. We try to gather as many people and disciplines involved in the care of the patient together. A typical meeting therefore includes the medical supervisor (chair), residents, nurses, physiotherapist, referring and all other specialists who are involved. To structure the information, we use a white-board. We start by reviewing the facts: prior medical history, reason of admittance, results of diagnostic procedures, interventions etc. The next step is drawing up an inventory of the actual situation, listing the current (medical) problems. From these two steps it becomes clear what information is missing and needs to be acquired. We then try to find out why a problem is perceived and here the nurses’ input is vital. Everyone is encouraged to contribute and we use the white-board to list the perceived problems.
This gives us a good idea of what is going on. The fact that we write every point down acknowledges the relevance of input from individual participants and prohibits repetition of facts and arguments over and over. From this collection of information, we try to make an honest estimation of the prognosis for the patient. Although it’s possible to deal with each of the separate issues related to a disease within the ICU environment (e.g. pneumonia, renal insufficiency, peritonitis), we need to evaluate whether everything to be dealt with is compatible with the reserves of the patient. It may be necessary to make restrictions, such as a Do Not Resuscitate order, for example.
The next step is to make a plan to tackle each of the current problems: do we need extra information or should others be involved? What is needed to wean the patient off the ventilator? How can we treat a depression or delirium? Does the family need a special intervention? This leads to a structured daily program, written down, for everyone to follow. In this phase, creativity is required from everyone: dealing with non-standard problems requires finding non-standard solutions. Examples are: allowing the partner to sleep on the ward for a night, providing more privacy for the patient, taking the patient out of the ward while still on mechanical ventilation, or providing the right music or movies on DVD.
Lack of progress is one of the reasons why it is very difficult to care for long-term patients. We therefore try to set goals in time: the effort that we make to improve the situation should also be visible. Such goals might be: with the proper antibiotics started today and adequate treatment of the delirium, the patient should be able to breathe by him or herself for two hours a day in a week from today, or, if we will perform a CT-scan of the abdomen, but find no treatable cause of infection, there are no other options for this patient.
Following the meeting we write a report, so that all team members are informed. In this report who is responsible to do what and goals in time are clear, and everyone is informed when the next meeting to discuss this patient conflict will be held. Usually we plan weekly meetings, and these last as long as necessary.
From the above, a small check list can be derived to evaluate whether the meeting has covered everything:
- Has the prognosis been honestly evaluated?
- Has limitation of treatment or a DNR-order been discussed?
- Have goals been set in time?
- Has a daily program been discussed?
- Is it clear who will do what?
- Has a follow-up meeting been planned?
- Is there a written résumé of the meeting?
A team meeting does not need to cost much time: we usually achieve this in 30-45 minutes. In exceptional circumstances, especially when doctors and nurses are highly emotionally involved, we have been using an external chair for the meeting, usually a psychiatrist highly respected by the conflicting parties.
Although it is important to understand that conflicts in an ICU often erupt over patient management, the root of the conflict may not always be sourced in this area. If conflicts keep recurring and you are unable to solve them at this level, then the source is probably from another area. Theoretically there are four other domains to be taken into account (although not within the scope of this article):
- conflicts relating to tasks/organization of the unit;
- conflicts arising from needs, goals or achievements of the individual co-workers;
- conflicts related to identity or vision;
- conflicts linked to social or emotional aspects of individuals or the whole team.
Resolving the conflicts encountered in patient management are important for ICU-teams. These types of conflict occur frequently, especially in the patient group that exceeds the average length of stay. Early recognition of conflicts through a set of indicators and a standard process for dealing with them can promote good team management and lead to more satisfied workers.