Introduction
Countries in Europe as well as the United States are in the process of widely adopting a pioneering approach to interdisciplinary collaboration wherein specialists in multiple fields work together with a common goal centered on the patient/family (Reeves et al., 2017). Under this approach, interdisciplinary members work together in a horizontal relationship, in which all positions are presumed to share common knowledge, skills, and values (Tamura, 2018). Whereas the primary aim of interdisciplinary collaboration in most countries is to improve the quality of medical care, in Japan, the primary aims include reducing physician burden (Tsuruta, 2019) and transferring skills from physicians to nurses or other healthcare professionals (Tamura, 2018). In other words, interdisciplinary collaboration in Japan is largely a complement to job sharing.
In intensive care units (ICUs), interdisciplinary collaboration is vital to providing safe and effective care to patients (Aghamohammadi et al., 2019; Reader et al., 2009), and physician-nurse collaboration is associated with improved long-term patient outcomes (Baggs et al., 1999). However, nurses struggle in the decision-making process of patient care in the ICU (Coombs & Ersser, 2004), and lack of collaboration is a contributing factor for both burnout and turnover (Sundin-Huard, 2001). In recent reports, lack of cooperation has been found to be a factor in burnout for not only nurses but also ICU physicians (See et al., 2018; Welp et al., 2019). Hence, interdisciplinary collaboration is an important issue not only for patient care quality but also for ICU healthcare professionals.
In Japan, medical policies include the enhancement of interdisciplinary collaboration. Leadership is necessary to provide interdisciplinary collaboration and quality care, and good leadership has been shown to improve healthcare provider satisfaction (Kiwanuka et al., 2021). One of the effects of ICU leadership is improving the ability to make appropriate decisions (Brewster et al., 2020). This underscores the importance of leadership in bringing patients, families, and healthcare providers together to make decisions about patient care (Kiwanuka et al., 2021).
Currently, most ICU interdisciplinary collaboration leaders are physicians. However, hospital management systems require that physicians also work outside the ICU, making healthcare professionals other than physicians necessary to achieve effective interdisciplinary collaboration. The process of integrating interdisciplinary collaborations is complex, and historical hierarchical factors and boundaries must be overcome (Goldsberry, 2018). In fact, there are differences in perceptions of interdisciplinary collaboration in ICUs among different healthcare providers, and nurses and clinical engineers tend to be less satisfied with collaboration than physicians (Yamamoto, 2020). Nurses should develop leadership abilities to make autonomous decisions and take actions to better care for patients and their families.
The movement to promote team-based medical care has grown over the years, with its principles already woven into the essence of becoming a nurse (Ujike, 2016). Critical care nurses require a high level of practice to understand the complex medical conditions of their patients and to provide pain relief and promote physical functional recovery effectively. Nurses are the healthcare professionals who spend the most time with patients and their families and are thus in a good position to understand patient needs at an early stage (Lakanmaa et al., 2015). For example, ICU nurse leaders collaborate with various disciplines, including nursing, to meet the needs of patients and their families (Milner et al., 2020). In addition, they promote the release of physical restraints through appropriate assessments of patients under restraint (Kirk et al., 2015).
Practical ability in nurses requires leadership, the ability to exercise membership, and the ability to coordinate (Bender, 2016). Nurses work in a timely manner to provide the care necessary to meet the needs of patients and their families (Sakata & Murata, 2017).
Considering that each professional has been trained to provide effective team care with positive interpersonal interactivity, nurses are well qualified to lead teams (A. B. Hamric & Blackhall, 2007; Mayo et al., 2017). Leading the team also benefits the health professional as a whole (Cooper et al., 2019) to promote collaboration within the healthcare team with skilled practitioners and leaders as "bridging."
According to Urisman et al. (2018), nurse participation in interdisciplinary rounds in the surgical ICU improves communication and collaboration among practitioners. Moreover, leadership is important for safe treatment in ICU incident rates (Pronovost et al., 2006). In other words, nurses should exercise leadership to improve patient and family care and coordinate with various healthcare providers for the smooth provision of medical care.
Having the coordination skills necessary to build excellent communication and relationships is critical to the development of leadership abilities (Tracy & O'Grady, 2019). This practice will promote interdisciplinary collaboration. However, the role of ICU nurses in interdisciplinary collaboration and leadership in patient care remains unclear. It is considered that clarifying this will help elucidate the impact of nurses on interdisciplinary collaboration and lead to the development of nurses who are better prepared to promote interdisciplinary collaboration.
This study was designed to determine the relationship between leadership ability in critical care nurses and interdisciplinary collaboration.
Methods
Definition of Terms
Nursing leadership is defined as follows: Nurses should take the initiative to influence relevant healthcare providers, patients, and patient families to provide patient-centered care. In addition, as patient advocates with the aim of providing patient-centered care, nurses influence the patients, patient families, and healthcare providers. This is required of all nurses who practice care.
Coordination is defined as smoothly providing necessary care to patients and their families by conducting activities that facilitate interdisciplinary and patient-family relationships.
Research Design and Participants
The design of this study was cross-sectional. The survey questionnaire used to collect data targeted 400 institutions with a certified ICU (as of April 2016) in Japan. This survey was conducted by mail, and the number of facilities targeted was determined based on the assumption of a 30% response rate. The institutes were asked by letter to participate in the research, with 168 agreeing to participate.
A total of 3,324 nurses, including certified nurses (CNs), certified nurse specialists (CNSs), nurse practitioners (NPs), and nurse managers, who had worked in their respective ICUs for at least 3 years were enrolled as participants. In Japan, CNS and CN qualifications may be obtained after completing a master's degree at least 5 years after obtaining a nursing license. CN is a qualification that a nurse who has been qualified as a nurse for >= 5 years may obtain after receiving 6 months of professional education. In this study, CN, CNS, and NP are identified collectively as advanced practice nurses (APNs). Three years or more of clinical experience was specified in this study based on Benner's (1999) "The Five Dreyfus Model Stages" statement that quality of care is ensured by grasping the whole experience and working with the medical team.
The Investigation
Nursing leadership ability (primary outcomes)
Leadership ability was defined based on the perspective presented in Oba (2009). With permission, we used a leadership practice index (Self-Assessment Inventory of Leadership role for staff nurses, SAIL; Cronbach's [alpha] = .90; Oba, 2009) for data collection. This scale was developed based on the idea that leadership, which includes nurses' influence on others, is necessary to providing patient-centered care. SAIL addresses five factors and consists of 20 items scored on a 5-point Likert scale ranging from 1 (not at all or not) to 5 (always present or sufficient). Scores for the five subscales and the entire scale (20-100 points) were calculated, with higher scores associated with better nursing leadership ability. The five SAIL subscales include (a) sharing of a common goal with patients (Are patient intervention goals set equally well by the patient and nurse?), (b) self-realization of the importance of relationship building with the patient (Is the interaction between the patient and the nurse centered on the patient?), (c) providing flexible care services (Does the financial instruments' business operator provide flexible and appropriate assistance in accordance with the situation?), (d) interdisciplinary collaboration (What is the quality of response by healthcare providers during delivery of care?), and (e) sense of professionalism and willingness to provide the best possible care (question the identity and ethics of nurses). Furthermore, collaboration with multiple healthcare providers includes receiving expert advice from other disciplines, discussing the role of nurses with other healthcare providers during care, and asking other healthcare providers to cooperate with the care plan.
Perception of interdisciplinary collaboration (secondary outcomes)
The items related to the actual state of interdisciplinary collaboration were the presence of interdisciplinary conferences, opportunities to discuss at conferences, interdisciplinary joint study meetings, consultation opportunities and protocols for medical teams, and authority transfer. In addition, the degree of leadership and coordination among team members for collaboration in the ICU, the degree of difficulty in collaboration, and the degree of collaboration among different professions were measured using a visual analog scale (1-100). To be recognized as team members, the participants were required to answer affirmatively to two questions and to freely describe their conscious acts as promoting interdisciplinary collaboration. Next, the education, experience of interprofessional education, existence of professional qualification, ICU management system, and basic attributes of the participants were investigated. The ICU management system is divided broadly into four categories: first, an intensivist (physician with a specialty in intensive care) who has full responsibility for patient care (closed ICU); second, the management system (work with the patient's primary physician) in which the ICU intensivists are involved in all treatment decisions for patients admitted to the ICU (mandatory critical care consultation; semi ICU-M); third, a management system that involves intensivists only when consulted by the patient's primary physician (electric critical care consultation; semi ICU-E); and fourth, a management system in which there is no intensivist in the ICU and the patient's primary physician is responsible for treatment (open ICU).
Moreover, the level of interdisciplinary collaboration across the ICU to which each participant belonged was determined using the Collaboration and Satisfaction About Care Decisions (CSACD) questionnaire (Baggs, 1994). The reliability of this scale was previously confirmed (Cronbach's [alpha] = .95), and it was reverse-translated into Japanese and used with the permission of the developer. The content validity of the Japanese version was confirmed using confirmatory factor analysis (adjusted goodness of fit index = .88, goodness of fit index = .94, comparative fit index = .96, root mean square error of approximation = .05), and the Cronbach's [alpha] was .94. The CSACD consists of seven items related to collaboration (range: 7-49 points) and two items related to satisfaction with collaboration (range: 2-14 points). This questionnaire is scored using a 7-point Likert scale, with higher scores associated with higher degrees of multidisciplinary collaboration in the ICU. Finally, the conscious acts of nurses related to interdisciplinary collaboration were investigated based on their free-form description.
Data Collection
A survey request form describing the purpose of this study, an anonymous self-administered questionnaire, and a return envelope were sent to ICU nurses at the 168 institutions that had cooperated in the survey in advance. The nurses confirmed the purpose and method of the survey in writing, and those who agreed to participate filled out the questionnaire and then returned it by mail. The survey period was from April to September 2016.
Data Analysis
Descriptive statistics were calculated for each question item. After checking the description normality, we calculated the estimation statistics. Next, using SAIL as the dependent variable and the others as the independent variables, we compared the items or independent variables using a t test or one-way analysis of variance. When a difference fell below the 5% significance threshold, we conducted a Tukey's multiple comparison test. When no equal group variance could be assumed, Welch's test was used. When the significant difference was less than 5%, we used the Games-Howell's multiple comparison method. The causal relationship of SAIL was examined using multiple regression analysis (forced input method). All of the statistical data were analyzed using the statistical analysis software SPSS Statistics Version 25 (IBM Inc., Armonk, NY, USA) and AMOS 4.0 (IBM Japan Ltd.) with the supervision of a statistics expert. A p value of < 5% was considered statistically significant, and the data were expressed as mean +/- SD.
The contents of the free-form description were analyzed using a text mining software program (IBM SPSS Text Analytics for Surveys [TAFS] 4.0). For the primary analysis, keywords were analyzed, and synonyms and unnecessary words in the extracted keywords (following the concept) were arranged. Next, modification analysis was performed. After the concept was extracted, the category was created using a linguistic method, followed by confirmation and manual correction. After calculating the basic statistics, we estimated the other items to be related to the categories derived by TAFS (binary data), and the significance was analyzed using a [chi]2 test.
Ethical Considerations
The investigator's ethics review committee approved this study (approval number: 27-337: 8222). As explained in writing, participation in this study was wholly voluntary, and each participant provided informed consent. The questionnaire was filled out and submitted anonymously.
Results
Participant Demographics
Participant characteristics are summarized in Table 1. The 2,062 valid responses gave a valid response rate of 62.0%. Of these, 696 (33.8%) responded that they were writing free-form description/opinion. The ICU management system provided the characteristic data for the participants. The largest number of participants were from open ICU (827 [40.1%]), followed by semi ICU-M (622 [30.2%]), semi ICU-E (458 [22.2%]), and closed ICU (155 [7.5%]). Furthermore, 124 (6.0%) were APNs (i.e., CNs, CNSs, or NPs).
Nursing Leadership Abilities
The Cronbach's [alpha] coefficients for the SAIL subscales I, II, III, IV, and V in this study were .83, .81, .83, .76, and .89, respectively, and was .90 for the SAIL total score. Qualified nurses scored significantly higher on all items than nonqualified nurses (p < .001) and nurses in higher position (p < .001). Conversely, no significant differences were found in the presence of APN in the institutions (p = .321) or in the ICU management system (p = .116; Table 2).
Perception of Interdisciplinary Collaboration
The results of participant perceptions of interdisciplinary collaboration are summarized in Table 3. In the ICU, 1,591 (77.2%) had attended interdisciplinary conferences, 1,239 (60.1%) had joined interdisciplinary joint study sessions, and 1,626 (78.9%) had related protocols. For the question "Who do you recognize as team members?" less than 50% of the respondents chose patients and their families. Moreover, regarding collaboration with multiple healthcare providers in the ICU, nurse-nurse collaboration was the highest (mean +/- SD = 81.5 +/- 17.8), followed by physician-nurse collaboration (65.9 +/- 22.9). The degree of difficulty in interdisciplinary collaboration in the ICU was 50.9 +/- 26.0, and the extent to which nurses coordinated collaboration among team members was 45.2 +/- 30.6.
The correlation between the total SAIL score and the collaborative score (CSACD) was [gamma] = 0.279 (p < .01) and that between the total SAIL score and the satisfaction score was [gamma] = 0.205 (p < .01).
Factors Influencing Nursing Leadership Ability
Factors associated with SAIL scores were determined using multiple regression analyses (Table 4). The SAIL scores were influenced by factors including coordination among team members for interdisciplinary collaboration ([beta] = .212), a high degree of ICU interdisciplinary collaboration (CSACD scores; [beta] = .196), a high number of perceived team members ([beta] = .140), and the APNs ([beta] = .128; p < .001).
Purposeful Practice of Critical Care Nurses for Interdisciplinary Collaboration
A TAFS analysis was then conducted based on the responses of 696 respondents who expressed a free-form opinion. The TAFS analysis results (Table 5) revealed that, of the 1,392 extracted concepts, 1,168 were obtained by registering synonyms and deleting unnecessary words. The concept was counted when one respondent used it and was counted once even if one person used the same concept several times. The most frequently used term was "patient" (240/696, 34.5%), followed by "opinion" (116/696, 16.7%), "nurse" (99/696, 14.2%), and "family" (99/696, 14.2%). There was no mention of leadership as a purposeful practice by ICU nurses for interdisciplinary collaboration. The contents of the description are as follows:
To clearly communicate the words of patients and their families.
Share information that is only available to nurses who are watching patients every day.
I will be a coordinator for various jobs.
We also examined whether frequently mentioned concepts showed differences between APNs and non-APNs. However, none of the categories revealed significant differences.
Discussion
Leadership Ability
The internal consistency of the nursing leadership ability instrument (SAIL) was sufficient for use in this study. Using this scale, we found that the leadership ability scores for critical care nurses were all higher than those of nurses working in general wards (Oba, 2009). As the differences/characteristics of practice skills among nurses assigned in various departments remain uninvestigated, making comparisons is difficult. However, critical care nurses assign relatively high self-ratings for their practical ability to care for patients with complex or severe illnesses (Lakanmaa et al., 2015). As critical care nurses care for patients/families in the ICU, they may be aware of their relationships and share patient care goals. Nurse leadership ability has been reported as associated with education (Conley, 2019), but no significant difference has been found. However, nursing leadership abilities were significantly higher in APNs, who had all acquired higher education, than in non-APNs.
Studies showing the efficacy of CNS APNs have reported safe and effective care for CNS patients (Newhouse et al., 2011). It has also been shown that experienced CNS activities affect team dynamics positively (Kilpatrick et al., 2016). This is consistent with the results of this study. In general, APNs who have received specialized education for a certain period are regarded as specialists within the organization and have high practical nursing abilities (A. Hamric, 2005). Leadership means working with people, providing synchronization to teams and organizations, and leading teams to achieve their goals (Wojner, 2001). The leadership capability of APNs includes the ability to manage change and revolution and to empower staff (Takekuma et al., 2016). Meanwhile, the leadership abilities of staff nurses and APNs in an organization were not significantly different, suggesting that the role of APNs in Japan is limited to the individual level and does not affect the entire organization. APNs are tasked mainly to improve the quality of patient/family care as well as organizational outcomes (A. B. Hamric, 1994). Moreover, APNs must become leaders and train nurses to work together harmoniously (Goldberry, 2018). As with APNs, non-APNs must grow to be able to work with and provide leadership across multiple disciplines. It is not yet clear what education APNs require to sufficiently master these competences. Further studies on this issue are needed.
Association Between Nurses' Leadership Ability and Interdisciplinary Collaboration
Higher levels of nursing leadership were found in this study to be associated with higher levels of interstaff coordination and interdisciplinary collaboration in the ICU. Reader et al. (2009) reported that leadership is associated with teamwork in ICUs and that coordination is essential to facilitate communication among team members. In addition, nurses may improve patient care decision making by functioning as hubs of communication among team members and patients/families and by improving the sharing of mutual information (Bender, 2016). In this study, keywords such as "communication," "patient," and "information sharing" also ranked high in the free-form description regarding what nurses consciously do for interdisciplinary collaboration. Although the keyword "leadership" did not rank highly, the practice of coordination suggests that nurses contribute to interdisciplinary collaboration. Moreover, leadership ability was associated with recognizing more members as team members. Many professionals work together in the ICU. The practice of patient care with the same awareness by each profession leads to early patient recovery. Therefore, confirming each other's goals and objectives of care and exchanging opinions are essential to providing the best care for patients and their families. However, only 50% of nurses considered patients and their families to be team members. Many patients in the ICU are not able to make sound decisions, reflecting the lack of opportunities for patients to make independent decisions. Patient autonomy in the ICU is reduced because of uncertainties about the patient's life and unclear will. Furthermore, family members are stressed that they are not able to cope efficiently by themselves and are often in a critical state (Ganz, 2019). Furthermore, the role of patient and family advocacy is especially important. To promote patient-centered care, nurses should consistently recognize patients/families as the focus of healthcare, provide information to multiple healthcare providers, and coordinate with various teams.
Hence, the leadership ability of nurses and the coordination ability of teams may influence collaboration within the ICU. Considering that nurses provide patient care around the clock, they may have the best understanding of the individuality of the patient within the team. Thus, the coordination of teams by nurses contributes to the realization of patient-centered medical care. We believe that improving leadership and coordination capabilities requires further education for nurses as well as APNs. Nurses coordinate in terms of information, time, and daily team activities but are often unaware of their actions (Kawashima, 2016). Awareness and clarification of these behaviors may improve the adjustment ability of nurses. To develop the ability of nurses to contribute to collaboration, all members must improve their skills and knowledge and expand their roles.
In the area of critical care, how to utilize limited manpower and conduct effective multidisciplinary collaboration for patient safety and early recovery presents a challenge. To support patient-centered care, it is important for nurses to be able to take active leadership. Nurses are expected to play a coordinating role in showing leadership ability and leveraging the strengths of team members. Finally, APNs in Japan must improve their capabilities not only to play an active role at the individual level but also to play an influential role at the organizational level.
Limitations of Research and Future Challenges
This observational study used a questionnaire and is thus limited by the analysis of the current state of leadership ability and interdisciplinary cooperation. Therefore, surveys that include evaluations by others and observational studies on this issue should be conducted in the future.
Conclusions
The results suggest that a relationship exists between the leadership ability of ICU nurses and the degree of interdisciplinary collaboration in ICU and that this relationship is more significant with regard to APNs. Moreover, the leadership ability of nurses was found to be associated positively with the level of interdisciplinary collaboration. Thus, improving leadership ability in nurses may promote interdisciplinary collaboration, and all nurses should enhance their knowledge and skills to enhance their leadership ability. In addition, examining and implementing educational methods, including the improvement of coordination ability (mainly by APNs), should be considered. It is recommended that the manpower allocation of APNs in ICUs should be assessed in the future to promote the nursing care ability of non-APNs.
Acknowledgments
I am deeply indebted to the physicians, clinical engineers, and nurses working in the intensive care units for their cooperation on this study.
References