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Development of a Model of Interprofessional Shared Clinical Decision Making in the ICU: A Mixed-Methods Study

DeKeyser Ganz, Freda PhD, RN; Engelberg, Ruth PhD; Torres, Nicole PhD; Curtis, Jared Randall MD, MPH

doi: 10.1097/CCM.0000000000001467
Clinical Investigations

Objectives: To develop a model to describe ICU interprofessional shared clinical decision making and the factors associated with its implementation.

Design: Ethnographic (observations and interviews) and survey designs.

Setting: Three ICUs (two in Israel and one in the United States).

Subjects: A convenience sample of nurses and physicians.

Interventions: None.

Measurements and Main Results: Observations and interviews were analyzed using ethnographic and grounded theory methodologies. Questionnaires included a demographic information sheet and the Jefferson Scale of Attitudes toward Physician-Nurse Collaboration. From observations and interviews, we developed a conceptual model of the process of shared clinical decision making that involves four stepped levels, proceeding from the lowest to the highest levels of collaboration: individual decision, information exchange, deliberation, and shared decision. This process is influenced by individual, dyadic, and system factors. Most decisions were made at the lower two levels. Levels of perceived collaboration were moderate with no statistically significant differences between physicians and nurses or between units.

Conclusions: Both qualitative and quantitative data corroborated that physicians and nurses from all units were similarly and moderately satisfied with their level of collaboration and shared decision making. However, most ICU clinical decision making continues to take place independently, where there is some sharing of information but rarely are decisions made collectively. System factors, such as interdisciplinary rounds and unit culture, seem to have a strong impact on this process. This study provides a model for further study and improvement of interprofessional shared decision making.

1Faculty of Medicine, Hadassah Hebrew University School of Nursing, Jerusalem, Israel.

2Division of Pulmonary and Critical Care Medicine, Cambia Palliative Care Center of Excellence, Harborview Medical Center, University of Washington School of Medicine, Seattle, WA.

3Department of Psychiatry and Behavioral Sciences, Center for Healthcare Improvement for Addictions, Mental Illness and Medically Vulnerable Populations and Harborview Medical Center, University of Washington, Seattle, WA.

This work was done at the Harborview Medical Center and at the Hadassah Medical Center.

Dr. DeKeyser Ganz consulted for Israel Higher Education Commission, received support for travel from Israel Association of Cardiology and Critical Care Nurses, and is employed by Hadassah Medical Organization. The remaining authors have disclosed that they do not have any potential conflicts of interest.

For information regarding this article, E-mail: Freda@hadassah.org.il

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