Journal of Critical Care (2011) 26, 104.e7–104.e15
Residents' and nurses' perceptions of team function in the
medical intensive care unit☆
Julia Adler-Milstein BAa , Katherine Neal MDb,c , Michael D. Howell MD, MPHb,c,d,⁎
a
Harvard University PhD Program in Health Policy, Beth Israel Deaconess Medical Center, Boston, MA 02215,
Cambridge, MA 02138, USA
b
Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA 02215, USA
c
Harvard Medical School, Boston, MA, USA
d
Silverman Institute for Healthcare Quality and Safety, Beth Israel Deaconess Medical Center, Boston, MA 02215, USA
Keywords:
Intensive care units;
Patient care team;
Trainee physicians;
Nurses;
Team training;
Team function
Abstract
Background: Team-based care is integral to modern intensive care units (ICUs). Trainee physicians
(“residents”) serve as core team members who provide direct patient care in academic ICUs. However,
little is known about how resident perceptions of ICU team function differ from those of other
disciplines. Therefore, we compared residents' perceptions to those of nurses', the other predominant
direct caregiver group, in the medical ICU.
Methods: A cross-sectional survey was performed with validated team function scales including
presence of a real team, communication quality, collaboration, and coordination. The survey was
administered to nurses and residents in medical ICUs in an urban academic medical center. We analyzed
differences between nurses and residents both in their responses and in their perceptions of how
constructs were interrelated.
Results: Residents felt that the team was more bounded, was more collaborative, and planned its
work to a greater degree, but they were less satisfied with communication, compared with nurses.
Residents and nurses perceived relationships between team function constructs in very similar ways.
Both groups felt that communication openness and collaboration were positively associated but that
communication accuracy and timeliness were negatively correlated, revealing an opportunity to
improve overall team performance.
Conclusions: We found important differences in the way that ICU nurses and medical trainee
physicians, the predominant types of providers caring for the critically ill in academic medical center
ICUs, perceive key aspects of team function. These results may be useful to those responsible for
administering academic ICUs as well as to residency program directors developing communicationand team-based curricula.
© 2011 Elsevier Inc. All rights reserved.
☆
Conflicts of interest: Ms Adler-Milstein has no conflicts of interest to disclose. Dr Neal has no conflicts of interest to disclose. Dr Howell has no conflicts
of interest to disclose.
⁎ Corresponding author. Critical Care Quality, Beth Israel Deaconess Medical Center, Boston, MA 02215, USA. Tel.: +1 617 632 7687 (O), +1 617 359
6331 (C); fax: +1 617 632 0369.
E-mail address: mhowell@bidmc.harvard.edu (M.D. Howell).
0883-9441/$ – see front matter © 2011 Elsevier Inc. All rights reserved.
doi:10.1016/j.jcrc.2010.04.003
104.e8
Multiprofessional care teams form a cornerstone of
modern critical care. In 1973, Max Harry Weil [1]
highlighted care delivered by teams of medical professionals as a fundamental goal of the developing specialty of
critical care medicine. Given the complex nature of critical
care, a dedicated intensive care unit (ICU) team, which
typically includes intensivists, nurses, respiratory care
practitioners, pharmacists, and others [2], enables optimal
care for the most severely ill patients [3,4]. Many studies
have investigated the benefits of team delivery of ICU care,
including its effects on mortality rates, length of ICU stay,
provider perception of quality of care, and costs of care
[5-7]. Collaboration and effective teamwork have also been
shown to improve several dimensions of nursing including
job satisfaction, turnover rate, and stress associated with
morally challenging situations [8,9].
High-performing ICU teams must overcome a unique set
of challenges stemming from the high degree of interprofessional communication and collaboration required from a
diverse team whose members constantly change [10]. This
can be particularly difficult for trainees who are simultaneously developing their clinical skills. In academic medical
centers, this has led to an array of team-training initiatives for
residents and medical students, reflected in a focus on
educational interventions in the literature on trainees and
teams [11]. However, such a focus fails to capture how
perceptions of team function vary by role, with comparatively little known about trainee physicians outside the
context of an educational intervention. This is an important
group to understand because they deliver a great deal of
bedside care and therefore have the potential to profoundly
impact patient outcomes. More specifically, little research to
date has addressed trainee physicians' perceptions of team
function in the ICU setting and how these differ from other
team members' perceptions. One series of articles has
explored the relationship between collaboration and satisfaction for nurses and physicians, with particular focus on the
relationship between collaboration in clinical decisionmaking (such as transfer of patients out of an ICU) and
provider satisfaction [9,12]. Broader insight into how trainee
physicians perceive the multiprofessional team may be
useful to both ICU administrators and residency program
directors. Therefore, we conducted a cross-sectional survey
of ICU trainee physicians and nurses to better understand
differences in perceptions of team function between these
2 key provider groups.
1. Methods
1.1. Research setting
This study was conducted in 6 adult ICUs at the Beth
Israel Deaconess Medical Center (BIDMC) in Boston, MA.
The BIDMC is an urban, academic teaching hospital with
490 total hospital beds, of which 77 are dedicated ICU beds.
J. Adler-Milstein et al.
The medical center has approximately 5000 ICU admissions
annually and an ICU clinical staff composed of nurses whose
practice is limited to critical care, attending physicians,
trainee physicians (including 63 medical interns and 94
medical residents), respiratory therapists, pharmacists, and
other disciplines (eg, physical therapists, social workers).
Some staff members rotate between units, whereas others are
dedicated to a single unit. All of our ICUs have similar
organizational characteristics. All ICUs follow either a fully
closed model (the attending of record is the attending
physician) or a mandatory comanagement model. All units
have had multiprofessional rounds for more than a decade.
These rounds occur in the morning and include nurses,
trainee physicians, attending physicians, and other disciplines such as respiratory therapy and pharmacy.
1.2. Survey development and administration
The survey was composed of a set of previously validated
scales that captured the constructs of interest. Team-level
constructs included presence of a real team, communication
quality, collaborative decision-making, and coordination.
Individual-level job autonomy and job satisfaction scales
were also included to understand the relationship with teamlevel constructs. The concept of a “real team,” as opposed to
a team in name only, means that the individuals responsible
for the work perceive themselves as part of a defined group
that performs interdependent work on an ongoing basis. We
measured this using Wageman's 8-item scale from the Team
Diagnostic Survey, which includes 3 subdimensions:
boundedness (team membership is clear), interdependence
(communication and coordination among team members are
required), and stability (team membership remains consistent
over time) [13]. Communication quality was measured using
Shortell's scale, developed for the ICU setting [14]. His
12-item scale captures 4 dimensions of communication
quality: openness, accuracy, timeliness, and satisfaction.
Collaborative decision-making was measured using Baggs'
5-item scale [15]. Also developed for the inpatient setting, it
includes statements such as “nurses and physicians plan
together to make the decision about care for this patient.”
Coordination was measured using Schippers' 8-item team
planning scale and 5-item action-after-planning scale [16].
Job autonomy (2 items) and job satisfaction (4 items) were
measured using a subset of Hackman's Job Diagnostic
Survey [17]. All responses were reported on a 1 to 7 Likert
scale, with 1 = strongly agree and 7 = strongly disagree.
After initial development of the survey, we conducted
cognitive testing with 3 ICU leaders to identify modifications
required to adapt it to the academic medical center's ICU
setting. In response, we made minor edits such as replacing
“team” with “patient care team,” but did not find any
questions in need of significant change. The survey was
uploaded to a Web-based tool on the hospital's intranet and
administered to the nursing and resident staff. Nurses and
residents received an initial e-mail informing them of the
Residents' and nurses' perceptions of team function
study and requesting their participation. A second e-mail was
sent to all nonrespondents followed by individual reminders.
Nurses completed the survey between November 28, 2006,
and April 29, 2007; residents completed the survey between
February 5, 2008, and June 18, 2008. All respondents gave
informed consent before beginning the online survey. There
was no incentive offered to complete the survey, and no work
time was made available specifically for survey completion.
The study protocol was approved by the medical center's
Institutional Review Board.
1.3. Scale validation
Although we used validated scales, the scales had not
been used together; and therefore, we conducted exploratory
factor analysis with oblique rotation on each of the scales to
verify that the subdimensions formed the intended groupings. The exploratory factor analysis largely replicated the
original scales, indicative of both convergent and divergent
validity. There were only 2 instances in which an item
loaded less than 0.45 on the subdimension and raised the
Cronbach α score of the subdimension when dropped. To
be conservative, we ran all analyses with the 2 items
excluded; and this did not materially change our results. To
further confirm scale reliability, we calculated Cronbach α
scores for each subdimension and report them here: real
team–bounded (.72), real team–interdependent (.76), real
team–stable (.81), communication quality–openness (.86),
communication quality–accuracy (.78), communication
quality–timeliness (.82), communication quality–satisfaction (.89), collaboration (.88), coordination-planning (.88),
coordination-action (.77), and job satisfaction (.70).
1.4. Statistical analyses
The goal of our analysis was to compare nurses and
residents along the constructs of interest. First, to test for raw
differences, a subdimension score was calculated for every
respondent by averaging their response to the items
comprising the subdimension. Mean subdimension scores
were then calculated for nurses and residents and assessed for
significant differences using t tests. Because some of the
scores were not normally distributed, we also ran a
nonparametric test of significance (Wilcoxon rank sum);
but results differed only minimally from the parametric test.
Thus, we present P values from the t tests as well as report a
Bonferroni-adjusted P value cutoff for these results to
address issues related to multiple testing. To investigate the
relationship between subdimensions, Pearson correlations
and unadjusted levels of significance were calculated for
nurses and for residents. We again report the Bonferroniadjusted P value cutoff for the results and indicate which
correlations remain significant at this level. Finally, we
compared nurses' and residents' Pearson correlations using
Fisher r-to-z transformation, a method of transforming
correlation coefficients into standard z scores to enable us
104.e9
to test for a significance difference between correlation
coefficients for nurses and residents. Again, we relied on a
Bonferroni-adjusted significance level cutoff to correct for
multiple tests of significance. All analyses were conducted in
Stata (version 10.1; StataCorp, College Station, TX).
2. Results
The overall response rate was 49.3%. Forty-six nurses
and 94 residents completed the survey, for a response rate
of 36% (46/127) and 60% (94/157), respectively. These
Table 1
Respondent demographics
Residents Nurses
n
Age
20-29
30-29
40-49
50-59
60-69
Not reported
Sex
Male
Female
Not reported
Race/ethnicity
American Indian/Alaska
Native
Asian
Black or African American
Hispanic or Latino
Multiple ethnicity
Other
White
Not reported
Education
Associate degree
(eg, AA, AS)
Bachelor's degree
(eg, BA, BS)
Master's degree
(eg, MA, MS, MBA)
Doctorate degree
(eg, MD PhD, DrPH)
Other
Not reported
Tenure
Mean years worked in
an ICU setting
Mean years worked
at BIDMC ICU
Mean years worked at
this hospital or other health
care delivery setting
Mean hours per week in ICU
P value
94 (60%) 46 (36%)
70%
28%
1%
0%
0%
1%
13%
37%
30%
17%
0%
2%
b.001
38%
61%
1%
15%
85%
0%
.014
1%
0%
.102
14%
1%
3%
1%
5%
70%
4%
0%
0%
2%
0%
0%
89%
4%
0%
7%
0%
78%
0%
7%
100%
0%
b.001
0%
7%
0%
2%
Mean (SD)
2 (1.0)
11 (9.2)
b.001
2 (0.9)
10 (9.3)
b.001
3 (8.4)
14 (9.4)
b.001
63 (29.6) 35 (5.8)
b.001
104.e10
J. Adler-Milstein et al.
Fig. 1
Nurse and resident subdimension scores.
response rates are consistent with those of other surveys
conducted in the hospital's ICUs. Table 1 presents
demographic data for the residents and nurses who
responded. Compared with nursing respondents, resident
respondents were younger, were less predominantly female
(61% vs 85%), and included a wider variety of self-identified
ethnic groups (70% “white” vs 89%). On average, nursing
respondents had 11 years of ICU experience, with an average
of 10 years at BIDMC. The residents had an average of 2
years of ICU experience. Residents reported working an
average of 63 hours per week (while on ICU rotation),
whereas nurses reported 35 hours per week.
Nurse and resident mean subdimension scores are
shown in Fig. 1, with corresponding mean scores presented
in Table 2. For each subscale, lower scores suggest greater
agreement with the statement; and higher scores are
consistent with less agreement. Nurses felt that the team
was less bounded (mean score, 3.1 ± 1.2) than did the
residents (2.4 ± 1.1, P = .001). Scores for team interdependence and stability were not statistically different. Nurses
and residents felt that communication was similarly accurate,
and open, and timely; however, nurses felt that communication was more timely (mean score, 2.3 ± 0.9) than did
residents (2.7 ± 1.1, P = .03). Nurses were also more satisfied
with communication than were residents (mean score, 1.8 ±
0.8 vs 2.2 ± 1.0; P = .003). Residents felt that the team
worked more collaboratively than did nurses (mean score,
2.0 ± 0.7 vs 2.6 ± 1.1; P b .001) and also felt that there was
more planning on the ICU team (mean score, 2.2 ± 0.7 vs 2.7
± 1.0; P = .002). Both groups felt that agreed-upon actions
Table 2
Nurse and resident mean subdimension scores
Subdimension
Residents Nurses
P value a
Mean (SD) Mean (SD)
Team is bounded
Team is interdependent
Team is stable
Communication is open
Communication is
accurate
Communication is timely
Satisfaction with
communication
Team works
collaboratively
Team plans its work
Team takes agreed upon
action after planning
My work is autonomous
I am satisfied with my job
2.4 (1.1)
1.6 (0.6)
5.3 (1.5)
2.1 (0.9)
1.9 (1.0)
3.1 (1.2)
1.7 (1.0)
4.9 (1.5)
1.9 (0.7)
1.7 (1.1)
.001
.51
.19
.41
.40
2.7 (1.1)
2.2 (1.0)
2.3 (0.9)
1.8 (0.8)
.03
.003
2.0 (0.7)
2.6 (1.1)
b.001
2.2 (0.7)
4.6 (1.0)
2.7 (1.0)
4.5 (1.0)
.002
.38
4.3 (1.6)
2.1 (0.9)
3.7 (1.6)
2.1 (1.0)
.04
.91
Responses were on a 7-point Likert-type scale, with 1 = strongly agree
and 7 = strongly disagree.
a
We report unadjusted P values. For this set of results, the Bonferroniadjusted P value cutoff is .0042 (0.05/12).
Residents' and nurses' perceptions of team function
were not always taken after planning. Overall, nurses felt that
their work was more autonomous than did residents (mean
score, 3.7 ± 1.6 vs 4.3 ± 1.6; P = .04). At the Bonferroniadjusted significance cutoff of 0.0042, differences in
communication timeliness and autonomy were no longer
significant.
In addition to raw differences in how residents and nurses
perceive individual constructs related to team function, our
data also shed light on how these provider groups understand
the relationship among different components of team
function (eg, although residents perceive that the team is
much more collaborative than nurses, both nurses and
residents may believe that collaborative teams also have
open communication). Therefore, we assessed how nurses
and residents perceived the relationship between subdimensions of team function (Tables 3A and 3B). On the whole,
residents and nurses perceived the relationships between
constructs quite similarly, with statistically indistinguishable
differences in correlation coefficients (results not shown to
conserve space). Both nurses and residents felt that
communication accuracy was negatively correlated with
communication timeliness (Pearson correlation coefficients,
−0.35 and −0.54, respectively; P b .001 for both); therefore,
the more quickly information is exchanged, the more likely
that the information is not correct. Collaboration was highly
positively correlated with several other dimensions for both
groups: communication openness (0.50, residents and 0.56,
nurses; P b .001 for both), communication timeliness (0.41,
residents and 0.49, nurses; P b .001 for both), and
coordinated planning (0.57 and 0.77, P b .001 for both).
Both groups also felt that communication timeliness and
coordinated planning were positively correlated, as were job
satisfaction and satisfaction with communication.
The 2 groups perceived the relationship between
subdimensions of team function differently in 4 instances,
although this may be an artifact of multiple testing. Although
both groups felt that collaboration and coordinated planning
were positively correlated, the correlation was much stronger
for nurses (0.59, residents and 0.77, nurses; P value for
difference = .04). Both groups also felt that boundedness and
communication accuracy were negatively correlated, but the
correlation was much stronger for residents (−0.55, residents
and −0.22, nurses; P value for difference = .03). More
notably, residents felt that team interdependence and
communication accuracy were negatively associated, whereas nurses felt the opposite (−0.25, residents and 0.20, nurses;
P value for difference = .003). Finally, residents felt that
team interdependence and boundedness were positively
associated, whereas nurses felt they were negatively
associated, although the strength of these associations was
relatively weak (0.17, residents and −0.20, nurses; P value
for difference = .02). However, at the Bonferroni-adjusted
significance cutoff of 0.00076, none of these differences in
Pearson correlation coefficients remained significant. In the
resident group, many more correlation coefficients achieved
statistical significance. Although some of this is due to the
104.e11
larger sample size, in general, residents felt that real team
subdimensions were highly correlated with communication
accuracy and timeliness, collaboration, and coordinated
planning and action.
3. Discussion
We systematically examined ICU teamwork using a set of
validated constructs that captured multiple perspectives on
team function, focusing on the perceptions of trainee
physicians and nurses. We found several notable differences
between residents and nurses, an important finding given that
these groups form the 2 largest bodies of providers caring for
the critically ill in academic medical centers. A key feature of
high-performing teams is a shared mental model [18,19];
therefore, differences between disciplines in their perception
of team performance highlight valuable opportunities for
improvement. Because modern critical care revolves around
multiprofessional team care, a better understanding of such
differences may be of particular interest to those responsible
for running academic ICUs and for residency programs
whose trainees rotate through ICUs. Our results also provide
data to inform curricular design for trainees in ICU settings
because team-based care is integral to effective critical care.
Concepts of “teamness” raised in the social and
behavioral science literature are less familiar to ICU
practitioners. However, they represent important and longstanding concepts in research into group function that are
very relevant in the critical care setting. Teams are more
effective when the individuals responsible for the work
perceive themselves as a real team as opposed to a team in
name only. This requires that team members feel “bounded,”
with clear distinctions between who is on the team and who
is not [13]. In the present study, residents felt that the team
was significantly more bounded than did nurses. This finding
is not surprising given the design of typical academic ICU
schedules. A differential sense of boundedness may be an
unintended consequence of structural requirements of
residents' educational rotations. First, the residents' experience in the ICU is more transient than nurses'. Residents
rotate through the ICU for 3 to 4 weeks at a time, with
slightly unsynchronized schedules. Therefore, in a year, a
nurse might see many different ICU physician teams,
whereas the residents only see one set of nurses. Second,
at our medical center, physician ICU teams usually consist of
upper-level residents and interns working with one attending
intensivist (and sometimes one critical care fellow). Each
day, the team of residents attends rounds with the attending
and/or the fellow for several hours; nurses are a key part of
rounds but may be pulled away due to patient care duties
(such as transport to imaging tests off the unit). Third, after
rounds and as the day progresses, a nurse may interact
with only 1 or 2 members of the team instead of seeing the
team all together.
104.e12
Table 3A
J. Adler-Milstein et al.
Relationship between subdimensions of team performance: residents
Pearson correlation coefficients. Significance cutoffs are based on unadjusted P values. For this set of results, the Bonferroni-adjusted P value cutoff is
.00076 (0.05/66); and gray cells indicate correlations that remain significant at this level.
*
P b .05.
†
Pb .01.
‡
Pb .001.
Structural scheduling issues may explain another finding
in our study: neither residents nor nurses found the team to be
stable over time. In addition to the scheduling issues noted
above, 2 factors are notable. First, our nurses generally work
three 12-hour shifts per week, perhaps creating further
structural barriers to the perception of team stability. Second,
resident duty hour regulations in our ICU result in frequently
changing membership of the ICU physician team. For
example, providing each trainee physician 1 day off per week
results in a situation in which the entire physician team is
present only on Tuesdays, Wednesdays, and Thursdays. This
has the unintended consequence of impairing a sense of team
stability, the second subdimension of a real team. In turn,
team members' opportunity to learn how to work well
together may theoretically be decreased [13].
Another important dimension of team function is the
quality of communication. In this study, residents perceived communication as less open, accurate, timely, and
satisfying than did nurses, although only the domain of
satisfaction was significantly different at a Bonferroniadjusted level. The etiology of this difference is not clear.
It may have to do with nurses usually being the first
clinical provider to receive information (from families,
from the laboratory, from physiologic monitors, etc); it
could reflect resident frustration with delays in communication with families or with fellows and attendings
regarding patient care decisions; or it may reflect the fact
that all medical residents are required to rotate through the
ICU, regardless of their area of future specialty, whereas
nurses self-select this area of practice. Alternatively, it
could reflect the fact that nurses sometimes directly call
more senior members of the physician team (eg, fellow or
attending) for issues that the nurses perceive as particularly
critical. Further studies on this particular construct would
be useful to shed light on the cause of this difference in
satisfaction with communication.
Despite being less satisfied with communication,
residents felt that there was greater collaboration than
did nurses. On the one hand, this may reflect structural
issues in ICU organization. Because nurses are frequently
pulled from rounds due to acute patient care duties, they
may be unaware of collaborative efforts of team members
when discussing a patient's plan of care. Furthermore,
residents contact the fellow or attending frequently during
the day to talk about patient care decisions and are the
primary contact points for consult services. On the other
hand, this may reflect issues of hierarchy. Nurses' input
may not be heard or not appreciated by the team of
Residents' and nurses' perceptions of team function
Table 3B
104.e13
Relationship between subdimensions of team performance: nurses
Pearson correlation coefficients. Significance cutoffs are based on unadjusted P values. For this set of results, the Bonferroni-adjusted P value cutoff is
.00076 (0.05/66); and gray cells indicate correlations that remain significant at this level.
*
P b .05.
†
P b .01.
‡
P b .001.
physicians, something clearly demonstrated in other
studies. For example, Thomas et al [20] report that,
whereas attending physicians rated the quality of collaboration and communication with nurses as high or very
high 73% of the time, only 33% of nurses reported the
same of physicians. Lingard et al [21] found that team
relations were strained when the information that nurses
felt was important for patient care was not heard by the
team of physicians.
Coordination is another vital aspect of team function.
Effective teams coordinate their work and take action after
planning. There was a notable difference between nurses
and residents on one of the dimensions of coordination.
Although both nurses and residents felt that there was a lot
of planning on the ICU team, residents felt more strongly
that planning occurred. This may be explained by some
of the tasks undertaken by the different groups. The
nurses' role in patient care is generally more autonomous than that of residents; for example, patient care
activities such as administering medications can be
completed with less involvement of others. Residents, on
the other hand, frequently coordinate with consultants and
discuss patients' plans of care with supervising physicians;
by definition, these tasks require more interdependence
among multiple team members and may be perceived as
less autonomous.
Both groups agreed that there was no coordinated action
after planning. This is an important finding because
coordinated group effort after taking the time to plan
seems necessary for delivery of patient care. Prior research
by Baggs and Schmitt [22] demonstrated that time spent
on collaboration (ie, plan formation) leads to time saved
in patient care. However, in our study, planning was
negatively correlated with coordinated action for both groups
(Tables 3A and 3B). There are several possible explanations
for this. First, tensions between team members may
undermine the process of actually carrying out a predetermined plan. Second, it may be that once a plan is established,
both groups feel that they are set off independently to
“get their own work done.” Third, and potentially most
likely, is another structural explanation relating to ICU
team organization: planning occurs during rounds. If more
time is spent planning, rounds then take longer, particularly
when there are a large number of patients on the team. When
rounds take longer, they finish later; and there is less time left
in the day to act upon plans made during rounds.
We also examined how different aspects of team
function related to each other. In 62 of 66 relationships,
104.e14
nurses and residents felt that constructs were similarly
related. For example, both groups felt that satisfaction
with communication was associated with overall job
satisfaction. This similarity of relationships among constructs between the 2 groups adds substantial confidence in
the overall validity of the survey instrument. One particularly interesting finding was that communication accuracy was negatively correlated with most of the constructs
studied and significant in both groups for communication
timeliness. Although timely communication is obviously
important, our data suggest that information relayed too
quickly is often perceived as inaccurate by ICU team
members. Numerous clinical examples of this phenomenon
exist (eg, when the final, official reading of a radiology
study differs from the middle-of-the night preliminary
interpretation), but this finding will require further study
and replication.
Our study has several strengths as well as several
limitations. We assessed team function in the ICU from
multiple perspectives, focusing on the 2 largest groups of
providers in academic medical centers. To do this, we drew
only from previously validated instruments; and then we
conducted cognitive testing of our instrument in the local
setting. We were also conservative in our instrument
validation and analysis. Our findings reveal important
differences in the ways that nurses and trainee physicians
perceive the function of the team. Such differences are
plausible based on the structure and function of the ICU,
and suggest areas in which ICU teamwork may be
improved. However, the limitations of our study are also
important to consider. First, this was a survey-based study;
we did not directly observe team interactions. Nonetheless,
many of the constructs important to team function are
directly related to internal, rather than observable, states
and therefore are not measurable via observation. Second,
our results required running many tests of significance,
increasing the potential for false positives. To address this,
we also report Bonferroni-adjusted significance level
cutoffs for each set of results. We also focused interpretation of results on those that remained significant at the
adjusted cutoff. Third, our overall response rate of 49%
could have been higher, particularly for nurses. However,
this response rate is similar both to our previous experience
with local surveys and to several other survey-based ICU
studies of communication [23-25]. Still, a low response rate
can result in selection bias among respondents and is an
important limitation of this study. Fourth, we surveyed the
2 groups of respondents at different times. Thus, observed
findings could relate to changes in the ICU over time as
opposed to differences between the groups. We think that
this is unlikely given that there were no major changes in
ICU structure or function during this period. Finally, this is
a single-center study; and caution is therefore required in
generalizing its findings to other centers. Our study design
does not permit causal inference, but is instead hypothesis
generating. In addition, our work does not provide
J. Adler-Milstein et al.
information about solutions to problems with communication. Rather, it should inform the design of future
interventional trials.
4. Conclusion
We found meaningful differences in the way that nurses
and trainee physicians in academic medical ICUs perceive
key aspects of team function. Such differences are
important to identify because these groups make up the
2 largest bodies of providers caring for the critically ill in
these settings. The results may be immediately useful to
those responsible for running academic ICUs, as well as to
residency program directors developing communicationand team-based curricula. Moreover, these differences
between disciplines in their perception of the quality of
team performance highlight important opportunities for
future investigation. These findings should inform design
of future interventional studies, such as team training
studies, that focus on ICU teams in academic settings.
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