Strengthened intra-professional communication through reflexive use of the EVLN-model: a transdisciplinary project in intensive care
Can conceptual tools from the social sciences be used to improve team work in intensive care? Intensive care demands complex multi-professional medical interventions in time compressed processes. Communication failures among intensive care staff can have dire consequences for patients, and because of this, there is a continual demand for research aimed at improving team work in acute care settings.
This project builds on a recent and intriguing development in the social sciences, wherein analytical concepts and categories are conversed into methodologies. In this project, this phenomenon is implemented in the intensive care units of a Swedish university hospital. By combining the analytical model of Exit, Voice, Loyalty and Neglect with the feminist methodological concept of reflexivity, this action research project aims at increasing employee commitment and by extension improve patient safety. The project thus builds on a transdisciplinary process wherein diverse experiences and forms of knowledge meet in the hope of improving professional practices in healthcare.
Final report
The project aimed to study teamwork in intensive care, to develop methods that can help stimulate interprofessional communication and reflection, which is assumed to increase retention. However, the project's purpose and questions had to be reworked because the start of the project coincided with the COVID-19 pandemic.
The project came to focus on the collegial management of the crisis in two intensive care units. Over sixty people were interviewed in depth: doctors, nurses, assistant nurses, managers, administrators, and HR experts were asked to share their experiences and analyses of how the organization and they themselves handled the crisis. In addition, observations took place inside the so-called COVID-ICU wards. Through recurring conversations with staff and managers, including participation in workplace meetings and training days, the analyses generated by the data collection could be reviewed by the research participants.
A key finding of the project was that the crisis followed a somewhat unexpected timeline. Staff experienced critical pressure not during the most intense phase of the pandemic, as the number of patients was highest - but before the patients actually started coming in, as well as when the pandemic was in a flattening phase and the number of patients was decreasing. The initial phase of the crisis was characterized by tensions that arose when different professional groups, and different individuals within those groups, could not agree on how best to interpret and manage the threat. Difficult ethical issues about how to prioritize and when - when should cancer surgeries be cancelled in order to begin the transition to pandemic management? - proved difficult to agree on when the crisis still seemed only a looming threat. Once patients started to arrive, there was a strong sense of cohesion among staff, and many felt they could concentrate fully on their core task of caring for patients. Unnecessary administration and other illegitimate tasks were eliminated during this period. At the same time, the work was extremely tough, and many felt that it was difficult for the outside world to understand the seriousness of the crisis within the healthcare system and the sacrifices required of healthcare staff.
It was when the pandemic began to phase out that the crisis became perhaps most difficult for staff. They suffered from exhaustion and compassion fatigue, and many began to question whether they had chosen the right profession. As the number of COVID-19 patients decreased, a 'care debt' of other patients whose treatment had been postponed awaited them. At the same time, there was a wage revision for nursing staff, which generated only modest pay raises. This was perceived as a sign of society's lack of understanding of the important role of nursing assistants in society. Based on the project’s results, it can be concluded that supportive interventions for frontline staff are needed early on during pandemics as well as in the leveling phase, and that society needs to prioritize care staff by valuing their work in terms of improved work environment and pay raises.
Another important finding was that Sweden's preparedness for health crises needs to be improved. A key reason for the staff's anxiousness especially in the build-up phase was the lack of medicine and protective equipment, the lack of experienced staff (which negatively affects care even under "normal" circumstances) and just-in-time systems that involve lean stockpiling. As expected, the shortcomings of the health care system in general – problems with staff retention, lack of beds, lack of time for reflection and learning, silo tendencies and coordination problems - become more pronounced before and during a crisis. Improving preparedness for health crises is therefore about creating good conditions for healthcare organizations under “normal” conditions. This means respect for and appreciation of the real value of healthcare workers and their contribution to all of society; making efforts to increase staff density, especially the number of specialist nurses and experienced assistant nurses; and a more resilient healthcare organization with enough material resources and preparedness for different types of crises, a healthcare workforce that is given the opportunity for continuous skills development and recovery, as well as sufficient time to build good social relationships in the workplace and improve on routines for reflection and learning.
The new research questions raised by the project are mainly about building resilient healthcare organizations and care teams on the one hand, and improving societal preparedness for health crises on the other. Questions about prerequisites and learning are at the heart of this: what types of resources and systems need to be in place for the healthcare organization to properly deal with crises? And what and how do we learn from previous crises?
The Flexit project has led to a new research project funded by the Swedish Research Council, which aims to study the prerequisites for good preparedness and organizational learning after health crises.
The Flexit project has led to a new research project funded by the Swedish Research Council, which aims to study the conditions for good preparedness and organizational learning after health crises.
Other research questions raised by the project concern teamwork in intensive care, especially regarding assessment criteria within the different professions around the intensive care patient. The interviews and observations indicated that different logics sometimes clash in the care of critically ill patients. The project led to another research project (developed and carried out together with an intensive care nurse from one of the participating departments) which deals with quantification in intensive care. What is measured and quantified and what is not, and what weight is attributed to different types of data for assessment? The Swedish Research Council is also funding this project.
The results of the research have been disseminated through a final conference aimed at both researchers and employers, as well as through numerous presentations in healthcare and in the research community. In addition, an extensive article in Sydsvenskan kultur, which was read by over fifty thousand people when it was published in February 2022, as well as a report written in Swedish. Several scientific articles are being prepared (all open access).
Article in Sydsvenskan Kultur:
https://www.sydsvenskan.se/2022-02-13/skracken-i-patientens-ogon-vad-hander-med-mig
Report on COVID-19 management in two intensive care units: https://www.genus.lu.se/rebecca-selberg/publication/193ce59e-71a9-4d97-b65e-60fb4e3bb8a6
The project came to focus on the collegial management of the crisis in two intensive care units. Over sixty people were interviewed in depth: doctors, nurses, assistant nurses, managers, administrators, and HR experts were asked to share their experiences and analyses of how the organization and they themselves handled the crisis. In addition, observations took place inside the so-called COVID-ICU wards. Through recurring conversations with staff and managers, including participation in workplace meetings and training days, the analyses generated by the data collection could be reviewed by the research participants.
A key finding of the project was that the crisis followed a somewhat unexpected timeline. Staff experienced critical pressure not during the most intense phase of the pandemic, as the number of patients was highest - but before the patients actually started coming in, as well as when the pandemic was in a flattening phase and the number of patients was decreasing. The initial phase of the crisis was characterized by tensions that arose when different professional groups, and different individuals within those groups, could not agree on how best to interpret and manage the threat. Difficult ethical issues about how to prioritize and when - when should cancer surgeries be cancelled in order to begin the transition to pandemic management? - proved difficult to agree on when the crisis still seemed only a looming threat. Once patients started to arrive, there was a strong sense of cohesion among staff, and many felt they could concentrate fully on their core task of caring for patients. Unnecessary administration and other illegitimate tasks were eliminated during this period. At the same time, the work was extremely tough, and many felt that it was difficult for the outside world to understand the seriousness of the crisis within the healthcare system and the sacrifices required of healthcare staff.
It was when the pandemic began to phase out that the crisis became perhaps most difficult for staff. They suffered from exhaustion and compassion fatigue, and many began to question whether they had chosen the right profession. As the number of COVID-19 patients decreased, a 'care debt' of other patients whose treatment had been postponed awaited them. At the same time, there was a wage revision for nursing staff, which generated only modest pay raises. This was perceived as a sign of society's lack of understanding of the important role of nursing assistants in society. Based on the project’s results, it can be concluded that supportive interventions for frontline staff are needed early on during pandemics as well as in the leveling phase, and that society needs to prioritize care staff by valuing their work in terms of improved work environment and pay raises.
Another important finding was that Sweden's preparedness for health crises needs to be improved. A key reason for the staff's anxiousness especially in the build-up phase was the lack of medicine and protective equipment, the lack of experienced staff (which negatively affects care even under "normal" circumstances) and just-in-time systems that involve lean stockpiling. As expected, the shortcomings of the health care system in general – problems with staff retention, lack of beds, lack of time for reflection and learning, silo tendencies and coordination problems - become more pronounced before and during a crisis. Improving preparedness for health crises is therefore about creating good conditions for healthcare organizations under “normal” conditions. This means respect for and appreciation of the real value of healthcare workers and their contribution to all of society; making efforts to increase staff density, especially the number of specialist nurses and experienced assistant nurses; and a more resilient healthcare organization with enough material resources and preparedness for different types of crises, a healthcare workforce that is given the opportunity for continuous skills development and recovery, as well as sufficient time to build good social relationships in the workplace and improve on routines for reflection and learning.
The new research questions raised by the project are mainly about building resilient healthcare organizations and care teams on the one hand, and improving societal preparedness for health crises on the other. Questions about prerequisites and learning are at the heart of this: what types of resources and systems need to be in place for the healthcare organization to properly deal with crises? And what and how do we learn from previous crises?
The Flexit project has led to a new research project funded by the Swedish Research Council, which aims to study the prerequisites for good preparedness and organizational learning after health crises.
The Flexit project has led to a new research project funded by the Swedish Research Council, which aims to study the conditions for good preparedness and organizational learning after health crises.
Other research questions raised by the project concern teamwork in intensive care, especially regarding assessment criteria within the different professions around the intensive care patient. The interviews and observations indicated that different logics sometimes clash in the care of critically ill patients. The project led to another research project (developed and carried out together with an intensive care nurse from one of the participating departments) which deals with quantification in intensive care. What is measured and quantified and what is not, and what weight is attributed to different types of data for assessment? The Swedish Research Council is also funding this project.
The results of the research have been disseminated through a final conference aimed at both researchers and employers, as well as through numerous presentations in healthcare and in the research community. In addition, an extensive article in Sydsvenskan kultur, which was read by over fifty thousand people when it was published in February 2022, as well as a report written in Swedish. Several scientific articles are being prepared (all open access).
Article in Sydsvenskan Kultur:
https://www.sydsvenskan.se/2022-02-13/skracken-i-patientens-ogon-vad-hander-med-mig
Report on COVID-19 management in two intensive care units: https://www.genus.lu.se/rebecca-selberg/publication/193ce59e-71a9-4d97-b65e-60fb4e3bb8a6