Using self-efficacy and transformative learning theories to examine interprofessional collaborative practice at end of life in the ICU between nurses and physicians

This dissertation will follow the manuscript style and is aimed to gain a better understanding of the collaboration process between nurses and physicians when they care for patients at end of life in a practice environment historically viewed as a setting for saving life's, the intensive care. The first manuscript is a qualitative study investigating nurses' ability to recognize dying in the prolonged mechanically ventilated patient. Using Strauss and Corbin (1998) grounded theory approach of a constant comparative method, two themes emerged. The first theme describes how nurses recognized two types of dying in the prolonged mechanically ventilated patient. The second theme describes the process in which the assessment of dying was communicated to the patient, family and other members of the healthcare team and their view of the physician's communication of dying to the patient and family. The findings from this confirmed that the participants can recognize dying following the premise of Porock's theory Recognizing Dying (2007, 2010) of an increased cognizance that patients under their care is near the end of life. The participants routinely expected to care for patients at end of life but felt the overall palliative purpose of the unit and the care to be delivered was not clearly communicated to the patient and family. This discrepancy led to difficulty in making the transition to comfort care. Nurses in the study were invited to attend family-team meetings where the team discussed the patient's prognosis and treatment plan but declined to attend. The nurses lacked the confidence to speak with the medical staff about their diagnosis of dying. They could determine the breakdown of the communication process but did not see their role as an integral component to improve communication and interprofessional collaboration. The second manuscript is an integrated literature review of research studies focused on interprofessional collaborative practice (IPCP) in the intensive care unit (ICU) between nurses and physicians. This review also examined IPCP between nurses and physicians in the ICU in end-of-life situations. Based on the results of the qualitative study of the first manuscript, the purpose of the integrated review was to identify research studies on the factors that impact IPCP in the ICU practice care setting when caring for dying patients. The synthesis of the literature indicated that the perceptions of healthcare professionals are that the ICU practice environment is complex, based on the bio-medical model, and utilizes advanced technology in managing and delivering the treatment plan. This environment focuses on medical knowledge as the foundation and often the subjective, complementary focus of nursing is not accepted as valid by medicine. Communication effects not only how professionals interact but is necessary for teamwork, development and implementation of the treatment plan and patient outcomes. Effective team work requires mutual respect among members, effective communication, and shared participation and responsibility in the decision making process which are the foundations of the core competencies of IPCP. The third manuscript is the final dissertation study which investigated the perceptions of nurses and physicians on the core competencies of IPCP using Self-Efficacy and Transformative Learning Theories as theoretical guides. The premise of this study theorized that ICU nurses have witnessed effective IPCP between their peers, physicians and communication scenarios between other members of the healthcare team. Nurses can reflect on these experiences and draw from their professional education and training to transform their behaviors and develop an outcome expectation that IPCP with physicians is obtainable. Although 75% of the nurses in this study reported having post licensure professional education and training in communication skills and teamwork, theoretically, reflection on this knowledge and skills should give nurses a means to improve how they communicate and work within the team however, the study did not find a correlation between professional education and training and years of intensive care experience to the core competencies of IPCP. The regression analysis showed that perceived authority for decision-making was a statistically significant predictor (? = -.514, p = .000) and professional valuing was marginally significant slightly above the alpha level of .05, p = .068. The regression model was significant F (4, 80) = 21.54, p < .001, and explained about 52% of the variance in IPCP. Findings from this study suggest that professional valuing, communication and most notably, perceived authority for decision-making have a statically significant impact on nurses' ability to engage in interprofessional collaborative behaviors with physicians in the intensive care practice environment when caring for patients who are at end of life.