Interdisciplinary Rounding and Patient Inclusion in the PCU

Introduction

The progressive care unit (PCU) is a practice setting in which the healthcare team is often failing to meet quality care objectives according to patient reporting on the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS). Opportunities for growth in quality care based on PCU HCAHPS scores include topic areas related to patient inclusion and the communication skills of healthcare team members. Patients perceive that the healthcare team in the PCU is unable to explain the care process in a way that makes patients and family members feel comfortable or adequately informed about the care being provided.

First-hand experience in the PCU, combined with direct feedback from patients, confirms this challenge. Patients report that care seems disjointed, that continuity is lacking, and that hearing different answers or explanations from different team members is deeply problematic. Care providers do not appear to be aligned, and patients and family members consequently report feeling helpless and excluded from their own care processes.

In order to empower patients, increase their engagement with the care process, and improve quality of care in the PCU with regard to patient and family inclusion, this study identifies specific procedures and processes in the PCU that can be altered to positively impact care providers' approach to promoting patient inclusion. Specifically, it addresses the issue through evidence-based practice (EBP), which is vital for helping nurses and care providers implement quality care practices grounded in research and evidence (Melnyk, Fineout-Overholt, Giggleman, & Choy, 2017).

EBP applies to the problem of inadequate patient inclusion in the following ways, which illustrate the nature of the problem: (1) the PCU nursing team conducts bed shift reports among nursing staff; (2) case management, respiratory therapy, physical therapy, occupational therapy, and the hospitalist group also conduct separate rounds on patients and family members; (3) the teams all have a designated meeting time for interdisciplinary meetings in which patient care issues are discussed; (4) however, the teams do not conduct rounding together in a way that incorporates the patient and/or family; and (5) this lack of interdisciplinary teamwork may contribute to patients' experiences of disjointedness in the care they receive while in the PCU. EBP is needed to clarify whether involving interdisciplinary teams in an approach designed to make the patient feel more included in the care process can increase the patient's sense of quality care while in the PCU. This issue is important because the PCU team is currently not scoring well with patients in terms of providing consistent, quality care.

In this proposal, the main problem and PICOT question to be examined are identified. A literature review follows, providing a summary of relevant literature on interdisciplinary teamwork and patient satisfaction. The sample, practice setting, and clinical context of the study are then described; a plan for implementation follows; and the main points of the paper are summarized in the conclusion.

Identification of the Problem and PICOT Question

The PICOT question for this proposal is: For progressive care unit patients (P), how does interdisciplinary rounding with patient/family inclusion (I) compared to individual rounding by team members (C) affect patient satisfaction and family anxiety (O) during their hospital stay (T)?

PICOT questions are useful for addressing clinical practice issues, as they represent an effective way to conduct an evidence-based clinical inquiry. The PICOT acronym helps the researcher organize the focus of the clinical inquiry (Melnyk & Fineout-Overholt, 2015). The P stands for population of interest, the I for intervention or issue of interest, the C for the comparison of interest, the O for the expected outcome, and the T for the time frame in which the intervention is expected to achieve the outcome. Not all components of the PICOT format are necessarily required for every clinical scenario, but researchers recommend that the population of interest and the intervention of interest always be included.

Hypothesis

It is expected that rounding exercises in which the patient and the patient's family are included with the interdisciplinary team will increase patient satisfaction scores on the HCAHPS, reduce patient anxiety, and possibly facilitate a decrease in the length of stay for patients—if the interdisciplinary team, working together, can collectively identify barriers to discharge.

Literature Review

To obtain evidence for this study, online peer-reviewed journal databases were searched using appropriate keywords. Databases searched include CINAHL, MEDLINE, and DynaMed. Keywords used to examine what researchers have documented on this topic included "interdisciplinary teamwork healthcare," "patient inclusion interdisciplinary," "evidence-based practice," and "patient inclusion rounding." A variety of research was found to be available on aspects of this topic.

Selection criteria for the PICOT question included the following: the study had to be published within the past five years in a peer-reviewed journal or on a professional healthcare organization website, such as the Institute of Medicine (IOM) or the Centers for Disease Control and Prevention (CDC); and the studies had to be of Level III or higher in terms of evidence-based research, including non-experimental studies such as systematic reviews, qualitative analyses, quasi-experimental studies, and experimental studies (randomized controlled trials).

McCaffrey and McConnell (2015) provide a systematic review of literature in their Level III study regarding how interdisciplinary teamwork can help nurses and care providers better communicate and provide compassionate, high-quality care to patients. The interdisciplinary approach fosters a sense of shared governance among care providers. Kutney-Lee, Germack, Hatfield, et al. (2016) demonstrate in their Level III cross-sectional observational study that in hospitals where there is a substantial sense of shared governance among nurses, patient outcomes are much higher than in facilities where shared governance is less prominent. Unfortunately, there is a lack of strong evidence specifically on the subject of interdisciplinary rounding and patients' sense of inclusion in their own care process. The Level III study by Bhamidipati, Elliott, Justice, Belleh, Sonnad, and Robinson (2016) is a systematic review of 22 qualitative studies, which found that there were few high-quality research articles on the topic of interdisciplinary rounds and their impact on patients' quality of care.

Al Danaf et al. (2017) demonstrated through a case study approach how proactive rounding can facilitate patient-oriented care and increase patients' positive perceptions of their care process. Other studies that have reached the same conclusion support the overall research hypothesis—that if teams work together across disciplines to take a more united, proactive, and consistent approach to rounding, answering questions, and educating patients about their care, patients will feel better about their care process overall (Pannick et al., 2015; Braus et al., 2016; Urisman, Garcia, & Harris, 2018; Bright, Austin, Garn, Glass, & Sample, 2017). The more that nurses, care providers, and staff demonstrate a combined effort to put the patient first by displaying a consistent and unified approach to care, the better patient experience outcomes have been shown to be.

However, the fact that research has shown benefits when teams work together to promote higher quality of care does not mean that implementing EBP is always straightforward. Sadeghi-Bazargani, Tabrizi, and Azami-Aghdash (2014) show in their Level III systematic review of barriers to EBP implementation that one of the most common obstacles to EBP is a lack of cooperation among care providers within a facility. Their study illustrates the difficulty care providers face when attempting to provide quality care: there is often little cooperation, communication, shared governance, or continuity of care. Baird, Rehm, Hinds, Baggot, and Davies (2016) find in their Level III qualitative research—which involved interviews with seven patients and twelve nurses—that continuity of care is critically important to patients, and something that nurses struggle to achieve because so many different nurses participate in rounding processes, are called upon to deliver advice or explanations, and have varying approaches to communicating with patients and peers.

EBP must be implemented to improve quality of care, as all professional care is ultimately based on evidence accumulated over time to inform care providers about best practices across different types of situations. As the healthcare industry continues to grow and develop, new situations arise that require new studies to help formulate EBP for care providers. The development of interdisciplinary teams in healthcare units like the PCU—and their cooperative approach to providing care to patients who want to feel more included in the care process—is an instance of a healthcare development that requires dedicated study.

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