We found that the use of SIDR significantly improved providers’ ratings of collaboration and teamwork on a medical teaching unit. The effect was driven by improved satisfaction with teamwork and collaboration among nurses. This is an important finding because prior research has shown that nurses are often dissatisfied with the quality of communication and collaboration with physicians.6–8
Potential explanations include fundamental differences between nurses and physicians with regard to status/authority, gender, training, and patient care responsibilities.6
Unfortunately, a culture of poor teamwork may lead to a workplace in which team members feel unable to approach certain individuals and uncomfortable raising concerns. A recent study involving interviews of resident physicians highlights the problem. Weinberg and colleagues found that, although residents were aware of communication problems with nurses, most believed that this posed no threat to patient care because the nurse’s role, as they saw it, was one of simply following orders.29
Not surprisingly, higher ratings of teamwork culture have been associated with nurse retention.30,31
SIDR provided a facilitated forum for interdisciplinary discussion, exchange of critical clinical information, and collaboration on the plan of care.
Our findings are also important because poor communication represents a major etiology of preventable adverse events in hospitals.1–5
Higher ratings of collaboration and teamwork have been associated with better patient outcomes in observational studies.24,32,33
Further research should evaluate the impact of improved interdisciplinary collaboration as a result of SIDR on the safety of care delivered on inpatient medical units.
Although there was significant improvement in nurse ratings, there was no difference in ratings of communication and collaboration by resident physicians on the intervention and control units. This is likely due to the fact that the vast majority of physicians rated the quality of communication and collaboration with nurses as high or very high at baseline.8
This makes further improvement difficult to attain. A growing body of evidence indicates that nurses, rather than physicians, are the members of the team least satisfied with collaboration and teamwork.6–8,23
Ratings of the safety climate were not significantly different between units in our study. Potential explanations include the intervention’s focus on collaboration and teamwork, rather than other aspects of patient safety, including staffing levels, adverse event reporting, and hospital management’s response to safety concerns. The potential exists for the unit medical director and nurse manager to collaborate on improving these important aspects of the safety climate.
The vast majority of providers agreed that SIDR improved patient care and that SIDR should continue indefinitely. Importantly, providers also felt that SIDR improved the efficiency of their work day and attendance was high among all disciplines. Prior studies on IDR either did not report attendance or struggled with attendance.34
Incorporating the input of frontline providers into the design of SIDR allowed us to create an intervention which fit into daily workflow.
We did not detect a benefit to LOS or cost with the use of SIDR. Two prior studies have shown a reduction in LOS and cost with the use of IDR.11,13
However, one study was conducted approximately 15 years ago and included patients with a longer mean LOS.13
The second study used a pre-post study design which may not have accounted for unmeasured confounders affecting LOS and cost.11
A third, smaller study showed no effect on LOS and cost with the use of IDR.14
In light of the final sample size for the intervention unit being slightly less than our intended target, it is possible that our study was underpowered to detect a difference in LOS or cost.
Our study has several limitations. First, it reflects the experience of an intervention unit and a control unit in a single hospital. Larger studies will be required to test the reproducibility and generalizabilty of our findings. Second, as previously mentioned, our study did not directly assess the effect of improved teamwork and collaboration on patient safety. Further study is needed to evaluate this. Although we are not aware of any other interventions to improve interdisciplinary communication on the intervention unit, it is possible that other unknown factors contributed to our findings. We believe this is unlikely due to the magnitude of the improvement in collaboration and the high ratings of SIDR by nurses and physicians on the intervention unit. Our initial analyses did not account for differences in the number of years nurses had been at the hospital. We conducted post-hoc multivariable regression analyses including years employed at the hospital as a covariate. Results were similar and therefore, not reported. Finally, the timing of survey administration for physicians and nurses was not identical. For logistical reasons, physicians were surveyed at the completion of each four week rotation over a six-month period while nurses were surveyed 16–20 weeks after implementation of SIDR. Although it is possible that this may have affected our results, we feel this is unlikely given that ratings of communication and collaboration among providers on the control unit were similar to a prior cross-sectional survey conducted at the same institution.8
In summary, SIDR had a positive effect on nurses’ ratings of collaboration and teamwork on a medical teaching unit. Future efforts should assess whether improved teamwork as a result of SIDR also translates into safer and higher quality patient care.