American Journal of Critical Care. 2006;15: 541-548
Changing the Work Environment in Intensive Care Units to Achieve Patient-Focused Care: The Time Has Come
By
Kathleen McCauley, RN, BC, PhD and
Richard S. Irwin, MD.
From the University of Pennsylvania School of Nursing and Hospital, Philadelphia, Pa (KM), and University of Massachusetts and UMass Memorial Medical Center, Worcester, Mass (RSI).
Corresponding author: Kathleen M. McCauley, RN, PhD, APRN-BC, University of Pennsylvania School of Nursing and Hospital, 420 Guardian Dr, Philadelphia, PA 19104-6096 (e-mail: kmccaule{at}nursing.upenn.edu).
 |
Abstract
|
|---|
The American Association of Critical-Care Nurses Standards for Establishing and Sustaining Healthy Work Environments and the American College of Chest Physicians Patient-Focused Care project are complementary initiatives that provide a road map for creating practice environments where interdisciplinary, patient-focused care can thrive. Healthy work environments are so influential that failure to address the issue would result in deleterious effects for every aspect of acute and critical care practice. Skilled communication and true collaboration are crucial for transforming work environments. The American College of Chest Physicians project on patient-focused care was born out of a realization that medicine as currently practiced is too fragmented, too focused on turf battles that hinder communication, and too divorced from a real understanding of what patients expect and need from their healthcare providers. Communication as well as continuity and concordance with the patients’ wishes are foundational premises of care that is patient-focused and safe. Some individuals may achieve some level of genuine patient-focused care even when they practice in a toxic work environment because they are gifted communicators who embrace true collaboration. At best, most likely those efforts will be hit-or-miss and such heroism will be impossible to sustain if the environment is not transformed into a model that reflects standards and initiatives set out by the American Association of Critical-Care Nurses and the American College of Chest Physicians. Other innovative models of care delivery remain unreported. The successes and failures of these models should be shared with the professional community.
The landmark Institute of Medicine (IOM) document To Err Is Human: Building a Safer Health System1 transformed the way we think about patients’ safety. By making public the dangers that patients face when they enter the current healthcare system, the IOM used its influence effectively to call for dramatic transformations in the way we evaluate errors and changed the focus of error prevention from individual punishment to one of system redesign. In Crossing the Quality Chasm: A New Health System for the 21st Century,2 the IOM then attacked the dysfunctional processes of our past and current healthcare system (eg, pervasive poor communication and noninterdisciplinary, often isolationist decision-making behavior). By focusing on effective team performance, data-driven analysis of system failures, and continuous process improvements to reduce risk, the IOM called for a revolution in the way we communicate with each other, anticipate and modify patients’ risk, and evaluate our effectiveness.
The leaders of the American Association of Critical-Care Nurses (AACN) and the American College of Chest Physicians (ACCP) have a long history of thoughtful dialogue about the important issues in critical care practice and have collaborated on key initiatives to enhance the practice knowledge of their members. Over the years, as their relationship has matured, the organizations have come to respect and value each other’s perspective, benefited from the unique knowledge and worldview each brings to planning for the future, and used this perspective to grow in ways that would not have been possible without this collaborative relationship.
As past presidents of AACN and ACCP, in this article we describe how the AACN Standards for Establishing and Sustaining Healthy Work Environments3 and the ACCP Patient-Focused Care project4 demonstrate true collaboration and synergy of thought. Together, these complementary initiatives provide a road map for creating the kind of practice environment where interdisciplinary, patient-focused care, as called for by the IOM, can thrive.
|
Response to a Flawed Health System
|
|---|
AACN’s decision to establish standards for healthy work environments grew from a strategic planning process in which the association identified the 3 most important issues facing its members and critical care nurses at large on which AACN’s voice and action would have the greatest effect. A healthy work environment was one of those issues and was judged to be so influential that failure to address it would result in deleterious effects for every aspect of critical care practice. A task force and national review panel led by past AACN president Connie Barden developed the standards that were launched at a Washington, DC, press conference in January 2005. More than 30 000 copies of the standards were downloaded from the AACN Web site the first month after their release; the number downloaded now exceeds 120 000. These standards are guiding transformation of the care environment in many institutions across the United States.
| Transforming our work environments is not negotiable to achieve nurse retention, job satisfaction, or improved outcomes for patients and their families.
|
The standards have been presented in several AACN publications.3,5 The 6 standards—addressing skilled communication, true collaboration, effective decision making, appropriate staffing, meaningful recognition, and authentic leadership—were derived from a strong base of research evidence. Each standard is considered essential, and the standards are designed to be used together, not as stand-alone organizational goals. The standards are forceful statements describing the actions required to transform the health of the work environment (see Table
).
View this table:
[in this window]
[in a new window]
|
Standards for establishing and sustaining healthy work environments put forth by the American Association of Critical-Care Nurses3(p189)
|
|
Transforming our work environments is not negotiable if we are to achieve 3 interconnected essential goals:
- retention and, indirectly through improved public perception, recruitment of nurses at a time of pervasive and lingering nursing shortages;
- improved job satisfaction among all members of the healthcare team; and, perhaps most importantly,
- improved outcomes for patients and patients’ families, particularly in the area of patients’ safety.
A growing body of research indicates the link between nurse staffing and patients’ outcomes6,7; between staffing, nurse burnout, and job satisfaction7; and between work environments, nurses’ satisfaction, and nurses’ clinical performance.8 Competence of multidisciplinary providers in leadership, care coordination, and conflict resolution behaviors decreased mortality rates and improved other key physiological risk variables among infants in neonatal intensive care units.9 Nurse-physician collaboration, specifically, has resulted in improved outcomes for patients,10,11 including reduction in mortality rates.12
|
Different Views of Collaboration
|
|---|
Evidence suggests, however, that nurses and physicians who work together differ in the way they view the quality of collaboration and communication in their workplace,13 with nurses tending to be much less pleased with the quality of collaboration than physicians are in the same setting.14 A disturbing finding from a recent survey14 of safety attitudes revealed that more than one third of nurses reported finding it difficult to speak up when they detected a problem with a patient. Pronovost and colleagues14(p1028) call this "interdependence without integration," an apt phrase that describes the critical nature of nurse-physician work and a relationship that must be improved if both nurses and physicians are to be effective.
Perhaps these different views of collaboration are related to the quality of the interaction. True collaboration as directed by the standards builds over time, leading to joint decision making that embraces each discipline’s worldview. True collaboration is normal, respectful, and ongoing.3 With true collaboration, each professional is a full partner in the dialogue; loud voices or lofty titles will not dominate the discussion or the decision.
Lip-service collaboration, on the other hand, is halfhearted. When we say that we want to hear the perspectives of others, we must really listen, and our actions must reflect an expanded worldview. Yet when the stakes are highest and the potential for disagreement is the greatest, we are at the greatest risk for lip-service collaboration.15
| Nurses are much less pleased with the quality of collaboration than are physicians in the same setting.
|
Therefore, we must agree about the best way to help an anxious or angry family support their critically ill loved one, and we must not respond by limiting their access to the patient. With true collaboration, physicians, nurses, and patients’ family members will figure out together the best ways to communicate, gain the families’ insights into the patients’ needs, and harness their healing energies.
True collaboration requires communicating effectively. In Crucial Conversations: Tools for Talking When Stakes Are High, a highly influential and practical guide to improving relationships and successfully handling difficult interactions, Patterson et al16 discuss the importance of colleagues agreeing on a mutual purpose in order to link seemingly disparate goals and strategies. A mutual purpose is one that is "more meaningful or more rewarding than the ones that divide the various sides."16(pp85–86) In healthcare, the most effective mutual focus of purpose is the patient. Hence, we view the connection between care that is truly patient focused and creation of healthy work environments as critical to our effectiveness as providers and to our success in transforming our practice environments.
|
Patient-Focused Care
|
|---|
The concept of patient-focused care was born out of a realization that medicine as currently practiced is too fragmented, too focused on turf battles that hinder communication, and too divorced from a real understanding of what patients expect and need from their healthcare providers. The solution lies in viewing every encounter with a patient as an opportunity to deliver the care we would want for our own family members. How could we not want those we love to receive care from competent, well-educated practitioners who embrace evidence-based practice and lifelong learning? Would we not expect that our families be treated with respect, their unique needs identified and met, and their wishes honored at the end of life? Continuous quality improvement efforts would drive care processes, and we would do our best to accommodate patients and their families even when, because of their limited knowledge or broken systems, they contribute to the difficulties we face in doing our job well.4
As president of ACCP in 2003–2004, one of us (R.S.I.) challenged members attending the annual meeting to join a revolution in healthcare—a revolution that refocuses what we do on the patient.4 As an organization, ACCP embraced patient-focused care by having members commit to the following pledge4(p1912):
I will strive to provide patient-focused care wherever and whenever I have the privilege of caring for patients. I will also work to ensure that all health care systems in which I provide care are patient-focused. Patient-focused care is compassionate, is sensitive to the everyday and special needs of patients and their families, and is based on the best available evidence. It is interdisciplinary, safe, and monitored. To ensure the provision of patient-focused care in my professional environments, I shall willingly embrace the concepts of lifelong learning and continuous quality improvement.
The ACCP visibly commemorated its commitment to a patient-focused care initiative in 2 ways. The organization mailed a "commit to patient-focused care" pin and copy of the pledge to each ACCP member, urging the members to wear the pin when caring for patients and to sign, frame, and visibly display the pledge in the members’ offices. ACCP also asked all new fellows of the group to recite the pledge during the convocation ceremony as the final step before induction as fellows. The favorable response provoked by this initiative throughout the United States and worldwide was striking. The concept of seeking to provide every patient with the same kind of care we would want for our family members universally resonated with ACCP members, no matter where the members lived.
| More than one third of nurses find it difficult to speak up when they detect a problem with patients.
|
|
Two Critical Standards
|
|---|
We embrace adoption of all 6 AACN standards as crucial for transforming the work environment. Yet 2 of the standards, skilled communication and true collaboration, seem particularly necessary to achieve the goal of patient-focused care because communication as well as continuity and concordance with the patients’ wishes are foundational premises of patient-focused care.17
Some individuals may achieve some level of genuine patient-focused care even when they practice in a toxic work environment because they are gifted communicators who embrace true collaboration. However, we contend that, at best, their efforts will be hit-or-miss, and such heroic efforts will be impossible to sustain if the environment is not transformed into a model that reflects the AACN standards. The barriers to transforming a toxic environment are indeed massive, but if those barriers are not overcome, the notion of "interdependence without integration" put forth by Pronovost and colleagues14 will prevail.
Imagine, then, working in an environment where skilled communication and true collaboration form the foundation from which to promote patient-focused care. This would be an environment that embodies the following:
- The current, common practice of totally separate medical and nursing schools would change. Physicians and nurses have selected classes and clinical experiences together as students so that each group enters practice with a respectful, accurate knowledge of the other’s clinical contribution.
- Interdisciplinary patient care rounds are the norm, and each discipline’s contribution is considered so essential that decisions are not made without all care providers weighing in.
- Each patient, when able, and the patient’s family are integral members of the decision-making team so that the patient’s values and wishes are key components of the planning process.
- All team members feel comfortable and supported in challenging care processes when the processes are perceived to be inaccurate, not evidence based, or inconsistent with professional values or the patient’s values.
- All team members actively seek and engage in educational programs that improve their communication and collaboration skills. Colleagues support each other in skill development and hold each other accountable for correcting lapses in respectful communication and collaboration patterns.
- Techniques such as SBAR18 (situation-background-assessment-recommendation) are widely used to increase effectiveness of communication, especially in critical situations.
- Structured forums such as ethics committees are used effectively to support clinicians in resolving disputes, provide clinicians a broader view of the issues, and ensure that patients’ values and wishes and, if appropriate, those of the patients’ family members are identified and incorporated.
- A high level of personal integrity characterizes the behavior of all team members.
- Concerns about competence or collaborative behaviors of team members are dealt with directly and respectfully so that patients are not harmed and team members receive support to correct communication and practice deficits.
- Interdisciplinary educational efforts are the norm for staff education in healthcare, with research findings from each discipline incorporated into the content of clinical education.
- "What is best for the patient" is driven by the patient’s perspective and values, integrating each discipline’s best practice knowledge.
- Evaluation of care processes includes evaluation of the burden that ineffective care systems place on patients and patients’ families, with quality improvement efforts designed to monitor and repair these broken systems.
- Ongoing efforts to enhance patients’ safety include monitoring communication and collaboration patterns and explicitly linking process improvements in these areas with improved outcomes related to patients’ safety.
- An organization’s success (or failure) to transform its work environment and achieve patient-focused care is systematically tracked and improved through a comprehensive outcome-monitoring program.
- Professional associations and other influential groups with a stake in the process support their members’ efforts to transform the members’ practice environments via Web sites, publications, and other strategies that foster exchange of best practices, tools for effective transformation, and recognition of centers of excellence (eg, the AACN Beacon Award for Critical Care Excellence).
- National regulatory and accrediting organizations such as the Joint Commission on Accreditation of Healthcare Organizations incorporate quality-of-care metrics that support this culture transformation.
| Current practice is too fragmented and too focused on turf battles that hinder communication.
|
|
Unit-Based Strategies for the Serious Organization
|
|---|
What interdisciplinary strategies could a critical care unit put into action to indicate its seriousness in implementing the AACN standards for healthy work environments3 with a strong focus on patients and patients’ families? Here are some suggestions for making skilled communication and true collaboration the norm:
- Use techniques such as SBAR18 to guide interdisciplinary communication.
- Assemble a small group of nurses, physicians, respiratory care practitioners, pharmacists, and other providers to develop processes for organizing truly collaborative interdisciplinary rounds. Set a 6-month goal by which time no patient will be discussed on rounds without the contribution of the full team.
- Plan educational programs about new and interesting care strategies that are taught jointly by at least 2 disciplines. Invite representatives from every discipline with a role in patients’ care, and students, not just medicine and nursing, to participate and contribute their perspectives.
- Although acute and critical care units are often considered the home base of nurses, ensure that other team members are not considered or treated as visitors or interlopers. Invite team members from all disciplines to attend and contribute to unit-based social events, such as potluck meals, and be sure to invite everyone, not just the most collaborative ones who already know and appreciate the valuable input of others. Getting to know each other as people can set or reinforce the tone for true collaboration.
- Invite the ethics committee chair to a unit staff meeting and discuss how the committee can offer guidance when tough disagreements happen. Do not focus solely on the familiar issues of discontinuing treatment and end-of-life care; also consider dilemmas such as providing quality care despite limited resources and verbal abuse, which carry equally serious ethical implications. Inviting the unit’s medical director and other team members to participate will create a climate of shared learning.
- Develop a welcome-to-our-unit program so that all new caregivers including physicians, nurses, respiratory care practitioners, pharmacists, and others can learn how to contribute in a culture of true collaboration and patient-focused care. Ensure that the unit’s nurse manager and medical director speak with all new care providers about how true collaboration is the standard.
- Review all unit-based programs for improving quality and patients’ safety to ensure that collaboration and evaluation of effectiveness are integral to each program.
- Develop a fix-the-ineffective-work-arounds task force to identify and fix as many broken systems as possible. Uncover the root causes of the broken system by inviting and actively listening to input from nurses, physicians, and all affected care providers. Work collaboratively, inviting hospital and nursing administrators to participate to abolish systems that do not work and to design effective new ones.
- Engage the organization’s executive leaders, including, as appropriate, the chief nursing officer, chief executive officer, and medical directors, in the challenge of transforming all systems for evaluating care providers to include assessment of communication and collaboration skills. Be sure to reward successful skill acquisition in meaningful ways.
| Imagine that interdisciplinary rounds are essential and that no decision can be made without all care providers weighing in.
|
|
A Virtual Critical Care Department
|
|---|
The virtual department of critical care at UMass Memorial Medical Center in Worcester, Mass, is an example of creating a better model for delivering critical care services across the 21st century healthcare organization. In 2003, chief executive officer John O’Brien identified the need for a better model of delivering critical care. O’Brien charged a strategic planning committee with 21 interdisciplinary members with the daunting task of inventing the model and establishing guiding principles for implementation. After 13 months of deliberation, the committee presented its report to the chief executive officer and a leadership council that included the chairs of all clinical departments and the medical center president. With the council’s unanimous support, a new era of critical care began on September 1, 2004.
Critical care was defined as caring for critically ill patients regardless of the patients’ location in the system through a system-wide virtual department (see Figure) that uses a collaborative, interdisciplinary, and patient-focused approach.
View larger version (50K):
[in this window]
[in a new window]
|
Organizational chart of the "Virtual" Department of Critical Care at UMass Memorial Medical Center. The Critical Care Operations Committee is composed of representatives of all groups with a stake in critical care; it is cochaired by a physician critical care specialist and the director of critical care services. The eICU refers to a live, real-time telemedicine program.
|
|
All issues related to critical care are discussed by a critical care operations committee that meets every 2 weeks. The committee is composed of the entire critical care community; it is cochaired by a critical care physician specialist and the medical center director for critical care services. The committee’s recommendations are presented to the medical center president and leadership council, who look to the committee for decision-making guidance where critical care is involved.
Although the medical directors of each unit shown in the Figure still primarily report to the chairs of their respective clinical departments, the days of silo building (ie, noninterdisciplinary, isolationist decision-making behavior) are gone. The critical care community as a whole now monitors and manages all critical care activities and budgetary matters. Activities, results, and/or behavior that fall outside what is expected are monitored in real time and managed by relying on data-driven peer pressure in collaboration with division chiefs and department chairs.
UMass Memorial Medical Center has been able to achieve impressive culture transformation and has begun to note measurable improvements in patients’ outcomes through this innovative reorganization of critical care delivery. The model works because it was intentionally designed to support the medical center’s clinical, teaching, and research missions. Through the model, clinicians, faculty members, and researchers collaborate to deliver accessible, excellent, patient-focused care, constantly evaluating and improving processes and services with the goal of achieving evidence-based practice and high levels of satisfaction among patients, patients’ families, and the healthcare team.
Since September 2004, the following structural and process changes have been implemented at UMass Memorial Medical Center:
- Nurse managers and medical directors of the intensive care units (ICUs) are considered peers with equal accountability for clinical outcomes and the performance of each group’s professional teams.
- A policy applied to the entire medical center requires that the care of every ICU patient be supervised by a critical care specialist.
- The care of all critically ill patients will be managed around the clock by a critical care specialist whether on site or via telemedicine. Phasing in of eICU (VISICU, Inc, Baltimore, Md) monitoring began June 27, 2006; full implementation by September 2007 is anticipated.
- Appropriately educated and certified acute care nurse practitioners and physician assistants have been recruited to join the clinical teams and work with intensivists, house staff, and nurses to ensure that standards are consistently applied to achieve expert and rapid response to patients’ acute needs. In order to facilitate the entry of these providers into the system in the future, a close collaborative educational and research partnership has been established with the University of Massachusetts Graduate School of Nursing and a nurse practitioner/physician assistant critical care mentorship program has been established.
- The need for additional ICU and progressive care beds has been identified, and all disciplines are involved in planning for these expanded services.
- All disciplines are involved in developing, implementing, and expanding an ever-growing list of clinical practice guidelines so that the care critically ill patients receive becomes uniformly evidence based. Front-line providers of patients’ care give their feedback about implementation of clinical practice guidelines to the leaders of the critical care operations committee during weekly interdisciplinary bedside rounds. Electronic documentation will be used throughout ICUs and in the eICU to support and improve communication and adherence to clinical practice guidelines.
- A tiered process for responding to the need for critical care beds has been developed and has greatly improved collaboration between the emergency and critical care departments, proactively managing patient throughput on the basis of the census and acuity levels of patients in all areas.
- A scorecard for monitoring critical care data is used to track progress and indicate needed improvements in case mix, outcomes, care processes, and staffing.
In designing a new and more effective structure, the UMass Memorial Medical Center team learned that it needed to communicate more effectively and in the process has strengthened its interdisciplinary relationships. Team members have more consistently come to understand and appreciate the perspective of others and, by constantly focusing on what is best for patients and patients’ families, are better able to resolve conflicts, solve problems, and refocus attention toward teamwork and quality evidence-based, patient-focused care. Only time will tell how successful the virtual department will be. However, it was clearly time for a change because the 20th-century model of delivering critical care has too many flaws—flaws that the IOM says portray all of medicine.
| Nurse managers and medical directors have equal accountability for clinical outcomes.
|
|
Essential Need for Innovative Care Models
|
|---|
We suspect that other innovative models remain unreported, and we urge readers to communicate their successes and, yes, failures to the professional community. We challenge readers to engage in this essential work of designing innovative care delivery. Consider what is required so that skilled communication, true collaboration, and patient-focused care can become the norm at your institution.
Which colleagues will be your immediate and eager allies in designing, implementing, and evaluating these changes? How will you ensure that all disciplines participate? What resources will be needed to support this transformation? How will the requisite energy and enthusiasm be sustained in order to persevere in such a strategically essential process? How will successes and failures be celebrated and learned from along the journey?
If the healthcare system in which you work will not allow the delivery of critical care to be transformed into an efficient, patient-focused, healthy work environment, perhaps it is time for you and your colleagues to suggest to the chief executive officer and other clinical leaders that it might be time to undertake a strategic planning process with the goal of redesigning critical care.
Linking patient-focused care as defined by the ACCP with work environment transformation based on the AACN healthy work environment standards will strengthen process and outcome by identifying a mutual purpose that unites disciplines in a common effort built upon shared values. This framework offers a road map to collaboratively achieve the vision of a healthcare system driven by the needs of patients and their families where each discipline makes its optimal contribution. Pronovost and colleagues14 are correct. Our disciplines are interdependent and must be integrated. Only then will we be supported in making our optimal contribution.
To purchase electronic or print reprints, contact The InnoVision Group, 101 Columbia, Aliso Viejo, CA 92656. Phone, (800) 809-2273 or (949) 362-2050 (ext 532); fax, (949) 362-2049; e-mail, reprints{at}aacn.org.
|
REFERENCES
|
|---|
- Corrigan J, Kohn LT, Donaldson M, eds. The Committee on Quality of Health Care in America, Institute of Medicine. To Err Is Human: Building a Safer Health System. Washington, DC: National Academies Press; 2000.
- Committee on Quality of Health Care in America, Institute of Medicine. Crossing the Quality Chasm: A New Health Care System for the 21st Century. Washington, DC: National Academies Press; 2001.
- American Association of Critical-Care Nurses. AACN standards for establishing and sustaining healthy work environments: a journey to excellence. Am J Crit Care. 2005;14:187–197.[Free Full Text]
- Irwin R. Patient-focused care. The 2003 American College of Chest Physicians Convocation Speech. Chest. 2004;125:1910–1912.[Free Full Text]
- Triola N. Dialogue and discourse: are we having the right conversations? Crit Care Nurse. February 2006;26:60–66.[Free Full Text]
- Needleman J, Buerhaus P, Mattke S, Stewart M, Zelevinsky K. Nurse staffing levels and the quality of care in hospitals. N Engl J Med. 2002;346:1715–1720.[Abstract/Free Full Text]
- Aiken L, Clarke S, Sloane DM, Sochalski J, Silber J. Hospital nurse staffing and patient mortality, nurse burnout and job dissatisfaction. JAMA. 2002;288:1987–1993.[Abstract/Free Full Text]
- Foley BJ, Jennings BM, Kee CC, Minick P, Harvey SS. Characteristics of nurses and hospital work environments that foster satisfaction and clinical expertise. J Nurs Adm. 2002;325:273–282.
- Pollack MM, Koch MA, the NIH-District of Columbia Neonatal Network. Association of outcomes with organizational characteristics of neonatal intensive care units. Crit Care Med. 2003;31:1620–1629.[Medline]
- Grap M, Strickland D, Tormey L, et al. Collaborative practice: development, implementation, and evaluation of a weaning protocol for patients receiving mechanical ventilation. Am J Crit Care. 2003;12:454–460.[Abstract/Free Full Text]
- Baggs JG, Schmitt MH, Mushlin AI, et al. Association between nurse-physician collaboration and patient outcomes in three intensive care units. Crit Care Med. 1999;27:1991–1998.[Medline]
- Knaus WA, Draper ES, Wagner DP, Zimmerman JE. An evaluation of outcome from intensive care in major medical centers. Ann Intern Med. 1986; 105:410–418.
- Thomas EJ, Sexton JB, Helmreich RL. Discrepant attitudes about team-work among critical care nurses and physicians. Crit Care Med. 2003; 31:956–959.[Medline]
- Pronovost PJ, Wu AW, Sexton JB. Acute decompensation after removing a central line: practical approaches to increasing safety in the intensive care unit. Ann Intern Med. 2004;140:1025–1033.[Abstract/Free Full Text]
- McCauley K. Is your collaboration true? AACN President’s Note. AACN News. December 2004:2.
- Patterson K, Grenny J, McMillan R, Switzler A. Crucial Conversations: Tools for Talking When Stakes Are High. New York, NY: McGraw-Hill; 2002.
- Irwin RS, Richardson ND. Patient-focused care: using the right tools. Chest. 2006;130(1 suppl):73S–82S.[Abstract/Free Full Text]
- Kaiser Permanente of Colorado. SBAR technique for communication: a situational briefing model. Institute for Health Care Improvement. Available at: http://www.IHI.org/IHI/Topics/PatientSafety/SafetyGeneral/Tools/SBARTechniqueforCommunicationASituationalBriefingModel.htm. Accessed August 3, 2006.
This article has been cited by other articles:
|
|
|
|
 
K. Dracup and C. W. Bryan-Brown
Creating a New Tipping Point in Intensive Care
Am. J. Crit. Care.,
November 1, 2006;
15(6):
537 - 539.
[Full Text]
[PDF]
|
|
|
Top
Abstract
Response to a Flawed...
