A Qualitative Examination of Interprofessional Teamwork for Infection Prevention: Development of a Model and Solutions

Abstract

Healthcare-associated infections (HAIs), such as central line-associated bloodstream infections (CLABSIs) and catheter-associated urinary tract infections (CAUTIs), are associated with patient mortality and high costs to the healthcare system. These are largely preventable by practices such as prompt removal of central lines and Foley catheters. While seemingly straightforward, these practices require effective teamwork between physicians and nurses to be enacted successfully. Understanding the dynamics of interprofessional teamwork in the HAI prevention context requires further examination. We interviewed 420 participants (physicians, nursing, others) across 18 hospitals about interprofessional collaboration in this context. We propose an Input-Mediator-Output-Input (IMOI) model of interprofessional teamwork in the context of HAI prevention, suggesting that various organizational processes and structures facilitate specific teamwork attitudes, behaviors, and cognitions, which subsequently lead to HAI prevention outcomes including timeliness of line and Foley removal, ensuring sterile technique, and hand hygiene. We then propose strategies to improve interprofessional teamwork around HAI prevention.

INTRODUCTION

Healthcare-associated infections (HAIs), such as catheter-associated urinary tract infections (CAUTIs) and central line-associated bloodstream infections (CLABSIs) are preventable infections in the healthcare setting and are associated with high costs and mortality (Saint, 2000; The Joint Commission, 2012). Yet, these HAIs are largely preventable (Pronovost et al., 2006; Rebmann & Greene, 2010) and can be mitigated by following best practices shown to reduce the rates of these events; for instance, CAUTIs can be significantly reduced by timely removal of Foley catheters (Rebmann & Greene, 2010). Similarly, CLABSIs can be reduced by removing unnecessary central lines in a timely manner (Dumont & Nesselrodt, 2012) and by ensuring sterile technique when inserting lines (Dumont & Nesselrodt, 2012).

While seemingly easy practices to implement, the context of the healthcare setting often provides multiple barriers to engaging in these practices successfully. One such barrier is lack of effective interprofessional teamwork, which is crucial for HAI prevention (Han et al., 2019; Srisatidnarakul, Tarver, Luna, & Flood, 2021). For example, in the case of timely line and Foley removal, nurses and physicians must work together to ensure this occurs, which can present challenges related to communication and coordination. In addition, a healthcare professional may inadvertently break sterile technique or hand hygiene protocols due to fatigue, workload, or other issues. In an ideal situation, a colleague would speak up to remind them to correct this, serving as the block in the “Swiss cheese” that prevents a mistake from becoming an adverse patient outcome (Reason, 2000). Yet, due to organizational, individual, and/or interpersonal factors, speaking up does not always occur (Roussin, Larraz, Jamieson, & Maestre, 2018). Along these lines, lower HAI rates have been associated with hospital units that report a good teamwork climate, especially highlighting the importance of interprofessional teamwork that is likely to be critical to the appropriate placement, maintenance, and removal of devices that contribute to the prevention of infections (Profit et al., 2017).

With respect to infection prevention practices, the interprofessional team may include nursing, physicians, infection preventionists, and hospital administrators. In this context, physicians develop and oversee the care plan for patients. Nurses are tasked with carrying out these plans, supported by nursing staff such as nurse assistants and patient care associates. Infection preventionists work to prevent HAIs by conducting surveillance and making recommendations for infection control and prevention protocols. Hospital administrators are tasked with overseeing all of these roles and ensuring that adequate infection prevention policies and practices are developed and implemented appropriately. While all these roles must work together to achieve infection prevention goals, physicians and nurses may have particularly unique challenges working together at the point of care to prevent HAIs at the “sharp end” (Dixon-Woods, Suokas, Pitchforth, & Tarrant, 2009). For example, collaboration between nurses and physicians is common when making the decision to remove Foley catheters (DePuccio et al., 2020). In addition, nurses often assist and provide oversight for sterile technique when a physician inserts a central line.

Challenges to Interprofessional Teamwork

Despite its positive impact on patient safety (Manser, 2009), interprofessional teamwork has historically been a challenge in healthcare; for example, nurses and physicians traditionally work under a formal or informal hierarchy wherein the nurse must defer to the physician (Leipzig et al., 2002). Although still in existence, this hierarchy has begun to shift, and nurse autonomy has been increasing. For instance, for prevention of CAUTIs, many hospitals have implemented a nurse-driven Foley catheter removal protocol. This protocol generally authorizes a bedside nurse to remove a patient’s Foley catheter without physician approval when there is no longer a medical indication for maintaining the catheter, thereby reducing infection risk caused by prolonged device insertion. However, interprofessional teamwork plays a role in the success of nurse-driven protocols for Foley removal as nurse deference to physicians, physician pushback, and miscommunication about device removal may impact protocol implementation (DePuccio et al., 2020). These implementation barriers hint at overarching challenges to effective interprofessional teamwork more broadly, such as hierarchy (Leipzig et al., 2002), professional cultures (autonomous vs. collaborative) (Leipzig et al., 2002), accountability (Mannahan, 2010), and perceptions of interprofessional collaboration (Krogstad, Hofoss, & Hjortdahl, 2004). Yet, research indicates that team member perceptions such as psychological safety can serve as a mediator to improve team effectiveness when there is power distance (Appelbaum et al., 2020).

While policies such as the nurse-driven protocol support increased nurse autonomy and improve patient safety, the extent to which such policies are successfully implemented and routinely followed is likely to vary. Variation in use may be driven by factors surrounding the interprofessional collaborative relationship, such as team communication, psychological safety, team stability, and team member familiarity (Edmondson, 1999, 2003). Further, the existence of organizational policies and practices around interprofessional collaboration–such as interprofessional rounding and interprofessional decision making–can vary across hospitals. Organizational structure, such as hospital size, can also contribute to these dynamics in the sense that larger hospitals are more likely to function as “patchwork quilts” (i.e., microsystems of units) (Edmondson, 2004, p. ii6), rather than as one cohesive team. Altogether, these factors can serve as barriers to successful interprofessional collaboration and teamwork, leading to practices that reduce patient safety and subsequently can increase HAIs.

The goal of our study was to investigate the role of interprofessional teamwork in the prevention of HAIs with a focus on CAUTI and CLABSI prevention. Framed by theory in the areas of teamwork and interprofessional collaboration, we propose a model and use the lens of management practices to characterize actionable strategies for managers that can support interprofessional teamwork in the context of infection prevention.

Conceptual Framework

While unique challenges are presented by the interprofessional context, interprofessional collaboration is a form of teamwork, defined as “a set of interrelated thoughts, actions, and feelings of each team member that are needed to function as a team and that combine to facilitate coordinated, adaptive performance and task objectives resulting in value-added outcomes” (Salas, Sims, & Burke, 2005). That is, teamwork is comprised of attitudes, behaviors, and cognitions (Salas, Shuffler, Thayer, Bedwell, & Lazzara, 2015). Teamwork attitudes, defined as what team members feel or believe (Salas et al., 2015), can include concepts such as motivation and trust. Teamwork behaviors, what team members do, include actions such as carrying out team tasks, and associated team processes such as coordination and providing feedback (Marks, Mathieu, & Zaccaro, 2001). Finally, teamwork cognition is defined as the extent to which team members have a shared understanding about roles, goals, plans, the environment, and each team member’s knowledge and skills (Gregory et al., 2021; Salas et al., 2015). This can include concepts such as shared mental models (Cannon-Bowers, Salas, & Converse, 1993), transactive memory systems (Lewis, 2003), and team decision-making (Cannon-Bowers et al., 1993).

Teamwork theory has often been framed in the context of the Input-Mediator-Output-Input model (IMOI; Ilgen, Hollenbeck, Johnson, & Jundt, 2005), an adaptation to the Input-Process-Output (IPO) model by McGrath (1964). In both models, inputs include factors at the individual, organizational, or team level that influence one or more teamwork mediators to subsequently result in a relevant team outcome. In contrast to the IPO model, the IMOI model allows for not just processes such as behaviors, but also emergent states such as attitudes, as well as team cognitions, to influence outcomes. These models are flexible in that they can be used to investigate a variety of variables and phenomena relevant to teams (e.g., team learning, Decuyper, Dochy, & Van den Bossche, 2010; team adaptation, Burke et al., 2006; teamwork engagement, Costa, Passos, & Bakker, 2014; etc.). In the case of infection prevention, teamwork attitudes, behaviors, and cognitions may be posited to serve as mediators between inputs (e.g., organizational culture) and outputs (e.g., reduced infections). The final I in the IMOI model stands for “input”, and indicates that the outputs inform future inputs (Ilgen et al., 2005). The current study sought to explore what aspects of teamwork–in particular, interprofessional teamwork–impact infection prevention practices. We also sought to determine what inputs yielded effective interprofessional teamwork in this context.

New Contribution

In contrast to most work on HAI prevention, we used qualitative–rather than quantitative–methodology. This allowed us to obtain richer data around the nuanced dynamics of interprofessional collaboration that influence HAI prevention. We also collected data from multiple unit types (e.g., emergency department, medical-surgical, intensive care units, etc.) across 18 hospitals, such that findings are not dependent upon one hospital’s teamwork culture or specific to one type of unit. Altogether, the current work is in contrast to prior work on teamwork in HAI prevention, which is focused on evaluating interventions (Gillespie et al., 2015; Nickel et al., 2014), is focused solely on one aspect of teamwork, such as communication (e.g., Bonaconsa et al., 2021), examines only one unit type (e.g., Carter, Pallin, Mandel, Sinnette, & Schuur, 2016), or mentions teamwork or interprofessional collaboration only at a high-level (e.g., Brewster, Tarrant & Dixon-Woods, 2016; Towell-Barnard, Slatyer, Cadwallader, Harvey, & Davis, 2020; Borek et al., 2020). This prior work does not unpack findings about teamwork into specific team attitudes, cognitions, and processes, nor does it describe the organizational structures and processes that facilitate these interprofessional team dynamics. The current study contributes new knowledge around interprofessional teamwork factors that positively impact HAI prevention efforts. The model we provide helps summarize these findings, while the qualitative data lends itself to translation into practical best practices which can be implemented in hospitals.

METHODS

Study Design

We conducted site visits to US hospitals from September 2017 to November 2019 to learn about the role of management practices such as interprofessional collaboration, leadership, communication and information sharing, and meaningful use of data in preventing HAIs. The primary focus of the study was on CAUTIs and CLABSIs, but general infection prevention efforts were also considered. The Institutional Review Board (IRB) at The Ohio State University approved this study [2017H0017].

Study Sites

Following a purposive sampling approach, 35 acute care hospitals in various regions of the United States were invited. We aimed to recruit both hospitals that were high- and low-performing in HAI prevention (as indicated by standardized infection ratios [SIRs], a summary statistic that compares observed HAIs to predicted HAIs based on a national benchmark), and sought to include hospitals that varied on characteristics such as size and teaching status.

Eighteen hospitals across 10 states agreed to participate. The participating hospitals varied with respect to their CLABSI and CAUTI infection rates, geographic regions, and organizational characteristics (e.g., hospital size). Detailed information about the characteristics of study sites is available in previously published work (MacEwan, Beal, Gaughan, Sieck, & McAlearney, 2021).

Data Collection and Analysis

With the help of key contacts at each hospital, informants were recruited to participate in study interviews based on their role. Interviews typically occurred in-person during normal work hours in hospital conference and break rooms, with some interviews alternatively occurring by phone as needed. Interviews were conducted as both one-on-one and group interviews to accommodate the various availabilities of the participants.

Interviews were conducted using a semi-structured interview guide that included questions about management practices important to HAI prevention (Crabtree & Miller, 1999a). Interviews ranged from 15–60 minutes and were audio-recorded, transcribed verbatim, and de-identified. Participants provided verbal consent.

Interview transcripts were analyzed using a deductive dominant thematic analysis allowing for categorization of data based on general themes derived from the interview guides, as well as identification of emergent themes through the constant comparative method (Armat, Assarroudi, Rad, Sharifi, & Heydari, 2018; Glaser & Strauss, 1967; Miles, 1994; Vaismoradi, Turunen, & Bondas, 2013). This approach allowed for comparison of themes across sites and enabled us to characterize aspects of interprofessional teamwork important to infection prevention. First, a preliminary coding dictionary based on the interview guide was developed, and three members of the coding team coded the same five transcripts using this dictionary, while noting new codes that emerged (Crabtree & Miller, 1999b). A revised coding dictionary was developed to incorporate these changes, and subsequently all transcripts from the first five hospital sites were coded by the coding team. The coding dictionary was revised as additional new codes emerged, and the team recoded transcripts as needed to incorporate new codes. This team met regularly to discuss their comparative coding process, overseen by the lead investigator. Subsequently, the remaining 13 sites were coded by a single coder from the original coding team, working in close collaboration with the lead investigator to ensure consistency of coding and agreement about any new emergent codes. The coded data was then analyzed and organized into thematic categories by the study team (Constas, 1992). The themes were then categorized following an IMOI model of teamwork (Salas et al., 2015) applied to HAI prevention (i.e., organizational inputs, teamwork attitudes, teamwork behaviors, teamwork cognitions, and HAI prevention outputs).

RESULTS

Hospital and Interviewee Characteristics

Hospitals were located in the U.S., in the midwest (n = 6), northeast (n = 5), south (n = 5), and west (n = 2), and were a mix of teaching and non-teaching hospitals. Hospitals varied in bed size including small (<300 beds; n = 6), medium (300–499 beds, n = 3), large (500–899 beds, n = 5), and extra large (>900 beds, n = 4). The participating hospitals also varied with respect to CAUTI and CLABSI performance and were scored worse, average, or better on the basis of SIRs reported in Centers for Medicare and Medicaid Services’ Hospital Compare data. Full details on the characteristics of participating hospitals are available in MacEwan, et al. (2021).

Across sites we held interviews with a total of 420 key informants across three categories of background and training: (1) nursing (e.g., registered nurses, licensed nursing assistants, patient care technicians, nurse practitioners) (n=336); (2) physicians (n=53); and (3) other healthcare workers (public health, nutrition, infection preventionist, etc.) (n=31). Participants were mostly female (n = 345; 82.1%).

Themes

We categorized findings into four components of interprofessional teamwork based on prior conceptual frameworks (Salas et al., 2015; Shuffler, DiazGranados, & Salas, 2011): 1) organizational structure and processes; 2) teamwork attitudes; 3) teamwork cognitions; and 4) teamwork behaviors. In terms of the IMOI model, organizational structure and process variables serve as the inputs, and the identified teamwork attitudes, cognitions, and behaviors function as mediators. Altogether, these appear to influence infection prevention behaviors (the output). The relationship between these components in the context of HAI prevention are visualized in Figure 1, with representative quotations illustrating these relationships presented in the accompanying Table 1.

Figure 1.

Interprofessional teamwork in the context of HAI prevention. Letters correspond to quotations in Table 1. Stars denote areas that can be directly influenced by management.

Table 1.

Representative Quotations Illustrating Relationships in Figure 1. Additional Supportive Quotations in Text.

Relationship in Model	Example Quotation
a. Organizational size-> Interprofessional team orientation	[Small hospital] “I would say it works really well… I don’t think you should recognize like certain people. I think it’s a collaborative group effort… I think we all work very well together to prevent this [infection].” -Physician
b. Organizational size-> Psychological safety	“I think because we are a smaller facility…everyone knows everyone. It’s easier to form those relationships because of a smaller setting. Everyone basically knows each other by first name because of the size, or lack of. But I think we pretty much all have a good relationship. Everyone, all floors like we know everyone.” -Nurse
c. Organizational size->Informal interactions	“It’s a small place and you know everybody, and so the nurses know who I am, so they can always come up when there’s a question when they see me rounding on the floor,”-Physician
d. Informal interactions-> Interprofessional team orientation and Psychological safety	“We’re much more, stop in your office and tell you if we need help with something. It’s not as much of a meeting… I would not be surprised if he were to just like pop in and say, ‘Hey I wanted to talk to you, what do you think about this?’ They’re very collaborative and… there’s a lot of respect. So, it’s like we really want to work together to make sure that we can maintain that respect for each other.”-Physician
e. Informal interactions -> Team cognition and interprofessional decision making	“Well, I share an office with the infection control practitioner so it’s about as interprofessional as we can get. I think it’s really important to just have it personally within you to make the contacts and develop the relationship because it’s such a large facility and institution that if you don’t take some of that on yourself you will always be finding things out behind, like later, or after the fact. But I think that just getting face time in front of all the disciplines, and various levels of administration, floor staff, even EVS [environmental services]…” -Other
f. Culture of accountability -> Speaking up	“Everyone holds everyone accountable for like hand washing and PPE, so like basics so kind of trying to really instill that culture, where it’s not disrespectful or rude just to be like, ‘Hey, can you tie your gown?’ So that’s been something I think that they focused on a lot recently. All disciplines and making sure that everyone’s adhering to those isolation signs and understanding what they mean.” -Nurse
g. Interprofessional rounds -> Team cognition and interprofessional decision making	“I think we do work pretty close together with everybody bouncing ideas off of each other. Like having interdisciplinary rounds where people from different job occupations come sit in this room, chat about certain patients and then kind of what the plan is if there’s any barriers and go from there.” -Nurse
h. Interprofessional team orientation-> Team cognition and interprofessional decision making	“If you don’t have everybody on the team you will miss something. You will miss one or two important perspectives…”-Physician
i. Psychological safety-> Team cognition and interprofessional decision making	“He will ask nursing questions all the time about certain patients, which I mean I think is just great for the interdisciplinary team kind of in general, but I personally think it also makes nurses more comfortable to approach that person to be like, ‘Hey, this is kind of what’s going on. Do you think that we need this? Do you think that we [don’t]?’ You know? They’re people that you can kind of step up to and approach and ask questions.”-Nurse
j. Psychological safety->Speaking up	“The nurses can actually say, ‘Hey, well I have an idea, I have a suggestion.’ Whereas before you were kind of told, ‘This is how it’s going to be, this is how you’re going to do it.’ Whereas nurses say, ‘Can we try this way?’”-Nurse
k. Interprofessional team orientation->Speaking up	“If the providers don’t bring it up, we do, like, ‘Hey do they really still need their Foley? Can we take it out?’ As far as central lines, it’s kind of the same thing. Whereas nurses, we’ll approach the providers and say, ‘Hey I got two peripherals in. Do they really need their central line?’ So, it’s definitely a lot of collaboration between the nursing and the providers as well as with our ‘champions’ that we have on the unit.”-Nurse
l. Speaking up->Team cognition and interprofessional decision making	“I mean we all have our fortes and we’re learning from each other and having that ability to, ‘Well, you might not know what I know, but let me try to explain my side and then you know, you telling me what I don’t know.’.”-Nurse
m. Speaking up->Safety behaviors	“The nurses are supposed to be very vigilant about watching the doctors if they break sterility. I mean I personally am comfortable telling them that they did, and that they need to get a new glove or like do something….” -Nurse
n. Team cognition and interprofessional decision making:->Timeliness of care	“Yes, very collaborative, very collaborative. And we encourage that. We encourage that because somebody can come with an idea, it’s never stated, you know, ‘Keep [the Foley/line] because I said so.’ Well you have to come with a reason and if you come with a reason somebody might say, ‘Oh I didn’t think about it.’ -Physician

Organizational Structure and Processes

Interviewees consistently emphasized the importance of organizational structure and processes in HAI prevention. This component of teamwork included four factors: 1) organization size; 2) informal interactions; 3) culture of accountability; and 4) interprofessional rounding. Additional representative quotations are presented in Table 1.

First, interviewees recognized that a smaller organization size made it easier for team members to know and support each other. One physician explained: “It’s a small place and you know everybody, and so the nurses know who I am, so they can always come up when there’s a question when they see me rounding on the floor, send me an email if there’s questions and I think it kind of goes with a lot, the physicians, staff, nursing staff, administration, I think it is a very supporting culture.” Similarly, a nurse shared, “I love it here with the doctor-nurse communication. We’re a small hospital so they’re pretty, pretty cool like with communications and suggestions. And so, they don’t give us any backfire or anything about it.”

Second, interviewees emphasized the importance of informal interactions among team members to build good working relationships. A nurse manager noted, “We’ve done several different things to improve that [working relationship] and to make it stronger. Just like we do education together annually with the doctors and the nurses together. Learn together. And it just builds relationships.” A physician shared how informal interactions among physicians from other disciplines contributed to collaborative and supportive relationships: “Sure, it’s very collaborative… We’re much more, stop in your office and tell you if we need help with something. It’s not as much of a meeting… I would not be surprised if he were to just like pop in and say, ‘Hey I wanted to talk to you, what do you think about this?’ They’re [other physicians] very collaborative and… there’s a lot of respect. So, it’s like we really want to work together to make sure that we can maintain that respect for each other.”

Third, providers emphasized the benefit of having a “culture of accountability.” A nurse manager shared, “There’s a certain amount of holding each other accountable to the best practices. So, you’re obliged to report that if you see somebody who’s not complying with what you would view as normal policy… So you really depend on the staff to hold each other accountable.” Similarly, an intensive care unit (ICU) physician explained, “The nurses have the power to stop the procedure if they see that something is going wrong. We do very thorough education of the residents and the interns before they start. And after they start, we do in the SIM [simulation] lab sessions from time to time to reinforce, to remind them, and to reinforce it.”

Interviewees also stressed the importance of interprofessional rounding in assessing necessity of catheters and lines, creating plans, and addressing any challenges, all which play a role in the prevention of HAIs. A nurse explained: “And we do rounds with the physicians and critical care every morning. And we go through like system by system, head to toe, everything about the patient. And then towards the end, they’ll do a whole like lines and drains section just to reiterate the importance of a central line, the importance of a catheter. Just to reiterate the fact like, ‘Do we really need this line and can we take it out?’ So, we go through every single day with the entire team to kind of go over the needs.” A hospitalist further shared: “Studies show that you forget the patient had a Foley and that’s how we would just leave it in for days. So the nurse is actually providing input for us as well, when we do RN-MD rounding, provide us some input from that standpoint… reminds that the patient has this, they probably don’t need it, we’d like to get them up to the chair, which is quite helpful.”

Teamwork Attitudes

Providers also discussed teamwork attitudes that facilitated the prevention of HAIs. This component included two categories: 1) interprofessional team orientation; and 2) psychological safety.

Interviewees stressed the importance of interprofessional team orientation, which is a reflection of respect and trust among interprofessional team members that creates an environment in which team goals are valued above individual goals (Jones, Vandenberg, & Bottsford, 2011). One infectious disease physician noted: “The reason that this hospital does so well [with infection prevention] is because of these great team members, the parts of the team work wonderfully well together, communicate well together, we’re passionate about what we do, we care about each other, we care about our patients… That mutual respect among disciplines whether it’s nursing, infection control nurse, doctors, housekeeping, you know we’re all part of a big team, we’re all part of one big team and nobody is better than anybody else. We all have our own jobs, or our own focus maybe, but we all have to work together.” A nurse similarly shared: “I think it really is our teamwork, communication, like I love these peeps to death. I would do anything in the world for them, and I want to see them do well. So, and I am not perfect, I learn from people every day, but I think to be successful in the job, and it’s a hard job, is like I can’t do it all myself. We all have to have each other to do it, and we’re just like a family.”

Psychological safety–a shared belief that it is safe to speak up about ideas, errors, or corrections, without fear of retribution (Edmondson, 1999)–was also identified as important in prevention of HAIs. An ICU physician noted, “I think the protocols, the equipment we have, and the teamwork, I think that’s what I would summarize because this is very, very important. And the nurse having the freedom to talk, to see what they think.” A nurse shared, “The nurses can actually say, ‘Hey, well I have an idea, I have a suggestion.’ Whereas before you were kind of told, ‘This is how it’s going to be, this is how you’re going to do it.’ Whereas nurses say, ‘Can we try this way?’”

Teamwork Cognitions

Teamwork cognitions were also identified as important. This component was organized in two categories: 1) team cognition; and 2) interprofessional decision making.

Team cognition–i.e., the specialized knowledge held by each member of the team (transactive memory systems; Lewis, 2003), coordinated to obtain a shared understanding among team members (shared mental models; Mathieu, Heffner, Goodwin, Salas, & Cannon-Bowers, 2000)–was emphasized as important. An ICU director shared, “If you don’t have everybody on the team you will miss something. You will miss one or two important perspectives that could change the outcome of whatever you’re trying to do.” A nurse manager similarly noted a collective understanding among team members by sharing, “They support and help each other. So, if I were a pharmacist and I’m reviewing medications and all these other things that may have impacted or may be related to the case, then that’s one piece. And then the nursing from the practice. And if we have done our deviation in the care, that’s what we focus on. And it actually helps put it together, a full picture.”

Further, interprofessional decision making, described as multiple professions working together to make decisions about patient care (Michalsen et al., 2019), was viewed as a critical component of teamwork among interviewees. A nurse noted the importance of making order sets together as a team, “So, it’s not just like it magically appears in the record and then everybody has to abide. Feedback is taken from every perspective so we’re not missing something that physicians may need and they’re not considering things that nurses might need. It’s very collaborative in that sense.” Similarly, another nurse shared: “We have to work together as a team from every single discipline to be able to fix the problem. It’s not one person that can fix it and its not gonna be fixed overnight. It’s just planning, and it takes a team of all disciplines to get it done… It keeps everyone involved. It’s not just like it’s the nurse and the doctor, the whole collaboration of efforts can come into making a decision for what’s best for the patient.”

Teamwork Behaviors

“Speaking up” to provide relevant and important insight to patient safety concerns was highlighted as an important teamwork behavior in the prevention of HAIs. Specifically, for CLABSIs and CAUTIs, speaking up allowed team members to voice concerns about line necessity, offer suggestions on clinical care, and point out breaches in protocol. One infectious disease physician noted, “Yeah, it’s definitely very strongly encouraged and well received to speak up.” Interviewees also shared that they voiced concerns about line necessity during rounds. A nurse described: “If the providers don’t bring it up, we do, like, ‘Hey do they really still need their Foley? Can we take it out?’ As far as central lines, it’s kind of the same thing. Whereas nurses, we’ll approach the providers and say, ‘Hey I got two peripherals in. Do they really need their central line?’ So, it’s definitely a lot of collaboration between the nursing and the providers as well as with our ‘champions’ that we have on the unit.”

Additional representative quotations regarding teamwork attitudes, cognitions, and behaviors are presented in Table 1.

DISCUSSION

While HAI prevention requires collaboration among multiple professionals, including nurses, physicians, infection preventionists, and hospital administrators, the focus of this paper was largely on the interactions between physicians and nurses, as the data largely converged around these two professions specifically. Consistent with evidence in the literature that suggests aspects of teamwork such as collaboration and communication may impact infection prevention outcomes (van Buijtene & Foster, 2019), our findings identified several components of interprofessional teamwork that may influence the success of infection prevention practices. These findings informed ways in which managers could impact different aspects of interprofessional teamwork, summarized in Figure 2.

Figure 2.

Management practices to support interprofessional teamwork in the context of infection prevention

The model and supporting quotations we have presented suggest that teamwork attitudes, cognitions, and behaviors ultimately influence the prevention of CAUTIs and CLABSIs through safety behaviors (e.g., ensuring sterile technique and hand hygiene) and timeliness of care (e.g., timely removal of Foley catheters and central lines). Overall, the behavior of “speaking up” seems to play a key role in directly influencing safety behaviors (e.g., ensuring sterile technique and hand hygiene) that prevent HAIs. Speaking up also seems to lead to improved timeliness of care (e.g., timely line and Foley removal) for HAI prevention indirectly by increasing team cognition, including interprofessional decision making and team cognitive factors such as shared mental models. Importantly, participants talked about speaking up as an outcome of teamwork attitudes such as interprofessional team orientation and psychological safety. Having a psychologically safe environment has been shown to be crucial for ensuring employees speak up (Edmondson, 1999). Similarly, Okuyama and colleagues’ (2014) findings from a literature review on speaking up for patient safety, suggest that speaking up is also positively influenced by psychological safety cultivated through leadership support. Additionally, evidence suggests that the behavior of speaking up can be improved by training that includes emphasis on leadership support for doing so (Sayre, McNeese-Smith, Leach, & Phillips, 2012). For example, psychological safety can support a nurse’s confidence in speaking up about device removal, leading to interprofessional decision making that results in the timely removal of a patient’s device that reduces their risk of developing an HAI. As shown in Figure 2, we suggest that organizations provide training to providers and staff to teach them how to speak up and how to facilitate psychological safety. Scripted language for pointing out potential errors, and responding to such feedback, can also be adopted by the organization and expected as part of the organizational culture to reduce the cognitive load of speaking up. Leadership support, however, is crucial in order to ensure that employees feel safe and supported in speaking up, particularly to team members of other professions or who are more experienced.

Moving from behavior to team attitudes, interprofessional team orientation emerged as a theme in that many participants described valuing the positive team environment in their organizations and good relationships between physicians and nurses. Based on our data, it seems plausible that healthcare professionals who prefer to work in teams and value interprofessionalism (vs. preferring to work individually and being less collaborative with other professions) may facilitate a climate of more psychological safety; this is likely an important area for future research, as little is known about the construct of interprofessional team orientation. In the meantime, managers can consider selecting new employees in part by considering their attitudes toward healthcare teams (e.g., Heinemann, Schmitt, Farrell, & Brallier, 1999).

In terms of team cognition, interprofessional decision making entails collaboration between members of multiple professions in making a decision about patient care (Legare et al., 2011; Stacey, Legare, Pouliot, Kryworuchko, & Dunn, 2010). In the infection prevention context, physicians and nurses can be successful in reducing HAI rates by working together to decide when to remove patients’ lines and Foleys. This process works best when team members have shared mental models, which can be developed by keeping team members updated. These interactions can take place in interprofessional rounds, and/or in informal interactions facilitated by physical proximity (e.g., interprofessional office-sharing, co-located charting areas for different professions, interprofessional social events, etc.).

Organizational structure and processes were identified as a category of inputs important to teamwork in infection prevention. An organizational culture of accountability was brought up by participants suggesting that such a culture led to increased likelihood to speak up because it was not perceived as “rude,” but rather, a normalized and expected behavior. Such a culture is characterized by shared values of continuous learning, adherence to evidence-based practice, performance measurement, reporting errors without punishment, and collaboration, and this can be fostered by emphasizing continuous improvement and gaining buy-in from healthcare providers (O’Hagan & Persaud, 2009). However, it is important to consider that a culture of accountability should be part of an overall “just culture” (Khatri, Brown, & Hicks, 2009), such that employees are not blamed or punished for errors; rather, while accountability for one’s adherence to infection prevention practices is important, mistakes should be considered in the context of failures within the organizational system and not attributed solely to individuals.

Another input that facilitated teamwork cognition was interprofessional rounding. These regular, interprofessional brief meetings between physicians and nurses can serve to provide daily reminders about patients who may no longer need a line or Foley and get care providers on the same page; they can also serve as a forum for interprofessional decision making when the decision to remove these lines is less clear. Furthermore, the literature suggests that interprofessional rounds are more effective when supportive information technology is provided (Gurses & Xiao, 2006).

We also found support for some input factors that tend to be less under control of management. For example, our findings suggest that small hospitals may have better interprofessional teamwork practices around infection prevention as compared to large hospitals. One hypothesis as to why this occurs is that the strength of the safety climate may be related to the organization size. Larger hospitals tend to be composed of various “microclimates” between disparate units (Edmondson, 2004), allowing for variation in teamwork membership, teamwork practices, and interprofessional collaboration around safety-oriented tasks such as infection prevention. In contrast, team stability may be greater in small hospitals, thus facilitating psychological safety (O’Leary, 2016) and other components of more effective interprofessional teamwork. Altogether, it is possible that these factors lead to higher trust within smaller hospitals, creating conditions that allow team members to work together more effectively. The exploration of this issue is unique, as the impact of organizational size on healthcare processes is understudied and not well-understood (Silvera, 2017). While organizational size cannot be controlled by management, and there are good reasons for some hospitals to be larger, managers can consider strategies to make larger hospitals ‘feel’ smaller, such as creating care teams that employees work within and scheduling employees accordingly.

Another unique contribution of this study is the finding about informal interactions as a driver of teamwork. This is in contrast to more designated, formal interactions, such as interprofessional rounds. Instead, informal interactions seemed to be ad hoc encounters often facilitated by physical proximity (Gum, Prideaux, Sweet, & Greenhill, 2012; Whittaker, Frohlich, & Daly-Jones, 1994), such as shared offices or passing others in the hall. While ensuring that employees engage in informal interactions is not fully under a manager’s control, strategies that can increase opportunities for informal interactions, such as having overlapping time on lunch breaks, starting meetings a few minutes late, or ending a few minutes early to allow employees to chat (e.g., “backstage” interactions; Ellingson, 2003), may be beneficial. Upper management can also consider how to co- locate members of various professions more optimally in shared work areas, e.g., putting physician work stations at or near the nursing station, and having shared offices and break rooms for multiple professions, instead of separate physician and nurse break rooms. These interactions appear to improve team cognition by providing informal opportunities to ask questions and updates on patient care (Ellingson, 2003).

Limitations

While we feel this model is representative of the themes we uncovered through 420 interviews across 18 varied hospitals, formal validation should be done in future research. Additionally, it is possible that perceptions of interprofessional collaboration are viewed differently by physicians and nurses within the same hospital, unit, or team; for instance, Krogstad and colleagues (2004) show that physicians tend to rate their experiences with interprofessional collaboration more positively than nurses. Yet, because we did not specifically ask about the factors in our model and instead found them emerge from our data, it is possible that some quotations represent only the experience and perceptions of one profession, and not the other. As such, the model should be validated from both physician and nurse perspectives.

Conclusion

We found overwhelming evidence for the importance of teamwork in infection prevention, succinctly summarized by a nurse manager we interviewed: “The goal is to do the best thing that we can for the patient, make sure that they’re safe and that we’re doing best practice, and in order for us to do that, we all have to work together.” Furthermore, the data-informed Input-Mediator-Output-Input model of interprofessional teamwork we have presented suggests that organizational processes and structures facilitate specific teamwork attitudes, cognitions, and behaviors, which subsequently lead to HAI prevention including timeliness of device removal, and ensuring sterile technique and hand hygiene. Applying the results of this study in practice can help managers improve interprofessional teamwork around HAI prevention and, ultimately, improve patient safety.