Running head: REGISTERED NURSES EVALUATION 1

Running head: REGISTERED NURSES EVALUATION 1 Registered Nurses Evaluation of the Addition of Intensivist Physicians in the Intensive Care Unit and the Neurosurgical Unit

REGISTERED NURSES EVALUATION 2 Abstract This study investigated if Registered Nurses (RNs) working in the Intensive Care Unit (ICU) and Neurosurgical Care Unit (NSU), found the addition of Intensivist physicians to be favorable. Satisfaction was evaluated on 17 different measures at baseline, prior to the addition of the Intensivist, and six months after working with the Intensivist for that amount of time. A 5-point Likert-type scale was developed for each measure. The target population was the total number of RNs working between both units and participation was voluntary. Participant demographic information was not obtained. Participation at baseline and follow-up was roughly 50% of the total number of staff working between these units. Three specific questions were analyzed for the purpose of this study, because they are of particular importance in the care provided in these units. These questions asked if there is an atmosphere of support and learning, if the Intensivist addresses end of life in an appropriate and timely manner, and the importance of daily rounding. Large effect sizes were noted for two out of the three measures, moderate for the third measure, and confidence intervals were resulted at 95%. The data supports a statistically significant change in RNs response from baseline to follow-up. Overall, the results indicate that RNs rated the three specifically analyzed questions more favorably after working with the Intensivist over six months. Keywords: registered nurses, intensivist physician, intensive care, neurosurgical care, support, end of life, daily rounds

REGISTERED NURSES EVALUATION 3 Introduction Being a nurse is challenging. This became particularly apparent during undergraduate course studies and clinical rotations, when it was realized that the nursing profession is unlike any other. There is an immense responsibility with little authority that many times patients, families, and professionals take for granted. Intensive care nurses are commonly found to be motivated and ambitious individuals with strong autonomy and confidence in advocating for what is right and just in the care of their patients. They also tend to strive for overall excellence and support continuing education through seminars, workshops, specialty certifications, and advanced degrees. Currently, there are seven nurses working toward graduate level degrees between the Intensive Care Unit (ICU) and the Neurosurgical Unit (NSU). In the ICU, nurses see people at their worst and also at their best. Working in the ICU can be frustrating, though this work can also be very rewarding. There are tears, there are joys, and there are great opportunities to see life unexpectedly return and people heal. Death is also a common occurrence in the ICU. Because of the amount of work typically required with just one ICU patient, collaboration with a strong multi-disciplinary team to effectively and efficiently provide holistic care through all stages of hospitalization is necessary. The team is particularly important to provide compassionate care reflective of the patient s wishes during end of life, focusing on comfort to allow for a dignified and peaceful departure from life, with undivided attention and support from staff. The team includes various physicians, registered nurses (RNs), pharmacists, resident physicians, dieticians, the ICU educator, and the case manager. Patients, if they are able, and family are encouraged to be involved with the team, especially during daily rounds, as a way to listen to the various disciplines and to be heard and respected in the care being provided. January, 2013, an Intensivist physician was added to the ICU team, and currently this position is rotated among 3 full-time Intensivists and 1 part-time fill-in Intensivist. The

REGISTERED NURSES EVALUATION 4 Intensivist oversees the care of all ICU status patients and is only a few steps away if needed, as well as reachable via pager when they are off shift. Before the intensivist, there was ambiguity as to which physician to contact should the need arise, in particular, for issues related to changes in patient condition to obtain orders and direction. Due to the high acuity typically found with intensive care patients, it is common to have several doctors comprising the multi-disciplinary team and working together to manage patient care. This required more phone calls to several doctors, prior to the Intensivist. One nurse stated that there were too many cooks in the kitchen. This made continuity of care difficult to achieve among the various providers. Typically, if an immediate need arose overnight, hospital residents would respond to assist with patient care and were many times unfamiliar with the complexities of each patient, which again resulted in a lack of continuity and ineffective collaboration. To evaluate satisfaction with the addition of the Intensivist, a survey assessing 17 different quality measures was completed by RNs at baseline, prior to working with the Intensivist, and six months after working with the Intensivist for that time period. The goal of this study is to determine if nurses find working with the Intensivist to be positive based on these variables. It is believed that RNs will agree more favorably with the 17 variables after 6 months of working with the Intensivist. Also, it is theorized that the Intensivist offers a strong presence creating a supportive atmosphere, as well as timely direction and collaboration to expedite care, which will ultimately lead to improved satisfaction among nurses. This evaluation will be based on the analyses of three out of the 17 questions. Review of Literature Upon review of the literature, it became apparent that there is not a lot of specific information regarding Intensivists and satisfaction with other team members, particularly RNs. This may be a newer concept, or because ICUs utilize other professionals in this leadership role, such as clinical nurse specialists or advanced practice nurses. According to an article by Wilson, Samirat, Yilmaz, Gajic, and

REGISTERED NURSES EVALUATION 5 Iyer (2013) there is a growing trend in the employment of 24 hour attending physician coverage in the ICU. There are identifiable concepts and theories that were noted through reviewing the literature that have been selected for discussion, because they directly relate to the three questions that were statistically analyzed. Atmosphere of Support and Learning Azoulay, Timsit, Sprung, Rusinova, Lafabrie et al. (2009) conducted a survey to identify sources of conflict in the ICU. This is important to consider, as conflict does not promote a supportive or learning friendly environment, and could potentially ruin effective collaboration. The authors recognized that nurse-physician conflicts were at 32.6%, and the most common behaviors leading to conflict were communication break-down, lack of trust, and negativity. The results also indicate that over 70% of staff in the ICU experienced some typed of conflict (Azoulay et al., 2009). It is essential that medical personnel working in the ICU are aware of the potential and actual occurrence of conflict. To foster an environment that thrives on support and learning, nurses and physicians, in particular, need to encourage and support this, so that optimal patient outcomes are achieved. Conflict causes barriers within people s ability to communicate well with each other, leading to decreased morale. This is especially troublesome in the ICU, due to the amount of coordination and level of care required. Ineffective collaboration between nurses and physicians negatively impacts patient care, with decreased quality of care, leading to dissatisfaction among staff (Tang, Chan, Zhou, & Liaw, 2013). This is problematic, as it also lacks support and encouragement to inspire a supportive learning environment. In another article, Albano, Elliott, Lusardi, Scott and Thomas (2005) looked at an adult medical-surgicaltrauma ICU that was found to provide excellent patient care. They attribute collaboration and expertise among the nursing staff, intensivists, and interdisciplinary colleagues as directly related to their award-winning unit (Albano et al., 2005, p. 169). Therefore, research again supports a strong need for collaboration to achieve an atmosphere of support and learning.

REGISTERED NURSES EVALUATION 6 End of Life Weigand, Grant, Jooyoung and Gergis (2013) identified that families of older adults do not always feel included or informed as well as they desire when making end-of-life (EOL) decisions. They state that creating a philosophy that identifies family needs to provide support is important. Weigand et al. (2013) suggests getting to know family members through open communication about their thoughts, perceptions, and patient wishes. They also state there is a need to support families as difficult and complex decisions are made in collaboration with the health care team, and prepare families for the dying process (Weigland et al., 2013, p. 61). Similar in design structure and goals of the present study, Wilson et al. (2013) conducted a retrospective design study to specifically evaluate death in the ICU six months before and six months after the addition of 24 hour ICU Intensivist coverage. The results showed overall improvement on areas related to do-not-resuscitate (DNR) status, length of life support, and shortened time to initiate family care conferences. The authors also concluded that continuity of care with Intensivist presence is key in providing strong collaborative efforts and improved patient care. White, Ernecoff, Billings, and Arnold (2013) investigated if patients prefer to die at home, instead of in the ICU, and related quality of life to the dying process. They state this concept of quality related to dying first arose with patients who had terminal cancer. White et al. (2013) pointed out that generalizing on this idea is difficult, because many patients in the ICU do not have clearly identifiable end-stage conditions. The authors state that critical illnesses, such as sepsis and vital organ injury, carry an approximate mortality rate of 50%. White et al. (2013) states it is rarely possible to make accurate, prospective (pre ICU admission) judgments that individual patients cannot survive their acute illness (p. 264). Therefore, it is especially important to identify realistic needs of the patient, and approach this topic delicately, with clear and supportive information as to the prognosis and expectations of the disease process. The Intensivist can be important in coordinating this type of care and having these difficult conversations.

REGISTERED NURSES EVALUATION 7 Daily Rounds An article by Lane, Ferri, Lemaire, McLaughlin, and Stelfox (2013) noted that patient care rounds in the ICU are a key tool that healthcare providers use to communicate and make patient care decisions. Lane et al. (2012) learned that research regarding this topic is limited and identified barriers to patient care rounds as interruptions during rounds and the length of time rounds can require. However, it is important to outweigh potential negative distractions with the benefits to be gained. A before and after study was conducted by Jacobowski, Girard, Mulder, and Ely (2010) to investigate the impact of daily rounds, explicitly, from a family perspective. Jacobowski et al. (2010) identified that 30-50% of families reported inadequate comprehension of the terminology used by medical personnel. They also learned that families appreciate this communication tool and the chance to have questions answered about the anticipated treatments and plan. However, an available physician to provide a summary to families in lay language assisted them to feel better prepared for more indepth conversations at a later time (Jacobowski et al., 2010). Families being included in daily rounds results in one cohesive team working toward the same goals in the care provided. Methods Participants The target population was Registered Nurses working in the ICU and NSU located in a hospital in a suburb of Chicago, Illinois, with a population of almost 200,000 residents in 2012. This study lacks participant demographic markers, such as gender, age, race, years of service, education level, and language preferences. Fall of 2012, prior to the addition of the intensivist physician, patients with neurological disease and neurosurgical procedures were separated from the general ICU population into an 8 bed unit, leaving 14 beds in ICU, totaling 22 intensive care beds. Logistically, the units are connected and the Intensivist works within both divisions. At the time of the survey, both units were under one manager as well.

REGISTERED NURSES EVALUATION 8 Materials and Procedure Participation was voluntary. Participants were asked to complete a written survey containing 17 questions with a 5-point Likert-type scale (See Appendix A). Responses varied from strongly disagree to strongly agree. Once data were obtained, participant responses were coded as: strongly disagree 1, disagree 2, neutral 3, agree 4, strongly agree 5, and the data were then entered into the Statistical Package for the Social Sciences (SPSS) program for analysis. Out of the 17 total questions, three will be evaluated for the purpose of this study. Specifically, these questions are as follows: question 2, there is an atmosphere of support and learning, question 6, physicians in the ICU address end of life in an appropriate and timely manner, question 15, daily rounds are an important part of patient care in the ICU. Descriptive statistics were completed for each of the three analyzed quality measures and include tables and graphs (See Appendix B). Inferential statistics, dependent sample repeated design t-test, was conducted for each variable as well (See Appendix C). The differences between baseline and follow-up questions are noted in Appendix D. Operational Definitions The dependent variables are the RNs responses to the 17 questions. The independent variable is the Intensivist. An Intensivist is a physician who specializes in the treatment and care provided to patients admitted to the intensive care unit. Question 2 asks if there is an atmosphere of support and learning. Support is commonly defined as preventing someone or something from falling, to advocate and corroborate, to patiently endure or tolerate. These terms are important to work that occurs in ICU. Question 6 inquires if physicians address end of life issues in a timely manner. End of life can be related to foreseen circumstances, such as progressively worsening illness, and unforeseen circumstances that could be related to a devastating new diagnosis of a life limiting disease or a traumatic injury. Issues related to end of life involve do-not-resuscitate status, family members experiencing difficulty and differing opinions in the care that should and should not be provided, and uncertainty about the wishes

REGISTERED NURSES EVALUATION 9 of the patient. Question 15 asks if daily rounds are an important part of care provided in the ICU. At this hospital, daily rounds occur Monday through Friday in the morning. Members of the multi-disciplinary team, including family members, gather outside each patient s room and discuss the patient s case, status, and potential needs. The team then makes plans and adjustments accordingly. Sample Size, Power, Precision The total number of RNs working between the ICU and the NSU was the intended sample size. The initial survey was completed December, 2012, on site in the unit. At the time of the initial survey, there were a total of 42 RNs working in the ICU and 18 in the NSU including full-time, part-time, and registry staff, for a total of 60 intensive care nurses. Out of this total, 23 participants (55%) working in the ICU, and seven (39%) working in the NSU, completed the initial survey, totaling 30 participants. When considering both units together, this equates to a 50% lack of initial participation. At the time of the follow-up survey in July of 2013, 36 RNs worked in the ICU and the total number of NSU RNs remained at 18, totaling 54. The follow-up survey included a total of 28 participants, 52% of the total number of RNs, 19 (53%) from the ICU and 9 (50%) from the NSU, leaving 48% lack of participation. The sample size was initially right at the mark to meet the central limit theorem; however, the number of participants who responded in follow-up decreased by two participants and the distribution of the follow-up survey changed. Statistical Hypothesis The null hypothesis states there is no difference between the paired questions 2 and 2b, 6 and 6b, 15 and 15b. (H0: paired difference = 0). The alternative hypothesis states there is a difference between the paired questions (H1: paired difference does not = 0). Alpha level is at.05; though, multiple correction comparison method, Bonferroni Correction, was performed to account for this dependent statistical test being performed at the same time on 3 different variables. The significance level (.05) was

REGISTERED NURSES EVALUATION 10 divided by three to lower the alpha level (.017) and take into account the number of comparisons being performed, which is three. There are 25 degrees of freedom and a 95% confidence interval. Results Assumptions Assumptions for the statistical evaluations completed were met, except in regards to normality test results. The dependent variable data was continuous, measured at interval level. A normal distribution was observed when looking at the histograms, and skewness and kurtosis fell within the range of -2.00 to +2.00, except for question 15b, where kurtosis resulted at 3.024. Boxplots revealed outliers for questions 2, 2b, 15, and 15b. Also, standard deviation (SD) was not exceedingly spread out from the mean on all three questions, where SD was less than the mean. A piori tests of normality, Kolmogorov-Smirnov and Shapiro-Wilk, reveal that p <.05 for each of the investigated questions, 2, 2b, 6, 6b, 15, 15b. This means that normality cannot be assumed for these questions. However, when considering the majority rule, there were more elements overall for each question, indicating normal distribution of the dependent variables (See Appendix B). Descriptive Statistics For all three questions, n = 30 at baseline with n = 2 for missing data. Follow-up questions, n = 28, with n = 4 for missing data. Question 2, the M = 3.43, SD = 1.104, skewness at -.313, and kurtosis at -.717. Question 2b, M = 4.18, SD =.863, skewness at -1.1, and kurtosis at 1.135. Question 6, M = 2.70, SD = 1.088, skewness at -.038, and kurtosis at -1.377. Question 6b, M = 3.39, SD = 1.227, skewness = -.445, kurtosis = -.855. Question 15, M = 3.73, SD =.868, skewness = -1.125, and kurtosis = 2.426. For question 15b, M = 4.36, SD =.826, skewness at -1.628, and kurtosis at 3.024 (See Appendix B). Paired Samples Correlations Correlations between the two scores from baseline to follow-up were reviewed. Question two, paired samples correlation equals -.045, with p =.828. Question 6, paired samples correlation equals

REGISTERED NURSES EVALUATION 11.034, with.869 alpha level. Question 15, paired samples correlation equals -.086, and alpha at.678. The null cannot be rejected at the.05 alpha level and, therefore, significance is questionable. Overall, this means that the data does not support significance that these questions should be paired. We do know, however, that in theory these questions should be related, since they are the same questions from baseline to 6 months follow-up. Inferential Statistics Dependent samples t-test was run to compare baseline data with responses obtained at 6 month follow-up for questions 2, 6, and 15 (See Appendix C). In regards to question 2, there is an atmosphere of support and learning, not retribution, the tabled critical value at.05 alpha = 2.060, df = 25, 2-tailed test. The value of the sample test statistic = -3.134, with sample p-value at.004. The observed t-value of -3.134 is beyond the critical boundary of 2.060, therefore, we reject the null and accept the alternative that there is a difference between the baseline and 6 month follow-up survey. Question 6, physicians address end of life in appropriate and timely manner, the tabled critical value at.05 alpha = 2.060, df = 25, 2-tailed. The value of the sample test statistic = -2.534, with sample p-value at.018. Because the observed t-value of -2.534 is beyond the critical boundary of 2.060, we reject the null and accept the alternative that a difference was noted between surveys. Question 15, daily rounds are an important part of ICU patient care, the tabled critical value at.05 alpha = 2.060, df = 25, 2-tailed test. The value of the sample test statistic = -3.143, with sample p- value at.004. Because the observed t-value of -3.143 is beyond the critical boundary of 2.060, we reject the null and accept the alternative that there is a difference between baseline and 6 month follow-up in regards to daily rounds. Confidence Intervals at 95% Error bars reveal midpoints for all three questions are separate from each other and do not overlap, which indicates a statistically significant difference between baseline and follow-up (See

REGISTERED NURSES EVALUATION 12 Appendix D). For all three questions, we are confident that out of 100 samples, 95 would contain the population mean difference parameter. Because all three intervals do not contain 0, we reject the null and retain the alternative hypothesis that 2, 2b, 6, 6b, 15, 15b are not equal to each other. Also, there is a lot of distance between the errors in the model and point estimates. Specifically, question 2 population mean difference parameter is estimated at -.846, within the interval of -1.402 and -.290. The distance between the error in the model is (.270) and the point estimate (-.846). For question 6, the population mean paired difference parameter, estimated at -.808, is within the interval of -1.464 and -.151. The distance between the error in the model is (.319) and the points estimate (-.808). Question 15, population mean paired difference parameter, estimated at -.692, falls within the interval of -1.146 and -.239. The distance between the error in the model is (.220) with the point estimate (-.692). Effect Size (Cohen s d) Because statistical differences were noted, effect size was computed, as the differences between each question from baseline to follow-up are believed to not be random. There is confidence that there are differences between the two means. Since the null was rejected, the magnitude of the mean differences were evaluated using the paired samples statistic results. Question 2 and 15 effect sizes =.89 and.90. These values are greater than Cohen s d benchmark value of.80, which represents a large effect size. There is about 9/10 standard deviation difference between baseline and follow-up in regards to these questions, and they were likely present in the population to a large degree. Question 6 effect size =.69, falls between benchmark values of.50 and.80, meaning the results are moderate in effect, with 7/10 standardized difference. Overall, in regards to questions 2, 6, and 15, we learned that there is a practical difference between how nurses rated these questions prior to working with the Intensivist, when compared to having worked with Intensivist over the course of 6 months.

REGISTERED NURSES EVALUATION 13 Power Analysis The null was rejected and the alternative hypothesis was accepted. Type II error was controlled against, where power values are greater than or equal to.80 for questions 2 and 15. Power for question 2 (.88) and question 15 (.89), means there is an 88% and 89% probability of achieving statistically significant results for these questions. Question 6 power value is at.69, meaning there is a 69% probability of achieving statistically significant results. Sample size, n = 26, is below the central limit theorem; however, since normality was assumed, n < 30 is appropriate. Results were calculated by entering effect size data, the paired sample means and SDs, into syntax file where results produced Cohen s d and power values listed below. Cohen's d and Power Independent and Dependent Sample t-tests: Cohens d Power Post-Hoc -.89.88 -.69.69 -.90.89 Tests of normality, Kolomov-Smirnov and Shapiro-Wilk, reveal that p >.05 for the difference between questions 2 and 2b, 6 and 6b, meaning we fail to reject the null and normality can be assumed for these questions. The dependent variable is believed to be similar to the population, skewness and kurtosis fall within the normal range of -2.00 to +2.00, the SD are less than the mean, and histograms and boxplots look good. The difference between question 2 and 2b, M = -.8462, SD = 1.38, skewness =.100, and kurtosis =.533. The boxplots reveal an outlier at baseline and also at follow-up. The difference between question 6 and 6b, M = -.8077, SD 1.63, skewness =.209, and kurtosis =.105. Question 15 and 15b, however, p <.05, and normality cannot be assumed. Also, when looking at the boxplot outlier is present. The mean difference = -.6923, SD = 1.12, skewness = 1.17, and kurtosis = 4.05. For this question, there are 4 indicators that there is not normal distribution, including Kolmongorov-Smirnov

REGISTERED NURSES EVALUATION 14 and Shapiro-Wilk normality tests, boxplot, and kurtosis. There were 2 indictors that support normality. Therefore, question 15 goes against majority rule and normality cannot be assumed (See Appendix D). Discussion Limitations Individual markers were not obtained for the participants, such as such as gender, age, race, years of service, education level, and language preferences. Therefore, it was not possible to analyze these characteristics at an aggregate level. This information would have been important, as it would allow for insight as to the RNs perceptions regarding the 17 different concepts at baseline and after working with the intensivist physician for six months. Understanding participant demographics would allow for further break down and a possible greater understanding of the results and how they relate. Another limitation is that the participants were identified with numbers at baseline and at six month follow-up, however, these numbers were not linked together to identify each participant from baseline to follow-up. This is problematic, because it is not possible to know if participant number one at baseline is participant number one at follow-up and, therefore, making comparisons among each participant is not likely. This may have affected the paired samples correlation results as well. It is also unfortunate this was not accounted for, since the goal of the study was to determine RNs satisfaction and essentially his or her opinions as to the agreement or disagreement on the variables. Additionally, without having linked participant numbers, it is unclear if the gain in two participants in the NSU was partially related to the four participant loss in the ICU, since there had been movement of staff between the units. Despite one question not being answered by a single participant, the overall missing data is systematic. This is because 4 participants from the ICU initially completed the survey; however, they did not complete the follow-up survey. Similarly, two participants from NSU did not complete the baseline

REGISTERED NURSES EVALUATION 15 survey, though the follow-up survey had two extra participants. The average missing data is over 5%, which is the rule to impute the mean, therefore, this would not be appropriate. When considering the paired samples correlation, significance in the relationship between each of the three paired measures was questionable. The lack of significance does not seem to be a spurious result, however. In theory, the three questions should be paired, as they are the same questions asked at baseline and again at follow-up. What may be questionable is within the sampled participants. Participants may not have completed baseline or follow-up surveys under the unit they were initially grouped with, though the total number of staff in NSU did not change from baseline to follow-up. There was a loss of six RNs from the total number of staff in ICU from baseline to follow-up. It seems possible that maybe two additional RNs from NSU completed the follow-up survey, despite not completing the initial survey. This information is lost and cannot be known at this point, due to lack of corresponding participant numbers. The consequence is that statistical analysis indicates the three questions should not be paired. Implications for Nursing Practice Overall, the results of this study support the addition of an Intensivist to the ICU team. It is possible that because of improved RN satisfaction, Intensivists can be crucial in providing support that nurtures learning. Educationally, Intensivists conduct research and participate in journal club, which occurs in this ICU as a way to review the literature and determine if current care is supported by the evidence. Openly communicating and discussing defects in the care delivery are necessary in providing excellent care to patients and their families. The results of this study indicate a positive response to the Intensivists promoting an atmosphere of support and learning, which will improve morale and lead to stronger practice methods and patient outcomes. Research also indicated that Intensivists can be important in coordinating end of life care and this study supports this as well. Improving this particular

REGISTERED NURSES EVALUATION 16 area is especially important, because the result is final. Daily rounds were noted as key to improving collaborative efforts and the RNs were in support of this activity. Future Research This topic is important and relevant to the ICU. The data alone is not as strong as it could have been with specific participant demographics. Future study should consider obtaining detailed participant characteristics, such as gender, age, race, years of service, education level, and language preferences. This information could be broken down to further understand the responses, especially when considering participant demographic details to identify a possible relationship between those demographics and the changes noted. Also, it would be advantageous for participants to be consistently identified numerically from baseline to follow-up. Identifying those details could help pinpoint where beneficial changes could be implemented. Future study should consider evaluating measures related to morale and staff retention in relation to the Intensivist, to determine if this role has an effect on those variables. Conclusion Overall, this study presents statistical significance supporting the addition of Intensivists to the ICU and NSU according to RN responses. The Intensivists are vital in facilitating collaboration among the multi-disciplinary team, leading to increased knowledge within a supportive learning environment, as well as providing excellent holistic care. When considering the three analyzed measures relating to an atmosphere of support and learning, end of life, and daily rounds, the results of this study are consistent with the available research presented. It is important to reiterate this study found the role of the Intensivist to be positive, as evidenced by the opinions of the RNs that work most closely with these physicians in this ICU.

REGISTERED NURSES EVALUATION 17 References Albano, A., Elliott, S., Lusardi, P., Scott, S., & Thomas, D. (2005). A step ahead: Strategies for excellence in critical care nursing practice. Critical Care Nursing Clinics of North America, 17(2), 169-175. Azoulay, E., Timsit, J. F., Sprung, C. L., Soares, M., Rusinova, K., & Lafabrie, A. et al. (2009). Prevalence and factors of intensive care unit conflicts: The conflicus story. American Journal of Respiratory & Critical Care Medicine, 180(9), 853-860. Jacobowski, N. L., Girard, T. D., Mulder, J. A., & Ely, E. W. (2010). Communication in critical care: Family rounds in the intensive care unit. American Journal of Critical Care, 19(5), 421-429. Lane, D., Ferri, M., Lemaire, J., McLaughlin, K., & Stelfox, H. T. (2013). A systematic review of evidenceinformed practices for patient care rounds in the ICU. Critical Care Medicine,41(8), 2015-2029. Tang, C. J., Chan, S. W., Zhou, W. T., & Liaw, S. Y. (2013). Collaboration between hospital physicians and nurses: An integrated literature review. International Nursing Review, 60(3), 291-302. Weigland, D. L., Grant, M. S., Jooyoung, C., & Gergis, M. A. (2013). Family-centered end-of-life care in the ICU. Journal of Gerontological Nursing, 39 (8), p. 60-68. White, D. B., Ernecoff, N., Billings, J. A., & Arnold, R. (2013). Is dying in an ICU a sign of poor quality endof-life care? American Journal of Critical Care, 22(3), 263-266. Wilson, M. E., Samirat, R., Yilmaz, M., Gajic, O., & Iyer, V. N. (2013). Physician staffing models impact the timing of decisions to limit life support in the ICU. Chest Journal, 143(3), 656-663.

REGISTERED NURSES EVALUATION 18 Appendix A Questions asked at baseline and 6 month follow-up: 1. Quality of care in this ICU is excellent 2. There is an atmosphere of support and learning (not retribution) when defects in care delivery are discussed in this ICU 3. There is excellent patient and family communication by physicians in this ICU 4. There is excellent sepsis care in this ICU 5. I am empowered to suggest changes in care that promote patient safety 6. Physicians in the ICU address End of Life decisions in an appropriate and timely manner 7. There is a sense of team and mutual respect that exists among ICU nurses and the physicians 8. Medical errors are discussed openly between the physicians and nurses 9. The physicians and nurses work together as a well-coordinated team 10. Morale in the unit is high when the physicians are present 11. Disagreements in care are resolved appropriately (i.e., not who is right but what is best for the patient) 12. The physicians have professional communication with bedside nursing staff 13. Patient orders are clearly communicated from the physicians to the nursing staff 14. Patients have central venous access place appropriately and quickly 15. Daily rounds are an important part of patient care in the ICU 16. I receive excellent physician response when needed for my patients in this ICU 17. Current medical practice in this ICU is current and follows evidence based guidelines

REGISTERED NURSES EVALUATION 19 Appendix B Statistics Atmosphere of support & learning Q2b Valid 30 28 N Missing 2 4 Mean 3.43 4.18 Median 4.00 4.00 Mode 4 4 Std. Deviation 1.104.863 Skewness -.313-1.113 Std. Error of Skewness.427.441 Kurtosis -.717 1.135 Std. Error of Kurtosis.833.858 25 2.75 4.00 Percentiles 50 4.00 4.00 75 4.00 5.00 Atmosphere of support & learning Frequency Percent Valid Percent Cumulative Percent strongly disagree 1 3.1 3.3 3.3 disagree 6 18.8 20.0 23.3 Valid neutral 7 21.9 23.3 46.7 agree 11 34.4 36.7 83.3 strongly agree 5 15.6 16.7 100.0 Total 30 93.8 100.0 Missing 999 2 6.3 Total 32 100.0

REGISTERED NURSES EVALUATION 20 2b Frequency Percent Valid Percent Cumulative Percent disagree 2 6.3 7.1 7.1 neutral 2 6.3 7.1 14.3 Valid agree 13 40.6 46.4 60.7 strongly agree 11 34.4 39.3 100.0 Total 28 87.5 100.0 Missing 999 4 12.5 Total 32 100.0

REGISTERED NURSES EVALUATION 21 Descriptive Statistics N Minimum Maximum Mean Std. Deviation Atmosphere of support & 30 1 5 3.43 1.104 learning Q2b 28 2 5 4.18.863 Valid N (listwise) 26

REGISTERED NURSES EVALUATION 22

REGISTERED NURSES EVALUATION 23 Statistics Physicians address end of life appropriate/timely Q6b Valid 30 28 N Missing 2 4 Mean 2.70 3.39 Median 2.50 4.00 Mode 2 4 Std. Deviation 1.088 1.227 Skewness -.038 -.445 Std. Error of Skewness.427.441 Kurtosis -1.377 -.855 Std. Error of Kurtosis.833.858 25 2.00 2.00 Percentiles 50 2.50 4.00 75 4.00 4.00 Physicians address end of life appropriate/timely Frequency Percent Valid Percent Cumulative Percent strongly disagree 4 12.5 13.3 13.3 disagree 11 34.4 36.7 50.0 Valid neutral 5 15.6 16.7 66.7 agree 10 31.3 33.3 100.0 Total 30 93.8 100.0 Missing 999 2 6.3 Total 32 100.0

REGISTERED NURSES EVALUATION 24 Q6b Frequency Percent Valid Percent Cumulative Percent strongly disagree 2 6.3 7.1 7.1 disagree 6 18.8 21.4 28.6 Valid neutral 4 12.5 14.3 42.9 agree 11 34.4 39.3 82.1 strongly agree 5 15.6 17.9 100.0 Total 28 87.5 100.0 Missing 999 4 12.5 Total 32 100.0

REGISTERED NURSES EVALUATION 25 Descriptive Statistics N Minimum Maximum Mean Std. Deviation Physicians address end of 30 1 4 2.70 1.088 life appropriate/timely Q6b 28 1 5 3.39 1.227 Valid N (listwise) 26

REGISTERED NURSES EVALUATION 26

REGISTERED NURSES EVALUATION 27 Statistics Daily rounds are an important part of ICU pt care Q15b Valid 30 28 N Missing 2 4 Mean 3.73 4.36 Median 4.00 4.50 Mode 4 5 Std. Deviation.868.826 Skewness -1.125-1.628 Std. Error of Skewness.427.441 Kurtosis 2.426 3.024 Std. Error of Kurtosis.833.858 25 3.00 4.00 Percentiles 50 4.00 4.50 75 4.00 5.00 Daily rounds are an important part of ICU pt care Frequency Percent Valid Percent Cumulative Percent strongly disagree 1 3.1 3.3 3.3 disagree 1 3.1 3.3 6.7 Valid neutral 7 21.9 23.3 30.0 agree 17 53.1 56.7 86.7 strongly agree 4 12.5 13.3 100.0 Total 30 93.8 100.0 Missing 999 2 6.3 Total 32 100.0

REGISTERED NURSES EVALUATION 28 Q15b Frequency Percent Valid Percent Cumulative Percent disagree 2 6.3 7.1 7.1 Valid agree 12 37.5 42.9 50.0 strongly agree 14 43.8 50.0 100.0 Total 28 87.5 100.0 Missing 999 4 12.5 Total 32 100.0

REGISTERED NURSES EVALUATION 29 Descriptive Statistics N Minimum Maximum Mean Std. Deviation Daily rounds are an 30 1 5 3.73.868 important part of ICU pt care Q15b 28 2 5 4.36.826 Valid N (listwise) 26

REGISTERED NURSES EVALUATION 30

REGISTERED NURSES EVALUATION 31 T-Test Question #2 Appendix C Paired Samples Statistics Mean N Std. Deviation Std. Error Mean Pair 1 Atmosphere of support & 3.42 26 1.102.216 learning Q2b 4.27 26.778.152 Paired Samples Correlations N Correlation Sig. Pair 1 Atmosphere of support & learning & Q2b 26 -.045.828 Paired Samples Test Paired Differences t df Sig. (2-tailed) Mean Std. Std. Error 95% Confidence Interval Deviation Mean of the Difference Pair 1 Atmospher e of support & learning - Q2b Lower Upper -.846 1.377.270-1.402 -.290-3.134 25.004

REGISTERED NURSES EVALUATION 32 T-Test Question #6 Paired Samples Statistics Mean N Std. Deviation Std. Error Mean Pair 1 Physicians address end of 2.65 26 1.093.214 life appropriate/timely Q6b 3.46 26 1.240.243 Paired Samples Correlations N Correlation Sig. Pair 1 Physicians address end of life appropriate/timely & Q6b 26.034.869 Paired Samples Test Paired Differences t df Sig. (2-tailed) Mean Std. Std. Error 95% Confidence Devia Mean Interval of the tion Difference Lower Upper Pair 1 Physicians address end of life appropriate/ti mely - Q6b -.808 1.625.319-1.464 -.151-2.534 25.018

REGISTERED NURSES EVALUATION 33 T-Test Question #15 Paired Samples Statistics Mean N Std. Deviation Std. Error Mean Pair 1 Daily rounds are an 3.77 26.815.160 important part of ICU pt care Q15b 4.46 26.706.138 Paired Samples Correlations N Correlation Sig. Pair 1 Daily rounds are an important part of ICU pt care & Q15b 26 -.086.678 Paired Samples Test Mean Std. Deviation Paired Differences t df Sig. (2- Std. Error 95% Confidence Interval tailed) Mean of the Difference Lower Upper Pair 1 Daily rounds are an important part of ICU pt care - Q15b -.692 1.123.220-1.146 -.239-3.143 25.004

REGISTERED NURSES EVALUATION 34 Appendix D Question #2 Case Processing Summary Cases Valid Missing Total N Percent N Percent N Percent differenceq2 26 81.3% 6 18.8% 32 100.0% Descriptives Statistic Std. Error Mean -.8462.27000 95% Confidence Interval for Mean Lower Bound -1.4022 Upper Bound -.2901 5% Trimmed Mean -.8419 Median -1.0000 Variance 1.895 differenceq2 Std. Deviation 1.37673 Minimum -4.00 Maximum 2.00 Range 6.00 Interquartile Range 2.00 Skewness.100.456 Kurtosis.533.887 Tests of Normality Kolmogorov-Smirnov a Shapiro-Wilk Statistic df Sig. Statistic df Sig. differenceq2.160 26.086.940 26.136 a. Lilliefors Significance Correction

REGISTERED NURSES EVALUATION 35

REGISTERED NURSES EVALUATION 36

REGISTERED NURSES EVALUATION 37 Question #6 Case Processing Summary Cases Valid Missing Total N Percent N Percent N Percent differenceq6 26 81.3% 6 18.8% 32 100.0% Descriptives Statistic Std. Error Mean -.8077.31874 95% Confidence Interval for Mean Lower Bound -1.4642 Upper Bound -.1512 5% Trimmed Mean -.8419 Median -1.0000 Variance 2.642 differenceq6 Std. Deviation 1.62528 Minimum -4.00 Maximum 3.00 Range 7.00 Interquartile Range 2.00 Skewness.209.456 Kurtosis.105.887 Tests of Normality Kolmogorov-Smirnov a Shapiro-Wilk Statistic df Sig. Statistic df Sig. differenceq6.156 26.105.960 26.382 a. Lilliefors Significance Correction

REGISTERED NURSES EVALUATION 38

REGISTERED NURSES EVALUATION 39

REGISTERED NURSES EVALUATION 40 Question #15 Case Processing Summary Cases Valid Missing Total N Percent N Percent N Percent differenceq15 26 81.3% 6 18.8% 32 100.0% Descriptives Statistic Std. Error Mean -.6923.22027 95% Confidence Interval for Mean Lower Bound -1.1460 Upper Bound -.2386 5% Trimmed Mean -.7564 Median -1.0000 Variance 1.262 differenceq15 Std. Deviation 1.12318 Minimum -3.00 Maximum 3.00 Range 6.00 Interquartile Range 1.00 Skewness 1.166.456 Kurtosis 4.048.887 Tests of Normality Kolmogorov-Smirnov a Shapiro-Wilk Statistic df Sig. Statistic df Sig. differenceq15.262 26.000.842 26.001 a. Lilliefors Significance Correction

REGISTERED NURSES EVALUATION 41

REGISTERED NURSES EVALUATION 42