Association between the levels of nurse-doctor interprofessional collaboration and in-patient mortality: A systematic review

doi:10.21203/rs.3.rs-1340553/v1

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Association between the levels of nurse-doctor interprofessional collaboration and in-patient mortality: A systematic review

https://doi.org/10.21203/rs.3.rs-1340553/v1

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Background

The level of nurse-doctor interprofessional collaboration may influence patient outcomes, including mortality. To date, no systematic reviews have investigated the association between the amount of nurse-doctor collaboration and inpatient mortality.

Methods

A systematic review. We included studies that measured the amount of nurse-doctor interprofessional collaboration and in-patient mortality. Five databases (MEDLINE, EMBASE, PsycInfo, CINAHL and the Cochrane register) were searched in June 2019 and February 2021. Two researchers undertook title and abstract and full-text screening. Risk of bias was determined using the Effective Public Health Practice Project (EPHPP) measure.

Results

Six documents from three observational studies met the inclusion criteria for the review. Participants included 191 doctors, 29591 nurses, and 1.32 million patients. Included studies had a high risk of bias. Of the three included studies, one reported a significant association and one no association between nurses’ reports of the amount of interprofessional collaboration. Although meeting inclusion criteria the third study did not test this association.

Conclusion

We found no high-quality evidence to suggest the amount of nurse-doctor interprofessional collaboration was associated with mortality in medical and surgical inpatients. There is a need for further high-quality research to evaluate the association between the amount of nurse-doctor interaction and patient outcomes.

Systematic review registration

PROSPERO CRD42019133543

Nurse-doctor communication

inpatient mortality

medical and surgical wards

systematic review

Interprofessional collaboration in clinical settings refers to health professionals from different disciplines working together, sharing ideas and opinions to provide evidence-based patient care [1–3]. There is debate as to the impact on patient outcomes of levels of nurse-doctor collaboration [4]. For example, it could be that poor collaboration can lead to a delay in sharing relevant clinical information resulting in poor quality patient care [5]. Conversely, positive collaborative working may ensure patients receive timely evidence based informed care and treatment [6].

There have been no systematic reviews that have examined the association between levels of interprofessional collaboration and patient outcomes. We identified two American multicentre observational studies where authors have tested the association between levels of nurse-doctor collaboration and patient outcomes in medical and surgical wards [7, 8]. In the first study, the authors reported that higher levels of nurse doctor collaboration - determined using the Practice Environment Scale - was associated with a three percent reduction in 30-day hospital readmissions [7]. In a second study, by the same corresponding author but with different team members, the association between the amount of nurse-doctor collaboration - measured using the nurse-physician interaction scale - and the rate of hospital-acquired pressure ulcers in adult medical and surgical patients was investigated [8]. The authors report a 19% reduction in the odds of developing pressure ulcers if patients were admitted to a hospital ward with high levels of nurse-doctor collaboration.

There have been four systematic and one umbrella review that have examined the effect of nurse and doctor teamwork - in which levels of collaboration is a component - on patient outcomes [9–13]. Spechhia et. al (2020) reported an umbrella-review to evaluate the effect of “tumour board” - a team approach to the management of cancer patients - on cancer reoccurrence and survival rates. The review included five systematic reviews that were appraised using the AMSTAR2 (Assessing the Methodological quality of SysTemAtic Reviews); all were rated high risk of bias. Pannick et al. (2015) conducted a systematic review and meta-analysis of 30 randomised controlled trials involving 66,548 patients evaluating the effect of interprofessional teamwork on patient outcomes in medical wards. The authors reported an eight percent reduction in the relative risk of hospital mortality. Included studies had a high risk of bias.

Teamwork and inter-professional collaboration are related but different concepts. Collaboration is a core component of effective team working [14, 15]. Sangaleti et al. (2017) argue that teamwork is a product of collaborative practice among healthcare workers. Whilst we acknowledge that people from different clinical specialties provide patient care, in this review we were interested in focus on the association between levels of nurse-doctor collaboration in general medical and surgical settings and patient outcomes, specifically mortality.

Our review protocol was registered on the Prospective Register of Systematic Reviews (PROSPERO Registration - CRD42019133543) prior to conducting our initial searches. We have published our protocol that describes our methodology in detail (reference removed for peer-review process). Our reporting complies with the updated Preferred Items for Systematic Review and Meta-Analysis (PRISMA) guidelines and we have included a completed checklist with the manuscript (Additional file 1) [16].

Eligibility criteria

We included observational and experimental studies if: 1. The study reported a measure of nurse-doctor interprofessional collaboration, 2. Fieldwork was conducted in medical or surgical inpatient wards, 3. Mortality was reported as an outcome, and 4. The manuscript was in English.

Information sources

Five databases were used in this review: MEDLINE, EMBASE, PsycINFO, CINAHL, and the Cochrane registry. The Ovid platform was used to search the MEDLINE, EMBASE and PsycINFO databases. We accessed CINAHL through Ebscohost. Searches were carried out on 15th June 2019 and updated on 16th February 2021.

Search strategy

We developed our search strategy around three concepts: 'nurses and doctors', 'collaboration', and 'mortality'. Each concept was further elaborated using synonyms and different truncations. For example, ‘cooperation’ and ‘coordination’ were used to represent ‘collaboration’. ‘Physician*’ and ‘doctor*’ were used to identify clinicians. Our search terms were peer-reviewed by an information scientist experienced in developing search strategies. We limited our search concepts to title and abstracts only. We have provided a detailed search strategy for each database (Additional file 2).

Selection process

Citations from individual databases were combined into a single endnote file (.xml). The .xml file was then uploaded into the ‘Covidence’ review manager software [17]. Duplicate citations were filtered and removed by Covidence. Screening of eligible study was carried out in two steps: 1. Title and abstract and 2. Full text. Two authors independently carried out screening. Any discrepancies were resolved either by discussion between the reviewers or in consultation with a third member of the team.

Multiple papers from a single study

If multiple papers were identified from a single study, we considered the first published paper reporting results from a study as the primary citation and other papers as secondary citations [18].

Checking for retraction

We checked the papers entry on the journal website to confirm the manuscript had not been retracted or there was an expression of concern.

Data collection process

We developed a template to extract data from included studies. Two reviewers independently carried out data extraction. Discrepancies in the data extraction were resolved by discussion between reviewers and checking information from the source manuscript. The corresponding author of included studies was contacted by email if additional information about an included study was required.

Data items

We extracted the following information from included papers: citation, year of publication, country where fieldwork was conducted, study setting, study design, sample size calculation, start and end of data collection, sample size (number of patients, nurses, and doctors enrolled in the study), measure of level of collaboration, and mortality outcomes.

Study risk of bias assessment

Quality appraisal of included studies was undertaken using the Effective Public Health Practice Project (EPHPP) measure. The EPHPP has good psychometric properties and is applicable for both interventional and observational studies [19, 20]. The EHPPP evaluates the risk of bias against six items: selection bias, study design, confounders, blinding, data collection method, and withdrawals/dropouts. Each of these categories is rated ‘strong’, ‘moderate’, or ‘weak’ against criteria. Based on the number of weak ratings an overall score is given: ‘strong’ (no weak ratings), ‘moderate’ (one weak rating), ‘weak’ (two or more weak ratings).

Two authors independently carried out the risk of bias assessment. Any discrepancies were resolved by discussion between the researchers.

Protocol amendment

We made an amendment to the protocol to include PhD dissertations in the review.

Study selection

Figure 1 (PRISMA flowchart) shows the flow of studies through the review. Our search identified 23,159 citations (18,089 citations from the initial search on 15th June 2019 and 4,070 from the updated search on 16th February 2021). Five documents (three peer-reviewed manuscripts and two doctoral theses) met our inclusion criteria from three discrete studies [21–25]. We obtained one additional document through correspondence with the study author (Baggs et al., 1997). None of the studies had been retracted or corrected as of the 12th of November 2021.

Study characteristics

Table 1 shows the characteristics of the three included studies. The fieldwork for all included studies was conducted in America using a cross sectional observational design [21, 23, 24]. Two collected data prospectively [21, 23]. One was a secondary analysis of an existing data set [24]. Participants included 191 doctors, 29,509 nurses, and 1.32 million patients (predominantly from the Kang, (2016) study)).

Clinical settings

Two studies were conducted in Intensive Care Unit (ICU) [21, 23] the third [24] in acute (medical and surgical) care inpatient settings.

How was mortality determined (dependent variable)?

Baggs (1990) and Baggs et al. (1999) determined mortality as death within one month of the transfer from the intensive care unit. In the Kang (2016) study mortality was defined as death within 30 days of the hospital admission (whilst in hospital or at home).

How was the level of nurse-doctor collaboration measured (independent variable)?

Three different self-administered measures were used to determine the level of nurse-doctor collaboration: Decision About Transfer (DAT) [21], Collaboration and Satisfaction About Care Decision (CSACD) [26], and the nurse-physician relations subscale of the Nurse Work Index (NWI) [27]. In included studies the DAT and CSACD was completed by both nurses and doctors whilst the NWI was rated only by nurses. We have provided a detailed description of the measures (Additional file 3). In summary, the DAT is a six-item measure where one item (‘how much collaboration between nurses and doctors (physicians) occurred in making the transfer decision’) was related to levels of collaboration between nurses and doctors. Developed specifically for the study, the psychometric properties of the measure were not established before fieldwork started. The CSACD is a seven item measure - based on the DAT - to measure levels of nurse-doctor collaboration with patient care decisions [26]. The psychometric properties of the CSACD have been reported [26]. The NWI has 31 items of which the three-item nurse-physician relations subscale determine the levels of collaboration. The validity of the NWI has been extensively studied and shown to have good psychometric properties [27–30].

Quality appraisal

Included studies had an overall weak rating (high risk of bias) (Table 2) on the EPHPP tool. All studies scored ‘poor’ for study design. Studies rated strong on data collection methods. A detailed information on the quality appraisal is provided with the manuscript (Additional file 4).

Results of individual studies

Interprofessional collaboration and patient mortality

All three studies reported nurses’ perceived levels of collaboration with doctors and patient mortality. Kang (2016) reported nurses’ rating of the amount of nurse-doctor collaboration was associated with reduced patient mortality after adjusting for patient and hospital characteristics (Kang, 2016). Baggs (1990) reported no association between nurses’ reported levels of collaboration with doctors and inpatient mortality. Baggs et al. (1999) did not report the relationship between collaboration and mortality. We contacted the authors to see if it was possible to access the data, however, according to the corresponding authors the data had been destroyed.

Two of the studies measured doctors’ reported collaboration with nurses [21, 23] but both did not test the association between doctors’ rating of collaboration and mortality. The third study did not measure doctors’ reported collaboration with nurses [24].

Meta-analysis

We were unable to extract the relevant data to undertake a meta-analysis.

Our systematic review investigated the association between the amount of nurse-doctor interprofessional collaboration and mortality in medical and surgical patients. Three observational studies were included; all had a high risk of bias. One included study reported a significant association and one no association between the level of nurses’ reported nurse-doctor collaboration and mortality. One included study did not report the association between the levels of nurses’ reported nurse-doctor collaboration and mortality.

The association between the amount of interprofessional collaboration and patient outcomes has not been extensively researched. Whilst there have been few studies that have examined the association between the amount of interprofessional collaboration and patient outcomes there is a substantial body of evidence that has observed the level of interprofessional collaboration between nurses and doctors [7, 8, 31, 32]. For example, a scoping review of measures of interprofessional collaboration in healthcare settings identified 29 measures to evaluate collaboration in healthcare settings [31]. Researchers have measured levels of interprofessional collaboration but not extended the work to show how these impacts of patient outcomes [33–35]. Perhaps this is explained by the methodological challenges in linking levels of interprofessional collaboration with patient outcomes [12, 14].

Effective interprofessional collaboration is generally considered a core aspect of providing high quality patient care, yet there seems to be a low level of evidence to support this tenant. Various factors, for example, levels of education and years of clinical practice, may impact the level of interprofessional collaboration. Besides, it has been acknowledged that quantifying the amount of interprofessional work may be a difficult task.

Limitations

There are a several limitations to our review that warrant consideration. Our review was narrow in scope and was focused on a single outcome (mortality). We did this because mortality is an important objective outcome that is routinely recorded [36–38]. Other patient outcomes, such as readmission rates may not be accurately and consistently recorded but should be considered in future reviews [39–41].

We did not search the grey literature, authors have argued that it is difficult to develop grey literature search strategy that can be replicated [42]. However, it is possible that we missed potentially relevant studies. A priori were decided to exclude studies that were reported as conference proceedings. During full text screening twelve potentially relevant studies were excluded for this reason. We could have made a post hoc amendment to our protocol to enable us to include these studies but considered that this would weaken the rigour of our work. Two studies that were not in English were also excluded during full text screening and again may have generated valuable data.

Our review suggests there is a need for further research to investigate the association between levels of nurse-doctor interprofessional collaboration and patient outcomes.

MEDLINE Medical Literature Analysis and Retrieval System

EMBASE Excerpta Medica

CINAHL Cumulative Index to Nursing and Allied Health Literature

EPHPP Effective Public Health Practice Project

PROSPERO Prospective Register of Systematic Reviews

AMSTAR2 Assessing the Methodological quality of SysTemAtic Reviews

PRISMA Preferred Items for Systematic Review and Meta-Analysis

PhD Doctor of Philosophy

ICU Intensive Care Unit

DAT Decision About Transfer

CSACD Collaboration and Satisfaction About Care Decision

NWI Nurse Work Index

Ethics approval

Not applicable.

Consent for publication

Not required.

Availability of data, code, and other materials

Data sharing is not applicable to this article as no datasets were generated or analysed during the current study.

Competing interest

We declare that the authors do not have any competing interests.

Funding

This review was carried out as a part of PhD dissertation of the first author. The study was supported by the Research Training Program (RTP) scholarship.

Author’s contributions

SP, MJ, and RG were involved in study design, search strategy development, protocol design.

SP, NM, DK, BP carried out title and abstract screening, full-text screening. MJ and RG carried out conflict resolution. SP and BP carried out data extraction and risk of bias assessment. SP prepared the draft of manuscript. MJ and RG revised the manuscript. All authors reviewed and accepted the final version of the manuscript.

Acknowledgements

We would like to acknowledge information scientists from La Trobe University: Ange John Hayden and Elizabeth Douglas for their help while developing the search strategy.

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Tables 1 and 2 are available in the Supplementary Files section.

Table1Characteristicsofincludedstudies.pdf
Table2QualityAppraisalSummary.pdf
Additionalfile1PRISMAChecklist.pdf
Additional file 1: PRISMA checklist
Additionalfile2SearchStrategy.pdf
Additional file 2: Search strategy
Additionalfile3Measuresofcollaboration.pdf
Additional file 3: Characteristics of the measures of collaboration
Additionalfile4Qualityappraisal.pdf
Additional file 4: Quality appraisal of the included studies

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Association between the levels of nurse-doctor interprofessional collaboration and in-patient mortality: A systematic review

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