*3.1.1.10 Appraisal of team members*

Feedback to individuals and the team reinforces positive behaviours and allows for continual development of the team. It also provides an opportunity for deficits to be identified and remediated. A 360-evaluation process may be utilised whereby many colleagues, regardless of discipline or seniority, will provide evaluation for a team member [7]. Interpersonal skills and professionalism are the core emphasis of this approach.

## *3.1.1.11 Research*

ICU team members must keep up to date with the latest emerging evidence in their respective fields. Critical care medicine is a technology-dependent speciality which is rapidly evolving. Specific assessment of new techniques, medications and equipment should be incorporated into a local coordinated research agenda. This is necessary to achieve continuously improving, team-based healthcare. Team members must be provided with sufficient time and resources to engage in relevant research, and feedback their results into clinical practice.

## *3.1.1.12 The patient and family as team members*

Vital to a high-performing ICU team is the inclusion of the patient and their family as integral members of the team. This concept of shared decision-making is gradually replacing a more paternalistic style of directing care [8]. It is important to involve the family in clinical decision making and to allocate sufficient time to meet with them. The patient's needs and expectations are the driving force for the team's

efforts, and some neonatal and paediatric intensive care units now facilitate unrestricted family visiting and limited participation in medical rounds.

## *3.1.2 Barriers to high-performance teamwork in the intensive care unit*

## *3.1.2.1 The changing team*

As staff change from day to night shift and junior doctors rotate through training posts, the multidisciplinary ICU team is continually changing. Although some team members will be a constant presence, the changing nature of the team can threaten its performance [9]. It may be difficult for new team members to join a well-established and experienced team and it takes time and effort for team members to build a trusting relationship with each other. The rotation of care providers may also influence the continuity of care delivered to the patient. This highlights the importance of having established written goals for patient care.

## *3.1.2.2 Interpersonal relationships*

With the amalgamation of many personalities and healthcare specialities, it is inevitable that conflict may occur within the ICU team. Tension may arise due to the existence of differing priorities or perspectives of team members [10]. Occasionally, the priorities of the team may not align with those of the patient or family. The relationship between team members and the patient and family is important in the overall delivery of care, job satisfaction and incidence of compassion fatigue. Tensions can be exacerbated by inefficient or infrequent communication between team members this contributes to disharmony in the patient's bedspace, especially if conflicting pieces of information and opinions are being passed onto the patient and their family. Although reaching an agreement between all team members is challenging, it can be facilitated with early and open communication. Senior team members must oversee conflict resolution with maturity and compassion [11, 12].

## *3.1.2.3 Psychological stress*

The ICU can be a demanding work environment which poses several challenges to team members. Caring for a critically unwell child and their family can be distressing. Team members are often faced with stressful resuscitations, emergencies, and death. Ethical dilemmas are often encountered and can have a psychological impact on the staff involved. A supportive environment is essential to allow staff members to manage these stressors and continue to function as a high-performing team. Debriefing should be used after critical incidents and staff should have access to a counselling service.

## *3.1.2.4 Resource limitations*

Whilst dependent largely upon the collaborative efforts of individual team members, a high-performance healthcare team does require organisational support to function maximally. Adequate resources must be in place to support the work of the team. Health informatics and technological resources should facilitate seamless communication between team members. Financial support should be in place to allow for education and research. Appropriate facilities should be provided for team meetings,

education sessions and simulation. Medical equipment should meet minimum standards to deliver care. Team members should be provided with adequate time for completion of clinical duties, continual professional development, and rest.

## **3.2 Regulatory aspects of medical care in the intensive care unit**

Regulation of medical practice in any speciality should focus on 'right touch'. This is a balance between onerous rules which may lead to defensive practice and light-touch regulation which may not be sufficient to guide good practice. Moving the emphasis of regulation upstream, to the issues which can positively impact a physician's professionalism will potentially reduce the number and significance of breaches of conduct and competence. Many regulatory bodies around the world now use this 'right touch' approach to medical regulation. There has been a move away from self-regulation in many jurisdictions, with the establishment of statutory bodies with a non-medical majority. This is a deliberate action to give reassurance to patients that public protection is the key remit of regulation.

In consultation with the public and the profession, high standards of education and practice are developed. These high standards of medical undergraduate and postgraduate education, postgraduate and speciality training, medical ethics and communication are then applied to educational institutions and individual doctors. Following assessment, recommendations for domains of improvement are made by the regulatory authority and followed up in a cycle of appropriate, targeted regulation. Tailored guides to specific areas of medical practice may be produced by a medical regulator to inform doctors and the public of the standards expected e.g., Telemedicine. A regulator will usually maintain a register of doctors who are qualified in that profession. That register is open to the public for inspection and assurance.

The Intensive Care Unit is a key part of a hospital environment. Intensive or critical care medicine has expanded over the last 2 decades to include premature neonates (Neonatology), infants and children (Paediatric Intensive Care) and adults (Adult ICU). Most ICUs will provide education and training to medical practitioners as part of structured training programs. The curriculum and formal assessment of the training program are decided by the certifying professional body e.g., European Society of Intensive Care Medicine (ESICM). A hospital and its medical staff will have a relationship with a medical regulatory body to ensure that there is protection of the public interest in its interactions with doctors employed within the hospital. All doctors must demonstrate their licence or registration with their regulatory body as part of their terms of employment. This provides the public with confidence that their doctor has the necessary medical qualifications to provide medical services.

## *3.2.1 Education and training*

Regulation extends into education and training with the setting of standards and the periodic evaluation of these standards by the regulatory body. In the ICU, all doctors are expected to meet a basic standard of medical practice and conduct, in addition to demonstrating ongoing learning. There may be overlap with individual training programs and a sharing of compliance data. Accreditation of training bodies by the regulator may be a feature of some healthcare systems, but the principles are the same. A doctor may be asked to demonstrate fitness to practice through a process of investigation if there is a significant complaint made against the doctor. Management of a complaint against a professional is outlined below in Section 2.7.

## *3.2.2 Continued professional development*

Each doctor working in the critical care environment has a professional and ethical obligation to keep up to date with clinical developments. Each year specific training courses may be mandated e.g., resuscitation procedures and algorithms. Professional competencies in communication are important in the ICU where giving patients and families bad news is a vital part of the senior medical role. Miscommunication is a common area of complaint where families have a grievance around how important information was imparted by a doctor. There are simulation modules and training drills in communication skills available.

## *3.2.3 Supervision and revalidation*

All doctors in training programs must be supervised by a doctor senior in experience. Supervision is a skilled intervention, providing oversight of clinical activity, guidance and the capacity for feedback and debriefing. Doctors of all training levels and ability should have access to a supervisor. As critical care medicine is an acute speciality where patients' clinical status can deteriorate rapidly, supervision should be accessible 24/7. Doctors returning to clinical practice in the ICU following a significant period of absence should be asked to work within a structured program of revalidation to ensure that the doctor is ready to return to full practice and deliver safe patient care. This revalidation program may be sourced from within larger intensive care units, or from the doctor's professional body.
