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Critical Care Reviews Meeting 2024

Just 4 days to go, latest research.

• Cox. Mobile mindfulness intervention for psychological distress among intensive care unit survivors: A randomized clinical trial. JAMA Intern Med 2024;epublished May 28th
• Gao. Immediate- or delayed-intensive statin in acute cerebral ischemia: The INSPIRES randomized clinical trial. JAMA Neurol 2024;epublished May 28th
• Watanyu Parapiboon. Lower dosage acute peritoneal dialysis versus acute intermittent hemodialysis in acute kidney injury: A randomized controlled trial. Clin J Am Soc Nephrol 2024;epublished May 29th

Lin. AI-enabled electrocardiography alert intervention and all-cause mortality: a pragmatic randomized clinical trial. Nat Med 2024;30(5):1461-1470

Varsha. Comparison of Propofol-based TIVA vs Volatile Anaesthesia with Sevoflurane for Post Operative Delirium in Adult Coronary Artery Bypass Grafting Surgery: Prospective Randomized Single Blinded Study. J cardiothorac Vasc Anesth 2024;epublished May 22nd

Updated June 3rd

Latest Guidelines

• American Heart Association. The Management of Elevated Blood Pressure in the Acute Care Setting: A Scientific Statement From the American Heart Association. Hypertension 2024;epublished May 28th
• French national protocol for diagnosis and management of epidermal necrolysis in adults (Stevens-Johnson syndrome and toxic epidermal necrolysis). Ann Dermatol Venereol 2024 Jun;151(2):103282
• The 2023 WSES guidelines on the management of trauma in elderly and frail patients. World J Emerg Surg 2024;19:18
• Dong. Clinical application and management of temporary mechanical circulatory support: A clinical consensus. Chinese Medical Journal 2024;137(10):1135-1139
• Heart Failure Association of the ESC. Differences in presentation, diagnosis and management of heart failure in women. A scientific statement of the Heart Failure Association of the ESC. European Journal of Heart Failure 2024;epublished May 23rd

Latest Narrative Reviews

Seiffge. Treatment for intracerebral hemorrhage: Dawn of a new era. Int J Stroke 2024;19(5):482-489

• Chalifoux. Cerebral autoregulation: A target for improving neurological outcomes in extracorporeal life support. Neurocrit Care 2024;epublished May
• Ortoleva. Diagnosis and management of vasoplegia in temporary mechanical circulatory support: A narrative review. J Cardiothorac Vasc Anesth 2024;38(6):1378-1389
• Re. Humidification during invasive and non-invasive ventilation: A starting tool kit for correct setting. Med Sci 2024;12(2):26
• Slim. Towards personalized medicine: A scoping review of immunotherapy in sepsis. Crit Care 2024;28:183
• Stevens. Biological basis of critical illness subclasses: From the bedside to the bench and back again. Crit Care 2024;28:186

Latest CCR Content

Heylen. Acute Invasive Pulmonary Aspergillosis: Clinical Presentation and Treatment. Semin Respir Crit Care Med 2024;45(01): 069-087

Saturday, June 8th

Join us to read one paper per day and cover the spectrum of critical care across 2024. Previous papers of the day are available here .

Newsletter 651

Critical Care Reviews Newsletter 651, bringing you the best critical care research and open access articles for the week May 27th to June 2nd, 2024

Subscriptions are available to individuals and departments

added June 3rd

Jessical Spence (Hamilton, Canada) talks about the B-FREE trial, investigating bendrodiazepine-free anaesthesia for the prevetion in delirium in cardiac surgical patients.

Added April 7th

Latest CCR Meeting Announcements

General registration opens next week for our December meeting in Melbourne. Those who registered an expression of interest should have received their early registration link

Added May 21st

CCR24 Announcement

There is just 1 weeks to CCR24!

Added June 6th

CCR Down Under Preparatory Visit

Phil Gillen and Rob Mac Sweeney headed south to Melbourne last week to join the Alfred ICU Academic Centre team for 3 days of preparations for CCR Down Under in December.

• Critical Care Medicine

Explore the latest in critical care medicine, including management of respiratory failure, sepsis, HAI prevention, end-of-life care, and more.

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Article type.

This Viewpoint discusses the limitations of current tools to improve sepsis outcomes and proposes that these tools be supplemented with “failure to rescue,” a systems-level approach for recognizing and addressing complications and managing sepsis throughout the hospitalization period.

This prognostic study investigates the ability of a large language model to perform risk stratification and predict postoperative outcomes using a description of the procedure and the patient’s preoperative clinical notes.

• The Quest for Evidence on Time to Antibiotics in Children With Sepsis—Finding the Sweet Spot JAMA Network Open Opinion June 5, 2024 Pediatrics Emergency Medicine Infectious Diseases Sepsis Resuscitation Full Text | pdf link PDF open access

This cohort study examines the association of the timing of antibiotic administration in the emergency department (ED) with the risk of sepsis-attributable mortality in children.

• Sepsis Quality Measurement and the Fraying of the Safety Net JAMA Network Open Opinion May 31, 2024 Health Disparities End of Life, Hospice, Palliative Care Health Care Economics, Insurance, Payment Health Care Quality Resuscitation Full Text | pdf link PDF open access

This cohort study evaluates how admission to safety-net hospitals is associated with in-hospital mortality, 30-day mortality, and discharge practices among patients with sepsis.

• Value in Optimizing the Components of App Interventions Before Final Testing JAMA Internal Medicine Opinion May 28, 2024 Complementary and Alternative Medicine Depressive Disorders Psychiatry and Behavioral Health Health Care Quality Full Text | pdf link PDF

This randomized clinical trial evaluates the most effective method for delivering a mindfulness program via mobile app to improve depression symptoms among intensive care unit (ICU) survivors.

This cohort study uses Medicare claims data to assess survival, function, and cognition among middle-aged and older adults after hospitalization in long-term acute care hospitals.

In this narrative medicine essay, a newly minted pediatric critical care physician learns firsthand what holistic medical care is from the love and attention she received during a hospitalization for mediastinal lymphoma.

• Intra-Arrest Transport vs On-Scene Cardiopulmonary Resuscitation for Children—Scoop and Run vs Stay and Play JAMA Network Open Opinion May 20, 2024 Emergency Medicine Cardiology Resuscitation Pediatrics Full Text | pdf link PDF open access

This cohort study examines whether survival differs for children with out-of-hospital cardiac arrest who receive intra-arrest transport compared with continued on-scene cardiopulmonary resuscitation.

This randomized trial assesses whether acetaminophen would increase the number of days alive and free of organ support to day 28 among critically ill patients with sepsis and respiratory or circulatory organ dysfunction.

This cohort study assesses all interventional and observational research studies that required prospective informed consent from a large academic pediatric intensive care unit (PICU) over 10 years and analyzes disparities in approach and consent by race and ethnicity, religion, spoken language, and socioeconomic status.

This essay describes what the author learned from being in the intensive care unit with her father during multiple cardiac arrests and surgery.

This cohort study compares 90-day mortality in patients with sepsis who received piperacillin-tazobactam vs cefepime for treatment of sepsis.

This cross-sectional study examines whether an increase in pediatric intensive care unit admissions is associated with changes in the use of high-flow nasal cannula and noninvasive ventilation in children with bronchiolitis aged younger than 2 years.

This cohort study assesses the association between social determinants of health and receipt of skilled rehabilitation during intensive care unit (ICU) hospitalizations for older US adults.

This essay describes the author’s experience of improved patient care and collaboration the day the electronic medical records system went down.

This clinical trial examines the effect of an antibiotic stewardship bundle (education, feedback, and real-time multidrug-resistant organism risk-based CPOE prompts) vs routine stewardship on antibiotic selection during the first 3 hospital days in adults with pneumonia.

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Page 1 of 374

Advanced waveform analysis of diaphragm surface EMG allows for continuous non-invasive assessment of respiratory effort in critically ill patients at different PEEP levels

Respiratory effort should be closely monitored in mechanically ventilated ICU patients to avoid both overassistance and underassistance. Surface electromyography of the diaphragm (sEMGdi) offers a continuous a...

• View Full Text

Comparative effectiveness of alternative spontaneous breathing trial techniques: a systematic review and network meta-analysis of randomized trials

The spontaneous breathing trial (SBT) technique that best balance successful extubation with the risk for reintubation is unknown. We sought to determine the comparative efficacy and safety of alternative SBT ...

Beyond opioids: revisiting pain management in post cardiac surgery infants

The original article was published in Critical Care 2024 28 :143

Sex differences in treatments and outcomes of patients with cardiogenic shock: a systematic review and epidemiological meta-analysis

Women are at higher risk of mortality from many acute cardiovascular conditions, but studies have demonstrated differing findings regarding the mortality of cardiogenic shock in women and men. To examine diffe...

A critical reappraisal of vasopressin and steroids in in-hospital cardiac arrest

Early sepsis recognition: how difficult can this be.

The original article was published in Critical Care 2024 28 :42

The original article was published in Critical Care 2024 28 :161

Development and external validation of a machine learning model for the prediction of persistent acute kidney injury stage 3 in multi-centric, multi-national intensive care cohorts

The aim of this retrospective cohort study was to develop and validate on multiple international datasets a real-time machine learning model able to accurately predict persistent acute kidney injury (AKI) in t...

Sampling and processing matter in airway microbiota discovery

The original article was published in Critical Care 2024 28 :133

The original article was published in Critical Care 2024 28 :147

The association of arterial partial oxygen pressure with mortality in critically ill sepsis patients: a nationwide observational cohort study

Although several trials were conducted to optimize the oxygenation range in intensive care unit (ICU) patients, no studies have yet reached a universal recommendation on the optimal a partial pressure of oxyge...

Biological basis of critical illness subclasses: from the bedside to the bench and back again

Critical illness syndromes including sepsis, acute respiratory distress syndrome, and acute kidney injury (AKI) are associated with high in-hospital mortality and long-term adverse health outcomes among surviv...

Biological effects of corticosteroids on pneumococcal pneumonia in Mice—translational significance

Streptococcus pneumoniae is the most common bacterial cause of community acquired pneumonia and the acute respiratory distress syndrome (ARDS). Some clinical trials have demonstrated a beneficial effect of cortic...

Composite outcome measures in high-impact critical care randomised controlled trials: a systematic review

The use of composite outcome measures (COM) in clinical trials is increasing. Whilst their use is associated with benefits, several limitations have been highlighted and there is limited literature exploring t...

Towards personalized medicine: a scoping review of immunotherapy in sepsis

Despite significant progress in our understanding of the pathophysiology of sepsis and extensive clinical research, there are few proven therapies addressing the underlying immune dysregulation of this life-th...

Comment to "Human cytomegalovirus seropositivity is associated with reduced patient survival during sepsis"

The original article was published in Critical Care 2023 27 :417

Triggers of intensive care patients with palliative care needs from nurses’ perspective: a mixed methods study

Triggers have been developed internationally to identify intensive care patients with palliative care needs. Due to their work, nurses are close to the patient and their perspective should therefore be include...

A scoping review of machine learning for sepsis prediction- feature engineering strategies and model performance: a step towards explainability

Sepsis, an acute and potentially fatal systemic response to infection, significantly impacts global health by affecting millions annually. Prompt identification of sepsis is vital, as treatment delays lead to ...

Exploring the lung-gut direction of the gut-lung axis in patients with ARDS

Acute respiratory distress syndrome (ARDS) represents a life-threatening inflammatory reaction marked by refractory hypoxaemia and pulmonary oedema. Despite advancements in treatment perspectives, ARDS still c...

The phenomenon of desorption: What are the best adsorber exchange intervals?

The original article was published in Critical Care 2023 27 :117

Transpulmonary pressure monitoring in critically ill patients: pros and cons

The use of transpulmonary pressure monitoring based on measurement of esophageal pressure has contributed importantly to the personalization of mechanical ventilation based on respiratory pathophysiology in cr...

Prompt antimicrobial therapy and source control on survival and defervescence of adults with bacteraemia in the emergency department: the faster, the better

Bacteraemia is a critical condition that generally leads to substantial morbidity and mortality. It is unclear whether delayed antimicrobial therapy (and/or source control) has a prognostic or defervescence ef...

Vitamin D metabolism in critically ill patients with acute kidney injury: not a sole player

The original article was published in Critical Care 2024 28 :108

Dyspnea is severe and associated with a higher intubation rate in de novo acute hypoxemic respiratory failure

Dyspnea is a key symptom of de novo acute hypoxemic respiratory failure. This study explores dyspnea and its association with intubation and mortality in this population.

Prognostic value of early EEG abnormalities in severe stroke patients requiring mechanical ventilation: a pre-planned analysis of the SPICE prospective multicenter study

Prognostication of outcome in severe stroke patients necessitating invasive mechanical ventilation poses significant challenges. The objective of this study was to assess the prognostic significance and preval...

Assessing the impact of early progressive mobilization on moderate-to-severe traumatic brain injury: a randomized controlled trial

Traumatic brain injury (TBI) is a major cause of neurodisability worldwide, with notably high disability rates among moderately severe TBI cases. Extensive previous research emphasizes the critical need for ea...

Expiratory flow limitation during mechanical ventilation: real-time detection and physiological subtypes

Tidal expiratory flow limitation (EFL T ) complicates the delivery of mechanical ventilation but is only diagnosed by performing specific manoeuvres. Instantaneous analysis of expiratory resistance (Rex) can be an ...

Targeted temperature control following traumatic brain injury: ESICM/NACCS best practice consensus recommendations

The aim of this panel was to develop consensus recommendations on targeted temperature control (TTC) in patients with severe traumatic brain injury (TBI) and in patients with moderate TBI who deteriorate and r...

Acute kidney injury after out-of-hospital cardiac arrest

Acute kidney injury (AKI) is a significant risk factor associated with reduced survival following out-of-hospital cardiac arrest (OHCA). Whether the severity of AKI simply serves as a surrogate measure of wors...

Development and validation of the tic score for early detection of traumatic coagulopathy upon hospital admission: a cohort study

Critically injured patients need rapid and appropriate hemostatic treatment, which requires prompt identification of trauma-induced coagulopathy (TIC) upon hospital admission. We developed and validated the pe...

Challenging ICU dogmas: a new perspective on venous congestion and preload dependency

The original article was published in Critical Care 2024 28 :52

Protocolized reduction of non-resuscitation fluids versus usual care in septic shock patients (REDUSE): a randomized multicentre feasibility trial

Non-resuscitation fluids constitute the majority of fluid administered for septic shock patients in the intensive care unit (ICU). This multicentre, randomized, feasibility trial was conducted to test the hypo...

Effects of mechanical ventilation on the interstitial extracellular matrix in healthy lungs and lungs affected by acute respiratory distress syndrome: a narrative review

Mechanical ventilation, a lifesaving intervention in critical care, can lead to damage in the extracellular matrix (ECM), triggering inflammation and ventilator-induced lung injury (VILI), particularly in cond...

Causes and attributable fraction of death from ARDS in inflammatory phenotypes of sepsis

Hypoinflammatory and hyperinflammatory phenotypes have been identified in both Acute Respiratory Distress Syndrome (ARDS) and sepsis. Attributable mortality of ARDS in each phenotype of sepsis is yet to be det...

Predicting outcome after aneurysmal subarachnoid hemorrhage by exploitation of signal complexity: a prospective two-center cohort study

Signal complexity (i.e. entropy) describes the level of order within a system. Low physiological signal complexity predicts unfavorable outcome in a variety of diseases and is assumed to reflect increased rigi...

Efficacy of expanded periurethral cleansing in reducing catheter-associated urinary tract infection in comatose patients: a randomized controlled clinical trial

The effect of the periurethral cleansing range on catheter-associated urinary tract infection (CAUTI) occurrence remains unknown. The purpose of this study was to evaluate the efficacy of expanded periurethral...

qSOFA combined with suPAR for early risk detection and guidance of antibiotic treatment in emergency department: a bit sweet and a bit sour randomized controlled trial

The Matters Arising to this article has been published in Critical Care 2024 28 :190

Organ donation after extracorporeal cardiopulmonary resuscitation: a nationwide retrospective cohort study

Limited data are available on organ donation practices and recipient outcomes, particularly when comparing donors who experienced cardiac arrest and received extracorporeal cardiopulmonary resuscitation (ECPR)...

Potential implications of long-acting GLP-1 receptor agonists for critically ill

Incidence, risk factors and outcomes of nosocomial infection in adult patients supported by extracorporeal membrane oxygenation: a systematic review and meta-analysis.

An increasing number of patients requires extracorporeal membrane oxygenation (ECMO) for life support. This supportive modality is associated with nosocomial infections (NIs). This systematic review and meta-a...

Effect of immediate initiation of invasive ventilation on mortality in acute hypoxemic respiratory failure: a target trial emulation

Invasive ventilation is a fundamental treatment in intensive care but its precise timing is difficult to determine. This study aims at assessing the effect of initiating invasive ventilation versus waiting, in...

Machine learning derived serum creatinine trajectories in acute kidney injury in critically ill patients with sepsis

Current classification for acute kidney injury (AKI) in critically ill patients with sepsis relies only on its severity-measured by maximum creatinine which overlooks inherent complexities and longitudinal eva...

Extent of microbial over-identification of endotracheal aspirate versus bronchoalveolar lavage in the diagnosis of ventilator-associated pneumonia

Past, present, and future of sustainable intensive care: narrative review and a large hospital system experience.

Healthcare systems are large contributors to global emissions, and intensive care units (ICUs) are a complex and resource-intensive component of these systems. Recent global movements in sustainability initiat...

The neurovanguard concept and real-world embracement

The original article was published in Critical Care 2024 28 :104

The original article was published in Critical Care 2024 28 :137

Effects of non-invasive respiratory support in post-operative patients: a systematic review and network meta-analysis

Re-intubation secondary to post-extubation respiratory failure in post-operative patients is associated with increased patient morbidity and mortality. Non-invasive respiratory support (NRS) alternative to con...

Inflammatory subphenotypes previously identified in ARDS are associated with mortality at intensive care unit discharge: a secondary analysis of a prospective observational study

Intensive care unit (ICU)-survivors have an increased risk of mortality after discharge compared to the general population. On ICU admission subphenotypes based on the plasma biomarker levels of interleukin-8,...

Critical care outcomes in decompensated cirrhosis: a United States national inpatient sample cross-sectional study

Prior assessments of critical care outcomes in patients with cirrhosis have shown conflicting results. We aimed to provide nationwide generalizable results of critical care outcomes in patients with decompensa...

Generative artificial intelligence is infiltrating peer review process

Sepsis mortality among patients with haematological malignancy admitted to intensive care 2000–2022: a binational cohort study.

Sepsis occurs in 12–27% of patients with haematological malignancy within a year of diagnosis. Sepsis mortality has improved in non-cancer patients in the last two decades, but longitudinal trends in patients ...

Bias caused by sample selection for lower respiratory tract microbiome research

The Matters Arising to this article has been published in Critical Care 2024 28 :188

Intermittent intravenous paracetamol versus continuous morphine in infants undergoing cardiothoracic surgery: a multi-center randomized controlled trial

To determine whether intermittent intravenous (IV) paracetamol as primary analgesic would significantly reduce morphine consumption in children aged 0–3 years after cardiac surgery with cardiopulmonary bypass.

The Matters Arising to this article has been published in Critical Care 2024 28 :193

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Workplace Violence Against Emergency Nurses

A literature review.

Ayasreh, Ibrahim R. PhD, RN; Hayajneh, Ferial A. PhD, RN

Faculty of Nursing, Jerash University, Jerash, Jordan (Dr Ayasreh); and Department of Clinical Nursing, School of Nursing, The University of Jordan, Amman, Jordan (Dr Hayajneh).

Correspondence: Ferial A. Hayajneh, PhD, MSc, Department of Clinical Nursing, School of Nursing, The University of Jordan, Queen Rania St, Amman 11942, Jordan ( [email protected] ).

The authors have disclosed that they have no significant relationships with, or financial interest in, any commercial companies pertaining to this article.

Violence against health care providers is one of the most pressing problems faced by health care systems around the world. Because of unpredictability and acuity of emergency cases, emergency nurses are more vulnerable to workplace violence. Violence against emergency nurses is a complex and multidimensional problem that has a devastating impact on the physical, psychological, and social well-being of nurse victims. The purpose of this review is to integrate evidence on manifestations, contributing factors, and consequences of workplace violence perpetrated by patients and/or their relatives against emergency nurses, in addition to behavioral responses of emergency nurse victims toward workplace violence. An integrative review was conducted by searching 3 main electronic databases: Web of Sciences, MEDLINE, and ScienceDirect. Eighteen studies met the inclusion criteria and were included in the final review process. The review identified the most common forms, contributing factors, unpleasant consequences of workplace violence, and behavioral reaction of nurse victims toward violence acts. Reporting rates of workplace violence among emergency nurses were found to be low. It is recommended to develop more effective workplace violence prevention and reporting programs.

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• DOI: 10.1186/s13054-024-04967-3
• Corpus ID: 270094155

Composite outcome measures in high-impact critical care randomised controlled trials: a systematic review

• Humphrey G M Walker , Alastair J. Brown , +6 authors Toby Jeffcote
• Published in Critical Care 28 May 2024

43 References

Use of composite outcomes in neonatal trials: an analysis of the cochrane reviews, statistical analyses of ordinal outcomes in randomised controlled trials: a scoping review, composite adverse outcomes in obstetric studies: a systematic review, which multicenter randomized controlled trials in critical care medicine have shown reduced mortality a systematic review., outcomes and statistical power in adult critical care randomized trials..

• Highly Influential

Patient-important outcomes in randomized controlled trials in critically ill patients: a systematic review

Randomised clinical trials in critical care: past, present and future, powering bias and clinically important treatment effects in randomized trials of critical illness., problems with use of composite end points in cardiovascular trials: systematic review of randomised controlled trials, pros and cons of composite endpoints in anesthesia trials., related papers.

Showing 1 through 3 of 0 Related Papers

• Research article
• Open access
• Published: 13 June 2023

The needs and experiences of critically ill patients and family members in intensive care unit of a tertiary hospital in Malaysia: a qualitative study

• E-Li Leong   ORCID: orcid.org/0000-0002-9042-8435 1 ,
• Chii-Chii Chew 1 ,
• Ju-Ying Ang 1 ,
• Sharon-Linus Lojikip 1 ,
• Philip-Rajan Devesahayam 1 , 2 &
• Kit-Weng Foong 3  

BMC Health Services Research volume  23 , Article number:  627 ( 2023 ) Cite this article

3469 Accesses

Metrics details

Admission to an intensive care unit (ICU) is a stressful experience for patients and their family members. While the focus of management is primarily on medical care, there can be other areas which are overlooked. The purpose of this study was to investigate the needs and experiences of ICU patients and family members.

This qualitative study involved four trained researchers conducting in-depth interviews (IDI) based on a semi-structured interview guide. The participants were ICU patients and family members. All IDIs were audio-recorded and transcribed verbatim. Four researchers independently analyzed the data via thematic analysis with the aid of QDA Miner Lite®. The themes and subthemes were generated and confirmed by literature and expert opinion.

Six IDIs were conducted with three patients and three family members, whose ages ranged from 31 to 64 years old. One pair of participants consisted of a patient and his respective family member, while the other four participants did not have a familial relationship with each other. Three main themes emerged from the analysis: (I) critical care services; (II) physical spaces; and (III) monitoring technology. Medical, psychological, physical, and social needs for critical care services were expressed by both patients and family members. Patients’ needs in clinical spaces were highlighted as a conducive ICU environment with ambient temperature and controlled noise levels. In non-clinical spaces, family members expressed a need for more chairs in the waiting area. Participants expressed the need for call bells as well as patients’ negative perceptions of medical equipment alarms in the ICU when it pertained to monitoring technology.

This study provides an in-depth view at the needs and experiences of ICU patients and family members who have a variety of unmet needs. This understanding is critical for guiding ICU personnel and stakeholders in their efforts to humanize ICU care.

Peer Review reports

Critical care is a multidisciplinary and inter-professional specialty that manages patients with acute, and life-threatening organ dysfunction. Admission to the intensive care unit (ICU) causes distress to both patients and their families [ 1 ]. ICU patient care emphasizes a holistic approach that not merely focuses on medical care but also aims to fulfill patients’ and families’ needs [ 2 , 3 ]. The needs identified by the patients warded in ICUs across different countries are broadly categorized as physical, medical, psychological, and social needs [ 4 ]. Generally, ICU patients desire individualized care from the medical personnel and prompt medical attention when the need arises. The patients also need to understand their medical conditions to make decisions on treatment priorities and at the same time to alleviate fear, anxiety, and panic attacks. A secure environment that creates a sense of security, fosters self-worth and motivation toward recovery is essential [ 5 , 6 , 7 , 8 ].

A sense of hope is an important need for family members of patients who are admitted to the ICU. Additionally, they require reassurance from the ICU personnel that the care provided is in the patient’s best interest [ 1 ]. Having an adequate understanding and attempting to meet the families’ needs would improve their ability to cope with the ICU admissions of their loved ones [ 9 ]. There is a slight geographical variation in family member’s needs. In Hong Kong and Malaysia, family members needed assurance that the patients were adequately cared for [ 10 , 11 , 12 ]. The primary concerns in Saudi Arabia were information, reassurance, spiritual healing, and support [ 13 ]. Moving west, in the United Kingdom, the needs were access to maintain proximity to patients; a positive and supportive environment; information; and hope [ 14 ]. An open communication and regular updates build mutual trust between the ICU personnel and the family members. In Ireland, families expressed their needs for truthful updates on the patient’s condition; understanding ICU admission is a dynamic and continuous process; being with their relatives; having the nurses’ assurances; and support for coping [ 15 ]. The difference in priorities and needs globally reflect disparities in culture, religion, and healthcare. In Malaysia, the challenge in providing culturally sensitive intensive care is further compounded due to its multiracial composition with diverse cultural and religious backgrounds.

Patient experience is defined as interactions that patients have with the healthcare system, including their management plan, the providers, and the providers’ practices in the healthcare institution [ 16 ]. Their experience in the ICU affects them physically and psychologically. The common physical discomforts experienced include pain, sleepiness, discomfort, inactivity or over-activity, noise, thirst, headache, discomfort associated with endotracheal tubes, and swallowing difficulties. Psychologically, they are affected by their disease progression, medical treatment, and perception of care concerning the manner and behavior of the ICU personnel. Patients reported hallucinations, fear, worry, anxiety, melancholy, loneliness, death thoughts, panic, uneasiness, uncertainty and despair [ 17 ]. These areas of patient experience can be easily overlooked when their critical illnesses are the primary focus of the managing team.

Family members experience distress when they learn that their loved ones have been admitted to the ICU. Emotional helplessness is experienced by family members when their need for information, reassurance, help, and support have not been met. They experience a lack of control, uncertainty, and loneliness. They undergo intense emotional changes whenever there is a morbid change in the status of their relatives. Family members are frustrated when their experiences deviate from their expectations, which are affected by their cultural background [ 18 ]. Gauging the needs and experiences of patients and their family members is a crucial step forward in establishing humanized ICU care. This study aims to learn about the needs and experiences of critically ill patients and their family members in a local setting.

Study design and setting

This exploratory qualitative study was conducted from February to March 2020 in a multidisciplinary ICU of a tertiary government hospital in Malaysia. The ICU had two wards with a total of 23 beds, with 1200 to 1400 admissions per year. A multi-disciplinary team of 150 to 160 personnel in the ICU includes two consultant intensivists, ICU trainees, anaesthesiologists, anaesthesia-trained medical officers, staff nurses, physiotherapists, pharmacists and attendants. The staff nurses in the ICU worked in shifts, and the medical doctors were subject to an on-call arrangement. The patients’ families were permitted to visit them twice a day, one at a time, between 1 pm and 2 pm and again between 5 pm and 6.30 pm. Due to the lack of a waiting room, family members were compelled to wait in the corridor outside the ICU during visiting hours. The corridor was furnished with seats for ten to fifteen individuals. During non-visiting hours, family members were called by phone if medical doctors wished to discuss the patient’s medical condition with family members. Family conferences were often held in the nursing manager’s office or the Intensivist’s office, while daily patient updates to family members were typically delivered at the bedside.

Sample and recruitment

Inclusion criteria.

Patients who were 18 and above, Malaysian, able to read and speak English, Malay or Mandarin, had their first ICU encounter, admitted to the ICU for at least 72 h to make sure there was enough time to establish their needs [ 11 , 19 ], had a Glasgow Coma Scale (GCS) of 15, a Richmond Agitation-Sedation Scale (RASS) of 0, a negative Confusion Assessment Method for the ICU (CAM-ICU), and an overall stable health condition at the discretion of consultant intensivists, were fit to participate in a 60-minute interview. Patients were recruited based on different characteristics such as age, gender, and the types of specialty care they received in order to enrich the data.

Family members, not limited to first-degree relatives, who had been the main person interacting with critical care personnel and were willing to share their experience were invited for interviews. The patients and the family members invited to the study were not necessarily related or paired as certain patients may not fit the eligibility criteria to participate in this study while their family members were.

Exclusion criteria

Patients with language or communication barriers, with underlying psychiatric disorders or newly diagnosed psychiatric disorders during ICU admission and those with intellectual impairment were excluded. Family members of critically ill patients with unstable vital signs or whose death was considered imminent were not included in this study out of respect for the grieving needs of the family members [ 19 ].

Interviewers

There were a total of four interviewers (ELL, SLL, CCC and JYA), all of whom were trained in qualitative research. Two of the interviewers held graduate degrees in medicine, while the other two held graduate degrees in pharmacy. Prior to the interview, the interviewers did not know the participants nor did they establish a relationship with them. Interviewers were guided by a semi-structured interview guide, which ensured consistency in the domains covered during each IDI. Additionally, prior to the actual data collection, trial interviews were conducted among the interviewers. These trial interviews served the purpose of establishing a shared understanding of the interview guide and techniques, thereby ensuring a more uniform approach across the IDIs.

Sample size and sampling method

Patients and their family members were recruited through purposive sampling. The potential patients were identified during daily ward rounds, and the family members were identified via prior interaction for patients’ updates by the treating intensivist. The participants who agreed to participate were then referred to the interviewers for a scheduled face-to-face interview.

A semi-structured interview guide in English was created separately for patients and family members based on existing literature that reported patients’ and families’ needs in ICU [ 20 , 21 , 22 , 23 ], as well as expert opinion. The domains were perception of the ICU, the experience of interacting with the health care personnel working in the ICU, information required, perspectives on medical care, the need for privacy (only applicable for patients), types of support needed, and requirements of facilities in the ICU. Subsequently, these guides were translated into Malay and Mandarin by native speakers of Malay and Chinese. Each language’s interview guide was pre-tested to ensure the comprehensibility of terms and phrases used in the interview guide.

Data collection

Approval to conduct this study was obtained from the Medical Research and Ethics Committee, Ministry of Health Malaysia with the protocol number NMRR-19-3358-51827 (IIR) prior to data collection.

Each participant signed a written informed consent form before data collection. The sociodemographic information of the participants was collected prior to the IDIs. The IDI sessions with the patients were conducted at the bedside, with curtains or blinds drawn to provide privacy. IDI sessions for family members were held in a private office room inside the ICU. Only two interviewers and a participant were present during each IDI. The IDIs lasted 40 to 60 min and were all audio-recorded. There were no additional interviews conducted. This study was terminated after the sixth IDI due to the prohibition on visitors and researchers entering the ICU, as well as possible changes in participants’ perspectives during the COVID-19 pandemic. All IDIs in this study were conducted before the implementation of pandemic-related movement restrictions in Malaysia [ 24 ]. Despite this, the last two consecutive IDIs did not yield any new themes, indicating that data saturation had been reached.

Data analysis

Three patients and three family members participated in this study. Coincidentally, there was only one pair of patient-family members who took part in this study. The remaining four participants were not patient-family members paired. The data collected from the patient-family member pair were analyzed separately.

The audio recordings were transcribed verbatim and the transcripts were not returned to the participants for verification. Data management was conducted using QDA Miner Lite®, and data analysis was performed following the six steps of thematic analysis established by Braun and Clark [ 25 ]. All researchers (ELL, SLL, CCC, and JYA) familiarized themselves with the transcript, and each transcript was independently coded by two researchers, with any disputes of coding being resolved by discussion and consensus between researchers. Emerging themes were later categorized based on the five domains of care for critically ill patients, reported by the World Federation of Societies of Intensive and Critical Care Medicine. The domains are (I) critical care services, (II) physical space, (III) monitoring technology, (IV) human resources, and (V) research and quality improvement [ 26 ]. Relevant sub-themes were grouped under respective themes. Study findings were further validated by the literature and expert opinion. Non-English quotes were translated into English by one researcher and were cross-checked by another researcher to ensure the accuracy of the translation.

The participants’ age ranged from 31 to 64 years old. The patients’ median age was 42 (IQR = 15.5) while the family members’ median age was 60 (IQR = 14.5). There were three Malay and three Chinese. Four of them were females and were all married. Four of the six participants had completed secondary school, one had completed primary school, and the other had completed university education. ICU stays ranged from 6 to 182 days (Table  1 ).

A total of three themes emerged in this study: (I) critical care services, (II) physical space, (III) monitoring technology; with several subthemes identified under each of them (Table  2 ).

Theme 1: critical care services

Critical care services needs and what the participants had experienced were not limited to the immediate need for the treatment of individual patients, but also the services that extend beyond basic care. The patients’ and family members’ need for critical services were further classified into medical, physical, psychological and social needs.

Medical needs

The medical needs of patients and their family members were identified based on their experience during the patients’ ICU stay. The needs include continuous pain relief management, effective ICU communication, a decision-making process, the provision of continuity of care and culturally competent care.

Continuous pain relief management

Pain experience was one of the concerns of ICU patients, the continuous need for pain relief has been reiterated by the patients in this study. Necessary analgesics that could not be provided on time have been a concern of ICU patients.

… if I need the medication to alleviate toothache, he (staff) could not give [the pain medication] immediately, [he will] delay in giving [the pain medication]. (Patient #3)

Effective communication in the ICU

This is part of the essential medical need that occurred between “patient-critical care personnel,“ “family members-patient” and “family members-critical care personnel”. “Patient-critical care personnel”: The patients described that they were unable to communicate their needs to the critical care personnel due to endotracheal tube barriers.

Like that time when I was inserted with the [breathing] tube, [and] my urine catheter was blocked, I was unable to call people [for help]. (Patient #3)

“Family member-patient”: the family members had difficulties learning about the needs of the intubated patients.

We (family members) could not guess what he (intubated patient) was saying. (Family member #2)

“Family members-critical care personnel”: Ineffective communication was seen in the non-synchronized conveying of patient information among ICU personnel. Family members were confused by the disparities in the information provided by different ICU personnel.

When I came in [to ICU], I told [the nurse that] Dr. XXX allowed me to come in [to see my wife] (family member presumed wife’s condition worsened)… I was taken aback (when the nurse responded that), “No, her condition is improving. Why do you want to come (for a visit)?“ (Family member #1)

Besides, a lack of designated communication channels in the ICU by having specific personnel and allocation of a specific time that allows the family members to get patients’ updates has been raised. The family members were uncertain about who and how to obtain patients’ information updates.

We could not find a suitable person to ask [regarding patients’ condition], [and] we do not know who to ask [for patients’ condition]. (Family member #2)

While some family members attempted to obtain information from the nurse, they were instructed to meet the doctors for updates. In contrast, doctors were perceived as rarely seen in the ward during family visiting hours, making it difficult for family members to obtain information.

But initially, we could not differentiate between who was a doctor and who was a nurse. Sometimes when I asked the nurse, she would say, “you [have to] wait for [the] doctor.” But we hardly saw the doctor when we were here [in ICU during family visiting hours]. (Family member #2)

Owing to the difficulty in locating the person in charge, a form of communication channel was suggested. The family members preferred bedside name tags that identified the person in charge of a specific patient, allowing them to directly request patient information from that individual.

Unless the name [of staff in charge] is stated, [then] I will find the person [directly]. That is [one of the] possible [solutions]. (Family member #3)

Cultural competence care

The ability of ICU personnel to provide culturally competent care to patients from diverse backgrounds that take into account language, communication styles, beliefs, attitudes, values, and behavioural diversity was identified as a need in critical care services [ 27 ]. The inadequacy of providing cultural competence care was recognised as an issue where some patients encounter language barriers when seeking medical care, necessitating the search for native-speaking critical care personnel to communicate their needs.

[About] Communication… because I am not very fluent in Bahasa Melayu (Malay language) … So when I see [a] Chinese nurse, I will ask her to help to translate. (Patient #2)

Cultural competent care has not been confined to medical care; addressing the beliefs of family members in terms of patients’ nutrition intake was notably a need. A few family members were unsatisfied with the food provided by the hospital to the patients, believing it to be less nutritious for patients.

Yes, sometimes I see one piece of chicken and some porridge with some squash, [which is] not suitable [for patients]. (Family member #2)

Participation in patient care

This study revealed that family members were willing to learn and perform simple care for their loved ones in the ICU. A family member articulated her willingness to acquire basic skills from the healthcare providers in order to ensure the sustenance of patient care.

Then, my son-in-law (who is a healthcare professional) taught me something easier, like how to help him (patient) to do phlegm suction (…) so when we see him (visit the patient in ICU), we will do [phlegm suction] by ourselves. (Family Member #2)

Decision making

The lack of medical treatment knowledge among the participants made them follow the decision of the medical doctors to receive critical care for the patients.

[We] listen to the doctors regarding all [medical treatment]. We totally have no idea [on medical treatment]. (Family member #2)

Psychological needs

The principal psychological needs in the ICU evolve around the elements, making them feel safe in the ICU. The elements include “knowing”, “hoping”, “trusting” and “regaining control”. These elements are greatly influenced by family and friends, ICU personnel, and religion [ 28 ]. This study identified that ICU personnel and religious support were highlighted by the family members as perceived psychological needs of the patients. Patient counselling service was mentioned as an important psychological need for patients in the ICU.

ICU personnel support

The ICU personnel is regarded as crucial in terms of providing patients with support and encouragement to live [ 28 ]. Some family members believed that the doctors’ encouragement would be more effective in motivating the patients than the families themselves.

[When] Dr. XXX passed by, he will encourage him (patient) [by saying]: “Uncle [you have] improved a lot over these few days.” (Family member #2)

The impact of ICU personnel on the patients’ psychological needs is perceived as substantial, including in a negative way. The family members believed that negative words would harm the patients. Therefore, they requested the doctor in charge to be cautious when disclosing information to patients.

Doctors’ words (information on patient’s condition) will affect patients (…) Hope [that we] can know [about the patient’s condition], but [we preferred that the doctor] do not disclose [the negative information] in front of the patient. (Family member #2)

Religious support

Some of the patients expressed a need for religious support while in the ICU.

Maybe listening to the radio. My husband helped on the radio and played verses from Al-Quran. (Patient #1)

Patient counselling

The family members agreed that patient counselling service would be one of the best ways to support the patients psychologically.

It is even better to counsel the patient because the patients need encouragement. (Family member #3)

Physical needs

Comfortable bed-bath.

Some of the patients had negative experiences with bed-bath by having to take late-night showers in cold water. There was a need to use warm water for bathing among the ICU patients.

[It was] eleven (o’clock at night) that [the staff] helped me to shower using … cold water. How [could I] bear with this (showering at night with cold water)? I told them (the staff) that … I would like to use warm water [instead]. He (the staff) agreed [to bring warm water], but what he brought over was cold water. He (staff) told me that … he (staff) would help me to shower at a faster speed. That time I was suffering. (Patient #2)

Social needs

Longer visiting hours.

The patients needed longer visiting hours to meet each of their loved ones during hospitalization in the ICU.

Because they (family members) only [had] one hour [of visiting time]. If it can be extended, [then] we (patient and family member) can talk [longer]… A lot of people (visitors) come [to visit me], [I have] not get to talk to each visitor (within the visiting hour) … So [it will be good] to have longer visiting hours. (Patient #2)

Theme 2: physical spaces

The physical spaces in the ICU are divided into clinical and non-clinical spaces. The clinical space includes the presence of a discrete location where it accommodates the beds, devices, and rooms; a nursing station; and multiple computer stations that are essential in patient care. The pantry, a room for medical personnel to rest, seminar rooms close by, and a place for families to wait are all part of the non-clinical space, which is outside of the physical boundaries of the patient care area [ 29 ]. The experience of physical space in the clinical area was described by the patients as a cold and noisy environment. Unmet needs for non-clinical spaces included a lack of visitor chairs in the waiting area.

Clinical spaces

Conducive ward.

Some patients complained of the cold environment in the ICU which resulted in the need to cover themselves with thick layers of blankets.

The air conditioner was too cold. I needed to cover three layers of blankets, yet [I was] still feeling cold. (Patient #3)

Family members were concerned about patients who were unable to sleep at night owing to the noisy environment in the ICU.

My husband (patient) complained to me that there were a few nights he could not sleep because they (the staff) kept talking loudly. (Family member #3)

Non-clinical spaces

Conducive waiting area.

Meanwhile, the participants raised the issue of insufficient chairs for family members in the waiting area, suggesting that the situation could be improved by adding a few additional chairs, especially for elderly visitors.

I thought that a few more chairs could be added outside the ICU because there were too many people (visitors). Sometimes, some elderly [visitors] do not have chairs to sit on and they need to climb up [the stairs to reach ICU]; yet there was only one row of chairs … I thought it (ICU) should have been equipped with few more chairs. (Family member #3)

Theme 3: monitoring technology

One of the aspects that distinguish critical care from traditional hospital treatment would be the availability of devices with advanced technologies that provide continuous monitoring of a patient’s physiologic status in an ICU [ 29 ]. The monitoring technology identified by the participants could be classified into medical devices and non-medical devices. The medical devices in the ICU frequently emitted alarms that startled the patients. On the other hand, the family members were concerned about malfunctioning call bells, which is an important non-medical device.

Perception of medical equipment alarms

The ICU was thought to be well-equipped with a variety of medical devices by the majority of the participants. Some were unconcerned about the devices that were attached, while others perceived a sense of hopelessness and fear hearing the alarms and seeing the lights emitted by the medical devices.

All sorts of sounds (from the devices), [it was] scary (…) [I felt] like no hope [in the ICU]. (Patient #1)

One of the family members believed it was dangerous to leave a patient in an isolated room without a functioning emergency call bell, especially if the patient has a health condition that causes breathing difficulties.

Yes, [you are] right. Sometimes they may be in danger, such as having breathing problems or any other condition, [it is] better to have the bell for them to press, otherwise it is very dangerous [in such a situation]. (Family member #3)

Discussions and recommendations

This study uncovered the needs and experiences of critically ill patients and their families in the ICU concerning the critical care services, physical environment, and equipment in the ICU. While previous local studies have focused on the family members of ICU patients [ 11 , 12 ], this qualitative study in Malaysia investigates the needs and experiences of critically ill patients as well as their family members.

The main medical need that is deemed unmet for the ICU patients in this study would be insufficient pain treatment. This inadequacy was attributed to difficulties in assessing and accurately locating pain, as well as poor awareness among healthcare personnel, particularly among patients who did not undergo any surgical procedures [ 30 ]. However, a culture of addressing pain in critically ill patients should be fostered, as dealing with pain complaints promptly has been shown to result in a less stressful stay [ 17 , 31 ]. One step forward could be reinforcing adherence to the appropriate pain management strategy supported by the Malaysia Ministry of Health [ 32 ].

Effective communication in the ICU is reiterated as an essential need of patients and family members. Critically ill patients who received invasive mechanical ventilation experienced communication difficulties. At the same time, ICU personnel and families reported difficulties in understanding patients’ needs as well [ 33 , 34 ]. The utilization of aided or unaided augmentative and alternative communication systems could assist in meeting this demand, and this should be implemented according to the local culture and setting [ 35 ].

The family members in this study had a great desire for up-to-date patients’ information, as identified as a fundamental need of family members [ 9 ]. They needed to know about the patients’ progress and prognosis, why certain activities were conducted for the patients, and who to call when they were away [ 36 , 37 ]. In Malaysia, patients’ information is disclosed by medical doctors and reinforced by nurses to the family members [ 38 ]. However, the medical doctors in the ICU tend to prioritise patients’ care, which may result in insufficient time for communication or difficulty locating them when they are managing other patients [ 34 ]. Hence, to establish family-centered care in the ICU and obtain standardised patient information promptly, a consensus for a point person, frequency and types of contact should be made between ICU personnel and family members [ 39 ]. However, these proposals should be addressed further among the ICU team in order to better adapt to the local system.

Family members’ participation in various patient care activities has been reported, ranging from massage, bathing, eye and mouth care, to positioning and adjusting equipment [ 40 ]. This study captured family members’ willingness to learn and participate in patient care. Such a desire to assist the patient, who is their loved one, stems from the kinship and relationship between family members and the patient, precipitating their desire to assist the patient [ 41 ]. Also, being able to get involved in patient care reduces family members’ fear and helplessness when their loved ones are critically ill. Family members’ involvement in patient care during the ICU stay also provides an opportunity for them to acquire relevant skills that enables them to care for the patient after discharge [ 26 ]. Nonetheless, such involvement necessitates additional attention and careful supervision from healthcare providers, which adds to their workload and may cause task delays [ 41 , 42 ]. Concerns about poor quality patient care, accidental extubation, and failure to adhere to infectious control measures have also been raised when family members are involved in patient care [ 43 ]. Hence, a clear policy is formed in the local ICU to direct the selection of patients and family members, the level of their involvement in patient care, and to offer ongoing supervision while they are involved in patient care.

In terms of the psychological needs of the patients, family members acknowledged the ICU personnel as vital individuals for providing psychological support to the patients. This involves requesting that ICU personnel selectively share information with patients to offer hope to patients. Typically, the Asian family culture wishes to shield their loved ones from unpleasant news. However, this request violates the medical ethics of patient autonomy [ 44 ]. Therefore, the ICU personnel has to be trained with strong communication and negotiation skills when challenged with a need for selective non-disclosure [ 45 ]. Apart from that, patients’ need of religious support and counselling have also been articulated in this study. Spiritual distress is common among ICU patients, and thus religious support (such as praying with the patient, discussing religious topics, and fostering religious growth) is regarded as a source of encouragement and hope [ 46 ]. Meanwhile, psychological support (such as counselling, stress management, and coping strategies) provided during ICU stay has been shown to reduce post-traumatic stress disorder and the need for psychiatric medication among patients [ 47 ]. In the local ICU, spiritual support is always offered to the family based on the patients’ religious beliefs. Such effort in supporting patients’ religious and counselling needs is thus to be applauded and should be more proactively offered to those who are in need, although identifying spiritual needs is rather difficult.

The unmet physical need highlighted by the ICU patients would be an unpleasant experience during bed-bath with cold water late at night. This finding is similar to a study in Istanbul that found bed-bath was prevalent between midnight and five o’clock in the morning [ 48 ]. This practice could be due to a less busy schedule during midnight for the nurses to conduct bed-baths. Aside from the timing of bed-baths, the water temperature should be ideal. It is recommended that bed-bathing timing be based on individual patient preference [ 49 ], with the water temperature set at 40 to 42.5 o C [ 50 ]. Though bed-bath may cause some discomfort to patients, it is vital in preserving patients’ hygiene and improving health outcomes [ 51 ].

Patients’ social needs, including seeing their family members [ 17 ], cannot be met due to the restricted visiting hours. Permission for flexible visiting hours to accommodate family members who have other commitments or different working schedules can facilitate family involvement in patient care. However, this has to be carefully considered taking into consideration the consequences on nursing care and disturbance to other patients [ 52 ]. Developing defined yet flexible visiting policies by tailoring visiting hours based on the needs of patients, families, and healthcare personnel may be more feasible and acceptable to all [ 53 ]. Currently, extended visiting hours in the ICU have been offered to family members of selected patients, particularly patients requiring long-term care. The provision of flexible visiting hours allows family members to engage in patient care with the assistance of the nurses.

Intolerable cold environments emerged as a negative experience for ICU patients when they were asked about the need for clinical spaces in the ICU. As part of the infection control recommendations, the Centers for Disease Control and Prevention (CDC) recommends that hospital wards maintain a temperature of 21-24 o C [ 54 ]. However, the cold environment may not be well tolerated by patients [ 55 ]. To strike a balance between CDC recommendations and patients’ comfort, patients could be reassured and given extra blankets to assist them to cope with the cold environment in the ICU.

In the aspect of non-clinical space, family members expressed the need for additional waiting chairs to be placed outside the ICU. Driving this need is the desire of families for reassurance and to be in close proximity with their loved ones during the critical phase [ 11 , 56 ]. In the United States, family members desired a comfortable waiting area where they could find solace in the company of other relatives of critically ill patients [ 57 ]. Unfortunately, at the ICU where the study was conducted, there was no designated ICU waiting room for family members. A hospital waiting-lounge facility is available within a five-minute walking distance from the ICU, but not all of the family members were aware of this facility [ 58 ]. They should be informed of the availability of the facility during the initial meeting with the ICU personnel.

The need for functioning call bells was raised by the participants, especially for patients who were placed in the isolated unit in the ICU. In case of an emergency, this medical device facilitates communication and connectivity of patients with healthcare providers. Patients felt safer knowing that they could reach healthcare providers for care or assistance when needed [ 59 , 60 ]. It is important for the ICU personnel to monitor the function of the call bell and to set up a call bell response system. However, due to structural limitations in this ICU, functional call bells were unable to be installed, and the team was continually exploring alternatives.

Consistent with the reports of other studies, some of the devices in the ICU emit sounds and alarms, which are a source of distress for the patients [ 55 , 61 , 62 ]. The alarms may trigger anxiety in patients, which, when combined with the patients’ lack of familiarity with the meaning of the sounds and alarms, causes them to perceive them as a threat [ 63 , 64 ]. This situation can be improved by minimizing the effects of the alarms by providing earplugs or setting “quiet times” [ 65 , 66 ]. Practicing light down and reducing alarms to create “quiet times” at night have been implemented in this ICU.

Strengths, limitations and recommendations

This research was undertaken just before the COVID-19 epidemic. The pandemic resulted in policy adjustments, including modifications to the visiting policy. Therefore, the data collection was stopped at the sixth participant when the Malaysian government declared a “Movement Controlled Order” on March 18, 2020, in response to the health emergency. Nonetheless, data from all six IDIs revolved around the same themes and no new themes emerged, data for the themes is thus saturated. Additionally, this study provides a baseline understanding of the needs and experiences of both critically ill patients and their families in Malaysia. Future research should focus on the disparities between the needs and experiences of critically ill patients and family members before and after the pandemic, and if the policy changes implemented during the COVID-19 pandemic affected their needs and experiences.

This study provides a comprehensive look at the needs and experiences of critically ill patients and their families. Some of the concerns are acknowledged as having no immediate solution. The study’s findings, on the other hand, would aid ICU professionals in recognising and communicating the needs of patients and families in order to foster mutual understanding. Addressing the challenges outlined in this study could provide insights into organisational and systemic reforms to humanise ICU care.

Availability of data and materials

The datasets used and/or analysed during the current study are available from the corresponding author upon reasonable request.

Abbreviations

Intensive Care Unit

Molter NC, Leske JS. Critical Care Family Needs Inventory. Heart and Lung. 1995. https://doi.org/10.1037/t37619-000 .

Holden J, Harrison L, Johnson M. Families, nurses and intensive care patients: a review of the literature. J Clin Nurs. 2002;11(2):140–8.

Article   PubMed   Google Scholar  

Pattison N. Psychological implications of admission to critical care. Br J Nurs Mark Allen Publ. 2005;14:708–14.

Article   Google Scholar  

Stein-Parbury J, McKinley S. Patients’ experiences of being in an intensive care unit: a select literature review. Am J Crit Care Off Publ Am Assoc Crit-Care Nurses. 2000;9(1):20–7.

CAS   Google Scholar  

Wåhlin I, Ek AC, Idvall E. Patient empowerment in intensive care–an interview study. Intensive Crit Care Nurs. 2006;22(6):370–7.

Hofhuis JGM, Spronk PE, van Stel HF, Schrijvers AJP, Rommes JH, Bakker J. Experiences of critically ill patients in the ICU. Intensive Crit Care Nurs. 2008;24(5):300–13.

Aro I, Pietilä AM, Vehviläinen-Julkunen K. Needs of adult patients in intensive care units of estonian hospitals: a questionnaire survey. J Clin Nurs. 2012;21(13–14):1847–58.

Wåhlin I, Samuelsson P, Ågren S. What do patients rate as most important when cared for in the ICU and how often is this met? - an empowerment questionnaire survey. J Crit Care. 2017;40:83–90.

Scott P, Thomson P, Shepherd A. Families of patients in ICU: A Scoping review of their needs and satisfaction with care. Nurs Open. 2019;6(3):698–712.

Lee LYK, Lau YL. Immediate needs of adult family members of adult intensive care patients in Hong Kong. J Clin Nurs. 2003;12(4):490–500.

Dharmalingam TK, Kamaluddin MR, Hassan SK, Zaini RHM. The needs of malaysian family members of critically ill patients treated in Intensive Care Unit. Hosp Universiti Sains Malaysia. 2016;12:8.

Google Scholar  

Mohamed Z, Sasikala M, Nurfarieza M, Siew Eng H. Needs of Family Members of Critically Ill Patients in a Critical Care Unit at Universiti Kebangsaan Malaysia Medical Centre. Med Health. 2016;11(1):11–21.

Al-Mutair AS, Plummer V, Clerehan R, O’Brien A. Needs and experiences of intensive care patients’ families: a saudi qualitative study. Nurs Crit Care. 2014;19(3):135–44.

Wilkinson P. A qualitative study to establish the self-perceived needs of family members of patients in a general intensive care unit. Intensive Crit Care Nurs. 1995;11(2):77–86.

Article   CAS   PubMed   Google Scholar  

McKiernan M, McCarthy G. Family members’ lived experience in the intensive care unit: A phemenological study. Intensive Crit Care Nurs. 2010;26(5):254–61.

Agency for Healthcare Research and Quality. What Is Patient Experience?. 2022 [cited 2022 Sep 23]. Available from: https://www.ahrq.gov/cahps/about-cahps/patient-experience/index.html .

Topçu S, Ecevit Alpar Ş, Gülseven B, Kebapçı A. Patient experiences in intensive care units: a systematic review. Patient Exp J. 2017;4(3):115–27.

Hirshberg EL, Butler J, Francis M, Davis FA, Lee D, Tavake-Pasi F et al. Persistence of patient and family experiences of critical illness. BMJ Open. 2020;10(4):e035213.

Coulter MA. The needs of family members of patients in intensive care units. Intensive Care Nurs. 1989;5(1):4–10.

Davidson JE, Powers K, Hedayat KM, Tieszen M, Kon AA, Shepard E et al. Clinical practice guidelines for support of the family in the patient-centered intensive care unit: American College of critical Care Medicine Task Force 2004–2005: Crit Care Med. 2007;35(2):605–22.

Khalaila R. Meeting the needs of patients’ families in intensive care units. Nurs Stand R Coll Nurs G B. 1987. 2014;28(43):37–44.

Novaes MAFP, Aronovich A, Ferraz MB, Knobel E. Stressors in ICU: patients’ evaluation. Intensive Care Med. 1997;23(12):1282–5.

Leung K, Chien WT, Mackenzie AE. Needs of chinese families of critically ill patients. West J Nurs Res. 2000;22(7):826–40.

Shah AUM, Safri SNA, Thevadas R, Noordin NK, Rahman AA, Sekawi Z et al. COVID-19 outbreak in Malaysia: Actions taken by the Malaysian government. Int J Infect Dis. 2020;97:108–16.

Braun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol. 2006;3(2):77–101.

Marshall JC, Bosco L, Adhikari NK, Connolly B, Diaz JV, Dorman T, et al. What is an intensive care unit? A report of the task force of the World Federation of Societies of intensive and critical Care Medicine. J Crit Care. 2017;37:270–6.

Butler M, McCreedy E, Schwer N, et al. Improving Cultural Competence to Reduce Health Disparities [Internet]. Rockville: Agency for Healthcare Research and Quality (US); 2016. (Comparative Effectiveness Reviews, No. 170.). https://www.ncbi.nlm.nih.gov/books/NBK361126/ . Accessed 23 Sept 2022.

Hupcey JE. Feeling safe: the psychosocial needs of ICU patients. J Nurs Scholarsh Off Publ Sigma Theta Tau Int Honor Soc Nurs. 2000;32(4):361–7.

Marshall JC, Bosco L, Adhikari NK, Connolly B, Diaz JV, Dorman T et al. What is an intensive care unit? A report of the task force of the World Federation of Societies of Intensive and Critical Care Medicine. J Crit Care. 2017;37:270–6.

Hasegawa R. Consideration of pain felt by patients in the ICU. J Intensive Care. 2017;5(1):73.

Article   PubMed   PubMed Central   Google Scholar  

Rotondi AJ, Chelluri L, Sirio C, Mendelsohn A, Schulz R, Belle S, et al. Patients’ recollections of stressful experiences while receiving prolonged mechanical ventilation in an intensive care unit. Crit Care Med. 2002;30(4):746–52.

Ministry of Health. Pain as the 5th vital sign. 2018. https://www.moh.gov.my/moh/resources/Penerbitan/Program%20Bebas%20Kesakitan/Garis%20Panduan/2_in_1_P5VS_Guideline_3rd_Edition_Corrected_2020.pdf . Accessed 30 Sept 2022.

Martinho CIF, Rodrigues ITRM. Communication of mechanically ventilated patients in intensive care units. Rev Bras Ter Intensiva. 2016;28(2):132–40.

Yoo HJ, Lim OB, Shim JL. Critical care nurses’ communication experiences with patients and families in an intensive care unit: a qualitative study. PLoS ONE. 2020;15(7):e0235694.

Article   CAS   PubMed   PubMed Central   Google Scholar  

Salem A, Ahmad MM. Communication with invasive mechanically ventilated patients and the use of alternative devices: integrative review. J Res Nurs JRN. 2018;23(7):614–30.

Alsharari AF. The needs of family members of patients admitted to the intensive care unit. Patient Prefer Adherence. 2019;13:465–73.

Al-Akash H, Maabreh R, AbuRuz M, Khader K, Shajrawi A. Jordanian Patients’ Family Members Need Perceptions in the Critical Care Settings: Nurses’ Perspectives versus Family Members’ Perspectives in the Context of Health Informatics. J Healthc Eng. 2021;2021:4071523.

Hussin R, Hashim F. Communication needs of family members with a relative in Intensive Care Unit. J ASIAN Behav Stud. 2017;2:19.

Schwartz AC, Dunn SE, Simon HFM, Velasquez A, Garner D, Tran DQ, et al. Making family-centered care for adults in the ICU a reality. Front Psychiatry. 2022;24:13:837708.

Liput SA, Kane-Gill SL, Seybert AL, Smithburger PL. A review of the perceptions of Healthcare Providers and Family Members toward Family involvement in active adult patient care in the ICU. Crit Care Med. 2016;44(6):1191–7.

Fateel EE, O’Neill CS. Family members’ involvement in the care of critically ill patients in two intensive care units in an acute hospital in Bahrain: the experiences and perspectives of family members’ and nurses’ - a qualitative study. Clin Nurs Stud. 2015;30(1):p57.

Hsiao PR, Redley B, Hsiao YC, Lin CC, Han CY, Lin HR. Family needs of critically ill patients in the emergency department. Int Emerg Nurs. 2017;30:3–8.

Azoulay E, Pochard F, Chevret S, Arich C, Brivet F, Brun F, et al. Family participation in care to the critically ill: opinions of families and staff. Intensive Care Med. 2003;29(9):1498–504.

McCabe MS, Wood WA, Goldberg RM. When the Family Requests Withholding the Diagnosis: Who Owns the Truth? J Oncol Pract. 2010;6(2):94–6.

Hallenbeck J, Arnold R. A request for nondisclosure: don’t tell mother. J Clin Oncol Off J Am Soc Clin Oncol. 2007;25(1):5030–4.

Ho JQ, Nguyen CD, Lopes R, Ezeji-Okoye SC, Kuschner WG. Spiritual care in the Intensive Care Unit: a narrative review. J Intensive Care Med. 2018;33(5):279–87.

Peris A, Bonizzoli M, Iozzelli D, Migliaccio ML, Zagli G, Bacchereti A, et al. Early intra-intensive care unit psychological intervention promotes recovery from post traumatic stress disorders, anxiety and depression symptoms in critically ill patients. Crit Care. 2011;15(1):R41.

Celik S, Oztekin D, Akyolcu N, Issever H. Sleep disturbance: the patient care activities applied at the night shift in the intensive care unit. J Clin Nurs. 2005;14:102–6.

American Association of Critical-Care Nurses. AACN Updates Patient Bathing Practices Protocol. 2013. https://www.infectioncontroltoday.com/view/aacn-updates-patient-bathing-practices-protocol . Accessed 30 Sept 2022.

da Silva CJB, Silva M, dos Reis S, Miranda FF, de Santos GCO. L dos, Lima DVM de. Bed bath for infarcted patients: crossover of the hydrothermal control 40 o C versus 42.5 o C. Online Braz J Nurs. 2016;15(3):341–50.

El-Soussi A, Abd El Hamid H. Examining bed-bath practices of critically ill patients. J Nurs Educ Pract. 2016;6(12):1–11.

Khaleghparast S, Joolaee S, Ghanbari B, Maleki M, Peyrovi H, Bahrani N. A review of visiting policies in Intensive Care Units. Glob J Health Sci. 2015;8(6):267–76.

Berwick DM, Kotagal M. Restricted visiting hours in ICUs: time to change. JAMA. 2004;11(6):736–7.

U.S. Department of Health and Human Services Centers for Disease Control and Prevention (CDC). Guidelines for Environmental Infection Control in Health-Care Facilities. 2003. https://www.cdc.gov/infectioncontrol/guidelines/environmental/index.html . Accessed 30 Sept 2022.

Krampe H, Denke C, Gülden J, Mauersberger VM, Ehlen L, Schönthaler E et al. Perceived Severity of Stressors in the Intensive Care Unit: A Systematic Review and Semi-Quantitative Analysis of the Literature on the Perspectives of Patients, Health Care Providers and Relatives. J Clin Med. 2021;10(17):3928.

Plakas S, Taket A, Cant B, Fouka G, Vardaki Z. The meaning and importance of vigilant attendance for the relatives of intensive care unit patients. Nurs Crit Care. 2014;19(5):243–54.

Kutash M, Northrop L. Family members’ experiences of the intensive care unit waiting room. J Adv Nurs. 2007;60(4):384–8.

“Anjung Kasih” Meets the Needs of the Target Group. Perak Today. 2017. https://peraktoday.com.my/2017/04/anjung-kasih-penuhi-keperluan-golongan-sasar/ . Accessed 30 Sept 2022.

Lasiter S. The button”: initiating the patient-nurse interaction. Clin Nurs Res. 2014;23(2):188–200.

Montie M, Shuman C, Galinato J, Patak L, Anderson CA, Titler MG. Conduits to care: call lights and patients’ perceptions of communication. J Multidiscip Healthc. 2017;10:359–66.

Ma P, Wang Y, Xi X, ming, Lin H yuan, Xu Y, Du B et al. [Epidemiology of unpleasant experiences in conscious critically ill patients during intensive care unit stay]. Zhongguo Wei Zhong Bing Ji Jiu Yi Xue Chin Crit Care Med Zhongguo Weizhongbing Jijiuyixue. 2008;20(9):553–7.

Soh KL, Soh KG, Ahmad Z, Raman RA, Japar S. Perception of intensive care unit stressors by patients in Malaysian Federal Territory hospitals. Contemp Nurse. 2008;31(1):86–93.

Johansson L, Bergbom I, Lindahl B. Meanings of Being Critically Ill in a Sound-Intensive ICU Patient Room - A Phenomenological Hermeneutical Study. Open Nurs J. 2012;6:108–16.

Darbyshire JL. Excessive noise in intensive care units. BMJ. 2016;353:i1956.

Darbyshire JL, Young JD. An investigation of sound levels on intensive care units with reference to the WHO guidelines. Crit Care. 2013;17(5):R187.

Burdick KJ, Callahan CJ. Sleeping Soundlessly in the Intensive Care Unit. Multimodal Technol Interact. 2020;4(1):6.

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Acknowledgements

The team thanks all staff in ICU Hospital Raja Permaisuri Bainun Ipoh for facilitating the interview sessions conducted in ICU. The team would also like to thank the Director General of Health, Malaysia, for his permission to publish this article.

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All authors contributed to the idea and drafting of the study protocol. CCC, JYA, ELL and SLL were involved in in-depth interviews and thematic analysis. KWF and PRD were involved in the final confirmation of the thematic analysis. ELL, CCC, JYA and SLL contributed to the writing of the manuscript. KWF and PRD contributed to the critical revision of the manuscript. All authors read, reviewed and approved the final version.

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Leong, EL., Chew, CC., Ang, JY. et al. The needs and experiences of critically ill patients and family members in intensive care unit of a tertiary hospital in Malaysia: a qualitative study. BMC Health Serv Res 23 , 627 (2023). https://doi.org/10.1186/s12913-023-09660-9

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Sharpening the lens to evaluate interprofessional education and interprofessional collaboration by improving the conceptual framework: a critical discussion

• Florian B. Neubauer 1 ,
• Felicitas L. Wagner 1 ,
• Andrea Lörwald 1 &
• Sören Huwendiek 1  

BMC Medical Education volume  24 , Article number:  615 ( 2024 ) Cite this article

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It has been difficult to demonstrate that interprofessional education (IPE) and interprofessional collaboration (IPC) have positive effects on patient care quality, cost effectiveness of patient care, and healthcare provider satisfaction. Here we propose a detailed explanation for this difficulty based on an adjusted theory about cause and effect in the field of IPE and IPC by asking: 1) What are the critical weaknesses of the causal models predominantly used which link IPE with IPC, and IPE and IPC with final outcomes? 2) What would a more precise causal model look like? 3) Can the proposed novel model help us better understand the challenges of IPE and IPC outcome evaluations? In the format of a critical theoretical discussion, based on a critical appraisal of the literature, we first reason that a monocausal, IPE-biased view on IPC and IPC outcomes does not form a sufficient foundation for proper IPE and IPC outcome evaluations; rather, interprofessional organization (IPO) has to be considered an additional necessary cause for IPC; and factors outside of IPC additional causes for final outcomes. Second, we present an adjusted model representing the “multi-stage multi-causality” of patient, healthcare provider, and system outcomes. Third, we demonstrate the model’s explanatory power by employing it to deduce why misuse of the modified Kirkpatrick classification as a causal model in IPE and IPC outcome evaluations might have led to inconclusive results in the past. We conclude by applying the derived theoretical clarification to formulate recommendations for enhancing future evaluations of IPE, IPO, and IPC. Our main recommendations: 1) Focus should be placed on a comprehensive evaluation of factual IPC as the fundamental metric and 2) A step-by-step approach should be used that separates the outcome evaluation of IPE from that of IPC in the overarching quest for proving the benefits of IPE, IPO and IPC for patients, healthcare providers, and health systems. With this critical discussion we hope to enable more effective evaluations of IPE, IPO and IPC in the future.

Peer Review reports

There is scant knowledge on the extent to which the quality of interprofessional education (IPE) and interprofessional collaboration (IPC) at healthcare institutions influences the patient care quality [ 1 , 2 , 3 ], the cost effectiveness of patient care, the job satisfaction of healthcare professionals [ 1 ] and, as a result, their retention [ 4 , 5 ]. Patients, people who organize and finance healthcare, policy makers, tax payers, and arguably societies as a whole have a reasonable interest in an answer to this question.

According to the peer-reviewed literature, relevant knowledge gaps persist about the benefits of IPE and IPC despite multiple studies on IPE and IPC outcomes covering a period of almost 50 years [ 2 , 3 , 6 , 7 , 8 , 9 , 10 , 11 , 12 , 13 ]. Several explanations as to how this can be possible are proposed: The number of evaluation studies is still too low [ 10 ]; the time periods typically covered by evaluations is too short to detect final outcomes of IPE/IPC interventions [ 2 , 8 , 11 , 14 , 15 ]; too much focus is placed on immediate results without including measures for final outcomes from the outset [ 10 ]; or, ultimately, positive effects of IPE and IPC simply might not exist [ 6 , 9 , 10 ]. Another frequent and non-contradictory explanation proposes that a lack of clarity in theory and terminology of IPE and IPC and an insufficient use of conceptual frameworks are major deficits which obscure evaluation results [ 8 , 12 , 13 , 16 , 17 , 18 , 19 , 20 , 21 ].

In this article, we argue the latter: That an insufficient use of conceptual frameworks has obscured evaluation results. We propose that the persistence of the knowledge gap relating to patient outcomes, satisfaction of healthcare professionals, and cost effectiveness of IPE and IPC activities (briefly, “patient, healthcare provider, and system outcomes”) is rooted in a lack of accuracy in the theoretical models used for mapping causes and effects in IPE and IPC. Our objective is to contribute to overcoming the inconclusiveness in IPE and IPC outcome evaluations by achieving the missing accuracy through the lens of a novel “multi-stage multi-causality” model. Specifically, our research questions are: 1) What are the critical weaknesses of the causal models predominantly used which link IPE with IPC, and IPE and IPC with final outcomes? 2) What would a more precise causal model look like? 3) Can the proposed novel model help us better understand the challenges of IPE and IPC outcome evaluations?

In answering these questions, we first show evidence from the literature that the existing causal models of IPE and IPC exhibit a crucial imprecision. Second, we present the “multi-stage multi-causality model of patient, healthcare provider, and system outcomes” which fixes this imprecision by making a small but important modification to the causal role of IPO. Third, we demonstrate the explanatory power of the multi-stage multi-causality model showing why evaluations using the modified Kirkpatrick classification of interprofessional outcomes (MKC) [ 11 , 22 , 23 ] — a tool commonly used to evaluate outcomes of IPE activities — have failed to substantiate positive outcomes of IPE and IPC; namely, we show how the misuse of MKC leads to inconclusiveness and difficulties in evaluating final patient, healthcare provider, and system outcomes. We conclude with recommendations for future evaluations in the field of IPE, IPO and IPC.

With this theoretical investigation, we hope to contribute to a deeper understanding of the causal factors in IPE, IPO and IPC and to enable more precise evaluations in the future.

Based on our research questions, we performed iterative literature searches (detailed below) followed by critical appraisal by the authors, and transformed the resulting insights into the critical discussion presented in the main section of the present article by applying the 6 quality criteria of the SANRA scale [ 24 ]:

Justification of the article's importance for the readership: Our target audience consists of researchers whose goal is to evaluate whether IPE, IPO or IPC improve patient, healthcare provider, and system outcomes. For our target audience the present study is meaningful because it advances the understanding of the theoretical foundations of evaluations in this field. Further, in local contexts where the potential of IPE, IPO, and IPC is still neglected, clear evidence demonstrating substantial benefits would help to foster programs aimed at implementing better IPE, IPO, or IPC.

Statement of concrete/specific aims or formulation of questions : We set out to explore the following questions: 1) What are the critical weaknesses of the causal models predominantly used which link IPE with IPC, and IPE and IPC with final outcomes? 2) What would a more precise causal model look like? 3) Can the proposed novel model help us better understand the challenges of IPE and IPC outcome evaluations?

Description of literature searches: We searched for existing definitions, causal models, relevant indicators, and evaluation instruments for IPE, IPO, and IPC using PubMed, Google and Google Scholar with the following search terms in different combinations: “interprofessional education”, “interprofessional collaboration”, “interprofessional organization”, “interprofessional team work”, “evaluation”, “outcome evaluation”, “process evaluation”, “modified Kirkpatrick”, “conceptual framework”, “theory”, “model”, “instrument”, “assessment scale”, “survey”, “review”. We conducted all searches in English, covering the time period from 1950 to 2023. We augmented the initial body of literature found by this strategy with citation tracking: for backward tracking, we followed the references provided in articles which we deemed relevant for our research questions; for forward searches, we used the "cited by" feature of PubMed and Google Scholar. The subchapter-specific literature search used in the development of our definition of IPC is described under “Definition of factual IPC”.

Referencing: We consistently back key statements by references.

Scientific reasoni ng: We enable the reader to easily follow our narrative by structuring the present article around the three research questions as stated above, following a logical flow of arguments.

Appropriate presentation of data: We present the data by distinguishing which findings were taken from the literature and which novel arguments for answering the research questions were derived by us.

Definitions

Definition of ipe.

Occasions when two or more healthcare/social care professions learn with, from and about each other to improve collaboration and the quality of care for patients/clients [ 2 ] (slightly refining the CAIPE definition [ 25 ]).

These occasions can happen formally or informally, in dedicated educational settings or at the workplace of healthcare/social care professions, and at any stage along the learning continuum, i.e. foundational education, graduate education, and post-licensure continuing professional development [ 8 , 26 ]. The central concept in IPE is learning [ 13 ], the gain of knowledge, skills, and attitudes, or — from a constructivist’s perspective — changes in the brains of individuals.

Definition of factual IPC

Presence of activities in the following 7 dimensions:

Patient-centered care, including a shared treatment plan and effective error management;

Shared creation of the treatment plan and coordination of its execution;

Mutual respect between professions;

Communication, including shared decision-making, sharing of information, appropriate communication tools, and accessibility of team members;

Shared definition and acceptance of roles and responsibilities;

Effective conflict management; and

Leadership, including outcome orientation.

How did we arrive at this definition? IPC has to be distinguished from traditional “multiprofessional collaboration”. In multiprofessional collaboration, patient care is organized in a discipline-oriented way, affecting its organization, leadership, communication, and decision-making. Different professions work separately, each with their own treatment goals; the physician delegates treatment options to the other healthcare professionals in one-way, mostly bilateral communication [ 27 , 28 ]. IPC, in contrast, is defined as the occasions “when multiple health workers from different professional backgrounds work together with patients, families, carers and communities to deliver the highest quality of care” [ 29 ]. This definition by the WHO remains in use today [ 30 ]. However, we found that, in order to talk about specific effects of IPE on IPC and to tailor evaluations towards less ambiguous results, an operationalized definition of IPC is required which provides a higher level of applicability. To create such a definition, we searched the literature to collect a comprehensive list of IPC dimensions which covers all possible settings of IPC. In an iterative process of content-based thematic clustering, reviews, original articles and preexisting questionnaires on the evaluation of IPE and IPC were added until there was agreement between the authors that saturation was reached with regard to all relevant IPC dimensions. This resulted in the following list of publications: [ 3 , 7 , 9 , 19 , 26 , 28 , 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 ]. Next, we clustered the terms for IPC dimensions found in this body of literature by consensus agreement on sufficient equivalence between three of the authors (FBN, FLW, SH). Clustering was required due to a lack of consistent terminology in the literature and resulted in the comprehensive set of 7 IPC dimensions used in our definition of IPC provided above. Finally, we needed to differentiate IPC from IPE and learning: At the workplace, informal learning happens all the time. As a result, interprofessional work processes can comprise both IPC and IPE at the same time; however, interprofessional learning is only a possible , not a necessary element of IPC and hence was not included in our definition of IPC. For example, a healthcare professional who is fully equipped with all competencies required for factual IPC could proficiently work in an established team in an interprofessional way without having to learn any additional IPC-related skills.

In order to stress that our definition of IPC includes all the healthcare-related interprofessional work processes actually taking place but excludes the activities required to create them (those fall in the domains of IPE or IPO), we use the term “factual IPC” throughout the present article. Factual IPC not only happens in formal interprofessional work processes like regular, scheduled meetings but also “on the fly”, i.e. during informal and low-threshold communication and collaboration.

Definition of IPO

All activities at a healthcare institution which create, improve, or maintain regular work processes of factual IPC or create, improve, or maintain institutional conditions supporting formal and informal parts of factual IPC, but excluding activities related to IPE.

There is no agreed upon definition of IPO in the literature, so we propose this refined one here that is broad enough to encompass the full variety of IPC-supporting activities at a healthcare institution while, at the same time, being narrow enough to exclude all manifestations of IPE.

According to this definition, IPO complements IPE within the set of jointly sufficient causes of factual IPC. IPO comprises all conditions required for the realization of factual IPC which are not related to interprofessional learning. It includes the actions of healthcare managers to implement work processes for IPC and to create supportive conditions for IPC (cf. the definitions of IPO in [ 6 , 8 , 13 , 17 , 23 , 26 , 30 , 31 , 33 , 40 , 41 , 42 ]). All interventions which establish or improve interprofessional work processes, i.e. which change how things are done in patient care, or which improve the conditions for factual IPC at an institution, belong in the domain of IPO. IPO is also the continued support for factual IPC by management like encouragement, clarification of areas of responsibility, incentives, staffing, room allocation, other resources, or funding. In contrast, established and regular interprofessional tasks themselves, after they have become part of the day-to-day work life of healthcare teams, without requiring further actions by management, would be categorized as factual IPC, not IPO.

Taken together, IPE is the umbrella term for planning, organizing, conducting, being subject to, and the results of interprofessional learning activities, whereas IPO is the umbrella term for all other activities that, in addition to individual competencies of team members, are necessary to cause factual IPC of high quality.

Critical discussion

What are the critical weaknesses of the causal models predominantly used which link ipe with ipc, and ipe and ipc with final outcomes.

We start by exploring the models in the literature that describe causes and effects of interprofessional activities in the context of patient care. We will derive evidence from the literature that the existing models exhibit a crucial imprecision regarding the causal role of IPO.

The causal model of IPC proposed by the WHO [ 29 , 43 ] (Fig.  1 ) was the model predominantly used in past evaluations of IPE and IPC. The WHO model suggests that IPE-related learning leads to IPC competence (knowledge, skills, and attitudes) in the “health workforce” that is “IPC-ready” post-IPE. This readiness “automatically” leads (as the long diagonal arrow in Fig.  1 suggests) to factual IPC. “The World Health Organization and its partners acknowledge that there is sufficient evidence to indicate that effective interprofessional education enables effective collaborative practice” [ 29 ]. Factual IPC, in turn “strengthens health systems and improves health outcomes” [ 29 ]. As a result, this model suggests a kind of “transitivity” between first causes and last effects: effective IPE activities are expected to ultimately yield positive patient, healthcare provider, and system outcomes on their own.

The WHO model of causes and effects in IPE and IPC (from [ 29 ], with permission)

After its publication, the WHO model was regularly cited and endorsed by IPE experts and continues to exert broad influence today. As of October 6, 2023, the “Google Scholar” search engine showed the original publication [ 29 ] to have 4393 citations, 367 of them in 2023 alone.

It is important to note that the WHO model is monocausal with respect to IPC, i.e. IPE is the sole necessary cause for factual IPC. While the model acknowledges that, next to IPE, there are further “mechanisms that shape how collaborative practice is introduced and executed”, it only ranks them as supportive: “ Once a collaborative practice-ready health workforce is in place [emphasis added], these [additional] mechanisms will help them [policy-makers] determine the actions they might take to support [emphasis added] collaborative practice” [ 29 ]. The following quotes by Reeves and colleagues further illustrate the strong emphasis causal models used to put on IPE: «It is commonly argued that IPE can promote the skills and behaviours required for effective IPC, which in turn can improve quality of health care and patient outcomes” [ 17 ] and “National organisations have created core competencies for interprofessional collaborative practice, positioning IPE as fundamental to practice improvement [emphasis added]” [ 10 ]. A couple of years later, Paradis and colleagues even state: “During this wave [of IPE; 1999–2015], advocates suggested IPE as the solution to nearly every health care problem that arose (…)” [ 6 ].

However, a scoping review by Reeves and colleagues aimed at improving “conceptualization of the interprofessional field” published soon after the WHO model, already acknowledged that the monocausal picture of factual IPC is incomplete [ 17 ]. Based on a broad analysis of the literature, their review offers a theoretical “Interprofessional framework” that includes the notion of IPO as an additional and different possible cause for desired interprofessional outcomes (Fig.  2 ). They define IPO interventions as “changes at the organizational level (e.g. space, staffing, policy) to enhance collaboration and the quality of care”. The explicit inclusion of IPO in this causal model of IPC was a very important step forward. The authors position IPO interventions parallel to IPE interventions, clearly indicating that IPO is an additional possible cause for desired interprofessional objectives and outcomes. However, in their framework, the capacity of IPO to be a second necessary cause in addition to IPE had not been clearly worked out yet.

The Interprofessional Framework (from [ 17 ], reprinted by permission of the publisher (Taylor & Francis Ltd, [ 44 ]). Note that, next to IPE, IPO is listed as a different, additional cause for desired interprofessional objectives and outcomes, but the crucial concept that it also is a necessary cause has not yet been worked out here

Side note: This model and publications using it (e.g. [ 45 ]) specify “Interprofessional Practice” (IPP) as a fourth domain, different from IPO (Fig.  2 , middle column). However, the IPP elements describe interventions that support work processes of factual IPC, and support for work processes of factual IPC is fully included in our definition of IPO. As a result, we see no necessity to set IPP apart from IPO and do not include IPP as an additional domain in our model below.

For completeness’ sake, we want to mention another explicit model by D’amour and Oandasan [ 26 ] with a comparable level of causal clarity which similarly claims that “there are many factors that act as determinants for collaborative practice to be realized”. As this model does not alter our line of argument it is not shown here.

The ongoing imprecision about the causal role of IPO naturally led to the next iteration of models. The authors of a 2015 review, commissioned by the Institute of Medicine of the National Academy of Sciences (IOM), provide the most recent influential model of causes and effects in IPC which they call “Interprofessional learning continuum model” [ 8 ] (Fig.  3 ).

The Interprofessional learning continuum model (from [ 8 ], with permission). Under the labels of “Institutional culture”, “Workforce policy”, and “Financing policy” it not only comprises IPO but assigns to IPO the crucial property of being an “enabling” factor, i.e. being co-causal for factual IPC (here labeled as “Collaborative behavior” and “Performance in practice”, lower left row). Despite this important improvement, the hierarchy of causes and effects remains partially vague: a The green arrow seems to imply direct effects of IPO on health and system outcomes without acknowledging that if IPO is supposed to have an effect on those at all, it necessarily must improve factual IPC first. b The impression remains that factual IPC mainly belongs on the left-hand side, being primarily an effect of IPE. IPO seems less effective on IPC, depending on how one interprets the influence of the green arrow on the larger red box which groups learner, health and system outcomes. c The left tip of the red double arrow in the center, indicating an effect of health and system outcomes on learning outcomes, is not discussed in the publication

In comparison to the WHO model (Fig.  1 ) and the Interprofessional Framework (Fig.  2 ), this causal model acknowledges that IPO is not just an additional but also a necessary cause of IPC and thus provides the most elaborate description of the causal relationships between IPE, IPO and IPC in the literature so far. The authors state, “Diverse and often opaque payment structures and differences in professional and organizational cultures generate obstacles to innovative workforce arrangements, thereby impeding interprofessional work. On the other hand, positive changes in workforce and financing policies could enable [emphasis added] more effective collaboration (…)” [ 8 ]. The word “enable” implies causal necessity : if an enabling factor is absent, the effect is disabled, hence the enabling factor is necessary . The key insight that IPO is a further necessary cause of IPC next to IPE can be found in several other, partly less recent publications, with the only difference that these publications do not embed this insight in a formal model [ 6 , 7 , 13 , 23 , 31 , 33 , 41 , 42 ]. The causal necessity of IPO becomes evident if one considers the extreme case: imagine a healthcare team whose individual members have all learned through IPE the skill set necessary for high quality IPC, i.e. they are optimally trained for IPC. However, they work at an institution that does not support proper IPC work processes, e.g. there is no dedicated time for team discussions of treatment plans and no electronic tools that allow all team members equal access to patient data. Consequently, there effectively cannot be an optimal manifestation of factual IPC, and it is impossible to expect that the IPE that the team members experienced during their training will significantly affect the quality of patient care in this setting.

What would a more precise causal model look like?

As we have seen, the notion of IPO in causal models of interprofessionality in the literature progressed from “IPO supportive” (Fig.  1 ) to “IPO possible but optional” (Fig.  2 ) to “IPO enabling, i.e. necessary” (Fig.  3 ). The key result of our study is a refinement missing from the existing causal model of IPE/IPO/IPC. It is the explicit statement that IPO is an equally necessary factor next to IPE in the causation of factual IPC. Only jointly are IPE and IPO sufficient to cause factual IPC of high quality. We deem this small modification crucial to reach the conceptual resolution required to fully understand the causes of factual IPC. The fully adjusted causal model is presented in Fig.  4 . In this “multi-stage multi-causality model of patient, healthcare provider, and system outcomes”, IPO is now unequivocally labeled as co-necessary for factual IPC alongside IPE-caused individual competencies.

Multi-stage multi-causality model of patient, healthcare provider, and system outcomes. Key ideas: IPO is an equally necessary co-factor in the causation of high-quality factual IPC, in addition to IPE. And the entire realm of interprofessional activities (red-outlined box), of which factual IPC is the final and active ingredient, is in turn only one of several causes leading to final outcomes of interest. Orange boxes: Domain of IPE, the domain of acquisition of competencies for IPC by an individual person through learning. Blue boxes: Domain of IPO, defined as the institutional domain of implementation, improvement, and maintenance of work processes of factual IPC and of IPC-supportive institutional conditions. Green box: Domain of factual IPC at a healthcare institution. Green-gray box, bottom row: Final outcomes of interest, i.e. patient care quality, job satisfaction of healthcare professionals, and cost effectiveness of patient care

Much more explicitly than previous ones, the multi-stage multi-causality model further shows that there are additional necessary causes for beneficial patient, healthcare provider, and system outcomes that lie entirely outside of the realm of IPC-related activities (i.e. outside of IPE/IPO/IPC). It is important to understand that not only factual IPC, but also the final patient, healthcare provider, and system outcomes have more than only one necessary cause, as reflected in the concept of “multi-causality on multiple stages”. This means that optimizing factual IPC is necessary but still not sufficient to optimize patient, healthcare provider, and system outcomes. Examples for necessary co-factors on the same level as factual IPC but from outside the realm of IPE/IPO/IPC are a) profession-specific (“uniprofessional”) competencies for aspects of a task that can only be accomplished by members of a specific healthcare profession ( task work vs. team work in [ 41 ]), b) details of health insurance policies, which can affect the cost effectiveness of patient care [ 46 ], salaries paid to health professionals by a healthcare institution, a factor which can influence job satisfaction [ 47 ], or good management decisions at an institution of patient care in general which comprise much more than just full support for factual IPC [ 46 ].

It should be noted that the co-causality in this conceptual framework is not compatible with the transitivity of the WHO model, where IPE ultimately leads to patient and healthcare provider outcomes via a predefined chain of “self-sustaining” secondary effects.

In sum, the adjusted causal model proposes that patient, healthcare provider, and system outcomes depend on multi-stage multi-causality. Stage 1: IPE + IPO = factual IPC: competencies for IPC in the workforce, the final result of interprofessional learning (IPE), plus creating and maintaining IPC work processes and supportive institutional conditions (IPO) together cause factual IPC. Stage 2: Factual IPC + non-interprofessional factors = patient, healthcare provider, and system outcomes: Factual IPC of high quality plus additional necessary but interprofessionality-independent factors together cause the final outcomes of interest.

The intention of our notion of “multi-stage multi-causality” is not to devalue the arrow-less “causal halos” of contextual factors in other models but rather to emphasize that even in “complex” systems (systems with multiple interacting elements) the actual sequence of causes and effects should be understood as precisely as possible for optimizing evaluations.

Brandt and colleagues, after reviewing the impact of IPE and IPC, note in their outlook on IPE, “given the complexity of the healthcare world, training learners in effective team work may not ultimately lead to improved health outcomes or reduce the cost of care” [ 9 ]. We don’t share this degree of pessimism; above we have shown that a monocausal, IPE-biased view on IPC simply might be insufficient for proper outcome evaluation of IPE and IPC. There is hope that by considering IPO, evaluations will become more conclusive. Wei and colleagues state in a systematic meta-review of systematic reviews about IPC, “Effective IPC is not linear; it does not occur naturally when people come together but takes a whole system’s efforts, including organizations, teams, and individuals” [ 30 ]. As we have explained, IPO has to be factored in as an additional necessary cause for IPC, and factors from outside the realm of IPE/IPO/IPC contribute to the “hard” outcomes of interest as well. We presented an adjusted causal model which explicitly acknowledges this multi-stage multi-causality of patient, healthcare provider, and system outcomes.

Can the proposed novel model help us better understand the challenges of IPE and IPC outcome evaluations?

We claim that the multi-stage multi-causality model exhibits strong explanatory power with regards to the difficulties of showing positive consequences of IPE and IPC in outcome evaluations in the past. To illustrate this, we must first describe the prominent role the modified Kirkpatrick classification of interprofessional outcomes [ 11 , 22 , 23 ] plays in outcome evaluations of IPE and IPC.

The modified Kirkpatrick classification (MKC)

MKC is regularly used to classify outcomes of IPE learning activities, curricula and programs [ 2 , 8 , 14 , 20 , 42 , 45 , 48 , 49 ]. It is a derivative of the original Kirkpatrick model for evaluating training results, named after its author, Donald L. Kirkpatrick, which distinguishes four categories of learning outcomes (Level 1: Reaction, Level 2: Learning, Level 3: Behavior, Level 4: Results) [ 50 , 51 ]. Expanding the original model, MKC assigns outcomes of IPE activities to six categories [ 11 ]:

Level 1: Reaction

Level 2a: Modification of perceptions & attitudes

Level 2b: Acquisition of knowledge & skills

Level 3: Behavioural change

Level 4a: Change in organisational practice (wider changes in the organization and delivery of care)

Level 4b: Benefits to patients/clients

In 2007, the authors of MKC claimed, “We have used these categories since 2000. They have proved useful and, contrary to our initial expectations, sufficient to encompass all outcomes in the hundreds of studies reviewed to date” [ 11 ]. This completeness has made MKC a useful tool for authors of review articles as it allows a retrospective classification of IPE outcomes not labeled in the original literature. As a result, MKC was quickly adopted by IPE evaluators around the world to describe the effectiveness of IPE interventions. As Thistlethwaite and colleagues put it in 2015, “This (…) model is now ubiquitous for health professional education evaluation” [ 42 ].

At first glance, the existence of such a clear and simple classification of IPE outcomes which not only covers all possible IPE outcomes but also is widely embraced in the literature, seems to be good news. What exactly is the problem then? Why did the introduction of MKC more than twenty years ago, plus the conceptual clarification provided by it, not resolve the difficulty in demonstrating IPE-caused patient, healthcare provider, and system outcomes (i.e. effects on MKC levels 4a and 4b)? In the following, we unfold a detailed answer to this question after application of the multi-stage multi-causality model.

To achieve progress, IPE and IPC outcome evaluations need to be complemented with process evaluations

MKC classifies outcomes but is agnostic about how these outcomes come into existence. For an evaluator using MKC, the effects of IPE-related interventions unfold inside a black box. The input into the black box is the intervention, the output constitutes 6 different classes of outcomes, i.e. the 6 levels of MKC described above. Naturally, such solely outcome-focused evaluations cannot explain functional interdependencies between the elements of the system. As we have seen, the benefits of IPE and IPC do not unfold as trivially as initially thought. Therefore, after two decades of (overall rather) inconclusive results of applying MKC to the outcomes of interprofessional interventions, the “why” should have moved to the center of the IPE evaluation efforts. This question is posed variously under well-known labels: Authors aware of said stagnancy either call for “formative evaluation” [ 52 ], “process evaluation” [ 14 ], or “realist evaluation” [ 42 ] in order to understand why interventions work as intended or not. In the following, we use the term “process evaluation” because we focus on understanding the underlying mechanisms.

Process evaluations require a causal model

Process evaluations require a causal model for the system under study to be able to select relevant indicators from a potentially much larger number of conceivable indicators. Appropriately selected indicators, which reflect the inner mechanisms of the system, then replace the black box, reveal bottlenecks, and allow explanations as to why interventions did or did not have the expected or intended outcomes. To explicitly demand the use of a causal model in an evaluation is a core principle, for example, of the “realistic evaluation” approach [ 53 ]. By directly criticizing the (original) Kirkpatrick model, Holton similarly suggests that a “researchable evaluation model” is needed which should “account for the effects of intervening variables that affect outcomes, and indicate causal relationships” [ 54 ]. Specifically for the domain of IPE and IPC, Reeves and colleagues [ 20 ] recommend “the use of models which adopt a comprehensive approach to evaluation” and the IOM authors conclude, “Having a comprehensive conceptual model provides a taxonomy and framework for discussion of the evidence linking IPE with learning, health, and system outcomes. Without such a model, evaluating the impact of IPE on the health of patients and populations and on health system structure and function is difficult and perhaps impossible [emphasis added]” [ 8 ].

MKC is not a causal model

Aliger and Yanak note that when Donald Kirkpatrick first proposed his model, he did not assert that each level is caused by the previous level [ 55 ]. Similarly, the developers of MKC acknowledge that “Kirkpatrick did not see outcomes in these four areas as hierarchical.” Rather, most likely in an attempt to avoid indicating causality in MKC themselves, they talk about “categories” not “levels” throughout the majority of their abovementioned paper [ 11 ]. They even knew from the outset that besides IPE the domain which we now call IPO influences outcomes on MKC levels 4a and 4b (but did not include IPO in MKC): “(…) impact of one professional’s changes in behavior depend[s] on [a] number of organisational constraints such as individual’s freedom of action (…) and support for innovation within the organisation” [ 13 ]. This means that by design neither the original Kirkpatrick model nor MKC are intended to be or to include causal models. MKC simply doesn’t ask at all whether additional causes besides an IPE intervention might be required for creating the outcomes it classifies, especially those of levels 3, 4a and 4b. In case such additional causes exist, MKC neither detects nor reflects them. Yardley and Dornan conclude that Kirkpatrick’s levels “are unsuitable for (…) education interventions (…) in which process evaluation is as important as (perhaps even more important than) outcome evaluation” [ 14 ].

Nevertheless, MKC continues to be misunderstood as implying a causal model

The numbered levels in the original Kirkpatrick model have drawn criticism for implying causality [ 14 , 54 , 55 ]. Originally, Kirkpatrick had used the term “steps” not “levels” [ 15 , 42 , 55 ] whereas all current versions of the Kirkpatrick model, including MKC, now use the term “levels”. Bates [ 52 ] cites evidence that Kirkpatrick himself, in his later publications, started to imply causal relationships between the levels of his model. Bates bluntly declares: “Kirkpatrick’s model assumes that the levels of criteria represent a causal chain such that positive reactions lead to greater learning, which produces greater transfer and subsequently more positive organizational results” [ 52 ]. Alliger and Janak [ 55 ] provide other examples from the secondary literature which explicitly assume direct causal links between the levels and continue to show that this assumption is highly problematic. Most strikingly, the current (2023) version of the Kirkpatrick model [ 51 ], created by Donald Kirkpatrick’s successors, explicitly contains a causal model which uses the exact same causal logic Alliger and Janak had proposed as underlying it almost 3 decades earlier [ 55 ].

As a derivative of the Kirkpatrick model, MKC has inherited just that unfortunate property of implying causality between levels. While starting their above-mentioned publication with the carefully chosen term “categories”, the authors of MKC, in the same publication, later fall back on using “levels” [ 11 ]. In earlier publications, they even had explicitly assigned explanatory causal power to MKC: “Level 4b: Benefits to patients/clients. This final level covers any improvements in the health and well being of patients/clients as a direct result [emphasis added] of an education programme” [ 22 ]. Taken together, the authors of MKC themselves, while acknowledging that the original Kirkpatrick model didn’t imply a causal hierarchy, at times contradictorily fuel the notion that MKC provides a viable causal model for the mechanisms of IPE and IPC. As Roland observes, it became common in the literature in general to see the levels of MKC as building on each other, implying a linear causal chain from interprofessional learning to collaborative behavior to patient outcomes [ 15 ].

Why has the wrong attribution of being a causal model to MKC remained stable for so long?

Why has this misunderstanding of MKC as a causal model not drawn more criticism and why has it been so stable? We speculate that a formal parallelism between the transitive relations in the WHO causal model (Fig.  1 ) and the numbered levels of MKC, if wrongly understood as a linear chain of subsequent causes and effects, strengthens the erroneous attribution of a causal model to MKC (Fig.  5 ). Our reasoning: The continued use of the mono-causal WHO model, as opposed to switching to a model incorporating multiple causes for patient, healthcare provider, and system outcomes, stabilizes the misunderstanding of the monothematic (IPE-constricted) MKC as a causal model. (In defense of this mistake, one could say, if the transitivity assumption associated with the WHO causal model was true, i.e. if the causal chain actually was mono-linear, then MKC would be a valid causal model because intermediate outcomes would be the sole causes of subsequent outcomes, covering the entire, linear chain of causes. As a result, there would be no difference between outcome evaluation and process evaluation, and MKC would be an appropriate tool for process evaluations.) Conversely, we suspect that the wrong but established use of MKC as a conceptual framework in IPE and IPC outcome evaluations stabilizes the continued use of the mono-causal linear WHO model, reinforcing the wrong impression that IPE is the only cause of interprofessional outcomes. The “transitivity” of the WHO model strongly resonates with the observation that the (original) Kirkpatrick model implies the assumption that “all correlations among levels are positive” [ 55 ]. If the most upstream event (an IPE activity) is positively correlated with the most downstream elements (patient, healthcare provider, and system outcomes) anyway, why should one bother evaluating intermediate steps? The same fallacy holds true for MKC. When its authors state that “Level 4b (…) covers any improvements in the health and well being of patients/clients as a direct result of an education programme” [ 22 ], they not only assign causal explanatory power to MKC, but also neglect the “multi-causality on multiple stages” of outcomes. They assume the same causal transitivity for MKC as is present in the WHO model and thereby expect an “automatic” tertiary effect from an IPE intervention on patient outcomes without considering at all whether the quality of factual IPC – as a necessary intermediate link in the causal chain – has changed due to the intervention or not.

“Unhealthful alliance” between the WHO causal model and MKC. MKC as an outcome classification does not contain a causal model, but uses the term “level” and has numbers attached to each, suggesting causal hierarchy nonetheless. The “levels” of MKC resonate with the causal chain of the WHO model. We speculate that this formal similarity stabilizes the false assignment of a causal structure to MKC (red arrows in the lower row) and, at the same time, as MKC is widely used, perpetuates the use of the WHO model

If misused as a causal model, MKC does not function and can hinder progress in IPE and IPC evaluations

So far we have established that a) Pure outcome evaluations do not answer the question why it is so hard to detect patient, healthcare provider, and system outcomes of IPE and IPC interventions; b) Process evaluations are required to address this “why” question and to achieve progress in IPE and IPC evaluations; c) A theoretical causal model is required for such process evaluations; d) MKC is not such a causal model; e) Nevertheless, MKC falsely keeps being used as such a causal model; and f) The misuse of MKC has remained rather stable, possibly due to a formal parallelism between the WHO causal model and MKC.

The multi-staged multi-causality model of patient, healthcare provider, and system outcomes now makes it clear why evaluations which implicitly or explicitly treat MKC as a causal model are bound to fail in their process evaluation part: MKC, when used as a causal model, is crucially incomplete: In terms of the causes of factual IPC (cf. Figure  4 , orange and blue boxes), MKC sees IPE but is blind to IPO; and in terms of the direct causes of patient, healthcare provider, and system outcomes (cf. Figure  4 , green and grey boxes), MKC sees factual IPC but is blind to the complementary non-interprofessional causes because none of its levels covers them. MKC is a classification limited to detecting outcomes of IPE, and neither IPO nor non-interprofessional factors are such outcomes. When speaking about the original model (but with his statement being transferable to MKC), Bates notes that “Kirkpatrick’s model implicitly assumes that examination of (…) [contextual] factors is not essential for effective evaluation” [ 52 ]. Citing Goldstein and Ford [ 56 ], he continues, “when measurement is restricted to (…) the four (…) levels no formative data about why training was or was not effective is generated” [ 52 ]. Specifically targeting the MKC version, Thistlethwaite and colleagues imply that MKC lacks IPO: “When thinking of applying of Kirkpatrick’s framework to IPE, we must remember the importance of the clinical environment (…) and consider how conducive it is to, and facilitative of, any potential change in behaviour arising from interprofessional learning activities” [ 42 ].

Bordage calls conceptual frameworks “lenses” through which scientists see the subjects of their studies [ 57 ]. Following this metaphor, we conclude that the resolution of the “conceptual lens” of MKC, if misused as a causal model, is too low for process evaluations. In our perspective, this, in turn, is the most likely reason why outcome evaluations of the past have failed to reliably demonstrate terminal benefits of IPE and IPC.

It is important to note that MKC by design solely, agnostically and successfully measures outcomes of interprofessional education in different dimensions. Therefore, its failure to detect bottlenecks in IPE and IPC is not its own fault, but the fault of evaluators who continue to use it as a causal model while failing to acknowledge the multi-staged multi-causality of patient, healthcare provider, and system outcomes.

We next take a closer look at how exactly MKC fails. In the mono-linear, low-resolution view of MKC, if a study that evaluates the effects of an intervention fails to detect final outcomes, the only logical possible conclusion is to question the effectiveness of previous levels. If there are changes in interprofessional behavior (level 3) but there is no benefit to patients (level 4b), the conclusion is that changes in interprofessional behavior are not beneficial to patients; if there are interprofessional competencies acquired by learners (level 2) but no subsequent change in interprofessional behavior (level 3), then interprofessional competencies do not translate into behavior. Using MKC as the conceptual lens, the logical answer to “why” is that “the training program was not designed in ways that fostered effective transfer or (…) other input factors blocked skill application” [ 52 ], and a straightforward overall conclusion with regards to the knowledge gap about the benefits of IPE and IPC would be that IPE is not very effective in terms of patient, healthcare provider, and system outcomes. While this disappointing result has actually been considered as a possibility [ 6 , 9 , 10 ], more often alternative explanations are sought in an attempt to rescue IPE efforts and to avoid the conclusion that IPE is ineffective while sticking with MKC as the causal model.

One of these “escape routes” is to claim that it is methodologically too difficult to measure outcomes on MKC levels 3, 4a and 4b by using different variants of a temporal argument. Paraphrasing Belfield et al. [ 58 ], Roland [ 15 ] states that “patient outcomes may only become apparent over a protracted period of time due to the time needed for the learner to acquire and implement new skills [emphasis added by us, also in the following quotations]” whereas Hammick and colleagues state, “It is unsurprising that all but one of the studies (…) evaluated IPE for undergraduate students. The time gap between their interprofessional learning and qualification clearly presents a challenges [sic] associated with evaluating levels 3, 4a and 4b outcomes” [ 11 ]. Yardley and Dornan add, “early workplace experience (…) might take months or even years to have any demonstrable effect on learners, let alone patients” [ 14 ]. The IOM comments that “Efforts to generate this evidence are further hindered by the relatively long lag time between education interventions and patient, population, and system outcomes” [ 8 ] while Reeves and colleagues note that “ the time gap between undergraduates receiving their IPE and them qualifying as practitioners presents challenges with reporting outcomes at Levels 3, 4a, and 4b” [ 2 ]. The core argument here is always that undergraduate IPE happens in educational institutions whereas IPC happens at the workplace at healthcare institutions much later . By this logic, the causal chain assumed by MKC might be fully intact but the time lag between an IPE intervention and effects on levels 3, 4a and 4b constitutes an insurmountable methodological difficulty and renders comprehensive evaluations of IPE outcomes impossible.

Another “escape route” is to invoke “complexity” of IPE as the reason why its final outcomes are hard to detect. Thistlethwaite and colleagues [ 42 ] agree with Yardley and Dornan [ 14 ] that the MKC is not suited to evaluate “the complexity of health profession education and practice.” The authors from the IOM state that “The lack of a well-defined relationship between IPE and patient and population health and health care delivery system outcomes is due in part to the complexity of the learning and practice environments” [ 8 ]. The term “complexity” usually refers to systems which are cognitively difficult to understand because they have many elements or because science has not figured out yet how to model their interactions [ 59 ]. In our opinion, the term “complexity” in the context of IPE is ill-defined and a placeholder for saying that the set of causes of patient, healthcare provider, and system outcomes is not being understood well and that a more precise causal model is required to figure out what is going on.

Compare and contrast: “multi-stage multi-causality” as causal model

If we use “multi-stage multi-causality” as the conceptual lens instead of MKC we increase the available resolution and can see more elements of the system. If evaluations fail to show beneficial outcomes of IPE or IPC, we now can do much better asking the right sub-questions to find an answer to “why”. Viewed through the high-resolution lens of the multi-stage multi-causality model, the list of possible failure points on this trajectory significantly expands. The resulting high-resolution picture provides an exquisite set of novel testable hypotheses (Table  1 ). Collecting data on different levels, including the level of factual IPC, should enable decisions as to which of these scenarios were attributable to an IPE intervention having no multi-level effect.

Taken together, we argue that the answers to “why” allowed by the low resolution lens of MKC when misused as a causal model might sometimes be wrong and should be replaced with more detailed explanations.

It is premature to conclude that IPE has no effects on patient, healthcare provider, and system outcomes unless the presence or absence of all co-causes has been considered.

The deeper cause of the temporal argument might be to mistakenly use MKC as a causal model because the use of MKC masks any problems with IPO or other co-causes. Given the higher resolution of the multi-stage multi-causality model, it is now possible to conceptually distinguish between the known challenge arising from the passage of time (creating various confounders) and the case in which a lack of IPO blocks the effects of IPE. It should be possible, in principle, to assess at any later point in time, for example by means of a survey, how much and which types of IPE members of an interprofessional team had experienced earlier in their career and how much they remember; or even to assess their current competencies for IPC in a practical exam. Such measurements might reveal that individual competencies for IPC are present, no matter how much time has passed since their acquisition, and that IPO is the actual bottleneck.

Likewise, alleged methodological perplexity due to IPE “complexity” is de-emphasized if we swap the low-resolution lens of MKC for the high-resolution lens of the multi-staged multi-causality model. The high-resolution picture (Fig.  4 ; Table  1 ) replaces the fuzzy placeholder of “complexity” by adding missing elements of the system to the model.

In sum we have demonstrated that when MKC is misused as a causal model it neglects co-causing factors with essential influence on IPE outcomes, is therefore an insufficient tool to detect bottlenecks, and edges out any better-suited, viable causal model. This miscast hampers meaningful process evaluations, the subsequent improvement of indicators and interventions, and thereby ultimately the progress in proving beneficial patient, healthcare provider, and system outcomes of IPE and IPC.

Limitations

One limitation of our theoretical critical discussion is that we did not illuminate how hard it is to quantify patient, healthcare provider, and system outcomes from a methodological point of view (e.g. document-based patient data analysis). Neither did we address the extent to which this limits the meaningfulness of IPE/IPC outcome evaluations. However, we claim that the conceptual weakness of missing co-causalities is the deeper root of the evaluation problem, not particular methods, and that methodological issues are solvable as soon as relevant co-causalities are appropriately considered.

Another limitation is that a model is always a simplification. For example, the multi-stage multi-causality model does not include personality traits of team members, intra-personal abilities like self-regulation, or the harmony of personality types within a team, which also play a role in factual IPC. These traits would be difficult to incorporate into the model and gathering such information for evaluations might even be unethical. Similarly, the model does not reflect the influence which the behavior and health literacy of patients (and their families, caregivers, and communities) might have on factual IPC.

A third limitation is that we did not discuss a particular setting in which the use of MKC as mono-linear causal model could work, namely, if IPE champions themselves become IPO managers and subsequently establish factual IPC in their institutions through an appropriate combination of IPE and IPO. In this scenario, the roles of health professionals (as carriers of IPE-induced competence for factual IPC) and managers (as IPO decision makers) overlap – obviously potentially optimal to foster factual IPC. In a certain sense, in this particular case, IPE would lead to IPO and to factual IPC with the potential of “transitively” improving patient, healthcare provider, and system outcomes. However, as we believe that there is no fixed relationship between undergoing IPE and becoming a healthcare manager, we did not pursue this line of argument further, regarding it as an exception.

Conclusions

In our critical discussion we have analyzed previous models of causes and effects in IPC based on the existing literature, proposed a novel “multi-stage multi-causality” model, and demonstrated its explanatory power by establishing that MKC is not suited to foster progress in proving or disproving beneficial final outcomes of IPE and IPC. We conclude with 6 practical, applicable recommendations for future IPE, IPO, and IPC outcome evaluations.

Recommendation 1: stop (mis-)using MKC as a causal model

We have pointed out that the continued use of MKC as causal model seems to severely inhibit the scientific exploration of the co-necessity of IPO and non-interprofessional factors and therefore delays answering the important question whether IPE and IPC actually improve patient, healthcare provider, and system outcomes. As early as 1989, the use of the original Kirkpatrick model as a causal model was questioned [ 55 ]. In 2004, Bates took the position that the continued use of this model is unethical if beneficial results are missed by evaluations due to the narrow focus on outcomes [ 52 ]. Today, we conclude that using MKC as a causal model in IPE, IPO or IPC outcome evaluations should be discontinued.

Recommendation 2: state the causal model under which evaluations of IPE/IPO/IPC operate

Evaluators should make an explicit statement about the causal model under which they design interventions and interpret results, including their additional assumptions about the chain of causes and effects. Knowledge of these assumptions allows the reader to detect inconsistencies – an important element for causal clarification – and should prevent the field of IPE, IPO, and IPC outcome evaluations from getting mired down for even more decades.

Recommendation 3: always include some process evaluation

Even if the primary goal of a study is summative outcome evaluation, evaluators should always include some process evaluation to test the causal model they assume and under which they designed their evaluation, and do so at least until the topic of causality in IPE, IPO, and IPC is fully settled. For example, if an IPE intervention aims at improving factual IPC, evaluators who assume multi-causality would co-evaluate IPO to make sure that IPO is no bottleneck in the evaluated setting.

Recommendation 4: strive for specificity in IPE, IPO, or IPC interventions

If the only goal of an intervention is to improve a certain outcome metric like patient safety, one might initiate a broad, non-specific intervention using best-practice guidelines and all available resources. However, if a goal of the intervention is also to show the existence of specific benefits of IPE, IPO, or IPC in a scientific way, then the multi-causality of outcomes must be taken into account. Intervention designs that change both, interprofessional and non-interprofessional causes of outcomes, must be avoided. For example, if uniprofessional training (a cause outside the domain of IPE/IPO/IPC) is also part of an intervention (e.g. the re-design of the entire workflow in an emergency department in order to enhance patient safety), then this mix of causes obscures the contribution of IPE, IPO, or IPC to the desired effect. Reeves and colleagues euphemistically and aptly call measuring the particular influence of IPE on patient outcomes in such multifaceted interventions a “challenge” [ 10 ]. This example shows why theoretical clarity about the causal model is required to effectively evaluate beneficial outcomes of IPE, IPO, or IPC. Respecting the multi-stage multi-causality of patient, healthcare provider, and system outcomes means designing interventions that improve interprofessional elements only, or, if other components inevitably change as well, to control for those components through comprehensive measurements and/or by adding qualitative methods that allow final outcomes to be causally attributed to IPE, IPO, or IPC.

Recommendation 5: always quantify factual IPC

Recommendations 5 and 6 are our most important recommendations. It is self-explanatory that without the emergence of factual IPC there cannot be any final, globally desirable outcomes of upstream IPE or IPO activities; not until IPE or IPO activities improve factual IPC, does the attempt to evaluate their effects on patient, healthcare provider, and system outcomes start to make any sense. Further, if a positive correlation exists between the quality of factual IPC and patient, healthcare provider, and system outcomes, then correlating factual IPC with final outcomes is the most conclusive way to show it. While the notion that factual IPC is the minimum necessary condition for final outcomes of interprofessional efforts is not new [ 8 , 19 ], the realization that the attached transitivity assumption (that IPE automatically creates the necessary IPC) is wrong, certainly is. As shown above, dismissing transitivity is a cogent consequence of embracing the multi-stage multi-causality of final outcomes. In future evaluations, the quantification of IPE therefore should no longer serve as a surrogate for the quantification of factual IPC. Rather, factual IPC, as an intermediate necessary step towards final outcomes and their most direct cause within the realm of IPE/IPO/IPC, always needs to be evaluated on its own. The same holds true for future evaluations of IPO. IPO interventions do not automatically lead to factual IPC, but first must be shown to improve factual IPC before they can be expected to cause any changes in patient, healthcare provider, and system outcomes. Taken together, a comprehensive measurement of the quality of factual IPC needs to be the centerpiece of any meaningful evaluation of final outcomes achieved by IPE interventions, IPO interventions, combined IPE + IPO interventions, or of factual IPC itself.

From the large number of dimensions of factual IPC (see “Methods”) arises the necessity to evaluate it in detail. Such completeness in the evaluation of factual IPC is important for several reasons:

Obtaining a meaningful sum score: Evaluating factual IPC in a given setting against a hypothetical optimum requires integration of all of its subdimensions into one sum score.

Not missing correlations: If an IPC score does not cover all dimensions of factual IPC, correlations between factual IPC and its effects (or causes) might be missed, even if these relationships truly exist. Example: An evaluation which only includes the dimensions of “mutual respect” and “conflict management” might miss an actually existing correlation between factual IPC and cost effectiveness, mainly driven, say by the dimension of “shared creation of the treatment plan and coordination of its execution”. The result of this evaluation could cast substantial doubt on the existence of positive effects of factual IPC despite them actually being there. Similarly, only a complete set of IPC indicators is suited to reveal potentially diverging effects of different subdimensions of factual IPC on different final outcomes. For example, optimal interprofessional team behavior that maximizes patient safety, might, at the same time, turn out to be less cost effective than multiprofessional team behavior that compromises on patient safety.

Optimizing process evaluation: A complete IPC coverage further provides valuable information for process evaluations aimed at identifying weaknesses in factual IPC. Significant correlations between outcomes and specific subdimensions of IPC can suggest causal relationships and uncover crucial components for successful IPC in a given setting. Focusing on strengthening these subdimensions could help optimize patient, healthcare provider, and system outcomes.

Enabling setting independence and comparisons: Factual IPC is setting-specific [ 11 , 19 , 35 , 60 , 61 ], i.e. the needs of patients for specific medical services differ across different contexts of patient care (e.g. emergency care; acute care; rehabilitation; chronic care; multimorbid patients; palliative care). As a consequence, different subdimensions of factual IPC contribute to the outcomes of interest to a variable degree depending on the specific healthcare setting. Even within a specific setting, requirements and behaviors necessary for effective IPC can vary due to the specifics of the case, e.g. the particular rareness or severity of the patient’s condition. Assumptions made prior to an evaluation about which subdimensions of factual IPC are most important in a specific setting therefore should not preclude the exploratory evaluation of the other subdimensions. If an evaluation grid misses IPC subdimensions, it may work well in one setting but fail in others. Hence, the completeness of indicators for factual IPC in an evaluation instrument creates setting independence, eliminates the burden of adjusting the included IPC subdimensions every time a new healthcare setting is evaluated, and allows unchanged evaluation instruments to be re-used in subsequent studies (called for by e.g. [ 16 ]) as well as multi-center studies (called for by e.g. [ 2 ]). A starting point for the operationalization of factual IPC including all of its subdimensions is provided in our definition of factual IPC (see “Methods”; a validated evaluation toolbox based on this operationalization will be published elsewhere; a published tool which also covers all subdomains of factual IPC, with a focus on adaptive leadership, is the AITCS [ 39 ]).

Recommendation 6: use a step-by-step approach for proving benefits of IPE and IPO

The multi-stage multi-causality of patient, healthcare provider, and system outcomes naturally implies that the process of proving that IPE or IPO benefits final outcomes could be broken down into discrete steps. The key idea is to evaluate the impact of interprofessional activities on each of the subsequent levels in the causal chain while controlling for non-interprofessional factors. Showing the effects of IPE on IPC competencies, the effects of IPC competencies on factual IPC, and the effects of factual IPC on patient, healthcare provider, and system outcomes then becomes three different research agendas that can be processed independently. If it can be shown in the first of these research agendas that IPE leads to learning (by controlling for non-interprofessional learning-related factors), and in the second, independent research agenda, that learning leads to improved factual IPC (controlling for IPO), and in the third research agenda that factual IPC leads to desired final outcomes (controlling for co-conditions for final outcomes like uniprofessional competencies), then the benefit of IPE on patient, healthcare provider, and system outcomes is ultimately proved. If this approach fails, then at least it will be exactly revealed where the chain of effects breaks down. The same holds true for IPO: Show that IPO interventions lead to work processes and/or favorable institutional conditions which support factual IPC, separately show that these work processes and conditions lead to improved factual IPC (if co-conditions for factual IPC like IPE are present), and show that better factual IPC leads to an improvement of final outcomes; then the positive impact of IPO is verified.

By covering the entire process, this “step-by-step” approach could build a compelling case for how interprofessional interventions lead to desired final outcomes. It further could markedly simplify the agenda of interprofessional research because it takes the burden of showing the effect of one particular IPE or IPO intervention on one particular final outcome off the shoulders of evaluators. After breaking down the evaluation task into separate steps that prove the impact from link to link, researchers are free to work on one step at a time only.

The presented critical discussion advances the theoretical foundations of evaluations in the field of IPE, IPO and IPC. To improve patient-centered care by means of IPC, one needs to think bigger than just training of healthcare professionals in the competencies and mindsets required for effective IPC; work processes also have to be established and optimized in a setting-dependent manner to allow for factual IPC to happen. Besides IPC, factors like discipline-specific knowledge of health professionals or administrative aspects of patient management have to be optimized, too, to achieve optimal patient, healthcare provider, and system outcomes.

By sharing the multi-stage multi-causality model and its pertinent theoretical clarification we hope to contribute to a deeper understanding of causes and effects in interprofessional collaboration, to answer the repeated call in the research community for improved theory in this field, to explain difficulties faced by past evaluations, and to provide helpful guidance for future research studies. Our key recommendations for future evaluations of interprofessional outcomes are to focus on a comprehensive evaluation of factual IPC as the most fundamental metric and to deploy a step-by-step research agenda with the overarching goal of proving beneficial patient, healthcare provider, and system outcomes related to IPE, IPO, and IPC. With these contributions, we hope to help healthcare institutions improve their evaluations of IPE, IPO, and IPC, ultimately benefiting health, healthcare provider, and system outcomes.

Availability of data and materials

No datasets were generated or analysed during the current study.

Abbreviations

• Interprofessional collaboration
• Interprofessional education
• Interprofessional organization
• Modified Kirkpatrick classification

World Health Organization

Körner M, Bütof S, Müller C, Zimmermann L, Becker S, Bengel J. Interprofessional teamwork and team interventions in chronic care: A systematic review. J Interprof Care. 2016;30(1):15–28.

Article   Google Scholar  

Reeves S, Fletcher S, Barr H, Birch I, Boet S, Davies N, et al. A BEME systematic review of the effects of interprofessional education: BEME Guide No. 39. Med Teach. 2016;38(7):656–68.

Reeves S, Pelone F, Harrison R, Goldman J, Zwarenstein M. Interprofessional collaboration to improve professional practice and healthcare outcomes. Cochrane Database Syst Rev. 2017. https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD000072.pub3/full . Accessed 23 Feb 2024.

Sibbald B, Bojke C, Gravelle H. National survey of job satisfaction and retirement intentions among general practitioners in England. BMJ. 2003;326(7379):22.

Cowin LS, Johnson M, Craven RG, Marsh HW. Causal modeling of self-concept, job satisfaction, and retention of nurses. Int J Nurs Stud. 2008;45(10):1449–59.

Paradis E, Whitehead CR. Beyond the lamppost: a proposal for a fourth wave of education for collaboration. Acad Med. 2018;93(10):1457.

Holly C, Salmond S, Saimbert M. Comprehensive Systematic Review for Advanced Practice Nursing. 2nd ed. New York: Springer Publishing Company; 2016.

Google Scholar  

IOM (Institute of Medicine). Measuring the impact of interprofessional education on collaborative practice and patient outcomes. Washington, DC: The National Academies Press; 2015.

Brandt B, Lutfiyya MN, King JA, Chioreso C. A scoping review of interprofessional collaborative practice and education using the lens of the Triple Aim. J Interprof Care. 2014;28(5):393–9.

Reeves S, Perrier L, Goldman J, Freeth D, Zwarenstein M. Interprofessional education: effects on professional practice and healthcare outcomes (Review) (Update). Cochrane Database Syst Rev. 2013. https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD002213.pub3/full . Accessed 23 Feb 2024.

Hammick M, Freeth D, Koppel I, Reeves S, Barr H. A best evidence systematic review of interprofessional education: BEME Guide no. 9. Med teach. 2007;29(8):735–51.

Zwarenstein M, Reeves S, Perrier L. Effectiveness of pre-licensure interprofessional education and post-licensure collaborative interventions. J Interprof Care. 2005;19(Suppl 1):148–65.

Barr H, Hammick M, Koppel I, Reeves S. Evaluating interprofessional education: two systematic reviews for health and social care. Br Edu Res J. 1999;25(4):533–44.

Yardley S, Dornan T. Kirkpatrick’s levels and education ‘evidence’. Med Educ. 2012;46(1):97–106.

Roland D. Proposal of a linear rather than hierarchical evaluation of educational initiatives: the 7Is framework. J Educ Eval Health Profess. 2015;12:35.

Thannhauser J, Russell-Mayhew S, Scott C. Measures of interprofessional education and collaboration. J Interprof Care. 2010;24(4):336–49.

Reeves S, Goldman J, Gilbert J, Tepper J, Silver I, Suter E, et al. A scoping review to improve conceptual clarity of interprofessional interventions. J Interprof Care. 2011;25(3):167–74.

Suter E, Goldman J, Martimianakis T, Chatalalsingh C, DeMatteo DJ, Reeves S. The use of systems and organizational theories in the interprofessional field: Findings from a scoping review. J Interprof Care. 2013;27(1):57–64.

Havyer RD, Wingo MT, Comfere NI, Nelson DR, Halvorsen AJ, McDonald FS, et al. Teamwork assessment in internal medicine: a systematic review of validity evidence and outcomes. J Gen Intern Med. 2014;29(6):894–910.

Reeves S, Boet S, Zierler B, Kitto S. Interprofessional education and practice guide No. 3: Evaluating interprofessional education. J Interprofess Care. 2015;29(4):305–12.

McNaughton SM, Flood B, Morgan CJ, Saravanakumar P. Existing models of interprofessional collaborative practice in primary healthcare: a scoping review. J Interprof Care. 2021;35(6):940–52.

Barr H, Freeth D, Hammick M, Koppel I, Reeves S. Evaluations of Interprofessional Education: A United Kingdom Review for Health and Social Care. Centre for the Advancement of Interprofessional Education and The British Educational Research Association. 2000. https://www.caipe.org/resources/publications/barr-h-freethd-hammick-m-koppel-i-reeves-s-2000-evaluations-of-interprofessional-education . Accessed 23 Feb 2024.

Barr H, Koppel I, Reeves S, Hammick M, Freeth D. Effective Interprofessional Education: Argument, assumption, and evidence. Wiley-Blackwell; 2005.

Baethge C, Goldbeck-Wood S, Mertens S. SANRA—a scale for the quality assessment of narrative review articles. Research integrity and peer review. 2019;4(1):1–7.

CAIPE (Centre for the Advancement of Interprofessional Education). About CAIPE, s. v. “Defining Interprofessional Education”. https://www.caipe.org/about . Accessed 23 Feb 2024.

D’amour D, Oandasan I. Interprofessionality as the field of interprofessional practice and interprofessional education: An emerging concept. J Interprof Care. 2005;19(Suppl 1):8–20.

Körner M, Wirtz MA. Development and psychometric properties of a scale for measuring internal participation from a patient and health care professional perspective. BMC Health Serv Res. 2013;13(1):374.

Körner M, Wirtz MA, Bengel J, Göritz AS. Relationship of organizational culture, teamwork and job satisfaction in interprofessional teams. BMC Health Serv Res. 2015;15(1):243.

World Health Organization. Framework for Action on Interprofessional Education & Collaborative Practice. 2010. https://www.who.int/publications/i/item/framework-for-action-on-interprofessional-education-collaborative-practice . Accessed 23 Feb 2024.

Wei H, Horns P, Sears SF, Huang K, Smith CM, Wei TL. A systematic meta-review of systematic reviews about interprofessional collaboration: facilitators, barriers, and outcomes. J Interprof Care. 2022;36(5):735–49.

Morey JC, Simon R, Jay GD, Wears RL, Salisbury M, Dukes KA, et al. Error reduction and performance improvement in the emergency department through formal teamwork training: evaluation results of the MedTeams project. Health Serv Res. 2002;37(6):1553–81.

D’Amour D, Ferrada-Videla M, San Martin Rodriguez L, Beaulieu M-D. The conceptual basis for interprofessional collaboration: core concepts and theoretical frameworks. J interprofess care. 2005;19(1):116–31.

San Martín-Rodríguez L, Beaulieu M-D, D’Amour D, Ferrada-Videla M. The determinants of successful collaboration: a review of theoretical and empirical studies. J Interprof Care. 2005;19(Suppl 1):132–47.

Guise J-M, Deering SH, Kanki BG, Osterweil P, Li H, Mori M, et al. Validation of a tool to measure and promote clinical teamwork. Simulation in Healthcare. 2008;3(4):217–23.

Orchard C, Bainbridge L, Bassendowski S.. A national interprofessional competency framework. Vancouver: Canadian Interprofessional Health Collaborative; University of British Columbia; 2010; Available online: http://ipcontherun.ca/wp-content/uploads/2014/06/National-Framework.pdf . Accessed 29 May 2024.

Oishi A, Murtagh FE. The challenges of uncertainty and interprofessional collaboration in palliative care for non-cancer patients in the community: a systematic review of views from patients, carers and health-care professionals. Palliat Med. 2014;28(9):1081–98.

Valentine MA, Nembhard IM, Edmondson AC. Measuring teamwork in health care settings: a review of survey instruments. Med Care. 2015;53(4):e16–30.

Lie DA, Richter-Lagha R, Forest CP, Walsh A, Lohenry K. When less is more: validating a brief scale to rate interprofessional team competencies. Med Educ Online. 2017;22(1):1314751.

Orchard C, Pederson LL, Read E, Mahler C, Laschinger H. Assessment of interprofessional team collaboration scale (AITCS): further testing and instrument revision. J Contin Educ Heal Prof. 2018;38(1):11–8.

Begun JW, White KR, Mosser G. Interprofessional care teams: the role of the healthcare administrator. J Interprof Care. 2011;25(2):119–23.

Weaver SJ, Salas E, King HB. Twelve best practices for team training evaluation in health care. The Joint Commission Journal on Quality and Patient Safety. 2011;37(8):341–9.

Thistlethwaite J, Kumar K, Moran M, Saunders R, Carr S. An exploratory review of pre-qualification interprofessional education evaluations. J Interprof Care. 2015;29(4):292–7.

Gilbert JH, Yan J, Hoffman SJ. A WHO report: framework for action on interprofessional education and collaborative practice. J Allied Health. 2010;39(3):196–7.

Taylor & Francis Online. http://www.tandfonline.com (2024). Accessed 23 Feb 2024.

Sockalingam S, Tan A, Hawa R, Pollex H, Abbey S, Hodges BD. Interprofessional education for delirium care: a systematic review. J Interprof Care. 2014;28(4):345–51.

Folland S, Goodman AC, Stano M. The Economics of Health and Health Care. 7th ed. New York, NY: Routledge; 2016.

Book   Google Scholar  

Hayes B, Bonner A, Pryor J. Factors contributing to nurse job satisfaction in the acute hospital setting: a review of recent literature. J Nurs Manag. 2010;18(7):804–14.

Curran V, Reid A, Reis P, Doucet S, Price S, Alcock L, et al. The use of information and communications technologies in the delivery of interprofessional education: A review of evaluation outcome levels. J Interprof Care. 2015;29(6):541–50.

Danielson J, Willgerodt M. Building a theoretically grounded curricular framework for successful interprofessional education. A J Pharmaceut Educ. 2018;82(10):1133–9.

Kirkpatrick D, Kirkpatrick J. Evaluating Training Programs: The Four Levels. 3rd ed. San Francisco, CA: Berrett-Koehler Publishers; 2006.

Kirkpatrick J, Kirkpatrick W. An Introduction to The New World Kirkpatrick Model. Kirkpatrick Partners. 2021. http://www.kirkpatrickpartners.com/wp-content/uploads/2021/11/Introduction-to-the-Kirkpatrick-New-World-Model.pdf . Accessed 30 Nov 2023.

Bates R. A critical analysis of evaluation practice: the Kirkpatrick model and the principle of beneficence. Eval Program Plann. 2004;27(3):341–7.

Pawson R, Tilley N. Realistic evaluation. 1st ed. London: Sage Publications Ltd; 1997.

Holton EF III. The flawed four-level evaluation model. Hum Resour Dev Q. 1996;7(1):5–21.

Alliger GM, Janak EA. Kirkpatrick’s levels of training criteria: Thirty years later. Pers Psychol. 1989;42(2):331–42.

Goldstein IL, Ford JK. Training in organisations: Needs assessment, development, and evaluation. 4th ed. Belmont, CA: Wadsworth; 2002.

Bordage G. Conceptual frameworks...: What lenses can they provide to medical education? Investigación en educación médica. 2012;1(4):167–9.

Belfield C, Thomas H, Bullock A, Eynon R, Wall D. Measuring effectiveness for best evidence medical education: a discussion. Med Teach. 2001;23(2):164–70.

Johnson N. Simply complexity: A clear guide to complexity theory. London: Oneworld Publications; 2009.

Retchin SM. A conceptual framework for interprofessional and co-managed care. Acad Med. 2008;83(10):929–33.

Schmitz C, Atzeni G, Berchtold P. Challenges in interprofessionalism in Swiss health care: the practice of successful interprofessional collaboration as experienced by professionals. Swiss Med Wkly. 2017;147: w14525.

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Neubauer, F.B., Wagner, F.L., Lörwald, A. et al. Sharpening the lens to evaluate interprofessional education and interprofessional collaboration by improving the conceptual framework: a critical discussion. BMC Med Educ 24 , 615 (2024). https://doi.org/10.1186/s12909-024-05590-0

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Health Coverage by Race and Ethnicity, 2010-2022

Latoya Hill , Samantha Artiga , and Anthony Damico Published: Jan 11, 2024

Health coverage plays a major role in enabling people to access health care and protecting families from high medical costs. There have been longstanding racial and ethnic disparities in health coverage that contribute to disparities in health. This brief examines trends in health coverage by race and ethnicity from 2010 through 2022 and discusses the implications for health disparities. All noted differences between groups and years described in the text are statistically significant at the p<0.05 level. It is based on KFF analysis of American Community Survey (ACS) data for the nonelderly population.

There were gains in coverage across most racial and ethnic groups between 2019 and 2022 after several years of rising uninsured rates during the Trump Administration. The coverage gains between 2019 and 2022 were largely driven by increases in Medicaid coverage, reflecting policies to stabilize and expand access to affordable coverage that were implemented during the COVID-19 pandemic. These policies included enhanced subsidies to purchase Marketplace coverage and a requirement that states keep Medicaid enrollees continuously enrolled during the public health emergency (PHE), which led to a substantial increase in Medicaid enrollment. These coverage gains helped narrow differences in uninsured rates for Hispanic, Black, and  American Indian and Alaska Native (AIAN) people compared with White people, but further progress may be at risk amid the unwinding of the Medicaid continuous enrollment requirement.

Despite these coverage gains, disparities in coverage persisted as of 2022. Nonelderly AIAN and Hispanic people had the highest uninsured rates at 19.1% and 18.0%, respectively as of 2022. Uninsured rates for nonelderly Native Hawaiian and Other Pacific Islander (NHOPI) (12.7%) and Black people (10.0%) also were higher than the rate for their White counterparts (6.6%). Coverage disparities have persisted over time, and in some cases widened, despite recent gains and earlier large gains in coverage under the Affordable Care Act (ACA). For example, between 2010 and 2022, the uninsured rate for AIAN people grew from 2.5 to 2.9 times higher than the uninsured rate for White people, the Hispanic uninsured rate grew from 2.5 to 2.7 times higher than the rate for White people, and Black people remained 1.5 times more likely to be uninsured than White people.

Uninsured rates in states that have not expanded Medicaid are higher than rates in expansion states across most racial and ethnic groups as of 2022. Further, the differences in coverage rates between Hispanic, Black and NHOPI people compared with White people are larger in non-expansion states compared with expansion states. However, the relative risk of being uninsured for Black and Hispanic people compared to White people is similar in expansion and non-expansion states.

The ongoing racial and ethnic disparities in coverage could further widen amid the unwinding of the Medicaid continuous enrollment provision. The Medicaid continuous enrollment provision, which had halted Medicaid disenrollments since March 2020, ended on March 31, 2023. As states  unwind the continuous enrollment provision , they will redetermine eligibility for all Medicaid enrollees and will disenroll those who are no longer eligible or who may remain eligible but are unable to complete the renewal process. Since states began redeterminations, millions of people have been disenrolled from the program. While the limited data available on disenrollments by race and ethnicity do not point to racial and ethnic disparities in disenrollment rates, because Hispanic, Black, AIAN and NHOPI people are more likely than their White counterparts to be covered by Medicaid, they are likely disproportionately affected by the unwinding. Some individuals disenrolled from Medicaid will move to other sources of coverage, including Marketplace coverage. However, others will become uninsured. As such, the unwinding could potentially widen racial and ethnic disparities in coverage going forward.

Efforts to prevent coverage losses and further close coverage disparities are important for addressing longstanding racial disparities in health . Beyond coverage, it also will be important to address other inequities within the health care system and across the broad range of social and economic factors that drive health.

Trends in Uninsured Rates by Race and Ethnicity, 2010-2022

Prior to the enactment of the ACA in 2010, nonelderly Hispanic, Black, Asian, AIAN, and NHOPI people were more likely to be uninsured compared to their White counterparts, with Hispanic and AIAN people at the highest risk of lacking coverage (Figure 1).  Their higher uninsured rates reflected more limited access to affordable health coverage options. Although the majority of individuals have at least one  full-time worker  in the family across racial and ethnic groups, there are ongoing disparities in employment and income that result in some individuals not having coverage offered by an employer or having difficulty affording private coverage when it is available. While Medicaid helped fill some of this gap in private coverage, prior to the ACA, Medicaid eligibility for parents in most states was limited to those with very low incomes (often below 50% of the poverty level), and adults without dependent children—regardless of how poor—were  ineligible under federal rules .

Between 2010 and 2016, there were large gains in coverage across racial and ethnic groups under the ACA, but racial and ethnic disparities in coverage persisted. The ACA created new coverage options for low- and moderate-income individuals. These included provisions to extend dependent coverage in the private market up to age 26 and prevent insurers from denying people coverage or charging them more due to health status that went into place. Further, beginning in 2014, the ACA expanded Medicaid coverage to nearly all adults with incomes at or below 138% of poverty in states that adopted the expansion and made tax credits available to people with incomes up to 400% of poverty to purchase coverage through a health insurance Marketplace. Following the ACA’s enactment in 2010 through 2016, coverage increased across all racial and ethnic groups, with the largest increases occurring after implementation of the Medicaid and Marketplace coverage expansions in 2014. Nonelderly Hispanic people had the largest percentage point increase in coverage, with their uninsured rate falling from 32.6% to 19.1%. Nonelderly Black, Asian, and AIAN people also had larger percentage point increases in coverage compared to White people over that period. Despite these larger gains, nonelderly Hispanic, Black, AIAN, and NHOPI people remained more likely than their White counterparts to be uninsured as of 2016.

Beginning in 2017, coverage gains began reversing, and the number of uninsured increased for three consecutive years. The uninsured rate for the total nonelderly population increased from 10.0% in 2016 to 10.9% in 2019. Nonelderly Hispanic people had the largest statistically significant increase in their uninsured rate over this period (from 19.1% to 20.0%). There were also small but statistically significant increases in the uninsured rates among nonelderly White and Black people, which rose from 7.1% to 7.8% and 10.7% to 11.4%, respectively, between 2016 and 2019. Rates for nonelderly AIAN, NHOPI, and Asian people did not have a significant change. These coverage losses likely reflected policy changes made by the Trump Administration after taking office in 2017. These changes included decreased funds for outreach and enrollment assistance, guidance encouraging states to seek waivers to add new eligibility requirements for Medicaid coverage as well as to increase the frequency of eligibility verifications, and changes to public charge immigration policy that made some immigrant families more reluctant to participate in Medicaid and the Children’s Health Insurance Program (CHIP) (which have since been reversed by the Biden Administration).

After increasing for several years prior to the pandemic, uninsured rates declined between 2019 and 2022 . Nearly 3.4 million nonelderly people gained coverage between 2019 and 2022 as the uninsured rate dropped from 10.9% to 9.6%. (Because of disruptions in data collection during the first year of the pandemic, the Census Bureau did not release 1-year ACS estimates in 2020.) AIAN people had the largest percentage point increase in coverage, with their uninsured rate falling from 21.7% in 2019 to 19.1% in 2022. There were also smaller but statistically significant declines in uninsured rates among Hispanic (from 20.0% to 18.0%), Black (from 11.4% to 10.0%), Asian (from 7.2% to 6.0%), and White people (from 7.8% to 6.6%) during this period. These coverage gains were primarily driven by increases in Medicaid coverage, which offset declines in employer-sponsored coverage over the period. NHOPI people did not have statistically significant changes in coverage over this period.

The coverage gains observed between 2019 and 2022 largely reflect policies adopted during the pandemic to stabilize coverage in Medicaid and enhance subsidies to purchase Marketplace coverage. Specifically, provisions in the Families First Coronavirus Response Act (FFCRA), enacted at the start of the pandemic, prohibited states from disenrolling people from Medicaid during the Public Health Emergency in exchange for enhanced federal funding. Coverage gains also likely reflected enhanced ACA Marketplace subsidies made available by the American Rescue Plan Act (ARPA) and renewed for another three years in the Inflation Reduction Act of 2022 (IRA), boosted outreach and enrollment efforts, a Special Enrollment Period for the Marketplaces provided in response to the pandemic, and low Marketplace attrition, Additionally, in 2019, the Biden Administration reversed changes the Trump Administration previously made to public charge immigration policies that had increased reluctance among some immigrant families to enroll in public programs, including health coverage.

Coverage disparities have persisted, and in some cases widened, over time even with recent gains and the large earlier gains in coverage under the ACA. For example, in 2010, the uninsured rate for AIAN people was 2.5 times higher than the uninsured rate for White people; however, in 2022, the uninsured rate for AIAN people had increased to 2.9 times higher than the rate for White people. Similarly, the Hispanic uninsured rate grew from 2.5 to 2.7 times higher than the rate for White people from 2010 to 2022, while Black people remained 1.5 times more likely to be uninsured than White people.

Coverage by Race and Ethnicity as of 2022

While overall uninsured rates continued to decline in 202 2, nonelderly Hispanic, Black, AIAN, and NHOPI people remained more likely than their White counterparts to be uninsured (Figure 2). Nonelderly AIAN and Hispanic people had the highest uninsured rates at 19.1% and 18.0%, respectively, as of 2022. Uninsured rates for nonelderly NHOPI (12.7%) and Black people (10.0%) also were higher than the rate for their White counterparts (6.6%). These differences in uninsured rates are driven by lower rates of private coverage among these groups. Medicaid coverage helps to narrow these differences but does not fully offset them.

Medicaid and CHIP coverage help fill gaps in private coverage and reduce coverage disparities for children, but some disparities in children’s coverage remain (Figure 2). Medicaid and CHIP cover larger shares of children than adults, reflecting more expansive eligibility levels for children. This coverage helps fill gaps in private coverage, with over half of Hispanic, Black, AIAN, and NHOPI children covered by Medicaid and CHIP. However, there remain some disparities in children’s coverage. For example, AIAN children are three times as likely as their White counterparts to lack coverage (11.9% vs. 3.9%). Moreover, Hispanic children are twice as likely as White children to be uninsured (8.1% vs. 3.9%).

Among the total nonelderly population, uninsured rates in states that have not expanded Medicaid are higher than rates in expansion states across most racial and ethnic groups as of 2022 (Figure 3). The differences in coverage rates between Black and Hispanic people compared with White people are larger in non-expansion states compared with expansion states. However, the relative risk of being uninsured for Black, Hispanic, and Asian people compared with White people is similar in expansion and non-expansion states. For example, nonelderly Hispanic people are roughly 2.6 times as likely as nonelderly White people to lack coverage in both expansion and non-expansion states. Uninsured rates for AIAN people are similar in expansion and non-expansion states. Overall, the differences in coverage by expansion status are primarily driven by differences in coverage rates among nonelderly adults. However, White, Hispanic, Black, Asian, and NHOPI children in non-expansion states also are more likely to be uninsured than those in expansion states. For example, 23.8% of NHOPI children in non-expansion states are uninsured compared to 7.6% of NHOPI children in expansion states.

Eligibility for Coverage among the Uninsured as of 2022

There are opportunities to increase coverage by enrolling eligible people in Medicaid or Marketplace coverage, but eligibility varies across racial and ethnic groups, and many remain ineligible for assistance. Overall, six in ten people who were uninsured in 2022 were eligible for financial assistance either through Medicaid or through subsidized Marketplace coverage, while the remaining four in ten were not eligible because they fell in the Medicaid coverage gap in states that have not expanded Medicaid, they were deemed to have access to an affordable Marketplace plan or offer of employer coverage, or they were ineligible due to their immigration status. However, the share of the remaining uninsured eligible for assistance varied by race and ethnicity. For example, nonelderly uninsured Black were people more likely than their White counterparts to fall in the coverage gap in states that have not expanded Medicaid, and uninsured nonelderly Hispanic and Asian people were less likely than White people to be eligible for coverage options, in part, reflecting higher shares of noncitizens who face immigrant eligibility restrictions among these groups (Figure 4).

Uninsured nonelderly Black people are more likely than White people to fall in the Medicaid “coverage gap” because a greater share live in states that have not implemented the Medicaid expansion. As of December 2023, 10 states have not adopted the ACA provision to expand Medicaid to adults with incomes through 138% of poverty. Most of these states are in the South, where a higher share of the Black population resides (Figure 5). In these states, 1.5 million uninsured people with incomes under poverty fall into the “coverage gap” and do not qualify for either Medicaid or premium subsidies in the ACA Marketplace.

Uninsured nonelderly Hispanic, NHOPI, and Asian people are less likely than their White counterparts to be eligible for coverage because they include larger shares of noncitizens who are subject to eligibility restrictions for Medicaid and Marketplace coverage (Figure 6) . Lawfully present immigrants face eligibility restrictions for Medicaid coverage, with many having to wait five years after obtaining lawful status before they are eligible to enroll in Medicaid. Undocumented immigrants are not eligible to enroll in Medicaid and are prohibited from purchasing coverage through the Marketplaces.

Looking Ahead

Policies implemented amid the COVID-19 pandemic helped stabilize coverage and contributed to gains in coverage during this period, but the unwinding of the Medicaid continuous enrollment provision could reverse these gains and widen disparities in coverage. The coverage gains experienced during the COVID-19 pandemic were largely driven by an increase in Medicaid coverage, which offset declines in employer-sponsored coverage. As noted, temporary continuous enrollment provisions stabilized Medicaid coverage during the PHE, contributing to increases in enrollment . Additionally, the temporary enhanced subsidies for Marketplace coverage provided under ARPA, which were extended through 2025 under the IRA, also contributed to coverage gains . However, even with these recent gains, disparities in coverage remain and could widen amid the unwinding of the Medicaid continuous enrollment requirement. Since the Medicaid continuous enrollment provision ended in March 2023, millions of people have been disenrolled. While the limited data available on disenrollments by race and ethnicity do not point to disparities in disenrollment rates, Hispanic, Black, AIAN and NHOPI people are likely disproportionately affected by the unwinding since they are more likely to be covered by Medicaid compared with their White counterparts. Many people who have been disenrolled from Medicaid could find low-cost coverage on the ACA Marketplaces, including , in some cases, coverage with a zero (or near-zero) monthly premium requirement. However, others may become uninsured. In focus groups , adults who were disenrolled from Medicaid reported losing coverage for a variety of reasons, including because they were no longer eligible; however, some believed they were still eligible and did not know why they were disenrolled. Many reported facing communication problems with their Medicaid agencies, and some who were disenrolled indicated that they faced gaps in coverage before reenrolling in Medicaid or became uninsured, which contributed to high out-of-pocket costs and difficulties accessing care that negatively impacted their health.

Mitigating coverage losses and closing disparities in coverage is important for addressing longstanding disparities in health. Beginning January 2024, states will be required to provide children with 12 months of continuous coverage in Medicaid and CHIP, enhancing their coverage stability and preventing gaps in coverage. Further, several states have implemented or proposed waivers to provide multi-year continuous Medicaid eligibility to children up to age six. Some states also obtained waivers to mitigate coverage losses amid the unwinding by increasing ex parte or automatic renewals, helping enrollees complete and submit renewal forms, and helping individuals re-enroll if they were disenrolled for procedural reasons. Continued efforts to improve renewal processes and reduce procedural disenrollments will be important beyond the unwinding period to prevent gaps in coverage. Moreover, opportunities remain to increase coverage and narrow disparities by enrolling eligible uninsured people in Medicaid or Marketplace coverage. These opportunities would increase if additional states adopted the Medicaid expansion . Two states implemented the Medicaid expansion in 2023, including South Dakota, as of July 1, 2023, and North Carolina, as of December 1, 2023. Ten states have not yet adopted the expansion. Research  shows that Medicaid expansion is associated with reductions in racial/ethnic disparities in health coverage as well as narrowed disparities in health outcomes for Black and Hispanic individuals, particularly for measures of maternal and infant health.

Overall, research shows that having health insurance makes a key difference in whether, when, and where people get medical care and ultimately how healthy they are. KFF data show that more than half of adults (59%) have a favorable view of the ACA. Future trends in coverage will have a significant impact on disparities in health access and use as well as health outcomes over the long-term. Any potential changes to scale back coverage could result in widening disparities in the future. However, beyond coverage, it also will be important to address inequities across the broad range of other social and economic factors that drive health and to address other inequities within the health care system.

• Racial Equity and Health Policy
• Race/Ethnicity

Also of Interest

• Key Facts on Health and Health Care by Race and Ethnicity
• How Has History Shaped Racial and Ethnic Health Disparities?  

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Role of Magnesium in the Intensive Care Unit and Immunomodulation: A Literature Review

Affiliations.

• 1 Santa Croce and Carle Hospital, Department of Emergency and Critical Care, 12100 Cuneo, Italy.
• 2 Division of Anesthesiology, Department of Anesthesiology, Intensive care and Emergency Medicine, Ospedale Regionale di Lugano, 69000 Lugano, Switzerland.
• 3 Department of Medicine and Surgery, University of Milan-Bicocca, 20900 Monza, Italy.
• 4 Department of Prehospital Emergency Medicine, ASL TA, Italian Society of Prehospital Emergency Medicine (SIS 118), 74121 Taranto, Italy.
• 5 Department of Neurology, Fondazione IRCCS San Gerardo dei Tintori, School of Medicine and Surgery, Milan Center for Neuroscience, University of Milano-Bicocca, 20900 Monza, Italy.
• PMID: 37376511
• PMCID: PMC10304084
• DOI: 10.3390/vaccines11061122

Both the role and the importance of magnesium in clinical practice have grown considerably in recent years. Emerging evidence suggests an association between loss of magnesium homeostasis and increased mortality in the critical care setting. The underlying mechanism is still unclear, but an increasing number of in vivo and in vitro studies on magnesium's immunomodulating capabilities may shed some light on the matter. This review aims to discuss the evidence behind magnesium homeostasis in critically ill patients, and its link with intensive care unit mortality via a likely magnesium-induced dysregulation of the immune response. The underlying pathogenetic mechanisms, and their implications for clinical outcomes, are discussed. The available evidence strongly supports the crucial role of magnesium in immune system regulation and inflammatory response. The loss of magnesium homeostasis has been associated with an elevated risk of bacterial infections, exacerbated sepsis progression, and detrimental effects on the cardiac, respiratory, neurological, and renal systems, ultimately leading to increased mortality. However, magnesium supplementation has been shown to be beneficial in these conditions, highlighting the importance of maintaining adequate magnesium levels in the intensive care setting.

Keywords: critical care; immunomodulation; infections; magnesium.

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Conflict of interest statement

The authors declare no conflict of interest.

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