“A very interesting article by Cathryn Domrose”
Alina Palanchuk, RN, BSN, vividly recalls an interprofessional education simulation exercise at the University of Washington, Seattle, where she graduated last year. A team of medical, nursing and pharmacy students were going over a case created by faculty, trying to create a plan of care. A medical student told the team, “We don’t need to go into detail, we all have the same information.”
But, Palanchuk said, the medical student didn’t know what the nursing students knew — that the patient had memory loss and was delirious.
The lessons Palanchuk learned during that session and others offered as part of the University of Washington’s interprofessional education program — the importance of speaking up, of constantly updating others about a patient’s condition, of speaking in a way that communicates her concern, of understanding and calling on the expertise of others, of realizing she isn’t alone in her concern for her patients’ well-being — have stayed with her in her professional practice.
Without those lessons, she said she might have been a little more hesitant to communicate her concerns or observations about a patient or to call pharmacy if she had a question about a medication change or dosage.
Team-based learning for health professionals is not a new concept, according to those who work in interprofessional education. More than 40 years ago, an Institute of Medicine report called “Educating for the Health Team” recommended students of various health professions learn together to acquire skills for team-based healthcare delivery in the U.S.
“You would think it was a document written today,” said Barbara F. Brandt, PhD, associate vice president for education at the University of Minnesota’s Academic Health Center and director of the National Center for Interprofessional Practice and Education. But despite sporadic efforts, until the last decade interprofessional education, sometimes called interdisciplinary or multidisciplinary education, was not truly integrated into health curriculums in the U.S., Brandt said.
That is changing. After two IOM reports in early 2000 calling for educating health professionals together, the 2010 IOM “Future of Nursing: Leading Change, Advancing Health” report specifically addressed the issue for nurses, recommending nurses be educated with physicians and other health professionals both as students and throughout their careers. Research showing how effective communication and teamwork improve outcomes for patients and provisions of the Affordable Care Act that reward providers for successful team efforts have contributed to increased interest in interprofessional education.
Healthcare leaders are “beginning to be aware that the only way to accomplish the outcomes they want to achieve is to have teams of people working together,” said Geraldine (Polly) Bednash, RN, PhD, FAAN, CEO and executive director of the American Association of Colleges of Nursing and president of the Interprofessional Education Collaborative. The best way to teach people how to work in teams, she said, is to educate and train them together, showing them the unique importance of each role and the value each profession brings to patient care.
Representatives of nursing, medical, dentistry, pharmacy, osteopathic medicine and public health schools formed the national Interprofessional Education Collaborative in 2009 and outlined core competencies for interprofessional education in a 2011 report. Increasing numbers of accreditors for health professions’ schools including nursing, pharmacy and medicine are making interprofessional education part of their requirements, though common standards within the organizations and among the professions still need to be worked out.
Schools of health professionals are starting to make interprofessional education and practice a permanent part of their curriculums, Bednash said. Some programs use classrooms and simulation, and some also have students work in teams doing actual patient care in community and home settings. Major challenges include coordinating schedules of students and faculty from various schools, finding appropriate settings for interprofessional learning and matching students according to levels of learning and profession.
About a year ago, the Health Resources and Services Administration awarded a $4 million grant to establish the National Center for Interprofessional Practice and Education in Minnesota in part to serve as a resource for schools that are creating interprofessional education programs. HRSA also has awarded grants to help schools create programs that promote teamwork, communication and leadership among future healthcare providers.
Various educators said they eventually would like to see interprofessional education start at the undergraduate level, with simulated communal problem-solving introduced into classes, such as anatomy, that students of different health professions can take together. From there interprofessional education could progress through postgraduate levels, with students seeing patients in teams, and continue in practice with debriefings that assess teamwork and communication as much as clinical work.
“My hope is that in healthcare, working together as a team will be business as usual,” said Brenda K. Zierler, RN, PhD, RVT, FAAN, associate director, Institute for Simulation and Interprofessional Studies at the University of Washington.
Three nursing schools, in three different areas of the country, have developed programs to educate nursing students with students in other professions in various settings. The programs, some funded with government grants for nursing education, are examples of many being developed to improve patient care through better communication and teamwork.
• Johns Hopkins University, Baltimore. When Kathleen Becker, RN, DNP, MSN, and Laura Hanyok, MD, began working together on an interprofessional education project in geriatric care in 2011, they realized nursing and medical faculty knew little about each other.
Hanyok, an assistant professor of medicine and a general internal medicine physician at Johns Hopkins Bayview Medical Center, said she didn’t realize nurse practitioners had so many specialties. Becker, an assistant professor at the Johns Hopkins University School of Nursing, didn’t know the extent to which medical education emphasized communication and holistic care. “We didn’t even speak the same language,” Becker said. “We really don’t know what we don’t know about each other.”
The original program paired nurse practitioners with first-year medical residents. Since then, with funding from HRSA, it has expanded to include pharmacy students from the University of Maryland, graduate pastoral students and faculty from each field. “It’s a much richer experience when you have multiple professions involved,” Becker said. “Nobody realized the level of science [knowledge] that pharmacists bring,” or how chaplains are trained to assess patients’ spiritual needs beyond religion, she said.
The three-part, jointly taught curriculum includes an online module on teamwork and geriatric care and problem-solving simulations in the classroom and during actual patient care. For Anthony Pho, RN, MSN, MPH, ANP-C, one of the students in the original program, the experience led him to make interprofessional education part of his career.
Pho, a staff associate in medicine at Weill Cornell Medical College and a nurse practitioner at NewYork-Presbyterian Hospital in New York City, said the program highlighted some of the common misconceptions physicians and nurses had about each other’s roles, as well as the respect they had for each other. He recalled one exercise when his recommendation included an assessment of a patient’s social and family support system, something his medical student partner said never would have occurred to him. “That made me feel validated as a nurse practitioner,” Pho said.
• University of Louisville (Ky.): Undergraduate and graduate nursing students work with students from other professions on specific scenarios of patient care. In a HRSA-funded oncology palliative care program nursing, medical, master’s level social work and pastoral care students learn about each other’s roles and training and work together to create care plans in simulation exercises. As part of clinical rotations they observe teams of practicing caregivers, write about the roles of each and share their reflections in groups.
The students “really learned how much [knowledge] is shared among all the disciplines and how unique some of their training is,” said Carla P. Hermann, RN, PhD, project co-investigator and professor at the University of Louisville School of Nursing. “Nurses sometimes feel like they have to do it all. It really opens up their eyes to the idea that, ‘I don’t have to do all of this by myself.’”
As part of a health assessment class, nurse practitioner and dental students study information on oral health assessment, work together on simulated cases presented by actors and see patients with dental residents at a local clinic. Along with teaching students about interprofessional communication and teamwork, the program aims to show them the connection between oral and general physical health, according to Whitney A. Nash, PhD, APRN, director of practice and international affairs and an assistant professor in the school of nursing. Nash said the program also aims to help students better manage conditions such as diabetes and heart conditions that might show initial symptoms in a patient’s mouth and jaw.
Preliminary data show students in both professions increased their confidence in working as part of an interdisciplinary team after going through the program, Nash said. “It’s a different dynamic than what it might be with nursing and medicine students. There are no real turf battles; they don’t see each other as infringing on territory.”
• University of Washington, Seattle: The university has been involved in interprofessional education since 1997 and has developed a number of programs, including web-based cases, team-building exercises, simulated scenarios, mock codes, shadowing health professionals and service learning in the community, Zierler said. A new dean’s initiative involves nursing, medical, pharmacy, dental, social work and public health students who attend six mandatory sessions, focused on topics such as error disclosure and early apology training. They are given scenarios based on real cases and asked to work together on patient assessment and care.
“They are most surprised at the overlap [in their studies], that they all take many of the same things,” Zierler said. In the simulated acute care cases, medical students were often surprised at the amount of assessment nurses do and many nursing students said they were surprised at how much the medical students relied on the nurses’ assessment information, she said. “And there’s a huge love-fest for pharmacy.” Nursing and medical students often don’t realize how much pharmacists know about medication interactions and dosages or how much they can contribute to patient care.
“If they learn nothing else, they learn to value that each person brings something entirely different” to patient care, she said.
Students also need to understand why they are working together and how skills such as communication, coordination, delegation and leadership contribute to quality patient care, Zierler said.
“It can’t be interprofessional education for interprofessional education’s sake,” she said. “We need to think about how we can create an environment to do this in practice.”