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July 2015, Vol 3, No 7 - Inside Patient Care

In a recent interview with Inside Patient Care, Pamela B. Edwards, EdD, MSN, RN-BC, Associate Chief Nursing Officer, Education, Duke University Health System, discussed projects at Duke University, and the role of the entire healthcare team in improving patient outcomes.

What is your clinical background, and what projects are you involved in at Duke University?

A: I have a background in nursing, and, more specifically, in nursing education. My clinical background is in medical-surgical nursing. I hold a master’s degree in nursing education, and my doctoral degree is in occupational and adult education.

As of May 2015, I have practiced as a registered nurse for 37 years, and have been engaged in professional staff development for about 32 years. I have been involved in the North Carolina Area Health Education Centers (AHEC) Program since 1987 with the primary focus of providing continuing medical education (CME) and continuing nursing education. In 1994, I moved into a role at Duke University, where I served as the Assistant Director of CME, and also worked with Duke Network Services, targeting CME activities to rural physicians and other health professionals. It was, and remains, one of the best decisions of my professional career to work at Duke University.

After coming to Duke, I began practicing in a jointly appointed role as Director of Clinical Ed­ucation & Professional Development, and Associate Consulting Professor at the Duke University School of Nursing, teaching in the nursing education major. I have served 3 elected terms on the North Carolina Board of Nursing, and served as the board’s chair during the past 2 years. A large part of my work at the Duke University School of Nursing involved serving as the principal investigator on a Health Resources and Services Administration (HRSA) grant seeking to increase the number of minority faculty within nursing education.

I was also working with a Duke Endowment grant, assisting the North Carolina Community College System faculty with a­chiev­ing a master of science in nursing in nursing education, via Duke University’s distance-based learning program. Since working with my first HRSA grant, I have also been the recipient of a simulation grant, and I am currently part of a 3-year, HRSA-funded collaborative agreement working to increase interprofessional teamwork in rural hospitals. While working at the Fayetteville AHEC—now called the Southern Regional AHEC—in North Carolina, I learned about an opportunity in continuing professional education at Duke.

I am currently finishing a couple of research projects, primarily in the area of interprofessional teamwork; the HRSA Interprofessional Collaborative Practice (IPCP) project finishes June 30, 2015, and the peer-to-peer (P2P) project concludes in July 2015. I serve as principal investigator of both projects, and each one consists of teams delivering project work daily.

The P2P project actually began when a colleague from graduate medical education, Stephen DeMeo, DO, reached out to nursing services to see if we were interested in a physician–nurse collaboration. Dr DeMeo’s clinical background at the Duke University Medical Center Intensive Care Nursery includes a strong physician–nurse partnership, and he wondered whether that relationship may be strengthened by resident physicians and nurse residents—Duke University participates in the University HealthSystem Consortium/American Association of Colleges of Nursing Nurse Residency Program—engaging in formal and informal peer mentoring. During early discussions, we found that both resident groups require a clinical performance improvement project, and concluded that working together would indeed be a great way to learn. We were extremely grateful that our project was funded by Duke AHEAD (Academy for Health Professions Education and Academic Development).

From what you have observed in the P2P program, how do healthcare professionals work together to deliver optimal access to high-quality care?

A: When considering the P2P project, we, a team comprising members from our School of Medicine, School of Nursing, and Health System, posed the following question: Does a structured interdisciplinary P2P mentoring program change attitudes toward nurse–physician collaboration? Next, we considered our own work culture/engagement data regarding the relationship, and found that there was indeed an opportunity for improvement. For example, newly licensed nurses at Duke University Hospital have demonstrated improvements from 2.81 (initial) to 3.57 (at 12 months) on a 4.0-point item on “MD Communication.” In addition, a meta-analysis of 51 surveys on interprofessional collaborations, involving >18,000 physicians, medical students, nurses, and nursing students, demonstrated that interprofessional educational interventions work to improve interprofessional collaborations between physicians and nurses.1,2 The significance of this project is to learn about real-life behaviors required for successful collaborations in professional healthcare environments, and to apply this information to practicing and prelicensure nursing education.

Our aims for the P2P project include: piloting a novel P2P nurse–physician mentoring program for future use across the health system; assessing for changes in attitudes toward nurse–physician collaboration in a group of nurse residents and resident physicians; and program leaders and program graduates applying knowledge gained through this program to improve their clinical and academic education and work settings.

The project recruited 15 nurse resident/resident physician dyads (30 participants total). Dyads include individuals who work in the same clinical area, and were selected from units across Duke University Health System (DUHS) that performed on the high and low percentiles for physician–nurse communication in the most recent Work Culture Survey administered at DUHS.

During the project, participants are involved in a 6-month program that is a combination of large group meetings, facilitated meetings between individual dyads, and regular online collaboration among the larger group.

The P2P project is currently under way, and we are seeing great collaboration so far. We also clearly see that physicians and nurses do not practice only as dyads, and that we should expand future projects to include other healthcare professionals, such as pharmacists.

What other projects have you participated in?

A: My team also works in collaboration with the Duke University School of Nursing, assisting in the placement of advanced practice nursing students into primary care clinical settings, within a national demonstration project. One of the positive side effects I have noticed resulting from these placements is that when we see learners from multiple disciplines (eg, physicians, physician assistants, nurse practitioners) working together in primary care, it creates an enhanced learning experience for all of the people involved. We also hear, anecdotally, from the preceptor that the team’s experiences are much richer and contribute more positively to the overall care of the patient and their family.

We are hopeful that the team-based care model will continue to evolve, and that prelicensure learning activities across disciplines will grow and become more robust and common, resulting in professional graduates who view teamwork as a model of excellence in care. For those practicing professionals, we aim to continue to engage interprofessional teams every time we develop projects and initiatives, and collaborate across agencies and organizations to improve all care transitions.

Why is team-based care so important in healthcare?

A: Great question. The challenge is in how we will create healthcare practice environments of the future that support patient/family-centered care. The answer begins with the implementation of innovative opportunities for healthcare providers across all disciplines to practice patient-centered care through groundbreaking projects aimed at meeting the goals articulated by the Interprofessional Education Collaborative in 2011.3 These goals include increasing communication and shared decision-making among practitioners; an environment based on mutual respect and effective dialogue among all members of the care team in care planning and problem solving; and more efficient and integrated practices that lead to high-quality patient and population-centered outcomes.

At Duke, we began addressing the need for interprofessional learning activities for professionals currently practicing across disciplines, by working with our nurse residency program and transitioning new nurses to practice. By “learning together to work together,”2 or leveraging cutting-edge educational technology (eg, learning intensives and immersive learning environments), we can successfully transition teams into confident, safe members of the interprofessional healthcare workforce who are able to contribute to meaningful changes in patient outcomes, as evidenced by the organization’s own publicly reported measures.

This was the premise of our HRSA-funded IPCP agreement. Our project included nursing, pharmacy, radiology, physical therapy, and respiratory therapy. We used simulation as an adjunct to didactic and clinical learning for rural teams working together to improve patient outcomes at 4 community hospitals. For example, our pharmacy colleagues created medication safety training for the rural partners; physical therapy team members collaborated on fall reduction education and implementation; respiratory therapy and pharmacy in a simulation model on managing the decompensating patient; and radiology in the handoff of care learning activities. Most of the team members from these disciplines also participated in TeamSTEPPS training, which was offered to their worksites.4 Although not all of our findings appear to be significant, we do have preliminary data that demonstrate how teams are able to move the dial or hold gains by learning together and working together on projects (eg, reducing falls, perception of teamwork, and reducing pressure ulcers).

As a nurse, I am concerned about the need for adequate preparation and transition to practice for novice nurses as an essential component of nursing responding to the healthcare needs of our country. However, we cannot ignore that nurses already work in teams with colleagues across various disciplines in the delivery of safe and effective care; the healthcare system in the United States has become increasingly complex, requiring mastery of new skills and technologies, as well as enhanced social/interpersonal skills to effectively manage more diverse patients and families.

What challenges and op­portunities lie ahead for the healthcare team?

A: In the 1960s, the lyrics to Bob Dylan’s “The Times They Are A-Changin’,” became the anthem for political and social movements during a turbulent time in our nation’s history. For healthcare teams, these lyrics ring true once again in 2015. Will there be enough healthcare professionals to provide evidence-based care for patients and families being added to the health insurance ranks? Will we rise to the challenges of a postreform healthcare environment? Will we serve as the leaders who bring together interprofessional teams to create our preferred future?

It is an exciting time to be involved in healthcare. However, we are facing many looming issues that force us to be creative and innovative at the same time. I was recently the speaker at a local program’s nursing pinning ceremony, where I used an image of a nurse reading The Wizard of Oz to a young patient. Dorothy Gale’s search for the legendary Wizard of Oz—who was her only hope for returning home—is a well-known story. Through­out Dorothy’s journey, she befriends other creatures who are also searching for things they believed to be missing from their lives. In the end, everything the characters needed was found within their own hearts and minds. It took the formation of a team for Dorothy and her friends to reach their goals, just as individual patients benefit from the banding together of interprofessional teams to care for their healthcare needs. None of the characters in the story could have made that journey alone.

Each team member had different strengths that contributed to the overall goal, and although that legendary search was for courage, a heart, a brain, and a way home, as health professionals we have a similar need to be courageous advocates for our patients, to help them, and to provide them with evidence-based care. We have strength in our diversity as healthcare teams comprised of professionals from various disciplines. We are stronger together, and whether we are talking about Dorothy’s journey home or the state of our nation’s health, teamwork has the potential to improve any outcome.




References

  1. Sollami A, Caricati L, Sarli L. Nurse-physician collaboration: a meta-analytical investigation of survey scores. J Interprof Care. 2015;29:223-229.
  2. Greiner AC, Knebel E; Committee on the Health Professions Education Summit. Health Professions Education: A Bridge to Quality. Washington, DC: National Academies Press; 2003.
  3. Interprofessional Education Collaborative Expert Panel. Core competencies for interprofessional collaborative practice: report of an expert panel. Washington, DC: Interprofessional Education Collaborative; 2011.
  4. Agency for Healthcare Research and Quality. TeamSTEPPS®: National Implementation. http://teamstepps.ahrq.gov/. Accessed June 3, 2015.
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