- Email: [email protected]
A pilot program to improve nursing and surgical intern collaboration: Lessons learned from a mixed-methods study
The American Journal of Surgery xxx (2016) 1e7
Contents lists available at ScienceDirect
The American Journal of Surgery journal homepage: www.americanjournalofsurgery.com
A pilot program to improve nursing and surgical intern collaboration: Lessons learned from a mixed-methods study Neha Raparla a, *, Diane Davis b, Daria Shumaker c, Anagha Kumar d, Shabnam Hafiz e, Jack Sava a, e, Katie Adams c, Shimae C. Fitzgibbons a, f a
Georgetown University School of Medicine, 3900 Reservoir Rd. NW, Washington, DC 20007, USA Georgetown University School of Nursing and Health Studies, 3700 Reservoir Rd. NW, Washington, DC 20007, USA MedStar SiTEL, 3007 Tilden Street, NW, Washington, DC 20008, USA d Medstar Health Research Institute, University Town Center, 6535 Belcrest Rd. #700, Hyattsville, MD 20782, USA e MedStar Washington Hospital Center, 110 Irving St. NW, Washington, DC 20010, USA f Medstar Georgetown University Hospital, 3800 Reservoir Rd. NW, Washington, DC 20007, USA b c
a r t i c l e i n f o
a b s t r a c t
Article history: Received 6 April 2016 Received in revised form 9 September 2016 Accepted 20 October 2016
Background: Inter-professional collaboration is an integral component of a successful healthcare team. We sought to evaluate the impact of nursing student participation in a one-day intensive interprofessional education (IPE) training session with surgical interns on participant attitudes toward inter-professional collaboration. Methods: Following IRB approval, pre and post IPE session survey responses were compared to determine the impact on participant attitudes toward inter-professional collaboration. Pre and post session semi-structured interviews were transcribed and analyzed to identify relevant themes. Results: Surgical interns (n ¼ 38) more than nursing students (n ¼ 11), demonstrated a measurable improvement in attitude towards ‘collaboration and shared education’ (interns: median score pre ¼ 26, post ¼ 28, p ¼ 0.0004; nursing student: median score pre ¼ 27, post ¼ 28, p ¼ 0.02). Qualitative analysis of interviews identified major themes that supplemented this finding. Conclusion: An eight hour, one day IPE session has a positive impact on collaborative attitudes and supports the case for increased inter-professional education amongst interns and nursing students. © 2016 Elsevier Inc. All rights reserved.
Keywords: Inter-professional training Communication Collaboration Residents Nursing students Surgery
1. Introduction Interprofessional education (IPE) is an area of increasing focus and attention for health care educators, occurring when “students from two or more professions learn about, from, and with each other to enable effective collaboration and improve health outcomes.1” Collaboration between healthcare professionals is a fundamental component of patient care. In an era emphasizing the team-minded approach to healthcare, collaboration and patient care are seen as increasingly interdependent factors: optimal interprofessional collaboration between team members enhances patient care, while its absence presents a direct threat to effective healthcare delivery. The Interprofessional Education Collaborative (IPEC) has defined particular competency targets for IPE, including
* Corresponding author. E-mail address: [email protected] (N. Raparla).
shared values and ethics, comprehension of individual roles and responsibilities, effective communication, and the ability to perform as a team. Focusing on these competencies, successful IPE allows efficient coordination between healthcare professionals and provides a basis for continued learning and ongoing dialogue.1 In recognition of the importance of this approach to healthcare education, organizations such as the American College of Surgeons, the Agency for Healthcare Research and Quality, and The Joint Commission's National Patient Safety Goals cite inter-professional communication, collaboration and training as essential practices in any healthcare organization seeking to deliver safe patient care.2e4 This national emphasis on interprofessional collaboration has increased the relative importance of this topic within nursing and physician undergraduate and graduate medical education. In fact, inter-professional collaboration is a core competency required of all surgical residents and nursing student graduates.5,6 The Interprofessional Education Collaborative, which includes both the
http://dx.doi.org/10.1016/j.amjsurg.2016.10.014 0002-9610/© 2016 Elsevier Inc. All rights reserved.
Please cite this article in press as: Raparla N, et al., A pilot program to improve nursing and surgical intern collaboration: Lessons learned from a mixed-methods study, The American Journal of Surgery (2016), http://dx.doi.org/10.1016/j.amjsurg.2016.10.014
2
N. Raparla et al. / The American Journal of Surgery xxx (2016) 1e7
American Association of Colleges of Nursing (AACN) and the Association of American Medical Colleges (AAMC), underscored the importance of this topic in its 2011 Core Competencies for Interprofessional Collaborative Practice.7 Within the broader topic of interprofessional collaboration, communication, as a unique and specific skill, is particularly fundamental. Efforts targeting improved collaboration often begin by tackling better interprofessional communication.4 Despite the recognized importance of this skill set for safe practice and patient care, formal training designed to strengthen and improve interprofessional communication is sparse. Effective, feasible options for interprofessional communication training are as yet underdeveloped, resulting in a gap between our proposed national standards and best-practices and the reality of our training systems. To meet this need, we present our efforts to develop an interprofessional training session with surgical interns and nursing students, designed to enhance interprofessional communication and improve attitudes toward interprofessional collaboration. The mixed methods and quasi-experimental approach employed in this pilot study helped us address our initial research questions: Can a one day, eight hour exposure to IPE training, focusing on interprofessional communication, effect a measurable improvement in participant attitudes toward interprofessional collaboration (quantitative arm)? And if a measurable impact is observed, what specific participant knowledge, beliefs or values are most affected or involved (qualitative arm)? 2. Methods 2.1. Study design Expedited Institutional Review Board (IRB) approval was obtained for this study. Participants included post-graduate year (PGY)-1 surgical interns from six university-affiliated general surgery and surgical subspecialty training programs, along with nursing students enrolled in their senior year of a baccalaureate in nursing program at an affiliated university. All surgical interns participating in the graduate medical education orientation at these programs were given the opportunity to consent and enroll in this study. This was done during an orientation lunch break set within a week-long intern on-boarding process. During this break, the study was explained by a member of the research team and written consent forms and the initial pre-IPE training session survey were distributed. Interns choosing to participate completed the consent and the survey at that time. Nursing students were selected via a voluntary convenience sample. All nursing students enrolled in the nursing program were presented with the opportunity to participate. Information regarding the study was distributed by nursing school faculty. The first eleven student volunteers to complete a consent form were included in the study. All study participants completed the Jefferson Scale of Attitudes towards Physician-Nurse Collaboration (JSAPNC) survey, one week prior to and, again, immediately following the IPE training session. The JSAPNC survey is a previously published and validated 4 point Likert-like scale (1 ¼ Strongly Disagree, 4 ¼ Strongly Agree).8 This survey focuses on respondent attitudes toward collaboration, autonomy, caring for the patient, and authority. In addition to completion of the JSAPNC survey, a convenience subset sample of six surgical interns and ten nursing students enrolled in the study participated in individual semi-structured interviews designed to better understand both their pre-existing attitudes toward nurse-physician collaboration, teamwork, and interprofessional training, and their post-session reflections on the impact of this particular event. All participants from the
quantitative portion of the study were contacted to participate in pre and post-IPE training session interviews. Those that consented were interviewed the week prior to the IPE training session. This same subset of six interns and ten nursing students was then interviewed again in the two weeks immediately following the IPE training session. All interviews were audio recorded for later transcription. All interviews were guided by specific question prompts and conducted by an individual not associated with the medical field. Question prompts for the pre-IPE training session interview included: “How you would define optimal physiciannurse collaboration with respect to patient care?”, “Have you had any personal experience with physician-nurse collaboration or patient care that's shaped your opinion?”, “What would you expect to get out of a one day session which included practicing skills related to physician-nurse collaboration in a simulated and supervised setting?”. Question prompts for the post-IPE training session included: “Having participated in the bootcamp session, do you feel your attitude towards physician-nurse collaboration has changed at all?”, “Having participated, do you think you're more able to engage in successful physician-nurse collaboration?”, “Was there anything unexpected about the experience, particularly in relation to working with another health professional?” 2.2. IPE training session The IPE training session was designed as an all-day (eight hour) educational event set within the orientation programming for new surgical interns, held mid-June and prior to the start of the interns' clinical duties. For nursing students, this day took place within the existing curriculum of their senior year. The session was structured to present participants with a series of bedside clinical scenarios. Each scenario required effective nurse and physician communication for successful completion. Participating interns and nursing students were directly observed during the scenario by both a nurse and physician faculty member present at the bedside. A total of 5 scenarios were employed, each with a unique peri-operative clinical challenge: 1) altered mental status, 2) hypotension, 3) oliguria, 4) hypoxemia, and 5) chest pain. Each clinical scenario was designed to be clinically straightforward and to require communication between the intern and the nurse for successful completion. A station was designed to take approximately 10 min (1 min for orientation to the scenario, 6 min to interact with the nurse and patient, and then initiate an initial plan of action, and 3 min for immediate post-session faculty feedback). Before the scenario began, nursing students were provided with clinical information important in the management of the acute peri-operative problem. Each scenario consequently began with the nursing student providing this information via a standardized communication tool (SBAR: Situation, Background, Assessment, and Recommendations) to the intern. Each intern rotated through each of the five clinical stations once. Nursing students also rotated amongst the different clinical scenarios. Unlike the interns, however, nursing students were kept at a given station for several rounds, allowing them to practice the same SBAR communication tool for a patient with chest pain, for example, with several different interns. Feedback sessions were held immediately following the scenarios with both the intern and nursing student, the standardized patient for that scenario, and the physician and nurse faculty observers. 2.3. Analysis 2.3.1. Quantitative JSAPNC scores were graded on a numerical scale. Fifteen questions were graded on a 1 to 4 Likert scale (Strongly agree ¼ 1 to Strongly disagree ¼ 4). Responses were added for a total possible
Please cite this article in press as: Raparla N, et al., A pilot program to improve nursing and surgical intern collaboration: Lessons learned from a mixed-methods study, The American Journal of Surgery (2016), http://dx.doi.org/10.1016/j.amjsurg.2016.10.014
N. Raparla et al. / The American Journal of Surgery xxx (2016) 1e7
value of 60 for each individual survey. Data from the JSAPNC surveys were analyzed via the Wilcoxon Signed Rank Test and the Wilcoxon Rank Sum Test. Comparisons were made between the overall pre-session and post-session scores of participants, and between the pre-session and post-session scores for the subset of responses pertaining specifically to attitudes toward collaboration. The Wilcoxon Signed Rank Test was used for all pre-post comparison calculations. Comparisons between the scores of nursing student participants and surgical intern participants were made using the Wilcoxon Rank Sum Test. The Bonferroni Correction was employed to account for multiple comparisons during the analysis of question subsets. Therefore, each hypothesis was tested at the 0.0125 level so as to maintain a family-wise type I error rate of 0.05. 2.3.2. Qualitative All semi-structured interview transcripts were coded by a single primary reviewer in two rounds of coding. A second supervisory reviewer inspected all transcripts, codes, and interpretations of emerging themes with the primary reviewer. The initial round of coding was applied to all transcripts, and used to better identify the ideal coding approach. Through this process, a set of “in vivo” and “values” codes were selected, and the transcripts were then recoded. In vivo coding consisted of pulling out words or phrases verbatim from the text, focusing on words or phrases appearing repeatedly throughout the different transcripts. Values coding entailed surveying the text for recurring “values, attitudes or beliefs” mentioned frequently in multiple transcripts.9 These codes were used to extract themes from the data with an emphasis placed on relevance to our initial research question, namely: understanding the impact of a one-day intensive interprofessional training session on participant attitudes toward interprofessional collaboration?
3
session (pre-training median score: 56 vs. post-training median score: 56.5, p ¼ 0.43) was observed. In the case of the surgical interns, however, a significant increase was seen between the pretraining and post-training scores (pre-training median score: 54 vs. post-training median score: 55.5, p ¼ 0.004), demonstrating a modest but significant improvement in their attitudes toward physician-nurse collaboration (Fig. 1). Survey response scores were then broken out by sub-category: attitudes toward collaboration, caring for patient, autonomy, and authority. A pre-post comparison of all four categories demonstrated no significant differences between pre and post-session scores for all nursing students (see Fig. 2). However, for surgical interns, a pre-post comparison of all four categories demonstrated a significant difference between pre and post-session scores within the sub-category of “collaboration” (pre-training median collaboration score: 26 vs. post-training median score: 28, p ¼ 0.0004) (Fig. 3). 3.3. Qualitative data analysis Following analysis of the transcribed semi-structured interviews, Role Definition, Value of the Nurse, and Lack of Teamwork emerged as the three most significant, relevant and recurring themes. 3.3.1. Role definition Role definition, or rather the lack of and need for clearer role definition, was a dominant theme identified throughout the interviews. This theme emerged during both nursing student and surgical intern interviews. Nursing students spoke of a basic lack of awareness and understanding of both nursing and physician roles
3. Results 3.1. Demographics All 38 surgical interns enrolled in the orientation program consented to participate in this study, along with 11 nursing students. Of the participating surgical interns, 34.2% were female, with a group mean age of 27 years. 57.9% of participating interns were general surgery interns, with the remaining participants representing orthopedic, urology, neurosurgery, otolaryngology and plastic surgery programs. In contrast to the interns, 100% of nursing students participating in the IPE training session were female, with an average age of 24 years. Of the nursing students, 80% had prior healthcare work experience ranging from 6 months to 2 years. These work experiences were diverse and included smoking cessation outreach, research positions, and health screening. 50% of the nursing students enrolled had no prior experience interacting directly with physicians. 3.2. Quantitative data analysis Of the 38 interns enrolled in the study, 30 interns successfully completed the entire JSAPNC survey. Similarly, of the 11 nursing students enrolled in the study, 10 successfully completed the entire JSAPNC survey. Comparison of the baseline (pre-IPE training session) cumulative JSAPNC survey scores for nursing students versus surgical interns showed no significant difference, indicating that overall attitudes toward physician-nurse collaboration between these two groups was similar (interns: 54, nursing students: 56, p ¼ 0.15). In a pre-post analysis of the cumulative JSAPNC survey scores for nursing students, no change before and after the IPE training
Fig. 1. Comparison of Pre and Post Inter-professional training session JSAPNC survey scores for participating surgical interns and nursing students (Surgical Interns pretraining median score: 54 vs. post-training median score: 55.5, p ¼ 0.004; Nursing student pre-training median score: 56 vs. post-training median p ¼ 0.43). score: 56.5.
Please cite this article in press as: Raparla N, et al., A pilot program to improve nursing and surgical intern collaboration: Lessons learned from a mixed-methods study, The American Journal of Surgery (2016), http://dx.doi.org/10.1016/j.amjsurg.2016.10.014
4
N. Raparla et al. / The American Journal of Surgery xxx (2016) 1e7
Fig. 2. Comparison of Pre and Post Inter-professional training session JSAPNC* survey scores for participating nursing students analyzed by sub-category. (Nursing student pretraining median score for collaboration sub-category: 27 vs. post-training median score: 28, p ¼ 0.02).
on the health care team, while surgical interns focused on how the lack of clarity about the nurse's role in particular made it difficult for them to understand their own place on the team: “I don't really know what doctors do, and I feel like most people in the world don't know what nurses do.” (Pre-session interview, Nursing Student) “I think that what would be productive for me, would be a better understanding of what the nurses are supposed to be
doing … then, that will also help identify, for me, what roles are specific to me, that don't belong to the nurses, so that my responsibilities are clarified” (Pre-session interview, Surgical Intern) Clarity surrounding the roles of nurses and physicians on the team was clearly a concern to both parties during pre-session interviews. Both groups seemed to benefit from the IPE training session, gaining a new confidence as a result of this role clarity. Of
Fig. 3. Comparison of Pre and Post Inter-professional training session JSAPNC* survey scores for participating surgical interns analyzed by sub-category. (Surgical intern pre-training median score for collaboration sub-category: 26 vs. post-training median score: 28, p ¼ 0.0004).
Please cite this article in press as: Raparla N, et al., A pilot program to improve nursing and surgical intern collaboration: Lessons learned from a mixed-methods study, The American Journal of Surgery (2016), http://dx.doi.org/10.1016/j.amjsurg.2016.10.014
N. Raparla et al. / The American Journal of Surgery xxx (2016) 1e7
5
note, interns in particular noted that their lack of understanding stemmed, in part, from having interacted with nurses only as medical students, rather than as full members of the healthcare team. The IPE simulations allowed them to practice as a fully empowered member of the team:
the team. In contrast, for surgical interns, these IPE training sessions seemed to reassure them that the potential value they hoped nurses would bring to the healthcare team was not simply theoretical but, in fact, a reality in practice.
“It was very helpful, I think, having a whole training session and getting to see what [nurses] do and what they need to hear from us.” (Post-Session interview, Surgical Intern)
3.3.3. Lack of teamwork While collaboration and good communication were seen as key attributes of effective teamwork by both cohorts, the theme of “lack of teamwork” was particularly prominent amongst the nursing students before the IPE training session. Specifically, nursing students perceived physicians as solo players, intentionally choosing not to act as team players. They associated physicians with the hierarchical role responsible for giving orders, while at the same time noting that physicians spent a significantly shorter amount of time at the patient's bedside:
“I think it was a good exercise, in terms of comfort, as well as [doctors] kind of understanding what [a nurses] role is in terms of giving that SBAR.” (Post-session interview, Nursing Student) For both nursing students, and new surgical interns, the opportunity to interact with each other while managing a clinical scenario allowed them to explore both their own role, and the role of their fellow team member. By setting this training session within a simulated “real world” clinical scenario, the actual rather than hypothetical contributions of and working relationships between individual team members was apparent. 3.3.2. Nurse value A second major theme to emerge during these interviews was the nursing students' belief that nurses were generally undervalued and, as patient advocates, should have a larger role in decisionmaking. “Since [nurses are] the eyes and [nurses are] with the patient a lot they should have a say” (pre-session interview, Nursing Student) Following the IPE training session, not only did nursing students better understand their role, they felt empowered to actively participate in that role by contributing vital information to the team: “It also made us realize how much power we have as nurses to share information and be able to get the physician on the same page as us.” (post-session interview, Nursing Student) In contrast, surgical interns did not identify the same initial “failure” to recognize a nurse's value on the team. In fact, presession comments tended to underscore an awareness of this value, and a tentative “hope” that this value, reflected in active nurse engagement in team efforts, would actually occur during patient care: “So my hope would be that [the nurse would] willingly give that information and supply it, so that, then, as a physician, I could respond and, at least be fully informed” (pre-session interview, Surgical Intern) Following the session, surgical intern participants expressed recognition of the nurse's value, and gratitude that this hoped-for support and participation had been realized: “Nurses helped me a lot when I was trying to figure out stuff, they had the information ready and reminded me … it was nice to have that support.” (post-session interview, Surgical Intern) Thus, for nurses, participation in the IPE training sessions provided them with an opportunity to explore the value they bring to
“And a lot of the times the nurses are doing all the hands-on work and the doctors come through and talk to the patients for like 5 minutes and they give the orders and they're off the unit.” (Pre-session interview, Nursing Student) After the IPE training session, nursing students noticed that, although some interns chose to make decisions and act without nursing input, there were also those that collaborated well. Importantly, nursing students also noted that the surgical interns that collaborated well performed more successfully during the simulation: “I think there are definitely some doctors, residents, that were really open to getting information from nurses and seeing the nurse as a team. But there were a few doctors that definitely saw it as a hierarchy.” (Post-session interview, Nursing Student) The theme of Lack of Teamwork identified by the nursing students related closely to their sense of the team hierarchy. While the IPE training session did not dispel their belief that a hierarchy exists within the healthcare team, it did allow them to appreciate how individual physicians might vary in their approach to this hierarchical structure. While physicians might always fill the role responsible for “writing orders”, for example, some physicians will be more open to questions or input from nurses regarding those orders. This seemed to reflect a new understanding that a doctor's performance on a team is less related to their role as physician, and more dependent on an individual's capacity for open information sharing and the principles of good teamwork. 4. Discussion IPE training targeted at improving communication and collaboration amongst healthcare team members is a rapidly growing field of study. The importance of the ability of healthcare professionals to effectively and efficiently function as members of a team is underscored by the widespread incorporation of this “skill” into our modern day nursing and physician educational curricula. Simulation based IPE in particular creates a low-risk environment where individuals can learn about each other from each other. Competencies in advancing teamwork, according to IPEC, include the ability to share accountability, to support collaboration, and to develop shared ethical principles.1 Simulation based IPE provides an opportunity to work on these IPEC core competencies and, in turn, potentially reduce technical errors, disruptions, distractions and morbidity and mortality while increasing patient safety.10 Known barriers to inter-professional teamwork and
Please cite this article in press as: Raparla N, et al., A pilot program to improve nursing and surgical intern collaboration: Lessons learned from a mixed-methods study, The American Journal of Surgery (2016), http://dx.doi.org/10.1016/j.amjsurg.2016.10.014
6
N. Raparla et al. / The American Journal of Surgery xxx (2016) 1e7
collaboration include lack of role clarity, absence of respect and trust within the team, and inflexible team hierarchy.11 Previous efforts to target these barriers have used various forms of IPE12e17 but have yielded somewhat conflicting results. One study evaluating the effect of IPE for medical students and nursing students found a positive effect on team communication,12 while another focusing on physicians and nurses found minimal changes in attitudes towards physician-nurse relationships, collaboration, or healthcare teams.13 The JSAPNC survey results provided a quantifiable, albeit somewhat blunt, metric of participant attitudes toward physiciannurse collaboration. Using this tool, we demonstrate that participating surgical interns and nursing students did not differ significantly in their initial “baseline” attitudes toward collaboration. Upon completion of this eight hour, one day IPE training session, however, surgical interns in particular increased both their overall scores and their scores relative to the specific subcategory of “attitudes toward collaboration and shared education”. Nursing students, on the other hand, did not demonstrate a statistically significant increase. Reviewing the pre and post-IPE session scores, one potential explanation for this difference may relate to the slightly higher starting JSAPNC score of nursing students. Meaning, nursing students appeared to enter into the IPE training session with a better attitude toward interprofessional collaboration than the surgical interns. While this finding may relate to differences between nursing and medical student education, it is worth noting that the convenience sample of nursing students used to enroll participants in this study may have played a role. Future studies evaluating the impact of similar training sessions may benefit from a different approach to the selection process, minimizing the selection bias that is inherent in the use of a voluntary convenience sample. It is also important to note that, even though a statistically significant difference was noted for surgical interns, the absolute difference in the pre versus post training scores was small, calling into question the “clinical relevance” of the finding. While acknowledging the small effect, we found it encouraging that the difference was measurable despite the relatively short exposure represented by this one-day IPE training event. Larger effects might be seen if an approach using several iterative sessions over time were employed, or with a larger sample size. Finally, it is reassuring to note that the impact measured by the JSAPNC survey was confirmed and expanded upon by qualitative analysis of the pre and post-session interviews. In structuring this particular IPE session, an attempt was made to identify the appropriate cohort of participating physicians and nurses. Specifically, some effort was made to match the two groups with respect to experience and learner level. Senior nursing students were paired with surgical interns in part because both groups represented relatively early stages in professional training, but not entirely without context for the learning objectives of an IPE session. To that point, it was interesting to note that 80% of nursing students had prior healthcare experience ranging from 6 months to 2 years and 50% of nursing students had prior professional interactions with physicians. Likewise, interns had a similar timeframe of “experience with nurses”, typically extending over the 2 years of medical school clerkships. While interns were slightly older than the nursing students, both interns and nursing students noted that their new roles on the team represented a novel challenge, despite past experience or exposures to healthcare. Both cohorts lacked hands-on practical experience in their new role as resident or nurse, which we felt helped level the playing field with respect to their potential gain from the IPE training session. The qualitative analysis was undertaken to help better elucidate the impact of this IPE training session on the various participants.
The semi-structured interviews were conducted with specific prompts targeting the participant's thoughts, beliefs and experiences related to collaboration between physicians and nurses. Presession interviews were constructed to better understand what pre-conceptions, or possible misconceptions, might exist amongst participants. Misconceptions still play a significant role in today's hospital environment. Physicians and nurses in particular have been found to have significantly different perceptions of nurse autonomy and nurse participation in patient care, as well as the resident's significance and role on the team.12 A recent study of such misconceptions, for example, found that 40% of surveyed nurses did not realize that interns were legally physicians.15 Perceptions in the operating room (OR) vary between surgeon and nurse. A study done by Makary et al., showed that nurses gave surgeons low ratings in terms of teamwork and collaboration, while surgeons rated nurses highly in terms of satisfaction. This was attributed to, among other things, differences in communication. Nurses are taught to communicate patient stories, with an emphasis on their subjective experiences, while surgeons are taught to communicate highlights of a patient's clinical course in a succinct, technical and concise manner.18,19 Understanding these differences can help to overcome them and improve team performance. The qualitative analysis of interview transcripts revealed that Role Definition in particular was a common concern and challenge, a finding supported by previously reported studies.14e17 Of interest in our analysis was the finding that, while clarity around the ‘nurse's role’ was perhaps most in need, participants appreciated the downstream challenge of fully understanding the physicians' role when the exact nature of a nurse's role was still in question. Understanding the inherent inter-dependence of role definition within a team appeared to be one of the more beneficial effects of the IPE session. The theme of Nurse Value emerged as a second important theme. Nurses felt the nature of the value they brought to the team was emphasized and reasserted during their participation in the IPE session. In contrast, the participating surgical interns felt that nurse value was never in doubt, but rather questioned the realization of that value in actual practice. In other words, surgical interns did not seem to question that nurses brought a distinct value to patient care. Rather, their comments focused on whether nurses would be willing to share that value (i.e. their knowledge about the patient, their understanding of a given problem, etc) with the physicians. While previous reports have focused on concerns of nurse autonomy,20 we found this theme of “nurse value” better reflected the pre-existing fears of participants. It was the worry that this value would not be recognized or realized that was assuaged by the training. Finally, the theme of Lack of Teamwork appeared to be a concern voiced primarily by nursing students. This theme was intimately connected to their understanding of the apparent hierarchy of the team. Specifically, nursing students identified the perceived hierarchy (who puts in the “orders”) as being closely related to “lack of teamwork” (the physician as a leader disqualifies them as a team player). While the session did not dispel the belief that hierarchy exists, it did introduce the idea that the role of leader could be held by a “team player” who invited communication and collaboration. This realization is important clinically given previous reports demonstrating nursing preference for a physician they feel can implement the principles of good teamwork.21 Study limitations included the relatively small sample size for each cohort. This limitation was in part overcome by the pre/post study design and the use of the Wilcoxon Signed Rank Test in our analysis. Additional studies with a larger sample size, however, could potentially help differentiate more subtle nuances in the
Please cite this article in press as: Raparla N, et al., A pilot program to improve nursing and surgical intern collaboration: Lessons learned from a mixed-methods study, The American Journal of Surgery (2016), http://dx.doi.org/10.1016/j.amjsurg.2016.10.014
N. Raparla et al. / The American Journal of Surgery xxx (2016) 1e7
impact of IPE, such as the variable impact of this type of training on the individual surgical subspecialties. Another important limitation to note is the use of a convenience volunteer sample for nursing student participants. It is possible that the attitudes or aptitudes of these volunteers differed from those of a broader population of learners. Finally, it is important to comment that a single, one day IPE training session may not be sufficient or ideal. Not only should future studies involve long term follow up of participant attitudes to determine the long-lasting effects of IPE sessions, but the potential role of recurring, reinforcing follow up sessions as well. An approach reflecting a more “distributed practice” approach to IPE may harbor superior results with respect to nurse/physician collaboration and IPE.22 In summary, we found that an eight hour, one day joint interprofessional training session targeting improved communication skills had a positive impact on attitudes toward nurse-physician collaboration primarily amongst physician participants. Specific pre-conceptions or beliefs addressed through IPE were those of role definition, nurse value and barriers to teamwork. This data supports the use of IPE sessions within the curricula of both physicians and nurses. In an era of resource scarcity despite expanding educational expectations, these 8 h, 1 day inter-professional training sessions can be leveraged by programs both large and small seeking to better promote inter-professional collaboration within their curricula. References 1. Interprofessional Education Collaborative. Core Competencies for Interprofessional Collaborative Practice: 2016 Update. Washington, DC: Interprofessional Education Collaborative; 2016. 2. American College of Surgeons. Statement on high-performance teams. Bull. 2010:95. 3. Agency for Healthcare Research and Quality. Making Health Care Safer II: an Updated Critical Analysis of the Evidence for Patient Safety Practices. vol. 211. 2013:472e479. 4. The Joint Commission. The National Patient Safety Goals: Hospital Accreditation Program, 2015. 2016. 5. The Accreditation Council for Graduate Medical Education. The General Surgery Milestone Project. The American Board of Surgery; 2015. 6. American Association of Colleges of Nursing. Competencies and Curricular
7
Expectations for Clinical Nurse Leader Education and Practice. 2013. 7. Interprofessional Education Collaborative Expert Panel. Core Competencies for Interprofessional Collaborative Practice: Report of an Expert Panel. 2011. 8. Ward J, Schaal M, Sullivan J, Bowen ME, Erdmann JB, Hojat M. The jefferson scale of attitudes toward physician-nurse collaboration: a study with undergraduate nursing students. J Interprof Care. 2008;22:375e386. 9. Saldana J. First-cycle coding methods. In: Seaman J, ed. The Coding Manual for Qualitative Researchers. second ed. London: SAGE Publications Ltd; 2013: 91e181. 10. Paige JT, Garbee DD, Brown KM, Rojas JD. Using simulation in interprofessional education. Surg Clin North Am. 2015;95:751e766. http://dx.doi.org/10.1016/ j.suc.2015.04.004. 11. McInnes S, Peters K, Bonney A, Halcomb E. An integrative review of facilitators and barriers influencing collaboration and teamwork between general practitioners and nurses working in general practice. J Adv Nurs. 2015;71: 1973e1985. 12. Brock D, Abu-Rish E, Chiu CR, et al. Interprofessional education in team communication: working together to improve patient safety. BMJ Qual Saf. 2013;22:414e423. 13. Kenaszchuk C, MacMillan K, van Soeren M, Reeves S. Interprofessional simulated learning: short-term associations between simulation and interprofessional collaboration. BMC Med. 2011;9, 29e7015-9-29. 14. Muller-Juge V, Cullati S, Blondon KS, et al. Interprofessional collaboration on an internal medicine ward: role perceptions and expectations among nurses and residents. PLoS One. 2013;8:e57570. 15. Schlitzkus LL, Agle SC, McNally MM, Schenarts KD, Schenarts PJ. What do surgical nurses know about surgical residents? J Surg Educ. 2009;66:383e391. 16. Severson MA, Maxson PM, Wrobleski DS, Dozois EJ. Simulation-based team training and debriefing to enhance nursing and physician collaboration. J Contin Educ Nurs. 2014;45:297e303. quiz 304e5. 17. Wang R, Shi N, Bai J, Zheng Y, Zhao Y. Implementation and evaluation of an interprofessional simulation-based education program for undergraduate nursing students in operating room nursing education: a randomized controlled trial. BMC Med Educ. 2015;15, 115e015-0400-8. 18. Makary MA, Sexton JB, Freischlag JA, et al. Operating room teamwork among physicians and nurses: teamwork in the eye of the beholder. J Am Coll Surg. 2006;202:746e752. doi: S1072-7515(06)00117-7. 19. Carney BT, West P, Neily J, Mills PD, Bagian JP. Differences in nurse and surgeon perceptions of teamwork: implications for use of a briefing checklist in the OR. AORN J. 2010;91:722e729. http://dx.doi.org/10.1016/j.aorn.2009.11.066. 20. Muller-Juge V, Cullati S, Blondon KS, et al. Interprofessional collaboration between residents and nurses in general internal medicine: a qualitative study on behaviours enhancing teamwork quality. PLoS One. 2014;9:e96160. 21. Braun HJ, O'Sullivan PS, Dusch MN, Antrum S, Ascher NL. Improving interprofessional collaboration: evaluation of implicit attitudes in the surgeonnurse relationship. Int J Surg. 2015;13:175e179. 22. Mitchell EL, Lee DY, Sevdalis N, et al. Evaluation of distributed practice schedules on retention of a newly acquired surgical skill: a randomized trial. Am J Surg. 2011;201:31e39. http://dx.doi.org/10.1016/j.amjsurg.2010.07.040.
Please cite this article in press as: Raparla N, et al., A pilot program to improve nursing and surgical intern collaboration: Lessons learned from a mixed-methods study, The American Journal of Surgery (2016), http://dx.doi.org/10.1016/j.amjsurg.2016.10.014
Contents lists available at ScienceDirect
The American Journal of Surgery journal homepage: www.americanjournalofsurgery.com
A pilot program to improve nursing and surgical intern collaboration: Lessons learned from a mixed-methods study Neha Raparla a, *, Diane Davis b, Daria Shumaker c, Anagha Kumar d, Shabnam Hafiz e, Jack Sava a, e, Katie Adams c, Shimae C. Fitzgibbons a, f a
Georgetown University School of Medicine, 3900 Reservoir Rd. NW, Washington, DC 20007, USA Georgetown University School of Nursing and Health Studies, 3700 Reservoir Rd. NW, Washington, DC 20007, USA MedStar SiTEL, 3007 Tilden Street, NW, Washington, DC 20008, USA d Medstar Health Research Institute, University Town Center, 6535 Belcrest Rd. #700, Hyattsville, MD 20782, USA e MedStar Washington Hospital Center, 110 Irving St. NW, Washington, DC 20010, USA f Medstar Georgetown University Hospital, 3800 Reservoir Rd. NW, Washington, DC 20007, USA b c
a r t i c l e i n f o
a b s t r a c t
Article history: Received 6 April 2016 Received in revised form 9 September 2016 Accepted 20 October 2016
Background: Inter-professional collaboration is an integral component of a successful healthcare team. We sought to evaluate the impact of nursing student participation in a one-day intensive interprofessional education (IPE) training session with surgical interns on participant attitudes toward inter-professional collaboration. Methods: Following IRB approval, pre and post IPE session survey responses were compared to determine the impact on participant attitudes toward inter-professional collaboration. Pre and post session semi-structured interviews were transcribed and analyzed to identify relevant themes. Results: Surgical interns (n ¼ 38) more than nursing students (n ¼ 11), demonstrated a measurable improvement in attitude towards ‘collaboration and shared education’ (interns: median score pre ¼ 26, post ¼ 28, p ¼ 0.0004; nursing student: median score pre ¼ 27, post ¼ 28, p ¼ 0.02). Qualitative analysis of interviews identified major themes that supplemented this finding. Conclusion: An eight hour, one day IPE session has a positive impact on collaborative attitudes and supports the case for increased inter-professional education amongst interns and nursing students. © 2016 Elsevier Inc. All rights reserved.
Keywords: Inter-professional training Communication Collaboration Residents Nursing students Surgery
1. Introduction Interprofessional education (IPE) is an area of increasing focus and attention for health care educators, occurring when “students from two or more professions learn about, from, and with each other to enable effective collaboration and improve health outcomes.1” Collaboration between healthcare professionals is a fundamental component of patient care. In an era emphasizing the team-minded approach to healthcare, collaboration and patient care are seen as increasingly interdependent factors: optimal interprofessional collaboration between team members enhances patient care, while its absence presents a direct threat to effective healthcare delivery. The Interprofessional Education Collaborative (IPEC) has defined particular competency targets for IPE, including
* Corresponding author. E-mail address: [email protected] (N. Raparla).
shared values and ethics, comprehension of individual roles and responsibilities, effective communication, and the ability to perform as a team. Focusing on these competencies, successful IPE allows efficient coordination between healthcare professionals and provides a basis for continued learning and ongoing dialogue.1 In recognition of the importance of this approach to healthcare education, organizations such as the American College of Surgeons, the Agency for Healthcare Research and Quality, and The Joint Commission's National Patient Safety Goals cite inter-professional communication, collaboration and training as essential practices in any healthcare organization seeking to deliver safe patient care.2e4 This national emphasis on interprofessional collaboration has increased the relative importance of this topic within nursing and physician undergraduate and graduate medical education. In fact, inter-professional collaboration is a core competency required of all surgical residents and nursing student graduates.5,6 The Interprofessional Education Collaborative, which includes both the
http://dx.doi.org/10.1016/j.amjsurg.2016.10.014 0002-9610/© 2016 Elsevier Inc. All rights reserved.
Please cite this article in press as: Raparla N, et al., A pilot program to improve nursing and surgical intern collaboration: Lessons learned from a mixed-methods study, The American Journal of Surgery (2016), http://dx.doi.org/10.1016/j.amjsurg.2016.10.014
2
N. Raparla et al. / The American Journal of Surgery xxx (2016) 1e7
American Association of Colleges of Nursing (AACN) and the Association of American Medical Colleges (AAMC), underscored the importance of this topic in its 2011 Core Competencies for Interprofessional Collaborative Practice.7 Within the broader topic of interprofessional collaboration, communication, as a unique and specific skill, is particularly fundamental. Efforts targeting improved collaboration often begin by tackling better interprofessional communication.4 Despite the recognized importance of this skill set for safe practice and patient care, formal training designed to strengthen and improve interprofessional communication is sparse. Effective, feasible options for interprofessional communication training are as yet underdeveloped, resulting in a gap between our proposed national standards and best-practices and the reality of our training systems. To meet this need, we present our efforts to develop an interprofessional training session with surgical interns and nursing students, designed to enhance interprofessional communication and improve attitudes toward interprofessional collaboration. The mixed methods and quasi-experimental approach employed in this pilot study helped us address our initial research questions: Can a one day, eight hour exposure to IPE training, focusing on interprofessional communication, effect a measurable improvement in participant attitudes toward interprofessional collaboration (quantitative arm)? And if a measurable impact is observed, what specific participant knowledge, beliefs or values are most affected or involved (qualitative arm)? 2. Methods 2.1. Study design Expedited Institutional Review Board (IRB) approval was obtained for this study. Participants included post-graduate year (PGY)-1 surgical interns from six university-affiliated general surgery and surgical subspecialty training programs, along with nursing students enrolled in their senior year of a baccalaureate in nursing program at an affiliated university. All surgical interns participating in the graduate medical education orientation at these programs were given the opportunity to consent and enroll in this study. This was done during an orientation lunch break set within a week-long intern on-boarding process. During this break, the study was explained by a member of the research team and written consent forms and the initial pre-IPE training session survey were distributed. Interns choosing to participate completed the consent and the survey at that time. Nursing students were selected via a voluntary convenience sample. All nursing students enrolled in the nursing program were presented with the opportunity to participate. Information regarding the study was distributed by nursing school faculty. The first eleven student volunteers to complete a consent form were included in the study. All study participants completed the Jefferson Scale of Attitudes towards Physician-Nurse Collaboration (JSAPNC) survey, one week prior to and, again, immediately following the IPE training session. The JSAPNC survey is a previously published and validated 4 point Likert-like scale (1 ¼ Strongly Disagree, 4 ¼ Strongly Agree).8 This survey focuses on respondent attitudes toward collaboration, autonomy, caring for the patient, and authority. In addition to completion of the JSAPNC survey, a convenience subset sample of six surgical interns and ten nursing students enrolled in the study participated in individual semi-structured interviews designed to better understand both their pre-existing attitudes toward nurse-physician collaboration, teamwork, and interprofessional training, and their post-session reflections on the impact of this particular event. All participants from the
quantitative portion of the study were contacted to participate in pre and post-IPE training session interviews. Those that consented were interviewed the week prior to the IPE training session. This same subset of six interns and ten nursing students was then interviewed again in the two weeks immediately following the IPE training session. All interviews were audio recorded for later transcription. All interviews were guided by specific question prompts and conducted by an individual not associated with the medical field. Question prompts for the pre-IPE training session interview included: “How you would define optimal physiciannurse collaboration with respect to patient care?”, “Have you had any personal experience with physician-nurse collaboration or patient care that's shaped your opinion?”, “What would you expect to get out of a one day session which included practicing skills related to physician-nurse collaboration in a simulated and supervised setting?”. Question prompts for the post-IPE training session included: “Having participated in the bootcamp session, do you feel your attitude towards physician-nurse collaboration has changed at all?”, “Having participated, do you think you're more able to engage in successful physician-nurse collaboration?”, “Was there anything unexpected about the experience, particularly in relation to working with another health professional?” 2.2. IPE training session The IPE training session was designed as an all-day (eight hour) educational event set within the orientation programming for new surgical interns, held mid-June and prior to the start of the interns' clinical duties. For nursing students, this day took place within the existing curriculum of their senior year. The session was structured to present participants with a series of bedside clinical scenarios. Each scenario required effective nurse and physician communication for successful completion. Participating interns and nursing students were directly observed during the scenario by both a nurse and physician faculty member present at the bedside. A total of 5 scenarios were employed, each with a unique peri-operative clinical challenge: 1) altered mental status, 2) hypotension, 3) oliguria, 4) hypoxemia, and 5) chest pain. Each clinical scenario was designed to be clinically straightforward and to require communication between the intern and the nurse for successful completion. A station was designed to take approximately 10 min (1 min for orientation to the scenario, 6 min to interact with the nurse and patient, and then initiate an initial plan of action, and 3 min for immediate post-session faculty feedback). Before the scenario began, nursing students were provided with clinical information important in the management of the acute peri-operative problem. Each scenario consequently began with the nursing student providing this information via a standardized communication tool (SBAR: Situation, Background, Assessment, and Recommendations) to the intern. Each intern rotated through each of the five clinical stations once. Nursing students also rotated amongst the different clinical scenarios. Unlike the interns, however, nursing students were kept at a given station for several rounds, allowing them to practice the same SBAR communication tool for a patient with chest pain, for example, with several different interns. Feedback sessions were held immediately following the scenarios with both the intern and nursing student, the standardized patient for that scenario, and the physician and nurse faculty observers. 2.3. Analysis 2.3.1. Quantitative JSAPNC scores were graded on a numerical scale. Fifteen questions were graded on a 1 to 4 Likert scale (Strongly agree ¼ 1 to Strongly disagree ¼ 4). Responses were added for a total possible
Please cite this article in press as: Raparla N, et al., A pilot program to improve nursing and surgical intern collaboration: Lessons learned from a mixed-methods study, The American Journal of Surgery (2016), http://dx.doi.org/10.1016/j.amjsurg.2016.10.014
N. Raparla et al. / The American Journal of Surgery xxx (2016) 1e7
value of 60 for each individual survey. Data from the JSAPNC surveys were analyzed via the Wilcoxon Signed Rank Test and the Wilcoxon Rank Sum Test. Comparisons were made between the overall pre-session and post-session scores of participants, and between the pre-session and post-session scores for the subset of responses pertaining specifically to attitudes toward collaboration. The Wilcoxon Signed Rank Test was used for all pre-post comparison calculations. Comparisons between the scores of nursing student participants and surgical intern participants were made using the Wilcoxon Rank Sum Test. The Bonferroni Correction was employed to account for multiple comparisons during the analysis of question subsets. Therefore, each hypothesis was tested at the 0.0125 level so as to maintain a family-wise type I error rate of 0.05. 2.3.2. Qualitative All semi-structured interview transcripts were coded by a single primary reviewer in two rounds of coding. A second supervisory reviewer inspected all transcripts, codes, and interpretations of emerging themes with the primary reviewer. The initial round of coding was applied to all transcripts, and used to better identify the ideal coding approach. Through this process, a set of “in vivo” and “values” codes were selected, and the transcripts were then recoded. In vivo coding consisted of pulling out words or phrases verbatim from the text, focusing on words or phrases appearing repeatedly throughout the different transcripts. Values coding entailed surveying the text for recurring “values, attitudes or beliefs” mentioned frequently in multiple transcripts.9 These codes were used to extract themes from the data with an emphasis placed on relevance to our initial research question, namely: understanding the impact of a one-day intensive interprofessional training session on participant attitudes toward interprofessional collaboration?
3
session (pre-training median score: 56 vs. post-training median score: 56.5, p ¼ 0.43) was observed. In the case of the surgical interns, however, a significant increase was seen between the pretraining and post-training scores (pre-training median score: 54 vs. post-training median score: 55.5, p ¼ 0.004), demonstrating a modest but significant improvement in their attitudes toward physician-nurse collaboration (Fig. 1). Survey response scores were then broken out by sub-category: attitudes toward collaboration, caring for patient, autonomy, and authority. A pre-post comparison of all four categories demonstrated no significant differences between pre and post-session scores for all nursing students (see Fig. 2). However, for surgical interns, a pre-post comparison of all four categories demonstrated a significant difference between pre and post-session scores within the sub-category of “collaboration” (pre-training median collaboration score: 26 vs. post-training median score: 28, p ¼ 0.0004) (Fig. 3). 3.3. Qualitative data analysis Following analysis of the transcribed semi-structured interviews, Role Definition, Value of the Nurse, and Lack of Teamwork emerged as the three most significant, relevant and recurring themes. 3.3.1. Role definition Role definition, or rather the lack of and need for clearer role definition, was a dominant theme identified throughout the interviews. This theme emerged during both nursing student and surgical intern interviews. Nursing students spoke of a basic lack of awareness and understanding of both nursing and physician roles
3. Results 3.1. Demographics All 38 surgical interns enrolled in the orientation program consented to participate in this study, along with 11 nursing students. Of the participating surgical interns, 34.2% were female, with a group mean age of 27 years. 57.9% of participating interns were general surgery interns, with the remaining participants representing orthopedic, urology, neurosurgery, otolaryngology and plastic surgery programs. In contrast to the interns, 100% of nursing students participating in the IPE training session were female, with an average age of 24 years. Of the nursing students, 80% had prior healthcare work experience ranging from 6 months to 2 years. These work experiences were diverse and included smoking cessation outreach, research positions, and health screening. 50% of the nursing students enrolled had no prior experience interacting directly with physicians. 3.2. Quantitative data analysis Of the 38 interns enrolled in the study, 30 interns successfully completed the entire JSAPNC survey. Similarly, of the 11 nursing students enrolled in the study, 10 successfully completed the entire JSAPNC survey. Comparison of the baseline (pre-IPE training session) cumulative JSAPNC survey scores for nursing students versus surgical interns showed no significant difference, indicating that overall attitudes toward physician-nurse collaboration between these two groups was similar (interns: 54, nursing students: 56, p ¼ 0.15). In a pre-post analysis of the cumulative JSAPNC survey scores for nursing students, no change before and after the IPE training
Fig. 1. Comparison of Pre and Post Inter-professional training session JSAPNC survey scores for participating surgical interns and nursing students (Surgical Interns pretraining median score: 54 vs. post-training median score: 55.5, p ¼ 0.004; Nursing student pre-training median score: 56 vs. post-training median p ¼ 0.43). score: 56.5.
Please cite this article in press as: Raparla N, et al., A pilot program to improve nursing and surgical intern collaboration: Lessons learned from a mixed-methods study, The American Journal of Surgery (2016), http://dx.doi.org/10.1016/j.amjsurg.2016.10.014
4
N. Raparla et al. / The American Journal of Surgery xxx (2016) 1e7
Fig. 2. Comparison of Pre and Post Inter-professional training session JSAPNC* survey scores for participating nursing students analyzed by sub-category. (Nursing student pretraining median score for collaboration sub-category: 27 vs. post-training median score: 28, p ¼ 0.02).
on the health care team, while surgical interns focused on how the lack of clarity about the nurse's role in particular made it difficult for them to understand their own place on the team: “I don't really know what doctors do, and I feel like most people in the world don't know what nurses do.” (Pre-session interview, Nursing Student) “I think that what would be productive for me, would be a better understanding of what the nurses are supposed to be
doing … then, that will also help identify, for me, what roles are specific to me, that don't belong to the nurses, so that my responsibilities are clarified” (Pre-session interview, Surgical Intern) Clarity surrounding the roles of nurses and physicians on the team was clearly a concern to both parties during pre-session interviews. Both groups seemed to benefit from the IPE training session, gaining a new confidence as a result of this role clarity. Of
Fig. 3. Comparison of Pre and Post Inter-professional training session JSAPNC* survey scores for participating surgical interns analyzed by sub-category. (Surgical intern pre-training median score for collaboration sub-category: 26 vs. post-training median score: 28, p ¼ 0.0004).
Please cite this article in press as: Raparla N, et al., A pilot program to improve nursing and surgical intern collaboration: Lessons learned from a mixed-methods study, The American Journal of Surgery (2016), http://dx.doi.org/10.1016/j.amjsurg.2016.10.014
N. Raparla et al. / The American Journal of Surgery xxx (2016) 1e7
5
note, interns in particular noted that their lack of understanding stemmed, in part, from having interacted with nurses only as medical students, rather than as full members of the healthcare team. The IPE simulations allowed them to practice as a fully empowered member of the team:
the team. In contrast, for surgical interns, these IPE training sessions seemed to reassure them that the potential value they hoped nurses would bring to the healthcare team was not simply theoretical but, in fact, a reality in practice.
“It was very helpful, I think, having a whole training session and getting to see what [nurses] do and what they need to hear from us.” (Post-Session interview, Surgical Intern)
3.3.3. Lack of teamwork While collaboration and good communication were seen as key attributes of effective teamwork by both cohorts, the theme of “lack of teamwork” was particularly prominent amongst the nursing students before the IPE training session. Specifically, nursing students perceived physicians as solo players, intentionally choosing not to act as team players. They associated physicians with the hierarchical role responsible for giving orders, while at the same time noting that physicians spent a significantly shorter amount of time at the patient's bedside:
“I think it was a good exercise, in terms of comfort, as well as [doctors] kind of understanding what [a nurses] role is in terms of giving that SBAR.” (Post-session interview, Nursing Student) For both nursing students, and new surgical interns, the opportunity to interact with each other while managing a clinical scenario allowed them to explore both their own role, and the role of their fellow team member. By setting this training session within a simulated “real world” clinical scenario, the actual rather than hypothetical contributions of and working relationships between individual team members was apparent. 3.3.2. Nurse value A second major theme to emerge during these interviews was the nursing students' belief that nurses were generally undervalued and, as patient advocates, should have a larger role in decisionmaking. “Since [nurses are] the eyes and [nurses are] with the patient a lot they should have a say” (pre-session interview, Nursing Student) Following the IPE training session, not only did nursing students better understand their role, they felt empowered to actively participate in that role by contributing vital information to the team: “It also made us realize how much power we have as nurses to share information and be able to get the physician on the same page as us.” (post-session interview, Nursing Student) In contrast, surgical interns did not identify the same initial “failure” to recognize a nurse's value on the team. In fact, presession comments tended to underscore an awareness of this value, and a tentative “hope” that this value, reflected in active nurse engagement in team efforts, would actually occur during patient care: “So my hope would be that [the nurse would] willingly give that information and supply it, so that, then, as a physician, I could respond and, at least be fully informed” (pre-session interview, Surgical Intern) Following the session, surgical intern participants expressed recognition of the nurse's value, and gratitude that this hoped-for support and participation had been realized: “Nurses helped me a lot when I was trying to figure out stuff, they had the information ready and reminded me … it was nice to have that support.” (post-session interview, Surgical Intern) Thus, for nurses, participation in the IPE training sessions provided them with an opportunity to explore the value they bring to
“And a lot of the times the nurses are doing all the hands-on work and the doctors come through and talk to the patients for like 5 minutes and they give the orders and they're off the unit.” (Pre-session interview, Nursing Student) After the IPE training session, nursing students noticed that, although some interns chose to make decisions and act without nursing input, there were also those that collaborated well. Importantly, nursing students also noted that the surgical interns that collaborated well performed more successfully during the simulation: “I think there are definitely some doctors, residents, that were really open to getting information from nurses and seeing the nurse as a team. But there were a few doctors that definitely saw it as a hierarchy.” (Post-session interview, Nursing Student) The theme of Lack of Teamwork identified by the nursing students related closely to their sense of the team hierarchy. While the IPE training session did not dispel their belief that a hierarchy exists within the healthcare team, it did allow them to appreciate how individual physicians might vary in their approach to this hierarchical structure. While physicians might always fill the role responsible for “writing orders”, for example, some physicians will be more open to questions or input from nurses regarding those orders. This seemed to reflect a new understanding that a doctor's performance on a team is less related to their role as physician, and more dependent on an individual's capacity for open information sharing and the principles of good teamwork. 4. Discussion IPE training targeted at improving communication and collaboration amongst healthcare team members is a rapidly growing field of study. The importance of the ability of healthcare professionals to effectively and efficiently function as members of a team is underscored by the widespread incorporation of this “skill” into our modern day nursing and physician educational curricula. Simulation based IPE in particular creates a low-risk environment where individuals can learn about each other from each other. Competencies in advancing teamwork, according to IPEC, include the ability to share accountability, to support collaboration, and to develop shared ethical principles.1 Simulation based IPE provides an opportunity to work on these IPEC core competencies and, in turn, potentially reduce technical errors, disruptions, distractions and morbidity and mortality while increasing patient safety.10 Known barriers to inter-professional teamwork and
Please cite this article in press as: Raparla N, et al., A pilot program to improve nursing and surgical intern collaboration: Lessons learned from a mixed-methods study, The American Journal of Surgery (2016), http://dx.doi.org/10.1016/j.amjsurg.2016.10.014
6
N. Raparla et al. / The American Journal of Surgery xxx (2016) 1e7
collaboration include lack of role clarity, absence of respect and trust within the team, and inflexible team hierarchy.11 Previous efforts to target these barriers have used various forms of IPE12e17 but have yielded somewhat conflicting results. One study evaluating the effect of IPE for medical students and nursing students found a positive effect on team communication,12 while another focusing on physicians and nurses found minimal changes in attitudes towards physician-nurse relationships, collaboration, or healthcare teams.13 The JSAPNC survey results provided a quantifiable, albeit somewhat blunt, metric of participant attitudes toward physiciannurse collaboration. Using this tool, we demonstrate that participating surgical interns and nursing students did not differ significantly in their initial “baseline” attitudes toward collaboration. Upon completion of this eight hour, one day IPE training session, however, surgical interns in particular increased both their overall scores and their scores relative to the specific subcategory of “attitudes toward collaboration and shared education”. Nursing students, on the other hand, did not demonstrate a statistically significant increase. Reviewing the pre and post-IPE session scores, one potential explanation for this difference may relate to the slightly higher starting JSAPNC score of nursing students. Meaning, nursing students appeared to enter into the IPE training session with a better attitude toward interprofessional collaboration than the surgical interns. While this finding may relate to differences between nursing and medical student education, it is worth noting that the convenience sample of nursing students used to enroll participants in this study may have played a role. Future studies evaluating the impact of similar training sessions may benefit from a different approach to the selection process, minimizing the selection bias that is inherent in the use of a voluntary convenience sample. It is also important to note that, even though a statistically significant difference was noted for surgical interns, the absolute difference in the pre versus post training scores was small, calling into question the “clinical relevance” of the finding. While acknowledging the small effect, we found it encouraging that the difference was measurable despite the relatively short exposure represented by this one-day IPE training event. Larger effects might be seen if an approach using several iterative sessions over time were employed, or with a larger sample size. Finally, it is reassuring to note that the impact measured by the JSAPNC survey was confirmed and expanded upon by qualitative analysis of the pre and post-session interviews. In structuring this particular IPE session, an attempt was made to identify the appropriate cohort of participating physicians and nurses. Specifically, some effort was made to match the two groups with respect to experience and learner level. Senior nursing students were paired with surgical interns in part because both groups represented relatively early stages in professional training, but not entirely without context for the learning objectives of an IPE session. To that point, it was interesting to note that 80% of nursing students had prior healthcare experience ranging from 6 months to 2 years and 50% of nursing students had prior professional interactions with physicians. Likewise, interns had a similar timeframe of “experience with nurses”, typically extending over the 2 years of medical school clerkships. While interns were slightly older than the nursing students, both interns and nursing students noted that their new roles on the team represented a novel challenge, despite past experience or exposures to healthcare. Both cohorts lacked hands-on practical experience in their new role as resident or nurse, which we felt helped level the playing field with respect to their potential gain from the IPE training session. The qualitative analysis was undertaken to help better elucidate the impact of this IPE training session on the various participants.
The semi-structured interviews were conducted with specific prompts targeting the participant's thoughts, beliefs and experiences related to collaboration between physicians and nurses. Presession interviews were constructed to better understand what pre-conceptions, or possible misconceptions, might exist amongst participants. Misconceptions still play a significant role in today's hospital environment. Physicians and nurses in particular have been found to have significantly different perceptions of nurse autonomy and nurse participation in patient care, as well as the resident's significance and role on the team.12 A recent study of such misconceptions, for example, found that 40% of surveyed nurses did not realize that interns were legally physicians.15 Perceptions in the operating room (OR) vary between surgeon and nurse. A study done by Makary et al., showed that nurses gave surgeons low ratings in terms of teamwork and collaboration, while surgeons rated nurses highly in terms of satisfaction. This was attributed to, among other things, differences in communication. Nurses are taught to communicate patient stories, with an emphasis on their subjective experiences, while surgeons are taught to communicate highlights of a patient's clinical course in a succinct, technical and concise manner.18,19 Understanding these differences can help to overcome them and improve team performance. The qualitative analysis of interview transcripts revealed that Role Definition in particular was a common concern and challenge, a finding supported by previously reported studies.14e17 Of interest in our analysis was the finding that, while clarity around the ‘nurse's role’ was perhaps most in need, participants appreciated the downstream challenge of fully understanding the physicians' role when the exact nature of a nurse's role was still in question. Understanding the inherent inter-dependence of role definition within a team appeared to be one of the more beneficial effects of the IPE session. The theme of Nurse Value emerged as a second important theme. Nurses felt the nature of the value they brought to the team was emphasized and reasserted during their participation in the IPE session. In contrast, the participating surgical interns felt that nurse value was never in doubt, but rather questioned the realization of that value in actual practice. In other words, surgical interns did not seem to question that nurses brought a distinct value to patient care. Rather, their comments focused on whether nurses would be willing to share that value (i.e. their knowledge about the patient, their understanding of a given problem, etc) with the physicians. While previous reports have focused on concerns of nurse autonomy,20 we found this theme of “nurse value” better reflected the pre-existing fears of participants. It was the worry that this value would not be recognized or realized that was assuaged by the training. Finally, the theme of Lack of Teamwork appeared to be a concern voiced primarily by nursing students. This theme was intimately connected to their understanding of the apparent hierarchy of the team. Specifically, nursing students identified the perceived hierarchy (who puts in the “orders”) as being closely related to “lack of teamwork” (the physician as a leader disqualifies them as a team player). While the session did not dispel the belief that hierarchy exists, it did introduce the idea that the role of leader could be held by a “team player” who invited communication and collaboration. This realization is important clinically given previous reports demonstrating nursing preference for a physician they feel can implement the principles of good teamwork.21 Study limitations included the relatively small sample size for each cohort. This limitation was in part overcome by the pre/post study design and the use of the Wilcoxon Signed Rank Test in our analysis. Additional studies with a larger sample size, however, could potentially help differentiate more subtle nuances in the
Please cite this article in press as: Raparla N, et al., A pilot program to improve nursing and surgical intern collaboration: Lessons learned from a mixed-methods study, The American Journal of Surgery (2016), http://dx.doi.org/10.1016/j.amjsurg.2016.10.014
N. Raparla et al. / The American Journal of Surgery xxx (2016) 1e7
impact of IPE, such as the variable impact of this type of training on the individual surgical subspecialties. Another important limitation to note is the use of a convenience volunteer sample for nursing student participants. It is possible that the attitudes or aptitudes of these volunteers differed from those of a broader population of learners. Finally, it is important to comment that a single, one day IPE training session may not be sufficient or ideal. Not only should future studies involve long term follow up of participant attitudes to determine the long-lasting effects of IPE sessions, but the potential role of recurring, reinforcing follow up sessions as well. An approach reflecting a more “distributed practice” approach to IPE may harbor superior results with respect to nurse/physician collaboration and IPE.22 In summary, we found that an eight hour, one day joint interprofessional training session targeting improved communication skills had a positive impact on attitudes toward nurse-physician collaboration primarily amongst physician participants. Specific pre-conceptions or beliefs addressed through IPE were those of role definition, nurse value and barriers to teamwork. This data supports the use of IPE sessions within the curricula of both physicians and nurses. In an era of resource scarcity despite expanding educational expectations, these 8 h, 1 day inter-professional training sessions can be leveraged by programs both large and small seeking to better promote inter-professional collaboration within their curricula. References 1. Interprofessional Education Collaborative. Core Competencies for Interprofessional Collaborative Practice: 2016 Update. Washington, DC: Interprofessional Education Collaborative; 2016. 2. American College of Surgeons. Statement on high-performance teams. Bull. 2010:95. 3. Agency for Healthcare Research and Quality. Making Health Care Safer II: an Updated Critical Analysis of the Evidence for Patient Safety Practices. vol. 211. 2013:472e479. 4. The Joint Commission. The National Patient Safety Goals: Hospital Accreditation Program, 2015. 2016. 5. The Accreditation Council for Graduate Medical Education. The General Surgery Milestone Project. The American Board of Surgery; 2015. 6. American Association of Colleges of Nursing. Competencies and Curricular
7
Expectations for Clinical Nurse Leader Education and Practice. 2013. 7. Interprofessional Education Collaborative Expert Panel. Core Competencies for Interprofessional Collaborative Practice: Report of an Expert Panel. 2011. 8. Ward J, Schaal M, Sullivan J, Bowen ME, Erdmann JB, Hojat M. The jefferson scale of attitudes toward physician-nurse collaboration: a study with undergraduate nursing students. J Interprof Care. 2008;22:375e386. 9. Saldana J. First-cycle coding methods. In: Seaman J, ed. The Coding Manual for Qualitative Researchers. second ed. London: SAGE Publications Ltd; 2013: 91e181. 10. Paige JT, Garbee DD, Brown KM, Rojas JD. Using simulation in interprofessional education. Surg Clin North Am. 2015;95:751e766. http://dx.doi.org/10.1016/ j.suc.2015.04.004. 11. McInnes S, Peters K, Bonney A, Halcomb E. An integrative review of facilitators and barriers influencing collaboration and teamwork between general practitioners and nurses working in general practice. J Adv Nurs. 2015;71: 1973e1985. 12. Brock D, Abu-Rish E, Chiu CR, et al. Interprofessional education in team communication: working together to improve patient safety. BMJ Qual Saf. 2013;22:414e423. 13. Kenaszchuk C, MacMillan K, van Soeren M, Reeves S. Interprofessional simulated learning: short-term associations between simulation and interprofessional collaboration. BMC Med. 2011;9, 29e7015-9-29. 14. Muller-Juge V, Cullati S, Blondon KS, et al. Interprofessional collaboration on an internal medicine ward: role perceptions and expectations among nurses and residents. PLoS One. 2013;8:e57570. 15. Schlitzkus LL, Agle SC, McNally MM, Schenarts KD, Schenarts PJ. What do surgical nurses know about surgical residents? J Surg Educ. 2009;66:383e391. 16. Severson MA, Maxson PM, Wrobleski DS, Dozois EJ. Simulation-based team training and debriefing to enhance nursing and physician collaboration. J Contin Educ Nurs. 2014;45:297e303. quiz 304e5. 17. Wang R, Shi N, Bai J, Zheng Y, Zhao Y. Implementation and evaluation of an interprofessional simulation-based education program for undergraduate nursing students in operating room nursing education: a randomized controlled trial. BMC Med Educ. 2015;15, 115e015-0400-8. 18. Makary MA, Sexton JB, Freischlag JA, et al. Operating room teamwork among physicians and nurses: teamwork in the eye of the beholder. J Am Coll Surg. 2006;202:746e752. doi: S1072-7515(06)00117-7. 19. Carney BT, West P, Neily J, Mills PD, Bagian JP. Differences in nurse and surgeon perceptions of teamwork: implications for use of a briefing checklist in the OR. AORN J. 2010;91:722e729. http://dx.doi.org/10.1016/j.aorn.2009.11.066. 20. Muller-Juge V, Cullati S, Blondon KS, et al. Interprofessional collaboration between residents and nurses in general internal medicine: a qualitative study on behaviours enhancing teamwork quality. PLoS One. 2014;9:e96160. 21. Braun HJ, O'Sullivan PS, Dusch MN, Antrum S, Ascher NL. Improving interprofessional collaboration: evaluation of implicit attitudes in the surgeonnurse relationship. Int J Surg. 2015;13:175e179. 22. Mitchell EL, Lee DY, Sevdalis N, et al. Evaluation of distributed practice schedules on retention of a newly acquired surgical skill: a randomized trial. Am J Surg. 2011;201:31e39. http://dx.doi.org/10.1016/j.amjsurg.2010.07.040.
Please cite this article in press as: Raparla N, et al., A pilot program to improve nursing and surgical intern collaboration: Lessons learned from a mixed-methods study, The American Journal of Surgery (2016), http://dx.doi.org/10.1016/j.amjsurg.2016.10.014