- Email: [email protected]
New rules for the game: Interdisciplinary education for health professionals
New Rules for the Game: Interdisciplinary Education for Health Professionals Elaine L. Larson,
RN, PhD, CIC, FAAN
To enhance interdisciplinary collaboration among medicine and nursing, and to better respond to societal health care needs, we must take a serious look at the educational systems that socialize young health professionals into their respective roles.
I
n 1967 the term "doctor-nurse game" was coined by Stein 1 in the Archives of General Psychiatry. The term caught on and has appeared intermittently in the literature over the past three decades. 24 The object of the game is to preserve the interactive roles traditionally held by the physician and nurse in clinical practice, with the physician seemingly the sole decision maker and team leader, and the nurse "allowed" to make recommendations as long as she appeared passive. Open disagreement was to be avoided at all costs. Rewards for playing the game well included respect for the nurse (a "damn good nurse") and smooth facilitation of work for the physician. The genesis of the game was attributed to differences in the education of medical and nursing professionals. It was suggested that medical students, inundated with facts vital to life and death and often trained in a confrontational interview style, developed a phobia of
NURS OUTLOOK 1995;43:180-5. Copyright o 1995 by Mosby-Year Book, Inc. 0029-6554/95155.00+ 0 3511151728
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making a mistake. As a p r o t e c t i v e mechanism, physicians adopted a defensive posture in which they attempted to be perceived as omniscient and all powerful. The game was thought to be learned during graduate training, when the physician felt pulled between the need to give patients the best care possible, which sometimes meant seeking advice from the nurse, and the need to protect the facade of omnipotence. Nursing students began their socialization to the game during school, in programs that were disciplined and inflexible. Their time was carefully, even militantly, controlled, and virtues such as duty, discipline, self-control, and obedience were extolled. Nursing students learned to be wary of independent decision making. A nurse writing in 1917 expressed the prevailing belief of that time: In my estimation obedience is the first law and the very cornerstone of good nursing . . . . No matter how gifted she may be, she will never become a reliable nurse until she can obey without question. 5 In the mid-1960s, at about the time
when "The Doctor-Nurse Game" was published, an experiment was conducted in which 22 nurses were given a telephone order by a physician for an obvious overdose of a drug. Twenty-one of the nurses said that they would have given the drug without question. 6 While nurses were socialized to a dependent role, they were also told that their skills were vital to the welfare of the patient and an invaluable asset to the physician. Thus the nurse and the physician were caught in a paradox, and the doctor-nurse game allowed a reasonable mechanism for maintaining the integrity of their respective perceived roles, while also facilitating patient care delivery. In 1990 Stein proposed that the game had changed as a result of changes in public perceptions of the physician, increasing numbers of women entering medicine, a shortage of nurses, the increasing responsibilities and authority of nurses, and changes in nursing education away from hospital-based training to the academic setting. 2 The game did not work any more because one of the players (the nurse) had decided to stop playing, expressing a desire for more autonomy and a more collaborative role as a partner in the health care team. At this point nurses' reactions to the game sometimes became defensive, overdetermined, assertive, and even hostile as they sought recognition. Physicians' reactions ranged from tentative support to puzzlement to feelings of betrayal and anger. They perceived that nurses were abandoning their focus on patient care and bemoaned the fact that
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nurses had been distracted by their own desire for recognition and status. On an individual level, roles may have changed little. Pillitteri and Ackerman, 3 in a content analysis of house officer journals from 1888 and 1990, concluded that physician-nurse interactions over the century were more similar than different, although the 1888 journal was more likely to mention instances of collaboration. On a professional level, however, roles for nurses have expanded rapidly to include research, academics, administration, and advanced practice. Thus the rules of the doctor-nurse game have changed, and new models for interdisciplinary interactions are needed. Current resource restraints and paradigm changes associated with health care reform bring additional challenges to the relationships. The changing health needs of the public have mandated a rethinking of the roles of the various disciplines. The Pew Health Professions Commission has identified the following competencies for health professions of the future: community health focus, delivery of contemporary clinical care, expanded accountability, appropriate use of technology and cost-effective care, prevention/promotion of healthy lifestyles, patient and family involvement in decision making, and information management with an orientation to lifelong learning. 7 If such competencies are to be acquired, there needs to be significant reordering of disciplinary priorities, revolutions in the curricula and practice of health professionals, and changes in their relationships with each other. Many barriers to change have been identified: mind-set, incentives, the value of preserving tradition, professional identity and territoriality, and a highly structured practice environment) Nevertheless, the options for relationships among the health professions, particularly medicine and nursing, are few: active battle and conflict, parallel play and potential competition (the Pentagon's description of peace as "permanent prehostility" might appropriately describe this situation), or collaborative practice. NURSING OUTLOOK
Nursing16-18
MedicaP s • Too diffuse, uncoordinated • Too long, redundant • Too much encouragement of specialization • Too linked to hospital reimbursement
• Lockstep, inflexible curriculum and authoritatian, passive teaching methods • Focus on specialized, fragmented acute care • Inadequate attention to lifelong learning process (e.g. critical thinking, decision-making collaboration) • Segregation of nursing practice and education
In this article I discuss the evidence that collaboration has positive effects on patient and provider outcomes, review recent recommendations for the reform of health care professional education, examine the extent to which the current educational curricula for physicians and nurses are designed to enhance an interdisciplinary, collaborative approach to practice, and make recommendations for educational approaches to better prepare physicians and nurses to work together. MEDICINE-NURSING COLLABORATION
In a recent article Fagin4 summarized studies of inpatient care and care of elders demonstrating positive patient outcomes and cost-effectiveness associated with physician-nurse collaboration. Additionally, collaboration has been associated with increased nurse self-esteem, improved job satisfaction, and a decline in moral outrage associated with moral dilemmas?ql Research on collaboration has focused on nurse, not physician, outcomes. This may be because successful collaboration occurs between persons who perceive themselves to be peers and to have shared goals. Since the balance of power continues to be weighted toward the physician, nurses may place more value on and be more inclined toward seeking an interdisciplinary practice than their physician counterparts. Over a decade ago, Mechanic and Aiken ~2 recognized that, although the complexities of health care had increased and the need for interdisciplinary collaboration was even more imperative, "medical schools and nursing
JULY/AUGUST 1995
schools have become increasingly isolated from one another." They urged that medical and nursing schools develop closer ties to improve the education of physicians and nurses and "to set the stage for more effective collaboration in the future." Others have noted that collaboration is difficult to establish in the acute tertiary care setting because young, highly stressed and inexperienced professionals (graduate nurses and house officers) are trying to develop interpersonal working relationships while
Faculty members themselves are not role models of collaborative interaction. at the same time gaining proficiency in clinical skills.i3 Education was identified by Fagin4 as one of the several barriers to collaboration in health care. Bulger and Bulger 14 pointed out that another obstacle to collegiality in the academic health center is the competitive nature of the research and service enterprises between and within departments and schools. Thus faculty members are not role models themselves of collaborative interaction. C O L L A B O R A T I O N IN CURRICULUM REFORM
Curriculum problems currently identified from within the two professions reflect real problems based on their historical roots--the need by the physician Larson
181
to be all-knowing and the need by the nurse to be competent, organized, and obedient. For example, problems identified in graduate medical education relate to the high costs and the amount of content covered, 15 whereas problems identified within nursing education relate more to the processes of learning 1618
(Box 1). There has been increasing discussion of the need for curriculum reform in both the medical and nursing literature, and a few groups such as the National League for Nursing and the Pew Health Professions Commission have highlighted the importance of collaboration and interdisciplinary socialization 19"25
(Box 2). Nevertheless, curriculum reform in medicine and nursing is occurring. For example, The Johns Hopkins University School of Medicine recently introduced its largest curriculum revision since 1893. Changes include the integration of clinical and basic sciences from the beginning of undergraduate training, an early introduction to community experiences, a more flexible curriculum with more interactive learning, but no courses in which the health disciplines are formally taught together. 26 A number of medical schools are considering some aspects of problem-oriented learning. The National League for Nursing and the American Association of Colleges of Nursing, the two major organizations concerned with nursing education, both published recommendations for major nursing education reform in 1993.18'2v But to date most reform efforts have emanated from and remain focused and segregated within the single disciplines. Bulger28 has commented: If the academic health c e n t e r . . , is to grow beyond the conservative and protective role of preserving the status quo and is to become more effective at helping with appropriate societal adjustments to new realities and new futures, then we must extend beyond our reductionist disciplines and specialties, without diminishing or denying them, and embrace cross-professional and interdisciplinary, integrative approaches to the individual and social value issues that confront us all. 182
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1. Josiah Macy Jr. Foundation. Proceedings of a conference chaired by Thomas Q. Morris. Taking charge of graduate medical education: To meet the nation's needs in the 21st century. 44 E. 64th Street, New York, NY 10021. Phone: 212-486-2424 1993 1. Establish federal commission on graduate medical education (GME) to • develop policies for funding and number of resident positions by specialty and geography. • direct allocation of GMe funds. • replace current commission. 2. Reorganize Accreditation Council on Graduate Medical Education to increase independence but maintain responsibility for educational standards. 3. Continue funding GME through Medicare Direct Medical Education Allowance. 4. Encourage innovation in GME curricula to address societal needs and new practices. 2. Pew Health Professionals Commission. Health professions education for the future: Schools in the service to the nation. 1388 Sutter St., Suite 805, San Francisco, CA 94109. Phone: 415-476-8181 February1993 1. Build from a foundation of values. 2. Concentrate on core educational activities. 3. Redefine political and economic relationships. 4. Focus on the health needs of the community. 5. Strengthen tools for change.
3. Bureau of Health Professions. An agenda for health professions reform. USDHHS. Public Health Service Health Resource and Services Administration 5600 Fishers Lane, Rockville, MD 20857 February1993 1. Promote primary care education. 2. Strengthen and expand public health education and practice. 3. Expand the capacity of nursing and allied health professions to meet the increasing demand for services. 4, Increase numbers of health care providers from minority/disadvantaged backgrounds. 5. Promote educational strategies to recruit and retain health care providers for underserved populations. 6. Advance continuous quality improvement in health professions education and practice. 7. Strengthen health professions data, information systems, and education research. 4 American Association of Colleges of Nursing. Nursing education's agenda for the 21st century. One Dupont Circle, NW, Suite 530, Washington, DC 20036 Phone: 202-463-6930 March 1993 1. Comprehensive review of mission for relevance to health care needs. 2. Organizational structure that facilitates new initiatives. 3. Redefine faculty scholarship to include practice. 4. Recruitment and retention of diverse student body. 5. Emphasize curricular processes that develop critical thinking, ethical decision-making, interdisciplinary participation, coordination, etc. 6. Curriculum content should include health promotion and maintenance; economics; ethical, legal, political principles; informatics. 7. Program evaluation and outcomes are integral in the curriculum. 8. Enhance integration of nursing research into schools and the mainstream scientific community. Continued on next page
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Box 2. Continued.
5. Council on Graduate Medical Education (prepared by ME Whitcomb, Director, Program for Health Policy and Health Services Research, the Ohio State University). Physician Workforce Policy: Goals, strategies, options, implementation issues, and legislative proposals 515 N. State Street, Chicago, IL 60610. Phone: 312-464-5472 June 1993 1. Congress should enact legislation to establish a federal GME Funding Pool to be administered by DHHS. 2. Congress should amend PHS Act (Title VII) to direct existing primary care grant funds to support undergraduate generalist medical education programs, 6. National League for Nursing. A vision for nursing education. National League for Nursing 350 Hudson Street, New York, NY 10014. Phone: 212-989-9393 1. Rethink mission of nursing education to promote quality for care and to create linkages for service. 2. Increasingly plan educational experiences when people are home, school, work, long-term care, etc. 3. Curricular reform • to match needs of health environment. • to focus on processes such as critical thinking, shared decision-making collaboration. 4. Faculty reform to focus on the scholarship of application.
June 1993
7. Alliance for Health Reform. Commanding Generalists: Increasing the availability of community-based primary care practitioners. 1133 20th Street, NW, Suite 220, Washington, DC 20036 Phone: 202-466-5626 July 1993 1. Change health professional schools' admissions policies. 2. Modify health professional schools' curriculum and environment to give students primary care experience in community settings. * primary care experience in community settings. • understanding of behavioral and social components of health and illness. • exposure to multidisciplinary teams. 3. Increase supply to nurse practitioners, nurse midwives, physician assistants and others. 4. Retrain specialists as generalists. 8. Association of American Medical Colleges. Academic Medicine and Health Care Reform: Graduate Medical Education. AAMC, 2450 N. Street, NW, Washington, DC 20037 Phone:202-828-4000 July 1993 1. Create incentive program to encourage medical students to choose careers to meet physician supply goals. 2. Require a national fund from all public and private payees of health care services to support GME. 3. Establish a National Physician Resources Commission. 4. Create formal "graduate medical education consortium." 5. Continue to accredit medical programs on the basis of established educational criteria. 6. Payments for GME should be congruent with actual costs and should be made to the organization or entity that incurs the costs. 7. Make transitional relief funds available to teaching hospitals that lose residency positions. 8. Continue to support educational costs through Medicare program.
To further assess the extent to which schools of medicine and nursing are seeking opportunity to socialize students together, we contacted approximately half NURSING OUTLOOK
of the academic health centers (n = 35) that have both schools. At only five centers (14.3%) was even one interdisciplinary course available; two centers had
JULY/AUGUST 1995
such courses planned for the future; and four others had offered such courses in the past, but they had been discontinued. Four of the five courses offered were electives for medical and nursing students and occasionally others, such as law, pharmacy, social work, or dentistry. Included were such topics as AIDS, ethics, family violence, adolescent health, human behavior, and growth and development. In one academic health center, second degree nursing students and undergraduate medical students took a required course together, in which they learned such skills as interviewing, history taking, physical assessment, epidemiology, and concepts of illness and wellness. An additional component, required for nursing and elective for medical students, included a half-day/week clinical experience, during which students were paired in community centers to practice assessment skills and be exposed to primary care. A second center had previously had a year-long community-based course for fourth-year nursing students and first-year medical students to learn collaboration and roles in primary care and concepts related to chronic illness. Another center was planning a joint community health clinical practicum/clerkship that would be required for medical and advanced nursing students. Institutions with no interdisciplinary curriculum or programs, and those centers at which such programs had been discontinued, cited three major barriers: costs, faculty attitudes, and difficulties in scheduling. Time required to plan and tO implement the programs was intensive; class times and schedules usually differed among the health professions schools; and a sustained high level of commitment to an interdisciplinary approach was necessary on the part of faculty members of all schools involved. The Kellogg Community Partnerships Initiative is funding some interdisciplinary education/service projects designed to bring the health professions together in the community. For example, the three academic health centers in West Virginia have formed a coalition that involves about 600 nursing, mediLarson
183
cal, pharmacy, and dental students each year in a minimum of 3 months of experience in rural health. The project covers 51 counties, all but two in the entire state. T h e C e n t e r for C o m m u n i t y Health Education, Research and Service involves Boston University School of Medicine and the School of Nursing at Northeastern University in a partnership in which nursing and medical students work a half day to a day and a half each week in the community for the entire duration of their undergraduate education. Social work, public health, and dental students are scheduled to be added to the program. But such efforts remain the exception.
A t only five centers was even one interdisciplinary course available. B U I L D I N G T H E BASE FOR COLLABORATION The Pew Health Professions Commission emphasizes that to focus on the health needs of the public, we must approach the task from a generalist-interdisciplinary orientation. 29 Accomplishing this
tion. ''3° Such structures will require close interdisciplinary linkages, and are not likely to emerge without external incentives. These incentives will come from federal policy related to financial support of health professions education, state policy related to practice acts and licensing regulations, p r o f e s s i o n a l policy with regard to a c c r e d i t a t i o n guidelines and professional standards, and policies w i t h i n i n s t i t u t i o n s of higher education. The 1993 Pew Report suggests the following higher education policies: • E n c o u r a g e h e a l t h professions schools to develop clear and distinctive strategic directions tied to the overall mission of the university. • Provide more integration between academic programs of the health professions schools and the rest of campus. • E n c o u r a g e h e a l t h professions schools to develop creative organizational structures, partnerships, and financial arrangements in order to meet their strategic directions. • Consider the work of the health professions schools in the overall service mission of the university. • Insist on routine and timely evaluation of all programs in the context of the mission of the university and school. 29
will require the alteration of some organizational structures and the development of new and different relationships with affiliated institutions and community-based practitioners. In part, these needs will be met by working across professional lines in clinical settings and by courses aimed at instilling the value of primary care, providing the skills necessary to maintain primary cfire, and promoting the teamwork skills vital to participation in primary care.
In January 1994 Mundinger 31 discussed the place of advanced nurse practitioners in primary care, citing evidence from a number of clinical trials and other studies conducted over the past three decades that demonstrate that nurse practitioners provide high- quality, costeffective care within the scope of their practice. She advocated a collaborative practice model in which
Single-discipline curriculum changes are insufficient unless accompanied by organization and structures that allow cross-fertilization between disciplines: The Alliance for Health Reform advises that "schools should have centralized authority for education that would be multidisciplinary and include both undergraduate and g r a d u a t e educa-
nurse practitioners bear the principal responsibility for the diagnosis and management of uncomplicated illness and provide the education, counseling, and management of disease prevention and health promotion . . . . The physician will always be the primary professional providing diagnosis and treatment in complex cases and managing critical and unstable medical conditions.
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She argued that patients in those practices receive more comprehensive and satisfying care than they would be given in practices composed of physicians only or nurses only. The primary point of a responding editorial was that many of the studies demonstrating efficacy of nurse practitioner performance were flawed in some w a y . 32 This objection was raised despite the fact that primary care delivered by nurse practitioners in a variety of settings has been studied more thoroughly than the care of any other provider. Certainly we need such research, but on the outcomes, costs, quality, and efficiency of care delivered by a variety of providers, not just nurse practitioners, as well as on collaborative models that might be put to trial. That we need more research should not be used as a smoke screen for maintaining the status quo. Rather, clinical studies should be incorporated as part of evaluation plans as new models emerge. Despite the barriers and disincentives to reaching out beyond disciplinary boundaries, the game has changed. Old roles do not work anymore. Academic health centers are one place where change must begin because of their role in the initial socialization and education of a variety of health professionals. Programs such as the Kellogg Community Partnership Initiative are evidence that given appropriate incentives, structure and process will be directed toward a collaborative approach. • I acknowledge the collaborative support and review of the manuscript by Dr. John Griffith, executive vice president for health sciences, Georgetown University. REFERENCES 1. Stein LI. The doctor-nurse game. Arch Gen Psychiatry 1967;16:699-703. 2. Stein LI, Watts DT, Howell T. The doctornurse game revised. N Engl J Med 1990; 322:546-9. 3. Pillitteri A, Ackerman M. The "doctor-nurse game":a comparisonof 100 years---1888-1990. NuRs OUTLOOK1993;41:113-6. 4. FaginCM. Collaborationbetween nurses and physicians: no longer a choice. Acad Med 1992;67:295-303. 5. Dock S. The relation of the nurse to the doc-
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tor and the doctor to the nurse. Am J Nurs 1917;17:394. 6. Hofling CK, Brotzman E, Dalrymple S, Graves N, Pierce CM. An experimental study in nursephysician relationships. J Nerv Ment Dis 1966;143:171-80. 7. Pew Health Professions Commission. Healthy America: practitioners for 2005. San Francisco: Pew Health Professions Commission, 1992. 8. Evans SA, Carlson R. Nurse-physician collaboration: solving the nursing shortage crisis. J Am Coil Cardiol 1992;20:1669-73. 9. Baldwin A, Welches L, Walker DD, Eliastom M. Nurse self-esteem and collaboration with physicians. West J Nuts Res 1987;9:107-14. 10. Pike AW. Moral outrage and moral discourse in nurse-physician collaboration. J Prof Nurs 1991;7:351-62. 11. Baggs JB, Ryan SA. ICU nurse-physician collaboration and nursing satisfaction. Nurs Econ 1990;8:386-92. 12. Mechanic D, Aiken LH. A cooperative agenda for medicine and nursing. N Engl J Med 1982;307:747-50. 13. Makodon HJ, Gibbons ME Nurses and physicians: prospects for collaboration [Editorial]. Ann Intern Med 1985;103:134-6. 14. Bulger RJ, Bulger RE. Obstacles to collegiality in the academic health center Bull NY Acad Med 1992;68:303-7. 15. Ebert RH, G inzberg E. The future of graduate medical education: fine tuning is not enough.
In: Morris TQ, Sirica CM, eds. Taking charge of graduate medical education: to meet the nation's needs in the 21st century. New York: Josiah Macy, Jr. Foundation, 1993:9-12. 16. de Tornyay R. The curriculum revolution [Editorial]. J Nurs Educ 1990;29:292-4. 17. Allen DG. The curriculum revolution: radical revisioning of nursing education. J Nurs Educ 1990;29:312-6. 18. American Association of Colleges of Nursing. Nursing education's agenda for the 21st century. Washington: American Association of Colleges of Nursing, 1993. 19. Kendall PL, Reader GG. Innovations in medical education of the 1950s contrasted with those of the 1970s and 1980s. J Health Soc Behav 1988;29:279-93. 20. Stillman PL, Hanshaw JB. Education of medical students: present innovations, future issues [Editorial]. Mayo Clin Prac 1989;64:1175-9. 21. Ende J, Atkins E. Conceptualizing curriculum for graduate medical education. Acad Med 1992;67:528-34. 22. French P, Cross D. An interpersonal-epistemological curriculum model for nurse education. J Adv Nurs 1992;17:83-9. 23. de Tornyay R. Reconsidering nursing education: the report of the Pew Health Professions Commission. J Nurs Educ 1992;31:296-301. 24. Allen DG. The curriculum revolution: radical re-vision of nursing education. J Nurs Educ 1990;29:312-6.
25. Regan PE The three r's: recruitment, restructuring the environment and reformulating the curriculum. Nurs Clin North Am 1990;25:51724. 26. Centofanti M. Carving out the next generation of physicians Johns Hopkins Magazine 1992;44:56-9. 27. National League for Nursing. A view for nursing education. New York: National League for Nursing, 1993. 28. Bulger RJ. The role of America's academic health centers in a reformed health system. J Am Health Policy 1992;2:35-8. 29. Pew Health Professions Commission. Health professions education for the future: schools in service to the nation. San Francisco: Pew Health Professions Commission, 1993. 30. Alliance for Health Reform. Commanding generalists: increasing the availability of community-based primary care practitioners. Washington: Alliance for Health Reform, 1993. 31. Mundinger MO. Advanced-practice nursing-good medicine for physicians [Editorial]? N Engl J Med 1994;330:211-3. 32. Kassirer JP. What role for nurse practitioners in primary care [Editorial[? N Engl J Med 1994;330:204-5.
ELAINE L. LARSON is dean of the Georgetown University School of Nursing, in Washington, D.C
Call for Manuscripts NURSING OUTLOOKwelcomes manuscripts related to nursing education, practice, or research or to health care policy and delivery. Please submit manuscripts to the Editor at the following address: Carole A. Anderson, PhD, RN, FAAN The Ohio State University College of Nursing 1585 Nell Avenue Columbus, OH 43210 For details about the JOURNAL'Seditorial policy and manuscript preparation, see the Information for Authors pages.
NURSING OUTLOOK
JULY/AUGUST 1995
Larson
185
RN, PhD, CIC, FAAN
To enhance interdisciplinary collaboration among medicine and nursing, and to better respond to societal health care needs, we must take a serious look at the educational systems that socialize young health professionals into their respective roles.
I
n 1967 the term "doctor-nurse game" was coined by Stein 1 in the Archives of General Psychiatry. The term caught on and has appeared intermittently in the literature over the past three decades. 24 The object of the game is to preserve the interactive roles traditionally held by the physician and nurse in clinical practice, with the physician seemingly the sole decision maker and team leader, and the nurse "allowed" to make recommendations as long as she appeared passive. Open disagreement was to be avoided at all costs. Rewards for playing the game well included respect for the nurse (a "damn good nurse") and smooth facilitation of work for the physician. The genesis of the game was attributed to differences in the education of medical and nursing professionals. It was suggested that medical students, inundated with facts vital to life and death and often trained in a confrontational interview style, developed a phobia of
NURS OUTLOOK 1995;43:180-5. Copyright o 1995 by Mosby-Year Book, Inc. 0029-6554/95155.00+ 0 3511151728
180
Larson
making a mistake. As a p r o t e c t i v e mechanism, physicians adopted a defensive posture in which they attempted to be perceived as omniscient and all powerful. The game was thought to be learned during graduate training, when the physician felt pulled between the need to give patients the best care possible, which sometimes meant seeking advice from the nurse, and the need to protect the facade of omnipotence. Nursing students began their socialization to the game during school, in programs that were disciplined and inflexible. Their time was carefully, even militantly, controlled, and virtues such as duty, discipline, self-control, and obedience were extolled. Nursing students learned to be wary of independent decision making. A nurse writing in 1917 expressed the prevailing belief of that time: In my estimation obedience is the first law and the very cornerstone of good nursing . . . . No matter how gifted she may be, she will never become a reliable nurse until she can obey without question. 5 In the mid-1960s, at about the time
when "The Doctor-Nurse Game" was published, an experiment was conducted in which 22 nurses were given a telephone order by a physician for an obvious overdose of a drug. Twenty-one of the nurses said that they would have given the drug without question. 6 While nurses were socialized to a dependent role, they were also told that their skills were vital to the welfare of the patient and an invaluable asset to the physician. Thus the nurse and the physician were caught in a paradox, and the doctor-nurse game allowed a reasonable mechanism for maintaining the integrity of their respective perceived roles, while also facilitating patient care delivery. In 1990 Stein proposed that the game had changed as a result of changes in public perceptions of the physician, increasing numbers of women entering medicine, a shortage of nurses, the increasing responsibilities and authority of nurses, and changes in nursing education away from hospital-based training to the academic setting. 2 The game did not work any more because one of the players (the nurse) had decided to stop playing, expressing a desire for more autonomy and a more collaborative role as a partner in the health care team. At this point nurses' reactions to the game sometimes became defensive, overdetermined, assertive, and even hostile as they sought recognition. Physicians' reactions ranged from tentative support to puzzlement to feelings of betrayal and anger. They perceived that nurses were abandoning their focus on patient care and bemoaned the fact that
VOLUME 43 * NUMBER 4
NURSING OUTLOOK
nurses had been distracted by their own desire for recognition and status. On an individual level, roles may have changed little. Pillitteri and Ackerman, 3 in a content analysis of house officer journals from 1888 and 1990, concluded that physician-nurse interactions over the century were more similar than different, although the 1888 journal was more likely to mention instances of collaboration. On a professional level, however, roles for nurses have expanded rapidly to include research, academics, administration, and advanced practice. Thus the rules of the doctor-nurse game have changed, and new models for interdisciplinary interactions are needed. Current resource restraints and paradigm changes associated with health care reform bring additional challenges to the relationships. The changing health needs of the public have mandated a rethinking of the roles of the various disciplines. The Pew Health Professions Commission has identified the following competencies for health professions of the future: community health focus, delivery of contemporary clinical care, expanded accountability, appropriate use of technology and cost-effective care, prevention/promotion of healthy lifestyles, patient and family involvement in decision making, and information management with an orientation to lifelong learning. 7 If such competencies are to be acquired, there needs to be significant reordering of disciplinary priorities, revolutions in the curricula and practice of health professionals, and changes in their relationships with each other. Many barriers to change have been identified: mind-set, incentives, the value of preserving tradition, professional identity and territoriality, and a highly structured practice environment) Nevertheless, the options for relationships among the health professions, particularly medicine and nursing, are few: active battle and conflict, parallel play and potential competition (the Pentagon's description of peace as "permanent prehostility" might appropriately describe this situation), or collaborative practice. NURSING OUTLOOK
Nursing16-18
MedicaP s • Too diffuse, uncoordinated • Too long, redundant • Too much encouragement of specialization • Too linked to hospital reimbursement
• Lockstep, inflexible curriculum and authoritatian, passive teaching methods • Focus on specialized, fragmented acute care • Inadequate attention to lifelong learning process (e.g. critical thinking, decision-making collaboration) • Segregation of nursing practice and education
In this article I discuss the evidence that collaboration has positive effects on patient and provider outcomes, review recent recommendations for the reform of health care professional education, examine the extent to which the current educational curricula for physicians and nurses are designed to enhance an interdisciplinary, collaborative approach to practice, and make recommendations for educational approaches to better prepare physicians and nurses to work together. MEDICINE-NURSING COLLABORATION
In a recent article Fagin4 summarized studies of inpatient care and care of elders demonstrating positive patient outcomes and cost-effectiveness associated with physician-nurse collaboration. Additionally, collaboration has been associated with increased nurse self-esteem, improved job satisfaction, and a decline in moral outrage associated with moral dilemmas?ql Research on collaboration has focused on nurse, not physician, outcomes. This may be because successful collaboration occurs between persons who perceive themselves to be peers and to have shared goals. Since the balance of power continues to be weighted toward the physician, nurses may place more value on and be more inclined toward seeking an interdisciplinary practice than their physician counterparts. Over a decade ago, Mechanic and Aiken ~2 recognized that, although the complexities of health care had increased and the need for interdisciplinary collaboration was even more imperative, "medical schools and nursing
JULY/AUGUST 1995
schools have become increasingly isolated from one another." They urged that medical and nursing schools develop closer ties to improve the education of physicians and nurses and "to set the stage for more effective collaboration in the future." Others have noted that collaboration is difficult to establish in the acute tertiary care setting because young, highly stressed and inexperienced professionals (graduate nurses and house officers) are trying to develop interpersonal working relationships while
Faculty members themselves are not role models of collaborative interaction. at the same time gaining proficiency in clinical skills.i3 Education was identified by Fagin4 as one of the several barriers to collaboration in health care. Bulger and Bulger 14 pointed out that another obstacle to collegiality in the academic health center is the competitive nature of the research and service enterprises between and within departments and schools. Thus faculty members are not role models themselves of collaborative interaction. C O L L A B O R A T I O N IN CURRICULUM REFORM
Curriculum problems currently identified from within the two professions reflect real problems based on their historical roots--the need by the physician Larson
181
to be all-knowing and the need by the nurse to be competent, organized, and obedient. For example, problems identified in graduate medical education relate to the high costs and the amount of content covered, 15 whereas problems identified within nursing education relate more to the processes of learning 1618
(Box 1). There has been increasing discussion of the need for curriculum reform in both the medical and nursing literature, and a few groups such as the National League for Nursing and the Pew Health Professions Commission have highlighted the importance of collaboration and interdisciplinary socialization 19"25
(Box 2). Nevertheless, curriculum reform in medicine and nursing is occurring. For example, The Johns Hopkins University School of Medicine recently introduced its largest curriculum revision since 1893. Changes include the integration of clinical and basic sciences from the beginning of undergraduate training, an early introduction to community experiences, a more flexible curriculum with more interactive learning, but no courses in which the health disciplines are formally taught together. 26 A number of medical schools are considering some aspects of problem-oriented learning. The National League for Nursing and the American Association of Colleges of Nursing, the two major organizations concerned with nursing education, both published recommendations for major nursing education reform in 1993.18'2v But to date most reform efforts have emanated from and remain focused and segregated within the single disciplines. Bulger28 has commented: If the academic health c e n t e r . . , is to grow beyond the conservative and protective role of preserving the status quo and is to become more effective at helping with appropriate societal adjustments to new realities and new futures, then we must extend beyond our reductionist disciplines and specialties, without diminishing or denying them, and embrace cross-professional and interdisciplinary, integrative approaches to the individual and social value issues that confront us all. 182
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1. Josiah Macy Jr. Foundation. Proceedings of a conference chaired by Thomas Q. Morris. Taking charge of graduate medical education: To meet the nation's needs in the 21st century. 44 E. 64th Street, New York, NY 10021. Phone: 212-486-2424 1993 1. Establish federal commission on graduate medical education (GME) to • develop policies for funding and number of resident positions by specialty and geography. • direct allocation of GMe funds. • replace current commission. 2. Reorganize Accreditation Council on Graduate Medical Education to increase independence but maintain responsibility for educational standards. 3. Continue funding GME through Medicare Direct Medical Education Allowance. 4. Encourage innovation in GME curricula to address societal needs and new practices. 2. Pew Health Professionals Commission. Health professions education for the future: Schools in the service to the nation. 1388 Sutter St., Suite 805, San Francisco, CA 94109. Phone: 415-476-8181 February1993 1. Build from a foundation of values. 2. Concentrate on core educational activities. 3. Redefine political and economic relationships. 4. Focus on the health needs of the community. 5. Strengthen tools for change.
3. Bureau of Health Professions. An agenda for health professions reform. USDHHS. Public Health Service Health Resource and Services Administration 5600 Fishers Lane, Rockville, MD 20857 February1993 1. Promote primary care education. 2. Strengthen and expand public health education and practice. 3. Expand the capacity of nursing and allied health professions to meet the increasing demand for services. 4, Increase numbers of health care providers from minority/disadvantaged backgrounds. 5. Promote educational strategies to recruit and retain health care providers for underserved populations. 6. Advance continuous quality improvement in health professions education and practice. 7. Strengthen health professions data, information systems, and education research. 4 American Association of Colleges of Nursing. Nursing education's agenda for the 21st century. One Dupont Circle, NW, Suite 530, Washington, DC 20036 Phone: 202-463-6930 March 1993 1. Comprehensive review of mission for relevance to health care needs. 2. Organizational structure that facilitates new initiatives. 3. Redefine faculty scholarship to include practice. 4. Recruitment and retention of diverse student body. 5. Emphasize curricular processes that develop critical thinking, ethical decision-making, interdisciplinary participation, coordination, etc. 6. Curriculum content should include health promotion and maintenance; economics; ethical, legal, political principles; informatics. 7. Program evaluation and outcomes are integral in the curriculum. 8. Enhance integration of nursing research into schools and the mainstream scientific community. Continued on next page
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Box 2. Continued.
5. Council on Graduate Medical Education (prepared by ME Whitcomb, Director, Program for Health Policy and Health Services Research, the Ohio State University). Physician Workforce Policy: Goals, strategies, options, implementation issues, and legislative proposals 515 N. State Street, Chicago, IL 60610. Phone: 312-464-5472 June 1993 1. Congress should enact legislation to establish a federal GME Funding Pool to be administered by DHHS. 2. Congress should amend PHS Act (Title VII) to direct existing primary care grant funds to support undergraduate generalist medical education programs, 6. National League for Nursing. A vision for nursing education. National League for Nursing 350 Hudson Street, New York, NY 10014. Phone: 212-989-9393 1. Rethink mission of nursing education to promote quality for care and to create linkages for service. 2. Increasingly plan educational experiences when people are home, school, work, long-term care, etc. 3. Curricular reform • to match needs of health environment. • to focus on processes such as critical thinking, shared decision-making collaboration. 4. Faculty reform to focus on the scholarship of application.
June 1993
7. Alliance for Health Reform. Commanding Generalists: Increasing the availability of community-based primary care practitioners. 1133 20th Street, NW, Suite 220, Washington, DC 20036 Phone: 202-466-5626 July 1993 1. Change health professional schools' admissions policies. 2. Modify health professional schools' curriculum and environment to give students primary care experience in community settings. * primary care experience in community settings. • understanding of behavioral and social components of health and illness. • exposure to multidisciplinary teams. 3. Increase supply to nurse practitioners, nurse midwives, physician assistants and others. 4. Retrain specialists as generalists. 8. Association of American Medical Colleges. Academic Medicine and Health Care Reform: Graduate Medical Education. AAMC, 2450 N. Street, NW, Washington, DC 20037 Phone:202-828-4000 July 1993 1. Create incentive program to encourage medical students to choose careers to meet physician supply goals. 2. Require a national fund from all public and private payees of health care services to support GME. 3. Establish a National Physician Resources Commission. 4. Create formal "graduate medical education consortium." 5. Continue to accredit medical programs on the basis of established educational criteria. 6. Payments for GME should be congruent with actual costs and should be made to the organization or entity that incurs the costs. 7. Make transitional relief funds available to teaching hospitals that lose residency positions. 8. Continue to support educational costs through Medicare program.
To further assess the extent to which schools of medicine and nursing are seeking opportunity to socialize students together, we contacted approximately half NURSING OUTLOOK
of the academic health centers (n = 35) that have both schools. At only five centers (14.3%) was even one interdisciplinary course available; two centers had
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such courses planned for the future; and four others had offered such courses in the past, but they had been discontinued. Four of the five courses offered were electives for medical and nursing students and occasionally others, such as law, pharmacy, social work, or dentistry. Included were such topics as AIDS, ethics, family violence, adolescent health, human behavior, and growth and development. In one academic health center, second degree nursing students and undergraduate medical students took a required course together, in which they learned such skills as interviewing, history taking, physical assessment, epidemiology, and concepts of illness and wellness. An additional component, required for nursing and elective for medical students, included a half-day/week clinical experience, during which students were paired in community centers to practice assessment skills and be exposed to primary care. A second center had previously had a year-long community-based course for fourth-year nursing students and first-year medical students to learn collaboration and roles in primary care and concepts related to chronic illness. Another center was planning a joint community health clinical practicum/clerkship that would be required for medical and advanced nursing students. Institutions with no interdisciplinary curriculum or programs, and those centers at which such programs had been discontinued, cited three major barriers: costs, faculty attitudes, and difficulties in scheduling. Time required to plan and tO implement the programs was intensive; class times and schedules usually differed among the health professions schools; and a sustained high level of commitment to an interdisciplinary approach was necessary on the part of faculty members of all schools involved. The Kellogg Community Partnerships Initiative is funding some interdisciplinary education/service projects designed to bring the health professions together in the community. For example, the three academic health centers in West Virginia have formed a coalition that involves about 600 nursing, mediLarson
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cal, pharmacy, and dental students each year in a minimum of 3 months of experience in rural health. The project covers 51 counties, all but two in the entire state. T h e C e n t e r for C o m m u n i t y Health Education, Research and Service involves Boston University School of Medicine and the School of Nursing at Northeastern University in a partnership in which nursing and medical students work a half day to a day and a half each week in the community for the entire duration of their undergraduate education. Social work, public health, and dental students are scheduled to be added to the program. But such efforts remain the exception.
A t only five centers was even one interdisciplinary course available. B U I L D I N G T H E BASE FOR COLLABORATION The Pew Health Professions Commission emphasizes that to focus on the health needs of the public, we must approach the task from a generalist-interdisciplinary orientation. 29 Accomplishing this
tion. ''3° Such structures will require close interdisciplinary linkages, and are not likely to emerge without external incentives. These incentives will come from federal policy related to financial support of health professions education, state policy related to practice acts and licensing regulations, p r o f e s s i o n a l policy with regard to a c c r e d i t a t i o n guidelines and professional standards, and policies w i t h i n i n s t i t u t i o n s of higher education. The 1993 Pew Report suggests the following higher education policies: • E n c o u r a g e h e a l t h professions schools to develop clear and distinctive strategic directions tied to the overall mission of the university. • Provide more integration between academic programs of the health professions schools and the rest of campus. • E n c o u r a g e h e a l t h professions schools to develop creative organizational structures, partnerships, and financial arrangements in order to meet their strategic directions. • Consider the work of the health professions schools in the overall service mission of the university. • Insist on routine and timely evaluation of all programs in the context of the mission of the university and school. 29
will require the alteration of some organizational structures and the development of new and different relationships with affiliated institutions and community-based practitioners. In part, these needs will be met by working across professional lines in clinical settings and by courses aimed at instilling the value of primary care, providing the skills necessary to maintain primary cfire, and promoting the teamwork skills vital to participation in primary care.
In January 1994 Mundinger 31 discussed the place of advanced nurse practitioners in primary care, citing evidence from a number of clinical trials and other studies conducted over the past three decades that demonstrate that nurse practitioners provide high- quality, costeffective care within the scope of their practice. She advocated a collaborative practice model in which
Single-discipline curriculum changes are insufficient unless accompanied by organization and structures that allow cross-fertilization between disciplines: The Alliance for Health Reform advises that "schools should have centralized authority for education that would be multidisciplinary and include both undergraduate and g r a d u a t e educa-
nurse practitioners bear the principal responsibility for the diagnosis and management of uncomplicated illness and provide the education, counseling, and management of disease prevention and health promotion . . . . The physician will always be the primary professional providing diagnosis and treatment in complex cases and managing critical and unstable medical conditions.
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She argued that patients in those practices receive more comprehensive and satisfying care than they would be given in practices composed of physicians only or nurses only. The primary point of a responding editorial was that many of the studies demonstrating efficacy of nurse practitioner performance were flawed in some w a y . 32 This objection was raised despite the fact that primary care delivered by nurse practitioners in a variety of settings has been studied more thoroughly than the care of any other provider. Certainly we need such research, but on the outcomes, costs, quality, and efficiency of care delivered by a variety of providers, not just nurse practitioners, as well as on collaborative models that might be put to trial. That we need more research should not be used as a smoke screen for maintaining the status quo. Rather, clinical studies should be incorporated as part of evaluation plans as new models emerge. Despite the barriers and disincentives to reaching out beyond disciplinary boundaries, the game has changed. Old roles do not work anymore. Academic health centers are one place where change must begin because of their role in the initial socialization and education of a variety of health professionals. Programs such as the Kellogg Community Partnership Initiative are evidence that given appropriate incentives, structure and process will be directed toward a collaborative approach. • I acknowledge the collaborative support and review of the manuscript by Dr. John Griffith, executive vice president for health sciences, Georgetown University. REFERENCES 1. Stein LI. The doctor-nurse game. Arch Gen Psychiatry 1967;16:699-703. 2. Stein LI, Watts DT, Howell T. The doctornurse game revised. N Engl J Med 1990; 322:546-9. 3. Pillitteri A, Ackerman M. The "doctor-nurse game":a comparisonof 100 years---1888-1990. NuRs OUTLOOK1993;41:113-6. 4. FaginCM. Collaborationbetween nurses and physicians: no longer a choice. Acad Med 1992;67:295-303. 5. Dock S. The relation of the nurse to the doc-
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tor and the doctor to the nurse. Am J Nurs 1917;17:394. 6. Hofling CK, Brotzman E, Dalrymple S, Graves N, Pierce CM. An experimental study in nursephysician relationships. J Nerv Ment Dis 1966;143:171-80. 7. Pew Health Professions Commission. Healthy America: practitioners for 2005. San Francisco: Pew Health Professions Commission, 1992. 8. Evans SA, Carlson R. Nurse-physician collaboration: solving the nursing shortage crisis. J Am Coil Cardiol 1992;20:1669-73. 9. Baldwin A, Welches L, Walker DD, Eliastom M. Nurse self-esteem and collaboration with physicians. West J Nuts Res 1987;9:107-14. 10. Pike AW. Moral outrage and moral discourse in nurse-physician collaboration. J Prof Nurs 1991;7:351-62. 11. Baggs JB, Ryan SA. ICU nurse-physician collaboration and nursing satisfaction. Nurs Econ 1990;8:386-92. 12. Mechanic D, Aiken LH. A cooperative agenda for medicine and nursing. N Engl J Med 1982;307:747-50. 13. Makodon HJ, Gibbons ME Nurses and physicians: prospects for collaboration [Editorial]. Ann Intern Med 1985;103:134-6. 14. Bulger RJ, Bulger RE. Obstacles to collegiality in the academic health center Bull NY Acad Med 1992;68:303-7. 15. Ebert RH, G inzberg E. The future of graduate medical education: fine tuning is not enough.
In: Morris TQ, Sirica CM, eds. Taking charge of graduate medical education: to meet the nation's needs in the 21st century. New York: Josiah Macy, Jr. Foundation, 1993:9-12. 16. de Tornyay R. The curriculum revolution [Editorial]. J Nurs Educ 1990;29:292-4. 17. Allen DG. The curriculum revolution: radical revisioning of nursing education. J Nurs Educ 1990;29:312-6. 18. American Association of Colleges of Nursing. Nursing education's agenda for the 21st century. Washington: American Association of Colleges of Nursing, 1993. 19. Kendall PL, Reader GG. Innovations in medical education of the 1950s contrasted with those of the 1970s and 1980s. J Health Soc Behav 1988;29:279-93. 20. Stillman PL, Hanshaw JB. Education of medical students: present innovations, future issues [Editorial]. Mayo Clin Prac 1989;64:1175-9. 21. Ende J, Atkins E. Conceptualizing curriculum for graduate medical education. Acad Med 1992;67:528-34. 22. French P, Cross D. An interpersonal-epistemological curriculum model for nurse education. J Adv Nurs 1992;17:83-9. 23. de Tornyay R. Reconsidering nursing education: the report of the Pew Health Professions Commission. J Nurs Educ 1992;31:296-301. 24. Allen DG. The curriculum revolution: radical re-vision of nursing education. J Nurs Educ 1990;29:312-6.
25. Regan PE The three r's: recruitment, restructuring the environment and reformulating the curriculum. Nurs Clin North Am 1990;25:51724. 26. Centofanti M. Carving out the next generation of physicians Johns Hopkins Magazine 1992;44:56-9. 27. National League for Nursing. A view for nursing education. New York: National League for Nursing, 1993. 28. Bulger RJ. The role of America's academic health centers in a reformed health system. J Am Health Policy 1992;2:35-8. 29. Pew Health Professions Commission. Health professions education for the future: schools in service to the nation. San Francisco: Pew Health Professions Commission, 1993. 30. Alliance for Health Reform. Commanding generalists: increasing the availability of community-based primary care practitioners. Washington: Alliance for Health Reform, 1993. 31. Mundinger MO. Advanced-practice nursing-good medicine for physicians [Editorial]? N Engl J Med 1994;330:211-3. 32. Kassirer JP. What role for nurse practitioners in primary care [Editorial[? N Engl J Med 1994;330:204-5.
ELAINE L. LARSON is dean of the Georgetown University School of Nursing, in Washington, D.C
Call for Manuscripts NURSING OUTLOOKwelcomes manuscripts related to nursing education, practice, or research or to health care policy and delivery. Please submit manuscripts to the Editor at the following address: Carole A. Anderson, PhD, RN, FAAN The Ohio State University College of Nursing 1585 Nell Avenue Columbus, OH 43210 For details about the JOURNAL'Seditorial policy and manuscript preparation, see the Information for Authors pages.
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