- Email: [email protected]
Successful implementation of a novel collaborative interprofessional educational curriculum for nurses and residents in a pediatric acute care setting
Journal Pre-proof Successful implementation of a novel collaborative interprofessional educational curriculum for nurses and residents in a pediatric acute care setting Laura Nicholson, Michael V. Ortiz, Yunfei Wang, Heather Walsh, Mary C. Ottolini, Dewesh Agrawal PII:
S2405-4526(19)30051-5
DOI:
https://doi.org/10.1016/j.xjep.2019.100284
Reference:
XJEP 100284
To appear in:
Journal of Interprofessional Education & Practice
Received Date: 12 March 2019 Revised Date:
28 May 2019
Accepted Date: 6 September 2019
Please cite this article as: Nicholson L, Ortiz MV, Wang Y, Walsh H, Ottolini MC, Agrawal D, Successful implementation of a novel collaborative interprofessional educational curriculum for nurses and residents in a pediatric acute care setting, Journal of Interprofessional Education & Practice (2019), doi: https:// doi.org/10.1016/j.xjep.2019.100284. This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2019 Published by Elsevier Inc.
Title: Successful Implementation of a Novel Collaborative Interprofessional Educational Curriculum for Nurses and Residents in a Pediatric Acute Care Setting Authors: Laura Nicholson, RN *1,2; Michael V. Ortiz, MD *3,4; Yunfei Wang, DrPH5; Heather Walsh, RN1,2; Mary C. Ottolini, MD3,6; Dewesh Agrawal, MD3,6 *Authors contributed equally Affiliations: 1 Division of Nursing, Children’s National Medical Center, Washington, DC 2 Simulation Program, Children’s National Medical Center, Washington, DC 3 Pediatric Residency Program, Children’s National Medical Center, Washington, DC 4 Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, NY 5 Center for Translational Science, Children’s National Medical Center, Washington, DC 6 School of Medicine, The George Washington University, Washington, DC First Author: Laura Nicholson, RN Children's National Medical Center 111 Michigan Avenue NW Washington, DC 20010 202-476-6443 [email protected] Abstract Word Count: 247 Abstract, Main Text, and References Word Count: 2155 Figures: 2 Tables: 2 Appendices: 3 Keywords: Interprofessional Education, Pediatrics, Simulation, Nursing, Residency Short Running Title: Pediatric Acute Care Interprofessional Education Curriculum Abbreviations: IPE = Interprofessional Education; NDNQI-PES = National Database of Nursing Quality Indicators - Practice Environment Scale; REDCap = Research Electronic Data Capture
Acknowledgements We would like to thank Dr. Pamela S. Hinds for her mentorship and ongoing support throughout this project and manuscript preparation. We would also like to thank Pam Samuelson BSN, RN for her collaboration and support throughout this project. Dr. Ortiz receives support from the Kristen Ann Carr Fund, the Met Life Foundation, the Pediatric Cancer Research Foundation, Hyundai Hope on Wheels, and the MSK Cancer Center Support Grant/Core Grant P30 CA008748. Dr. Ortiz is also supported by the National Cancer Institute of the National Institutes of Health under Award Number K12CA184746. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.
Pediatric Acute Care Interprofessional Education Curriculum
SUCCESSFUL IMPLEMENTATION OF A NOVEL COLLABORATIVE INTERPROFESSIONAL EDUCATIONAL CURRICULUM FOR NURSES AND RESIDENTS IN A PEDIATRIC ACUTE CARE SETTING Abstract Interprofessional collaboration is vital to maintain a successful healthcare team. We describe the development, implementation, and evaluation of an interprofessional educational curriculum on a large inpatient, acute care pediatric unit. Our objective was to improve attitudes towards collaborative care and collegial relations between staff nurses and pediatric medical residents. Nurses and residents participated in several interventions including a video for the nurses, a video for the residents, a teambuilding exercise, and three interprofessional clinical simulations. Participants’ attitudes toward collaborative care were evaluated by a self-reported questionnaire, adapted from several validated survey instruments, before and after the intervention. Each question was mapped to one of the four domains of interprofessional practice: Teams and Teamwork, Interprofessional Communication, Values and Ethics for Interprofessional Practice, and Roles and Responsibilities. The National Database of Nursing Quality Indicators - Practice Environment Scale (NDNQI-PES) question on collegial nurse and physician relations was also queried to corroborate these findings. There was a statistically significant improvement in the nurses’ response to 7/24 (29%) survey questions, of which 4 were within the domain of Teams and Teamwork. There was a statistically significant improvement in the residents’ response to 5/24 (21%) questions, of which 3 fell within the domain of Interprofessional Communication. None of the survey questions demonstrated a statistically significant decrease. There was also an improvement on NDNQI-PES scores for the target unit, both during and immediately following the intervention. In conclusion, this educational curriculum involving nurses and residents led to improved participants’ attitudes toward interprofessional collaboration.
Pediatric Acute Care Interprofessional Education Curriculum
Format Interprofessional education (IPE) has been advocated as a method of removing professional silos and improving collaboration amongst medical care team members (Canadian Interprofessional Health Collaborative, 2010; Gilbert, Yan, & Hoffman, 2010; Institute of Medicine, 2013). Medical and nursing schools are beginning to incorporate IPE into their curricula, but there is no standardized curriculum at the student or junior practitioner level, despite recommendations that IPE needs to be effectively integrated (Institute of Medicine Committee on the Health Professions Education, 2003; International Education Collaborative, 2011; Winterbottom & Seoane, 2012).
This manuscript describes our
experience in designing, implementing, and assessing the efficacy of an IPE curriculum. This IPE curriculum included two videos, one for the staff nurses (subsequently referred to as “nurses”) and another for the pediatric medical residents (subsequently referred to as “residents”), a small-group classroom-based team-building exercise, and three simulations in a clinical setting. This curriculum was integrated into their standard educational program from 10/1/13 to 4/30/14. Involvement in all activities was voluntary and did not provide any credit, but attendance was monitored to ensure all participants had the opportunity to be involved in each intervention at least once. Target Audience 100 nurses on a 50-bed pediatric acute care unit and 117 residents in an urban tertiary care academic children’s hospital were invited to participate. The target inpatient unit has residents of all levels, although the majority were first year residents. Similarly, the majority of the nurses on the unit were early in their career. Collectively the simulations included 146 nurses and residents. The preintervention survey was completed by 56 residents (48%) and 58 nurses (58%), whereas 40 residents (34%) and 38 nurses (38%) completed the post-intervention survey.
Pediatric Acute Care Interprofessional Education Curriculum
Objectives The goal of this study was to evaluate whether an IPE curriculum would both improve attitudes regarding collaboration and collegial relations between nurses and residents. The learning objectives and evaluation metrics to assess these objectives were based upon the core competencies of interprofessional practice. These competencies were developed in 2011 by an expert panel comprised of six healthcare disciplines sponsored by the Interprofessional Education Collaborative. This group defined four core competencies as the elements needed for interprofessional collaborative practice: Values and Ethics for Interprofessional Practice, Roles and Responsibilities, Interprofessional Communication, and Teams and Teamwork. Each of the interventions in our IPE curriculum was specifically designed to address at least two of these domains of competency, as shown in Table 1. The primary aim of this study was to evaluate whether there was a statistically significant change in attitudes towards interprofessional practice pre-post IPE curriculum and whether that improvement was general or specific to certain domains of interprofessional collaborative practice. Our secondary aim was to assess the impact of the IPE curriculum on collegial nursing-resident relations. Activity Description The authors previously performed a needs assessment to determine opportunities to improve patient care on our largest general inpatient pediatric acute care unit. This needs assessment revealed that both nurses and residents perceived that there was a need for improved interprofessional collaboration between them. We hypothesized that targeting these two groups with an IPE curriculum could improve participant attitudes toward interprofessional collaboration and collegial relations. The IPE curriculum itself involved several interventions: orientation videos for the nurses and residents, a team-building exercise, and three high-fidelity simulations. The orientation videos lasted approximately 10 minutes each, whereas the team-building exercise and simulations were each designed to last 45 to
Pediatric Acute Care Interprofessional Education Curriculum
60 minutes, including time for debriefing. Interventions were repeated monthly in order to coincide with resident rotations. Videos Both videos focused on their disciplines’ respective schedules, responsibilities, and optimal routes of communication and were shared during a social event including a small meal, which allowed for discussion to contextualize some of the content after the viewing. Videos were designed by both nursing and resident leadership in order to address perceived areas of deficiency in interprofessional collaborative practice, as defined in the needs assessment. Since the residents are more transient and rotate in a variety of different clinical settings in the institution every four weeks, a particular focus of their video was to welcome and orient them to the unit, with an emphasis on nursing interactions. By contrast, the needs assessment demonstrated a perceived lack of appreciation on the nurses’ behalf to the residents’ schedule. Therefore, a particular focus of the nursing video was to help better appreciate unique challenges of the resident work day (e.g. pre-rounding vs. rounding, protected time during handoff and mandatory educational activities, continuity clinic, and paging/calling etiquette). Team-building exercise The team-building exercises were performed in the context of a planned social meeting with food. During the team-building exercise, participants created a group résumé, highlighting each team member’s unique, shared, and diverse skills and experiences. Teams created team names, shared interesting personal and professional details as much as they were inclined to do so, and then identified leaders who would present their collective experiences. Team discussions were allowed to organically evolve, but if the conversations stagnated, nurse leaders and chief residents facilitated productive and positive discussions.
Pediatric Acute Care Interprofessional Education Curriculum
Simulations The simulations included: (1) a role reversal mock code in which the nurse and resident changed roles and attempted to solve an emergent case but did so in the other person’s role, (2) a case in which the resident discovered a decompensating patient unattached to a monitor and must collaborate with the bedside nurse to provide care, and (3) a scenario where the resident triaged multiple nurse phone calls and must effectively prioritize and respond to their concerns. The simulation templates are provided in Appendices 1-3. Course Facilitators The team-building exercises and simulations used at least one nursing and one physician facilitator, generally a unit-based nurse educator and a chief resident. Prior to the initiation of the curriculum, these facilitators received specific simulation facilitation training. Assessment To determine the effectiveness of our IPE curriculum on nurse and resident attitudes toward interprofessional collaboration, a survey instrument was provided to all participants before and after the study window. Survey questions were derived from components of three previously published survey instruments: the ICU Nurse-Physician Questionnaire (Hojat et al., 2001), Jefferson Scale of Attitudes Towards Physician-Nurse Collaboration (Lake, 2002), and the Practice Environment Scale of the Nursing Work Index (Shortell, Rousseau, Gillies, Devers, & Simons, 1991). Additional survey questions were based upon specific concerns from the initial needs assessment. As shown in Table 2, each question was specifically assigned to a single domain of interprofessional collaborative practice.
Three unique
questions were only given to one participant group and not the other. Thus, in total there were 27 survey questions, and residents and nurses each completed 24 questions. Responses to the survey questions were graded on a 1-4 Likert scale where 1 - Strongly Disagree, 2 - Disagree, 3 - Agree, and 4 Strongly Agree. The survey was written with both positive and negative items; however, for purposes of
Pediatric Acute Care Interprofessional Education Curriculum
the analysis, the survey questions that were negatively worded were reverse coded such that higher scores meant positive responses. Study data were collected and managed using the Research Electronic Data Capture (REDCap) program (Harris et al., 2009). In order to assess the impact of our IPE curriculum on collegial relations, we also analyzed results from The National Database of Nursing Quality Indicators - Practice Environment Scale (NDNQI®PES). This national survey is administered annually to nurses at this hospital. The NDNQI® survey specifically measures job satisfaction and evaluates the practice environment. The NDNQI® survey measures satisfaction on a 0-3.5 score, with 3.5 being the highest score. We monitored the more global and lasting effect of the curriculum on nurses working on the intervention unit via an analysis of the NDNQI-PES domain score for collegial nursing-physician relations before, during, and one year after the intervention. Evaluation Pre-post survey results were intentionally anonymized and therefore unable to be paired. All data were descriptively analyzed using univariate statistics. Pre- versus post- intervention scores from these two surveys were compared using the Wilcoxon test against the null hypothesis of no change between the pre- and post-intervention scores. 12/48 (25%) questions demonstrated a statistically significant improvement, and 0/48 (0%) demonstrated a statistically significant decrease, as shown in Figure 1. There was a statistically significant improvement in the nurses response to 7/24 (29%) survey questions, of which 4 were within the domain of Teams and Teamwork and 1 each within the domains of Interprofessional communication, Roles and Responsibilities, Values and Ethics for Interprofessional Practice. There was a statistically significant improvement in the residents’ response to 5/24 (21%) questions, of which 3 were within the domain of Interprofessional Communication, and 1 each within the domains of Teams and Teamwork and Values and Ethics for Interprofessional Practice.
Pediatric Acute Care Interprofessional Education Curriculum
The 7 specific nursing questions that demonstrated statistically significant improvement were “It is easy to ask for advice from residents on the unit”(p = 0.02), “I feel that I can speak to the resident when needed” (p = 0.004), “Residents at this hospital appreciate what nurses do” (p = 0.002), “I feel that certain nurses don't completely understand the information they receive” (p = 0.01), “Residents and nurses have bad working relationships on the unit”(p = 0.02), “I do not find it enjoyable to talk with residents on the unit” (p = 0.03), and “There is poor teamwork between nurses and physicians” (p = 0.001). Specific resident questions that demonstrated statistically significant improvements were “It is easy for me to talk openly with nurses on the unit” (p = 0.0004), “I cannot complete my work due to frequent interruptions from nurses” (p = 0.02), “Nurses at this hospital generally appreciate the residents’ work” (p = 0.002), “There is poor teamwork between nurses and physicians” (p = 0.05), and “I do not find it enjoyable to talk with nurses on the unit” (p = 0.007).
The average score on the NDNQI-PES collegial nursing-physician relations question was 2.53 prior to the intervention (baseline), 2.85 during the intervention, and 3.02 immediately following the intervention. One year after completion of the intervention, the score was 2.78, which remained above the baseline. Impact Nurses’ and residents’ attitudes toward interprofessional collaboration improved in four domains as a result of this educational curriculum. There were discipline-specific improvements, most notably in the nurses’ response to questions in the domain of Teams and Teamwork and residents’ response to questions in the domain of Interprofessional Communication. These improvements in attitude are further supported by an increase on the NDNQI survey question focusing on collegial nursephysician relations following the IPE curriculum.
Pediatric Acute Care Interprofessional Education Curriculum
Residents spend the majority of their intern year on the intervention unit; hence it is important to create a foundation of collaboration with nurse colleagues. It is equally important for new graduate nurses, who may not have previously worked with physician trainees, to develop working relationships with physicians to foster teamwork and optimize patient care. Since nurses and residents spend much time working together on inpatient units, it is essential that they appreciate the unique differences in their education and training, share knowledge of their respective expertise, and reflect on experiences and challenges in a safe learning environment. This curriculum created opportunities for the nurses and residents to get to know one another on a personal level and to discuss work challenges and how to overcome them. These face-to-face activities are important, as many clinical interactions occur via technology (e.g. one-way text paging, phone calls, electronic order entry) with lack of closed loop communication.
The team-building
exercises enhanced nurse and resident understanding and appreciation of their discipline-specific roles and responsibilities. The simulations permitted nurses and residents to practice escalating patient concerns and establishing a management plan, while the debriefings further reinforced the need for teamwork and communication through sharing of ideas and reflection. Other institutions may easily replicate the components of this curriculum by incorporating the simulation scenarios into the residency curriculum or other unit-based education. Key to the curriculum’s success was the support from nursing and physician leaders, including pediatric residency leadership, and partnerships between unit-based leaders, nurse educators, simulation educators, and chief residents. As a result of this curriculum’s success, the interprofessional in-situ simulation program with nurses and residents has expanded from the intervention unit to the remaining six pediatric acute care units. The simulations are designed to meet the learning needs of each unit and are periodically changed to ensure the nurses who are unit-based will experience different scenarios. As residents
Pediatric Acute Care Interprofessional Education Curriculum
rotate monthly, they experience a new simulation during each clinical block. Interprofessional activities continue on the intervention unit as social gatherings both on the unit and outside of the hospital. Required Materials This IPE curriculum includes a simulation facilitator’s guide for each of the three simulations (Appendices 1-3), post-simulation evaluations, the pre-post intervention survey questions (Table 2), welcome videos for residents and a day in the life of the resident video for nurses, and food items for the social events. Additional information such as simulation equipment list, instructions for the résumé building activity, and specific social event details can be obtained by emailing [email protected].
Pediatric Acute Care Interprofessional Education Curriculum
References
Amos, M. A., Hu, J., & Herrick, C. A. (2005). The impact of team building on communication and job satisfaction of nursing staff. Journal of Nursinges Staff Development, 21(1), 10-16; quiz 17-18. Baggs, J. G., Schmitt, M. H., Mushlin, A. I., Mitchell, P. H., Eldredge, D. H., Oakes, D., & Hutson, A. D. (1999). Association between nurse-physician collaboration and patient outcomes in three intensive care units. Critical Care Medicine, 27(9), 1991-1998. Canadian Interprofessional Health Collaborative (2010). A National Interprofessional Competency Framework. Retrieved from https://www.cihc.ca/files/CIHC_IPCompetencies_Feb1210.pdf Core competencies for interprofessional collaborative practice: Report of an expert panel (2011) Retrieved from https://www.aacom.org/docs/default-source/insideome/ccrpt05-1011.pdf?sfvrsn=77937f97_2 Gilbert, J. H., Yan, J., & Hoffman, S. J. (2010). A WHO report: framework for action on interprofessional education and collaborative practice. Journal of Allied Health, 39 (1), 196-197. Harris, P. A., Taylor, R., Thielke, R., Payne, J., Gonzalez, N., & Conde, J. G. (2009). Research electronic data capture (REDCap)-a metadata-driven methodology and workflow process for providing translational research informatics support. Journal ofBiomedical J Biomed Informatics, 42(2), 377-381. doi:10.1016/j.jbi.2008.08.010 Hojat, M., Nasca, T. J., Cohen, M. J., Fields, S. K., Rattner, S. L., Griffiths, M., Garcia, A. (2001). Attitudes toward physician-nurse collaboration: a cross-cultural study of male and female physicians and nurses in the United States and Mexico. Nursing Research, 50(2), 123-128. Institute of Medicine (2013). Interprofessional education for collaboration: learning how to improve health from interprofessional models across the continuum of education to practice: Workshop summary. Washington, DC: The National Academies Press.
Pediatric Acute Care Interprofessional Education Curriculum
Institute of Medicine Committee on the Health Professions Education (2003). In A. C. Greiner & E. Knebel (Eds.), Health Professions Education: A Bridge to Quality. Washington (DC): National Academies Press (US) Copyright 2003 by the National Academy of Sciences. Lake, E. T. (2002). Development of the practice environment scale of the Nursing Work Index. Research in Nursing & Health, 2524(3), 176-188. doi:10.1002/nur.10032 Larrabee, J. H., Ostrow, C. L., Withrow, M. L., Janney, M. A., Hobbs, G. R., Jr., & Burant, C. (2004). Predictors of patient satisfaction with inpatient hospital nursing care. Research in Nursing & Health, 27(4), 244-268. doi:10.1002/nur.20021 Lewis, R., Strachan, A., & Smith, M. M. (2012). Is high fidelity simulation the most effective method for the development of non-technical skills in nursing? A review of the current evidence. The Open Nursing Journal, 6, 82-89. doi:10.2174/1874434601206010082 Muller-Juge, V., Cullati, S., Blondon, K. S., Hudelson, P., Maitre, F., Vu, N. V., Nendaz, M. R. (2013). Interprofessional collaboration on an internal medicine ward: role perceptions and expectations among nurses and residents. PLoS One, 8(2), e57570. doi:10.1371/journal.pone.0057570 Muller-Juge, V., Cullati, S., Blondon, K. S., Hudelson, P., Maitre, F., Vu, N. V., Nendaz, M. R. (2014). Interprofessional collaboration between residents and nurses in general internal medicine: a qualitative study on behaviours enhancing teamwork quality. PLoS One, 9(4), e96160. doi:10.1371/journal.pone.0096160 Reeves, S., Perrier, L., Goldman, J., Freeth, D., & Zwarenstein, M. (2013). Interprofessional education: effects on professional practice and healthcare outcomes (update). Cochrane Database Systematic Review (3), Cd002213. doi:10.1002/14651858.CD002213.pub3
Pediatric Acute Care Interprofessional Education Curriculum
Shortell, S. M., Rousseau, D. M., Gillies, R. R., Devers, K. J., & Simons, T. L. (1991). Organizational assessment in intensive care units (ICUs): construct development, reliability, and validity of the ICU nurse-physician questionnaire. Medical Care, 29(8), 709-726. Vahey, D. C., Aiken, L. H., Sloane, D. M., Clarke, S. P., & Vargas, D. (2004). Nurse burnout and patient satisfaction. Medical Care, 42(2 Suppl), 57-66. doi:10.1097/01.mlr.0000109126.50398.5a Winterbottom, F., & Seoane, L. (2012). Crossing the quality chasm: it takes a team to build the bridge. Ochsner Journal, 12(4), 389-393. Woods, D. (2002). Medical error: what do we know? What do we do? BMJ : British Medical Journal, 32524(7358), 285-285.
Pediatric Acute Care Interprofessional Education Curriculum
Table 1: Mapping of each IPE curricular intervention to specific domains of interprofessional practice Domain
Team
Orientation
Simulations
Building
Video
Role Reversal The Unattached Triaging Mock Code Patient Phone Calls
Exercise Values and Ethics
X
X
X
for Interprofessional Practice Roles and
X
X
X
X
X
X
X
X
X
X
X
Responsibilities Interprofessional Communication Teams and Teamwork
Pediatric Acute Care Interprofessional Education Curriculum
Table 2. Survey instrument questions targeting specific domains of interprofessional collaborative practice Domain Survey Instrument Questions (Nurse Version) Teams
and 1. There is poor teamwork between nurses and physicians (Lake, 2002)
Teamwork
2. Residents and nurses have bad working relationships on the unit (Lake, 2002) 3. It is easy to ask advice from residents on the unit. (Hojat et al., 2001) 4. I feel that I can speak to the resident when needed. ¥
Interprofessional
5. I do not find it enjoyable to talk with residents on the unit. (Hojat et al., 2001)
Communication
6. It is easy for me to talk openly with residents on the unit (Hojat et al., 2001) 7. I cannot complete my work due to frequent interruptions from residents. 8. I feel that the nurses call my phone for non-urgent concerns.* 9. When nurses talk with residents on unit, there is a good deal of understanding. (Hojat et al., 2001) 10. There are barriers that prevent open communication with nurses and residents. 11. Communication between nurses and physicians on the unit is very open. * 12. The accuracy of information passed between nurses and residents on the unit leaves much to be desired. (Hojat et al., 2001)
Values and Ethics 13. Residents at this hospital appreciate what nurses do. for Interprofessional Practice
14. There is collaboration (joint practice) between nurses and residents. (Lake, 2002) 15. Residents do not respect the skill and knowledge of the nursing staff. ¥ 16. Nurses respect the time of day when the residents are in lecture/rounds. * 17. Nurses should clarify a resident’s order when they feel that it might have the
Pediatric Acute Care Interprofessional Education Curriculum
potential for detrimental effects on the patient. (Shortell et al., 1991) 18. A nurse should be viewed as a collaborator and colleague rather than the physician’s assistant. (Shortell et al., 1991) Roles
and 19. I feel that certain nurses don’t completely understand the information they
Responsibilities
receive. (Hojat et al., 2001) 20. Orders are updated/cleaned up by residents in a timely manner. ¥ 21. I can think of a number of times when I received incorrect information from residents. (Hojat et al., 2001) 22. It is often necessary for me to go back and check the accuracy of information I have received from residents. (Hojat et al., 2001) 23. I am aware of the plan of care on nights. 24. I have a good understanding of the resident’s role. 25. There are many overlapping areas of responsibility between residents and nurses. (Shortell et al., 1991) 26. I am aware of the plan of care on weekends. 27. Nurses should have responsibility for monitoring the effects of medical treatment. (Shortell et al., 1991)
* Resident only question;
¥
Nurse only question; Note that this is the nursing version of the survey.
Survey questions to the residents had “nurse” or “resident” replaced where appropriate.
Pediatric Acute Care Interprofessional Education Curriculum
Figure 1. Average change in survey question response after IPE curricular intervention, stratified by respondent type and domain of interprofessional collaboration
Pediatric Acute Care Interprofessional Education Curriculum
Appendix 1: Role Reversal Mock Code Name: Arbitrary Age: 6 year old Weight: 25 kg Allergies: No Known Drug Allergies Immunizations: Up To Date Past Medical History: Previously healthy male; no hospitalizations Present History: 6 year-old boy admitted from outside hospital with dehydration, fever, altered mental status changes concerning for viral encephalitis. He has just arrived on the floor. Upon entering the room the parent expresses concerned that he is “sleepier than usual and not behaving like himself.”
LEARNING OBJECTIVES At the completion of this simulation, the participants will be able to: • Describe the available resources needed to perform technical skills (e.g. IO placement, retrieval of medication/supplies from code cart and medication pyxis, bag mask ventilation and intubation) • Identify strategies to overcome potential stressors that contribute to communication breakdown • Demonstrate effective team communication and understand its role in facilitating patient care and safety
Participant Roles: • • • • • • •
Resident Senior resident Primary nurse Backup nurse Charge nurse Parent Observers
OUTLINE OF SCENARIO PROGRESSION Segment/ timing: Resident called to assess:
Mannequin Actions Patient Position:
Expected Participant Actions Primary nurse verbalizes concern to resident
Patient lying in bed
Recognize deteriorating clinical status
Talking, but appears sleepy
Assign roles (stickers will be provided)
First 2 minutes
Not on Monitor to start
Resident: Gathering information (further history) & perform assessment
Once on Monitor: Vital Signs: Heart Rate: 120 Respiratory Rate: 36 Temperature: 39.0 - oral Blood Pressure: 100/64
Nurse: Begin interventions (monitor, leads, VS)
Oxygen saturation: 94%
Resident: Order Normal saline bolus
Nurse: Talks to mom regarding status/ concerns Resident: Discuss/ attempts IV access, STAT Tylenol
Cues: Facilitator: You are caring for a 6 year old patient who was directly admitted from an outside hospital for dehydration and recent viral URI symptoms. Patient off monitor, no IV access, no suction or seizure precautions at the bedside. Baseline normal development - had been alert and talking, mom had to wake him to eat dinner and he vomited twice. No fluids today with exception of a few sips at breakfast Unable to obtain IV access
Nurse or resident: Initiate Oxygen (Nasal Cannula, Non-rebreather) Team at bedside: Second 5 minutes
Patient Position: Bed Patient begins to seize Vital Signs: Heart Rate: 136 Respiratory Rate: 12 Temperature: 39.0 Blood pressure: 140/80 Oxygen saturation 80% Cyanosis
Recognize worsening status/ seizure Discussion of team assessment and shared mental model Nurse or resident: turn patient on his side; begin timing Call for help- charge nurse, senior, IV nurse/ crisis nurse, respiratory therapist Establish IV access, Initiate Rapid Response Team vs. Code Nurse: Bring code cart Resident: Check electrolytes, glucose Nurse or resident: Apply 100% non-rebreather
Facilitator: Charge nurse comes to room if called Senior resident comes to room if called Respiratory therapist in emergency room- unable to come Crisis nurse unavailable (in staffing) Capillary refill 5 seconds Skin cool
Pediatric Acute Care Interprofessional Education Curriculum
Appendix 2: The Unattached Decompensating Patient Scenario: The unattached patient Estimated Scenario Time: 15 minutes Estimated Debriefing Time: 30 minutes Closing: 10 minutes Target Group: Registered nurses & Residents Brief Description Name: Age: 6 month old Weight: 6kg Allergies: No Known Drug Allergies Immunizations: Up To Date Past Medical History: Previously healthy Present History: Admitted for bronchiolitis, currently awaiting discharge after an overnight stay briefly requiring supplemental oxygen and albuterol treatment
LEARNING OBJECTIVES At the completion of this simulation, the participants will be able to: • Perform the appropriate application and functioning of various patient monitoring tools as a nursing-resident team. • Employ strategies for open, effective communication using safety techniques. • Demonstrate use of institutional escalation algorithms to escalate concerns.
Participant Roles • • • • • •
Resident Primary nurse Charge nurses Respiratory therapists Parent Observers
OUTLINE OF SCENARIO PROGRESSION Segment/ timing: Initial assessment by resident: First 5 minutes
Mannequin Actions Patient Position:
Nurse Enters Room: Second 5 minutes
Patient Position: Crib Patient is coughing, when patient is hooked to monitor oxygen saturation is 86% on room air
Lying in crib (flat) – lips blue – coughing – emesis noted on gown
When oxygen is applied oxygen saturations go up to 88%
Expected Participant Actions Resident is discharging patient: -
Assesses patient Calls for help (nurse?) Applies oxygen Tries to suction Suction not working (fix suction or use the bulb syringe)
Primary Nurse: - Nurse places patient on monitor - Applies oxygen if not already done - Either fixes suction or uses bulb syringe to suction nares - Obtains VS (BP cuff is too big) -Primary nurse calls charge nurse
When patient suctioned oxygen saturations go up to 94% if the nurse has already applied oxygen
-Resident may call senior who cannot come to room for 10 minutes due to another situation
Cues: Facilitator: You are performing your discharge counseling and confirming a primary care doctors appointment as Mom gives the patient a bottle and Dad waits downstairs in the car. After the bottle, the baby begins coughing with emesis and Mom worriedly points to the baby’s lips, which are blue. What do you do next? Facilitator: states that the senior resident and attending cannot come to room for 15 minutes as they are in a CAT Respiratory therapist will finish another treatment and be there in about 15 minutes Charge nurse comes to room if called
Pediatric Acute Care Interprofessional Education Curriculum
Segment/ timing: Resident: Third 5 Minutes
Mannequin Actions If patient not suctioned but oxygen is applied, oxygen saturation goes up to 88% If patient not placed on oxygen but is suctioned, oxygen saturations stay at 88%
Expected Participant Actions Primary Nurse:
Cues:
Nurse puts patient on oxygen if not done in second five minutes Resident suggests oxygen if nurse does not Nurse suctions if not already done
Appendix 3: Triaging Phone Calls Brief Description Nurse #1 calls resident Nurse #2 pages resident Nurse #3 calls resident Nurse #4 pages resident Resident responds to each concern, triages priority & urgency of each, takes appropriate action
LEARNING OBJECTIVES At the completion of this simulation, the participants will be able to: • Utilize SBAR to communicate and triage interprofessional concerns • Apply escalation techniques based on patient care needs
Resident Sign-Out Patient Summary
To-Dos
Smith 702
8 year old female with known type one diabetes, transferred to floor from Pediatric Intensive Care Unit for diabetic ketoacidosis On Lantus/ Novolog
Johnson 707
5 year old male with LLE cellulitis vs. osteomyelitis Orthopedics consulting, possible debridement tonight depending on MRI
Follow-up MRI, touch base with orthopedics
Robertson 728
6 year old female with status asthmaticus Weaned to albuterol every 2 hours, weaning Oxygen
wean to albuterol every 4 hours
Walker 736
5 year old male with developmentally delayed, tracheostomy dependent, admitted with bacterial pneumonia vs. viral illness Weaning supplemental oxygen, suctioning, antibiotics
Nurse Sign-Out Nurse Patient
Summary
Situation
Nursing action
Nurse 1
Johnson, K. Room 707
5 year old male with left lower extremity cellulitis vs. osteomyelitis Orthopedics consulting, possible debridement tonight depending on MRI
Patient just returned from MRI and dinner cart is leaving in 5 minutes. Currently has nothing by mouth (NPO) order in system and cannot get tray.
You call resident regarding need for a diet order as soon as possible to get dinner tray.
Nurse 2
Smith, R. Room 702
8year old female with known type one diabetes mellitus, transferred to floor from pediatric intensive care unit for diabetic ketoacidosis On Lantus/ Novolog
Blood glucose 350 after dinner despite pre-dinner Novolog; no other issues, patient stable.
You page resident to ask if your patient needs extra Novolog?
Pediatric Acute Care Interprofessional Education Curriculum
Nurse 3
Nurse 4
Walker, E. Room 736
Portillo, M. Room 728
5year old male with complex medical history of developmental delay, tracheostomy dependent, now admitted with bacterial pneumonia vs. viral illness Weaning supplemental oxygen, suctioning, antibiotics
First time you’ve had patient.
6year old female with status asthmaticus Weaned to albuterol every 2 hours, weaning oxygen Patient otherwise stable
Family just arrived for quick 15 minute visit.
On report, patient was requiring 28% oxygen and comfortable, now 40% oxygen and tachypnea.
You call resident to notify that patient’s clinical status has changed.
You page resident that family is requesting update from MD now.
Conflict of Interest and Authorship Conformation Form Please check the following as appropriate:
o
All authors have participated in (a) conception and design, or analysis and interpretation of the data; (b) drafting the article or revising it critically for important intellectual content; and (c) approval of the final version.
o
This manuscript has not been submitted to, nor is under review at, another journal or other publishing venue.
o
The authors have no affiliation with any organization with a direct or indirect financial interest in the subject matter discussed in the manuscript
o
The following authors have affiliations with organizations with direct or indirect financial interest in the subject matter discussed in the manuscript:
Author’s name
Affiliation
Laura Nicholson, RN* Michael V. Ortiz, MD * Yunfei Wang, DrPH Heather Walsh, RN Mary C. Ottolini, MD Dewesh Agrawal, MD
1, 2 3, 4 5 1, 2 3, 6 3, 6
1 Division of Nursing, Children’s National Medical Center, Washington, DC 2 Board of Visitors Simulation Program, Children’s National Medical Center, Washington, DC 3 Pediatric Residency Program, Children’s National Medical Center, Washington, DC 4 Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, NY 5 Center for Translational Science, Children’s National Medical Center, Washington, DC 6 School of Medicine, The George Washington University, Washington, DC
S2405-4526(19)30051-5
DOI:
https://doi.org/10.1016/j.xjep.2019.100284
Reference:
XJEP 100284
To appear in:
Journal of Interprofessional Education & Practice
Received Date: 12 March 2019 Revised Date:
28 May 2019
Accepted Date: 6 September 2019
Please cite this article as: Nicholson L, Ortiz MV, Wang Y, Walsh H, Ottolini MC, Agrawal D, Successful implementation of a novel collaborative interprofessional educational curriculum for nurses and residents in a pediatric acute care setting, Journal of Interprofessional Education & Practice (2019), doi: https:// doi.org/10.1016/j.xjep.2019.100284. This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2019 Published by Elsevier Inc.
Title: Successful Implementation of a Novel Collaborative Interprofessional Educational Curriculum for Nurses and Residents in a Pediatric Acute Care Setting Authors: Laura Nicholson, RN *1,2; Michael V. Ortiz, MD *3,4; Yunfei Wang, DrPH5; Heather Walsh, RN1,2; Mary C. Ottolini, MD3,6; Dewesh Agrawal, MD3,6 *Authors contributed equally Affiliations: 1 Division of Nursing, Children’s National Medical Center, Washington, DC 2 Simulation Program, Children’s National Medical Center, Washington, DC 3 Pediatric Residency Program, Children’s National Medical Center, Washington, DC 4 Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, NY 5 Center for Translational Science, Children’s National Medical Center, Washington, DC 6 School of Medicine, The George Washington University, Washington, DC First Author: Laura Nicholson, RN Children's National Medical Center 111 Michigan Avenue NW Washington, DC 20010 202-476-6443 [email protected] Abstract Word Count: 247 Abstract, Main Text, and References Word Count: 2155 Figures: 2 Tables: 2 Appendices: 3 Keywords: Interprofessional Education, Pediatrics, Simulation, Nursing, Residency Short Running Title: Pediatric Acute Care Interprofessional Education Curriculum Abbreviations: IPE = Interprofessional Education; NDNQI-PES = National Database of Nursing Quality Indicators - Practice Environment Scale; REDCap = Research Electronic Data Capture
Acknowledgements We would like to thank Dr. Pamela S. Hinds for her mentorship and ongoing support throughout this project and manuscript preparation. We would also like to thank Pam Samuelson BSN, RN for her collaboration and support throughout this project. Dr. Ortiz receives support from the Kristen Ann Carr Fund, the Met Life Foundation, the Pediatric Cancer Research Foundation, Hyundai Hope on Wheels, and the MSK Cancer Center Support Grant/Core Grant P30 CA008748. Dr. Ortiz is also supported by the National Cancer Institute of the National Institutes of Health under Award Number K12CA184746. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.
Pediatric Acute Care Interprofessional Education Curriculum
SUCCESSFUL IMPLEMENTATION OF A NOVEL COLLABORATIVE INTERPROFESSIONAL EDUCATIONAL CURRICULUM FOR NURSES AND RESIDENTS IN A PEDIATRIC ACUTE CARE SETTING Abstract Interprofessional collaboration is vital to maintain a successful healthcare team. We describe the development, implementation, and evaluation of an interprofessional educational curriculum on a large inpatient, acute care pediatric unit. Our objective was to improve attitudes towards collaborative care and collegial relations between staff nurses and pediatric medical residents. Nurses and residents participated in several interventions including a video for the nurses, a video for the residents, a teambuilding exercise, and three interprofessional clinical simulations. Participants’ attitudes toward collaborative care were evaluated by a self-reported questionnaire, adapted from several validated survey instruments, before and after the intervention. Each question was mapped to one of the four domains of interprofessional practice: Teams and Teamwork, Interprofessional Communication, Values and Ethics for Interprofessional Practice, and Roles and Responsibilities. The National Database of Nursing Quality Indicators - Practice Environment Scale (NDNQI-PES) question on collegial nurse and physician relations was also queried to corroborate these findings. There was a statistically significant improvement in the nurses’ response to 7/24 (29%) survey questions, of which 4 were within the domain of Teams and Teamwork. There was a statistically significant improvement in the residents’ response to 5/24 (21%) questions, of which 3 fell within the domain of Interprofessional Communication. None of the survey questions demonstrated a statistically significant decrease. There was also an improvement on NDNQI-PES scores for the target unit, both during and immediately following the intervention. In conclusion, this educational curriculum involving nurses and residents led to improved participants’ attitudes toward interprofessional collaboration.
Pediatric Acute Care Interprofessional Education Curriculum
Format Interprofessional education (IPE) has been advocated as a method of removing professional silos and improving collaboration amongst medical care team members (Canadian Interprofessional Health Collaborative, 2010; Gilbert, Yan, & Hoffman, 2010; Institute of Medicine, 2013). Medical and nursing schools are beginning to incorporate IPE into their curricula, but there is no standardized curriculum at the student or junior practitioner level, despite recommendations that IPE needs to be effectively integrated (Institute of Medicine Committee on the Health Professions Education, 2003; International Education Collaborative, 2011; Winterbottom & Seoane, 2012).
This manuscript describes our
experience in designing, implementing, and assessing the efficacy of an IPE curriculum. This IPE curriculum included two videos, one for the staff nurses (subsequently referred to as “nurses”) and another for the pediatric medical residents (subsequently referred to as “residents”), a small-group classroom-based team-building exercise, and three simulations in a clinical setting. This curriculum was integrated into their standard educational program from 10/1/13 to 4/30/14. Involvement in all activities was voluntary and did not provide any credit, but attendance was monitored to ensure all participants had the opportunity to be involved in each intervention at least once. Target Audience 100 nurses on a 50-bed pediatric acute care unit and 117 residents in an urban tertiary care academic children’s hospital were invited to participate. The target inpatient unit has residents of all levels, although the majority were first year residents. Similarly, the majority of the nurses on the unit were early in their career. Collectively the simulations included 146 nurses and residents. The preintervention survey was completed by 56 residents (48%) and 58 nurses (58%), whereas 40 residents (34%) and 38 nurses (38%) completed the post-intervention survey.
Pediatric Acute Care Interprofessional Education Curriculum
Objectives The goal of this study was to evaluate whether an IPE curriculum would both improve attitudes regarding collaboration and collegial relations between nurses and residents. The learning objectives and evaluation metrics to assess these objectives were based upon the core competencies of interprofessional practice. These competencies were developed in 2011 by an expert panel comprised of six healthcare disciplines sponsored by the Interprofessional Education Collaborative. This group defined four core competencies as the elements needed for interprofessional collaborative practice: Values and Ethics for Interprofessional Practice, Roles and Responsibilities, Interprofessional Communication, and Teams and Teamwork. Each of the interventions in our IPE curriculum was specifically designed to address at least two of these domains of competency, as shown in Table 1. The primary aim of this study was to evaluate whether there was a statistically significant change in attitudes towards interprofessional practice pre-post IPE curriculum and whether that improvement was general or specific to certain domains of interprofessional collaborative practice. Our secondary aim was to assess the impact of the IPE curriculum on collegial nursing-resident relations. Activity Description The authors previously performed a needs assessment to determine opportunities to improve patient care on our largest general inpatient pediatric acute care unit. This needs assessment revealed that both nurses and residents perceived that there was a need for improved interprofessional collaboration between them. We hypothesized that targeting these two groups with an IPE curriculum could improve participant attitudes toward interprofessional collaboration and collegial relations. The IPE curriculum itself involved several interventions: orientation videos for the nurses and residents, a team-building exercise, and three high-fidelity simulations. The orientation videos lasted approximately 10 minutes each, whereas the team-building exercise and simulations were each designed to last 45 to
Pediatric Acute Care Interprofessional Education Curriculum
60 minutes, including time for debriefing. Interventions were repeated monthly in order to coincide with resident rotations. Videos Both videos focused on their disciplines’ respective schedules, responsibilities, and optimal routes of communication and were shared during a social event including a small meal, which allowed for discussion to contextualize some of the content after the viewing. Videos were designed by both nursing and resident leadership in order to address perceived areas of deficiency in interprofessional collaborative practice, as defined in the needs assessment. Since the residents are more transient and rotate in a variety of different clinical settings in the institution every four weeks, a particular focus of their video was to welcome and orient them to the unit, with an emphasis on nursing interactions. By contrast, the needs assessment demonstrated a perceived lack of appreciation on the nurses’ behalf to the residents’ schedule. Therefore, a particular focus of the nursing video was to help better appreciate unique challenges of the resident work day (e.g. pre-rounding vs. rounding, protected time during handoff and mandatory educational activities, continuity clinic, and paging/calling etiquette). Team-building exercise The team-building exercises were performed in the context of a planned social meeting with food. During the team-building exercise, participants created a group résumé, highlighting each team member’s unique, shared, and diverse skills and experiences. Teams created team names, shared interesting personal and professional details as much as they were inclined to do so, and then identified leaders who would present their collective experiences. Team discussions were allowed to organically evolve, but if the conversations stagnated, nurse leaders and chief residents facilitated productive and positive discussions.
Pediatric Acute Care Interprofessional Education Curriculum
Simulations The simulations included: (1) a role reversal mock code in which the nurse and resident changed roles and attempted to solve an emergent case but did so in the other person’s role, (2) a case in which the resident discovered a decompensating patient unattached to a monitor and must collaborate with the bedside nurse to provide care, and (3) a scenario where the resident triaged multiple nurse phone calls and must effectively prioritize and respond to their concerns. The simulation templates are provided in Appendices 1-3. Course Facilitators The team-building exercises and simulations used at least one nursing and one physician facilitator, generally a unit-based nurse educator and a chief resident. Prior to the initiation of the curriculum, these facilitators received specific simulation facilitation training. Assessment To determine the effectiveness of our IPE curriculum on nurse and resident attitudes toward interprofessional collaboration, a survey instrument was provided to all participants before and after the study window. Survey questions were derived from components of three previously published survey instruments: the ICU Nurse-Physician Questionnaire (Hojat et al., 2001), Jefferson Scale of Attitudes Towards Physician-Nurse Collaboration (Lake, 2002), and the Practice Environment Scale of the Nursing Work Index (Shortell, Rousseau, Gillies, Devers, & Simons, 1991). Additional survey questions were based upon specific concerns from the initial needs assessment. As shown in Table 2, each question was specifically assigned to a single domain of interprofessional collaborative practice.
Three unique
questions were only given to one participant group and not the other. Thus, in total there were 27 survey questions, and residents and nurses each completed 24 questions. Responses to the survey questions were graded on a 1-4 Likert scale where 1 - Strongly Disagree, 2 - Disagree, 3 - Agree, and 4 Strongly Agree. The survey was written with both positive and negative items; however, for purposes of
Pediatric Acute Care Interprofessional Education Curriculum
the analysis, the survey questions that were negatively worded were reverse coded such that higher scores meant positive responses. Study data were collected and managed using the Research Electronic Data Capture (REDCap) program (Harris et al., 2009). In order to assess the impact of our IPE curriculum on collegial relations, we also analyzed results from The National Database of Nursing Quality Indicators - Practice Environment Scale (NDNQI®PES). This national survey is administered annually to nurses at this hospital. The NDNQI® survey specifically measures job satisfaction and evaluates the practice environment. The NDNQI® survey measures satisfaction on a 0-3.5 score, with 3.5 being the highest score. We monitored the more global and lasting effect of the curriculum on nurses working on the intervention unit via an analysis of the NDNQI-PES domain score for collegial nursing-physician relations before, during, and one year after the intervention. Evaluation Pre-post survey results were intentionally anonymized and therefore unable to be paired. All data were descriptively analyzed using univariate statistics. Pre- versus post- intervention scores from these two surveys were compared using the Wilcoxon test against the null hypothesis of no change between the pre- and post-intervention scores. 12/48 (25%) questions demonstrated a statistically significant improvement, and 0/48 (0%) demonstrated a statistically significant decrease, as shown in Figure 1. There was a statistically significant improvement in the nurses response to 7/24 (29%) survey questions, of which 4 were within the domain of Teams and Teamwork and 1 each within the domains of Interprofessional communication, Roles and Responsibilities, Values and Ethics for Interprofessional Practice. There was a statistically significant improvement in the residents’ response to 5/24 (21%) questions, of which 3 were within the domain of Interprofessional Communication, and 1 each within the domains of Teams and Teamwork and Values and Ethics for Interprofessional Practice.
Pediatric Acute Care Interprofessional Education Curriculum
The 7 specific nursing questions that demonstrated statistically significant improvement were “It is easy to ask for advice from residents on the unit”(p = 0.02), “I feel that I can speak to the resident when needed” (p = 0.004), “Residents at this hospital appreciate what nurses do” (p = 0.002), “I feel that certain nurses don't completely understand the information they receive” (p = 0.01), “Residents and nurses have bad working relationships on the unit”(p = 0.02), “I do not find it enjoyable to talk with residents on the unit” (p = 0.03), and “There is poor teamwork between nurses and physicians” (p = 0.001). Specific resident questions that demonstrated statistically significant improvements were “It is easy for me to talk openly with nurses on the unit” (p = 0.0004), “I cannot complete my work due to frequent interruptions from nurses” (p = 0.02), “Nurses at this hospital generally appreciate the residents’ work” (p = 0.002), “There is poor teamwork between nurses and physicians” (p = 0.05), and “I do not find it enjoyable to talk with nurses on the unit” (p = 0.007).
The average score on the NDNQI-PES collegial nursing-physician relations question was 2.53 prior to the intervention (baseline), 2.85 during the intervention, and 3.02 immediately following the intervention. One year after completion of the intervention, the score was 2.78, which remained above the baseline. Impact Nurses’ and residents’ attitudes toward interprofessional collaboration improved in four domains as a result of this educational curriculum. There were discipline-specific improvements, most notably in the nurses’ response to questions in the domain of Teams and Teamwork and residents’ response to questions in the domain of Interprofessional Communication. These improvements in attitude are further supported by an increase on the NDNQI survey question focusing on collegial nursephysician relations following the IPE curriculum.
Pediatric Acute Care Interprofessional Education Curriculum
Residents spend the majority of their intern year on the intervention unit; hence it is important to create a foundation of collaboration with nurse colleagues. It is equally important for new graduate nurses, who may not have previously worked with physician trainees, to develop working relationships with physicians to foster teamwork and optimize patient care. Since nurses and residents spend much time working together on inpatient units, it is essential that they appreciate the unique differences in their education and training, share knowledge of their respective expertise, and reflect on experiences and challenges in a safe learning environment. This curriculum created opportunities for the nurses and residents to get to know one another on a personal level and to discuss work challenges and how to overcome them. These face-to-face activities are important, as many clinical interactions occur via technology (e.g. one-way text paging, phone calls, electronic order entry) with lack of closed loop communication.
The team-building
exercises enhanced nurse and resident understanding and appreciation of their discipline-specific roles and responsibilities. The simulations permitted nurses and residents to practice escalating patient concerns and establishing a management plan, while the debriefings further reinforced the need for teamwork and communication through sharing of ideas and reflection. Other institutions may easily replicate the components of this curriculum by incorporating the simulation scenarios into the residency curriculum or other unit-based education. Key to the curriculum’s success was the support from nursing and physician leaders, including pediatric residency leadership, and partnerships between unit-based leaders, nurse educators, simulation educators, and chief residents. As a result of this curriculum’s success, the interprofessional in-situ simulation program with nurses and residents has expanded from the intervention unit to the remaining six pediatric acute care units. The simulations are designed to meet the learning needs of each unit and are periodically changed to ensure the nurses who are unit-based will experience different scenarios. As residents
Pediatric Acute Care Interprofessional Education Curriculum
rotate monthly, they experience a new simulation during each clinical block. Interprofessional activities continue on the intervention unit as social gatherings both on the unit and outside of the hospital. Required Materials This IPE curriculum includes a simulation facilitator’s guide for each of the three simulations (Appendices 1-3), post-simulation evaluations, the pre-post intervention survey questions (Table 2), welcome videos for residents and a day in the life of the resident video for nurses, and food items for the social events. Additional information such as simulation equipment list, instructions for the résumé building activity, and specific social event details can be obtained by emailing [email protected].
Pediatric Acute Care Interprofessional Education Curriculum
References
Amos, M. A., Hu, J., & Herrick, C. A. (2005). The impact of team building on communication and job satisfaction of nursing staff. Journal of Nursinges Staff Development, 21(1), 10-16; quiz 17-18. Baggs, J. G., Schmitt, M. H., Mushlin, A. I., Mitchell, P. H., Eldredge, D. H., Oakes, D., & Hutson, A. D. (1999). Association between nurse-physician collaboration and patient outcomes in three intensive care units. Critical Care Medicine, 27(9), 1991-1998. Canadian Interprofessional Health Collaborative (2010). A National Interprofessional Competency Framework. Retrieved from https://www.cihc.ca/files/CIHC_IPCompetencies_Feb1210.pdf Core competencies for interprofessional collaborative practice: Report of an expert panel (2011) Retrieved from https://www.aacom.org/docs/default-source/insideome/ccrpt05-1011.pdf?sfvrsn=77937f97_2 Gilbert, J. H., Yan, J., & Hoffman, S. J. (2010). A WHO report: framework for action on interprofessional education and collaborative practice. Journal of Allied Health, 39 (1), 196-197. Harris, P. A., Taylor, R., Thielke, R., Payne, J., Gonzalez, N., & Conde, J. G. (2009). Research electronic data capture (REDCap)-a metadata-driven methodology and workflow process for providing translational research informatics support. Journal ofBiomedical J Biomed Informatics, 42(2), 377-381. doi:10.1016/j.jbi.2008.08.010 Hojat, M., Nasca, T. J., Cohen, M. J., Fields, S. K., Rattner, S. L., Griffiths, M., Garcia, A. (2001). Attitudes toward physician-nurse collaboration: a cross-cultural study of male and female physicians and nurses in the United States and Mexico. Nursing Research, 50(2), 123-128. Institute of Medicine (2013). Interprofessional education for collaboration: learning how to improve health from interprofessional models across the continuum of education to practice: Workshop summary. Washington, DC: The National Academies Press.
Pediatric Acute Care Interprofessional Education Curriculum
Institute of Medicine Committee on the Health Professions Education (2003). In A. C. Greiner & E. Knebel (Eds.), Health Professions Education: A Bridge to Quality. Washington (DC): National Academies Press (US) Copyright 2003 by the National Academy of Sciences. Lake, E. T. (2002). Development of the practice environment scale of the Nursing Work Index. Research in Nursing & Health, 2524(3), 176-188. doi:10.1002/nur.10032 Larrabee, J. H., Ostrow, C. L., Withrow, M. L., Janney, M. A., Hobbs, G. R., Jr., & Burant, C. (2004). Predictors of patient satisfaction with inpatient hospital nursing care. Research in Nursing & Health, 27(4), 244-268. doi:10.1002/nur.20021 Lewis, R., Strachan, A., & Smith, M. M. (2012). Is high fidelity simulation the most effective method for the development of non-technical skills in nursing? A review of the current evidence. The Open Nursing Journal, 6, 82-89. doi:10.2174/1874434601206010082 Muller-Juge, V., Cullati, S., Blondon, K. S., Hudelson, P., Maitre, F., Vu, N. V., Nendaz, M. R. (2013). Interprofessional collaboration on an internal medicine ward: role perceptions and expectations among nurses and residents. PLoS One, 8(2), e57570. doi:10.1371/journal.pone.0057570 Muller-Juge, V., Cullati, S., Blondon, K. S., Hudelson, P., Maitre, F., Vu, N. V., Nendaz, M. R. (2014). Interprofessional collaboration between residents and nurses in general internal medicine: a qualitative study on behaviours enhancing teamwork quality. PLoS One, 9(4), e96160. doi:10.1371/journal.pone.0096160 Reeves, S., Perrier, L., Goldman, J., Freeth, D., & Zwarenstein, M. (2013). Interprofessional education: effects on professional practice and healthcare outcomes (update). Cochrane Database Systematic Review (3), Cd002213. doi:10.1002/14651858.CD002213.pub3
Pediatric Acute Care Interprofessional Education Curriculum
Shortell, S. M., Rousseau, D. M., Gillies, R. R., Devers, K. J., & Simons, T. L. (1991). Organizational assessment in intensive care units (ICUs): construct development, reliability, and validity of the ICU nurse-physician questionnaire. Medical Care, 29(8), 709-726. Vahey, D. C., Aiken, L. H., Sloane, D. M., Clarke, S. P., & Vargas, D. (2004). Nurse burnout and patient satisfaction. Medical Care, 42(2 Suppl), 57-66. doi:10.1097/01.mlr.0000109126.50398.5a Winterbottom, F., & Seoane, L. (2012). Crossing the quality chasm: it takes a team to build the bridge. Ochsner Journal, 12(4), 389-393. Woods, D. (2002). Medical error: what do we know? What do we do? BMJ : British Medical Journal, 32524(7358), 285-285.
Pediatric Acute Care Interprofessional Education Curriculum
Table 1: Mapping of each IPE curricular intervention to specific domains of interprofessional practice Domain
Team
Orientation
Simulations
Building
Video
Role Reversal The Unattached Triaging Mock Code Patient Phone Calls
Exercise Values and Ethics
X
X
X
for Interprofessional Practice Roles and
X
X
X
X
X
X
X
X
X
X
X
Responsibilities Interprofessional Communication Teams and Teamwork
Pediatric Acute Care Interprofessional Education Curriculum
Table 2. Survey instrument questions targeting specific domains of interprofessional collaborative practice Domain Survey Instrument Questions (Nurse Version) Teams
and 1. There is poor teamwork between nurses and physicians (Lake, 2002)
Teamwork
2. Residents and nurses have bad working relationships on the unit (Lake, 2002) 3. It is easy to ask advice from residents on the unit. (Hojat et al., 2001) 4. I feel that I can speak to the resident when needed. ¥
Interprofessional
5. I do not find it enjoyable to talk with residents on the unit. (Hojat et al., 2001)
Communication
6. It is easy for me to talk openly with residents on the unit (Hojat et al., 2001) 7. I cannot complete my work due to frequent interruptions from residents. 8. I feel that the nurses call my phone for non-urgent concerns.* 9. When nurses talk with residents on unit, there is a good deal of understanding. (Hojat et al., 2001) 10. There are barriers that prevent open communication with nurses and residents. 11. Communication between nurses and physicians on the unit is very open. * 12. The accuracy of information passed between nurses and residents on the unit leaves much to be desired. (Hojat et al., 2001)
Values and Ethics 13. Residents at this hospital appreciate what nurses do. for Interprofessional Practice
14. There is collaboration (joint practice) between nurses and residents. (Lake, 2002) 15. Residents do not respect the skill and knowledge of the nursing staff. ¥ 16. Nurses respect the time of day when the residents are in lecture/rounds. * 17. Nurses should clarify a resident’s order when they feel that it might have the
Pediatric Acute Care Interprofessional Education Curriculum
potential for detrimental effects on the patient. (Shortell et al., 1991) 18. A nurse should be viewed as a collaborator and colleague rather than the physician’s assistant. (Shortell et al., 1991) Roles
and 19. I feel that certain nurses don’t completely understand the information they
Responsibilities
receive. (Hojat et al., 2001) 20. Orders are updated/cleaned up by residents in a timely manner. ¥ 21. I can think of a number of times when I received incorrect information from residents. (Hojat et al., 2001) 22. It is often necessary for me to go back and check the accuracy of information I have received from residents. (Hojat et al., 2001) 23. I am aware of the plan of care on nights. 24. I have a good understanding of the resident’s role. 25. There are many overlapping areas of responsibility between residents and nurses. (Shortell et al., 1991) 26. I am aware of the plan of care on weekends. 27. Nurses should have responsibility for monitoring the effects of medical treatment. (Shortell et al., 1991)
* Resident only question;
¥
Nurse only question; Note that this is the nursing version of the survey.
Survey questions to the residents had “nurse” or “resident” replaced where appropriate.
Pediatric Acute Care Interprofessional Education Curriculum
Figure 1. Average change in survey question response after IPE curricular intervention, stratified by respondent type and domain of interprofessional collaboration
Pediatric Acute Care Interprofessional Education Curriculum
Appendix 1: Role Reversal Mock Code Name: Arbitrary Age: 6 year old Weight: 25 kg Allergies: No Known Drug Allergies Immunizations: Up To Date Past Medical History: Previously healthy male; no hospitalizations Present History: 6 year-old boy admitted from outside hospital with dehydration, fever, altered mental status changes concerning for viral encephalitis. He has just arrived on the floor. Upon entering the room the parent expresses concerned that he is “sleepier than usual and not behaving like himself.”
LEARNING OBJECTIVES At the completion of this simulation, the participants will be able to: • Describe the available resources needed to perform technical skills (e.g. IO placement, retrieval of medication/supplies from code cart and medication pyxis, bag mask ventilation and intubation) • Identify strategies to overcome potential stressors that contribute to communication breakdown • Demonstrate effective team communication and understand its role in facilitating patient care and safety
Participant Roles: • • • • • • •
Resident Senior resident Primary nurse Backup nurse Charge nurse Parent Observers
OUTLINE OF SCENARIO PROGRESSION Segment/ timing: Resident called to assess:
Mannequin Actions Patient Position:
Expected Participant Actions Primary nurse verbalizes concern to resident
Patient lying in bed
Recognize deteriorating clinical status
Talking, but appears sleepy
Assign roles (stickers will be provided)
First 2 minutes
Not on Monitor to start
Resident: Gathering information (further history) & perform assessment
Once on Monitor: Vital Signs: Heart Rate: 120 Respiratory Rate: 36 Temperature: 39.0 - oral Blood Pressure: 100/64
Nurse: Begin interventions (monitor, leads, VS)
Oxygen saturation: 94%
Resident: Order Normal saline bolus
Nurse: Talks to mom regarding status/ concerns Resident: Discuss/ attempts IV access, STAT Tylenol
Cues: Facilitator: You are caring for a 6 year old patient who was directly admitted from an outside hospital for dehydration and recent viral URI symptoms. Patient off monitor, no IV access, no suction or seizure precautions at the bedside. Baseline normal development - had been alert and talking, mom had to wake him to eat dinner and he vomited twice. No fluids today with exception of a few sips at breakfast Unable to obtain IV access
Nurse or resident: Initiate Oxygen (Nasal Cannula, Non-rebreather) Team at bedside: Second 5 minutes
Patient Position: Bed Patient begins to seize Vital Signs: Heart Rate: 136 Respiratory Rate: 12 Temperature: 39.0 Blood pressure: 140/80 Oxygen saturation 80% Cyanosis
Recognize worsening status/ seizure Discussion of team assessment and shared mental model Nurse or resident: turn patient on his side; begin timing Call for help- charge nurse, senior, IV nurse/ crisis nurse, respiratory therapist Establish IV access, Initiate Rapid Response Team vs. Code Nurse: Bring code cart Resident: Check electrolytes, glucose Nurse or resident: Apply 100% non-rebreather
Facilitator: Charge nurse comes to room if called Senior resident comes to room if called Respiratory therapist in emergency room- unable to come Crisis nurse unavailable (in staffing) Capillary refill 5 seconds Skin cool
Pediatric Acute Care Interprofessional Education Curriculum
Appendix 2: The Unattached Decompensating Patient Scenario: The unattached patient Estimated Scenario Time: 15 minutes Estimated Debriefing Time: 30 minutes Closing: 10 minutes Target Group: Registered nurses & Residents Brief Description Name: Age: 6 month old Weight: 6kg Allergies: No Known Drug Allergies Immunizations: Up To Date Past Medical History: Previously healthy Present History: Admitted for bronchiolitis, currently awaiting discharge after an overnight stay briefly requiring supplemental oxygen and albuterol treatment
LEARNING OBJECTIVES At the completion of this simulation, the participants will be able to: • Perform the appropriate application and functioning of various patient monitoring tools as a nursing-resident team. • Employ strategies for open, effective communication using safety techniques. • Demonstrate use of institutional escalation algorithms to escalate concerns.
Participant Roles • • • • • •
Resident Primary nurse Charge nurses Respiratory therapists Parent Observers
OUTLINE OF SCENARIO PROGRESSION Segment/ timing: Initial assessment by resident: First 5 minutes
Mannequin Actions Patient Position:
Nurse Enters Room: Second 5 minutes
Patient Position: Crib Patient is coughing, when patient is hooked to monitor oxygen saturation is 86% on room air
Lying in crib (flat) – lips blue – coughing – emesis noted on gown
When oxygen is applied oxygen saturations go up to 88%
Expected Participant Actions Resident is discharging patient: -
Assesses patient Calls for help (nurse?) Applies oxygen Tries to suction Suction not working (fix suction or use the bulb syringe)
Primary Nurse: - Nurse places patient on monitor - Applies oxygen if not already done - Either fixes suction or uses bulb syringe to suction nares - Obtains VS (BP cuff is too big) -Primary nurse calls charge nurse
When patient suctioned oxygen saturations go up to 94% if the nurse has already applied oxygen
-Resident may call senior who cannot come to room for 10 minutes due to another situation
Cues: Facilitator: You are performing your discharge counseling and confirming a primary care doctors appointment as Mom gives the patient a bottle and Dad waits downstairs in the car. After the bottle, the baby begins coughing with emesis and Mom worriedly points to the baby’s lips, which are blue. What do you do next? Facilitator: states that the senior resident and attending cannot come to room for 15 minutes as they are in a CAT Respiratory therapist will finish another treatment and be there in about 15 minutes Charge nurse comes to room if called
Pediatric Acute Care Interprofessional Education Curriculum
Segment/ timing: Resident: Third 5 Minutes
Mannequin Actions If patient not suctioned but oxygen is applied, oxygen saturation goes up to 88% If patient not placed on oxygen but is suctioned, oxygen saturations stay at 88%
Expected Participant Actions Primary Nurse:
Cues:
Nurse puts patient on oxygen if not done in second five minutes Resident suggests oxygen if nurse does not Nurse suctions if not already done
Appendix 3: Triaging Phone Calls Brief Description Nurse #1 calls resident Nurse #2 pages resident Nurse #3 calls resident Nurse #4 pages resident Resident responds to each concern, triages priority & urgency of each, takes appropriate action
LEARNING OBJECTIVES At the completion of this simulation, the participants will be able to: • Utilize SBAR to communicate and triage interprofessional concerns • Apply escalation techniques based on patient care needs
Resident Sign-Out Patient Summary
To-Dos
Smith 702
8 year old female with known type one diabetes, transferred to floor from Pediatric Intensive Care Unit for diabetic ketoacidosis On Lantus/ Novolog
Johnson 707
5 year old male with LLE cellulitis vs. osteomyelitis Orthopedics consulting, possible debridement tonight depending on MRI
Follow-up MRI, touch base with orthopedics
Robertson 728
6 year old female with status asthmaticus Weaned to albuterol every 2 hours, weaning Oxygen
wean to albuterol every 4 hours
Walker 736
5 year old male with developmentally delayed, tracheostomy dependent, admitted with bacterial pneumonia vs. viral illness Weaning supplemental oxygen, suctioning, antibiotics
Nurse Sign-Out Nurse Patient
Summary
Situation
Nursing action
Nurse 1
Johnson, K. Room 707
5 year old male with left lower extremity cellulitis vs. osteomyelitis Orthopedics consulting, possible debridement tonight depending on MRI
Patient just returned from MRI and dinner cart is leaving in 5 minutes. Currently has nothing by mouth (NPO) order in system and cannot get tray.
You call resident regarding need for a diet order as soon as possible to get dinner tray.
Nurse 2
Smith, R. Room 702
8year old female with known type one diabetes mellitus, transferred to floor from pediatric intensive care unit for diabetic ketoacidosis On Lantus/ Novolog
Blood glucose 350 after dinner despite pre-dinner Novolog; no other issues, patient stable.
You page resident to ask if your patient needs extra Novolog?
Pediatric Acute Care Interprofessional Education Curriculum
Nurse 3
Nurse 4
Walker, E. Room 736
Portillo, M. Room 728
5year old male with complex medical history of developmental delay, tracheostomy dependent, now admitted with bacterial pneumonia vs. viral illness Weaning supplemental oxygen, suctioning, antibiotics
First time you’ve had patient.
6year old female with status asthmaticus Weaned to albuterol every 2 hours, weaning oxygen Patient otherwise stable
Family just arrived for quick 15 minute visit.
On report, patient was requiring 28% oxygen and comfortable, now 40% oxygen and tachypnea.
You call resident to notify that patient’s clinical status has changed.
You page resident that family is requesting update from MD now.
Conflict of Interest and Authorship Conformation Form Please check the following as appropriate:
o
All authors have participated in (a) conception and design, or analysis and interpretation of the data; (b) drafting the article or revising it critically for important intellectual content; and (c) approval of the final version.
o
This manuscript has not been submitted to, nor is under review at, another journal or other publishing venue.
o
The authors have no affiliation with any organization with a direct or indirect financial interest in the subject matter discussed in the manuscript
o
The following authors have affiliations with organizations with direct or indirect financial interest in the subject matter discussed in the manuscript:
Author’s name
Affiliation
Laura Nicholson, RN* Michael V. Ortiz, MD * Yunfei Wang, DrPH Heather Walsh, RN Mary C. Ottolini, MD Dewesh Agrawal, MD
1, 2 3, 4 5 1, 2 3, 6 3, 6
1 Division of Nursing, Children’s National Medical Center, Washington, DC 2 Board of Visitors Simulation Program, Children’s National Medical Center, Washington, DC 3 Pediatric Residency Program, Children’s National Medical Center, Washington, DC 4 Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, NY 5 Center for Translational Science, Children’s National Medical Center, Washington, DC 6 School of Medicine, The George Washington University, Washington, DC