Interdisciplinary Clinical Collaborative Practice Model

1
Interdisciplinary Clinical Collaborative Practice
Model

• Ann Coleman, EdD, RN Teri Newsom, MSN
  Kelly Vandenberg, PhD (c)
• With Contributions from
• John Rogers, MDBaylor College of Medicine
• Sharon Decker, PhD
• Mercedes Baldwin
• Sandra CabalelroTexas Tech University
• Patti Hamilton, PhD
• Texas Womans University
• February 19, 2008
• HPSN, Meti Conference

2
Table of Contents

• Objectives 2
• Background 4
• ICCP Project 12
• Collaborative Model 15
• Team Roles 16
• Expected Outcomes 20
• Scenario Selection 21
• Student Selection 27
• Competencies 28
• Communication 29
• Patient Care 40
• Collaboration 42

• Pilot 43
• Debriefing 44
• Conclusion 48
• Thoughts 49
• Next Steps 56
• Project Team 57
• References 58

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Objectives

• At the conclusion of this workshop the
  participants will be able to
• Develop a model for collaborative medical
  nursing student clinical practice using high
  fidelity simulators.
• 2.  Identify 2 scenarios for effective
  interdisciplinary clinical practice using high
  fidelity simulators.
• 3.  Identify three competencies for collaborative
  interdisciplinary scenario simulation practice
  using high fidelity simulators.

4
BackgroundIOM

• The Institute of Medicines various quality
  reports have served as the basis to identify and
  describe the foundational element of poor
  communication amongst the health care team as the
  key to improve health care.
• The IOM recommended implementing
  interdisciplinary education as a primary solution
  to ensure collaboration and communication within
  the team.
• IOM, 1999, 2001, 2003, 2004

5
BackgroundAACN

• The American Association of Colleges of Nurses
  postulated that interdisciplinary education
  enables the nursing graduate to enter the
  workplace with
• Draft 2007

6
BackgroundAACN

• competencies in establishing collegial
  relationships with physicians

7
BackgroundAACN

• be able to recognize role expectations and
  unique disciplinary practice spheres

8
BackgroundAACN

• be prepared for open communication

9
BackgroundAACN

• have an optimized level of respect and trust that
  can lead to better patient care outcomes.

10
BackgroundJCAHO

• JCAHO reports that breakdowns in communication
  are major causes of health care errors and
  failures to rescue.

Joint Commission 2008 National Patient Safety
Goals Hospital Program
11
Healthcare WE have a problem!
12
ICCP Project

• The Interdisciplinary Clinical Collaborative
  Practice (ICCP) Project
• two colleges of nursing
• Texas Womans University
• Texas Tech
• medical school
• Baylor College of Medicine

13
ICCP Project

• Establish an interdisciplinary collaborative
  clinical education program in a patient safe,
  risk free environment using high fidelity
  simulators.

14
Project Content

• Nursing and medical student
• Patient scenario

15
Collaborative Project Team Model

• Content (clinical-nursing/medicine)
• Communication
• Simulation
• Project Manager

16
Project Team Roles

• Clinical content
• Patient care tasks/activities
• Establish competencies
• Develop evaluation tool

17
Project Team Roles

• Communication
• SBAR, RIME,
• Establish competencies
• Develop evaluation tool

18
Project Team Roles

• Simulation
• Scenario
• Moulage
• Cueing
• Video

19
Project Team Roles

• Project Manager
• Coordinate meetings
• Organize work products
• Participate

20
Expected Outcomes

• Correct and accurate transfer of vital patient
  information
• Effective team collaboration that produces
  positive patient care outcomes
• Behaviors that aid and encourage respect, trust
  and credibility among team members

21
Scenario Selection

• Reviewed METI high acuity scenarios. Selected
• Pulmonary embolism in a postoperative patient
• COPD exacerbation with respiratory failure

22
Scenario Selection

• Why
• Involve changes in assessment
• Have a variety of treatment options
• Patient can die if communication isn't clear and
  inclusive of all team members
•  

23
Scenario Selection

• Rationale
• These scenarios force
• relating information between team members
• discussion
• working through these opportunities
  (communication, conflict resolution, team
  building) build respect and trust

24
Pilot Scenario Selection

• Post-op PE scenario selected
• appropriate for surgery or medicine Sub-Intern.

25
Scenario Selection

• Workflows
• Items that are to be in the room,
• Programmed into the simulator
• Actions that the students must take
• Points of dialogue  

26
Scenario Selection

• CUEING (Script of key statements)
• For the patient 
• For the Nurse
• For the Physician
• Cueing clues noted (frequency) in the overall
  evaluation score of the students patient care

27
Student Selection

• Volunteers
• Last semester of program

28
Competencies

• Communication
• Patient care activities
• Collaboration

29
Communication CompetenciesNursing Perspective

• Utilize key components of information transfer
  model (SBAR) to formulate collaborative practice.
  

30
SBAR

• Framework for communication among health care
  professionals regarding a patient or situation.
• SBAR is a communication technique that conveys
  only the most critical information.
• Standardized prompts to ensure clear, concise,
  focused information is conveyed.
• Introduced in 2004 by Michael Leonard, MD and his
  colleagues at Kaiser

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Key Components of Communication to Evaluate

• Situation - What is going on with the patient?
• Background - What is the clinical background or
  context?
• Assessment - What do I think the problem is?
• Recommendations - What would I do to correct it?
• Collaboration (thinking/planning processes)

32
SBAR RubricDeveloped by P. Hamilton, PhD
33
Communication CompetenciesPhysician Perspective

• Utilize key components of information transfer
  model (RIME) to formulate collaborative practice.

34
RIME

• Reporter - denotes reliability and competence in
  the collection and communication of clinical
  information, specifically emphasizing the
  reliability, honesty, and professional qualities
  that are required in medical interviewing,
  physical examination, oral presentation, note
  writing, follow- through on assigned tasks, and
  working with patients and hospital personnel.
• Interpreter describes additional attributes that
  build on those seen in the reporter. This term
  involves functions of independent, critical
  thinking in the consideration of clinical data
  and advocation or refutation of diagnostic
  hypotheses. Students at this stage demonstrate
  consistency in prioritizing problem lists and
  offering differential diagnoses without prodding.
  
• Ogburn Eve Espey, 2003

35
RIME

• Manager -describes a high degree of direct
  involvement in patient care at the level expected
  of interns and subinterns. Students who are
  consistent managers can propose diagnostic and
  therapeutic options and can demonstrate judgment
  in working with patients and families and
  reliability in implementing the treatment plan.
• Educator denotes a pattern of self-directed
  learning beyond the basics and frequent
  contribution to the education of fellow students,
  residents, and even faculty members. Students who
  function as educators demonstrate an ability to
  frame important questions that are posed by
  complicated cases and to resolve these questions
  through independent and efficient literature
  research
• Ogburn Eve Espey, 2003

36
Communication HOW

• Education
• Training
• History
• Learned behaviors attitudes from training
  environment
• Traditional role heirarchy

37
The Key Moment

• Nurse to Physician information exchange
• 1st Contact (Telephone)
• Who, What, When, Where, Why SBAR
• HOW Communication

38
Be PREPARED to communicate
39
Be PREPARED to respond
40
Patient Care Activities

• Nursing Perspective
• Minimal Expected Behaviors-taken from the
  scenario
• Assessments, labs, contact physician, anticipates
  needs, obtains equipment, implements procedures
• Rating scale 0-4

41
Patient Care Activities

• Physician Perspective
• BCM Relevant Core Competency Graduation Goals
• Obtains vital information, orders correct
  tests/procedures/treatments, examines patient,
  consults as needed
• Rating scale Done or Not Done

42
Collaboration Competencies

• Interpersonal Communication Skills
• Patient Care Outcome
• Perceptions (student faculty)

43
The Pilot

• Brief excerpt of the pilot scenario with the
  nursing student and the medical student

44
Debriefing

• Student Survey (3 sections)
• 4 point Likert type scale
• Definitely Yes
• Somewhat Yes
• Somewhat No
• Definitely no
• Extrapolation from BCM Briefing Framework JCAHO
  Patient Safety Goals related to communication
• Discussion

45
Student Survey Section 1 Interpersonal
Communication Skills

• Introductions, used names
• Asked for input, encouraged to ask questions
• Did not interrupt
• Gave non-verbal cues to encourage to talk

• Displayed interest in team members
  thoughts/assessment/evaluation of the situation
• Asked knowledgeable questions
• Collaborative discussion regarding next steps

46
Student Survey Section IIPerceptions of
Collaborative Practice

• Teamwork
• Treated with respect
• Shared thoughts
• Felt safe to make mistakes
• Trusted clinical judgment skills

• Communicated pertinent patient information
• Credibility
• Communication style permitted collaborative
  practice

47
Student SurveySection III Discussion

• Great experience, made mistakes, but valuable
  learning process
• Needed the actual experience
• Should be a part of the program

48
Conclusion

• Project Team Thoughts
• Next Steps

49
Thoughts from the Project Team

• Nurses have numerous courses in communication
• Physicians have a lecture Physician believes
  that the nurse is a trained communicator

50
Thoughts from the Project Team

• Nurse Physicians speak different language
• i.e. Assessment
• Nurse data collection
• MD outcome of the data collection (tentative
  diagnoses)

51
Thoughts from the Project Team

• Does gender play a role in the interaction of the
  nurse/physician team?

52
Thoughts from the Project Team

• Do cultural/language differences affect their
  ability to communicate?

53
Thoughts from the Project Team

• How does the power differential affect their
  ability to communicate and patient care outcomes?

54
Thoughts from the Project Team

• Sometimes the physician expects the nurse to be
  assertive and offer recommendations
• Esp if the nurse is more experienced or
  seasoned

55
Thoughts from the Project Team

• In actual practice, do nurses (new) use assertive
  language to recommend their evaluation as was
  used in this pilot?
• What is the ruling on the difference between a
  recommendation vs. a diagnosis?

56
Next Steps

• Develop a program where nursing and medical
  students form teams to care for patients as a
  normal integration process in their curriculum.

57
Project Team

• TWU, Houston - Ann Coleman, EdD -
  pcoleman2_at_twu.edu
• BCM, Houston - John Rogers, MD -
  jrogers_at_bcm.tmc.edu
• TWU, Houston -Teri Newsom, MSN -
  terinewsom_at_twu.edu
• TWU, Denton - Patti Hamilton, PhD -
  phamilton_at_twu.edu
• TWU, Houston -Kelly Vandenberg, PhD (c) -
  kvandenberg_at_twu.edu
• TTech, Lubbock -Sharon Decker, PhD -
  sharon.decker_at_ttuhsc.edu
• Sandra Caballero Mercedes Baldwin

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References
American Association of Colleges of Nursing.
(2007) Position Statement Draft revision of the
essentials of baccalaureate nursing education
August 1, 2007. Washington, D.C. Hendel, T.,
Fish, M., and Berger, O. (2007) Nurse/Physician
conflict management mode choices Implications
for improved collaborative practice. Nursing
Administration Quarterly, 32(3),
244-253 Institute of Medicine (1999) To err is
human building a safer health system. Washing,
DC National Academies Press.
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References
Institute of Medicine (2001) Crossing the quality
chasm A new health system for the 21st century.
Washing, DC National Academies Press. Institute
of Medicine (2003). Patient safety Achieving a
new standard for care. Washing, DC National
Academies Press. Institute of Medicine (2003)
Health professions education A bridge to
quality. Washing, DC National Academies
Press. Institute of Medicine (2004) Keeping
patients safe Transforming the work environment
of nurses. Washing, DC National Academies
Press.
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References

• Joint Commission 2008 National Patient Safety
  Goals Hospital Program
• Maxwell, N. (2007) Shaping humane healthcare
  systems. Nursing Administration Quarterly, 32(3),
  195-201
• Ogburn, T. Espey, E. (2003) The R-I-M-E method
  for evaluation of medical students on an
  obstetrics and gynecology American Journal of
  Obstetrics and Gynecology, 189, (3), 666-669.
• Wheeler, B., Powelson, S., Kim, J. (2007)
  Interdisciplinary clinical education. Nurse
  Educator, 32 (3) 136-140