A surgeon walks into a "nurses' station" . . . The nursing coordinator greets him attentively, stands quietly while he reviews a patient chart, answers two or three clipped questions, accepts his directions for new procedures for the patient, takes the chart he extends to her as he leaves the sta tion . . . Colla bora tion ? ]oin t practice? Interdisciplinary communication?
If the answer to each of these queries is "no," then what would describe "interdisciplinary collaboration" in an acute care setting? At the same time that we strive to answer this question ourselves as health professionals, how do we build models for an interdisciplinary team approach into baccalaureate nursing education? As a nursing faculty member responsible for a senior-year practicum which includes the course "Nursing in the Health Care Delivery System," I asked myself this question. Content elements for this course include those related to interdisciplinary collaboration in the health care delivery system. It occurred to me that this was an objective tha t could well be met by real experiences in the medical center environment, as opposed to theoretical discussions from a reading assignment. I pondered the possibility of having each student spend a day with another health professional in his or her work setting, doing what would be involved in an "ordinary work day." Would a senior student find this too elementary? Would health professionals in the medical center be interested? I wondered. Believing the old adage, "nothing ventured, nothing gained," I decided to try it.
Beginning the Project
In an early class meeting, I presented this project to the 12 students in my practicum group. They responded positively to the possibility of spending a day in the medical center with another health professional, one of their own choice. I then contacted the health professionals selected, explaining that our course objectives included developing understanding of the specific focus of other health professions in the process of preparing the students for interdisciplinary collaboration as professional nurses in the future.
In addition to persons I anticipated, the students selected certain other health professionals I had not thought of originally. The individuals contacted included: pharmacist, chaplain, social worker, dietitian, respiratory therapist, child psychiatrist, physical therapist, occupational therapist, physician director of infectious disease division, enterostomal therapist, pediatric surgeon, pediatric cardiologist, hospital administrator (some students chose two).
The request directed to the health professionals contacted was twofold. First, 1 explained our project and asked for their willingness to have a student spend a day with them. Secondly, I asked them to attend an "interdisciplinary seminar" later in the semester, at which they would have an opportunity as members of an interdisciplinary panel to discuss the unique nature of their own professions and the potential they saw for interdisciplinary collaboration, especially with nursing.
Student Learning Experiences
The next steps were up to the students. High levels of motivation followed from the fact that they were setting up experiences with health professionals they had chosen (by profession - not by personal acquaintance, since the majority were meeting persons contacted for the first time). Thus, for individual reasons, the students had a real interest in learning more about the work of the person in the medical center whom they contacted. Resulting experiences were diverse and enlightening! They included such activities as individual conferences, assisting in a specialty clinic, observations in surgery facilitated by the surgeon, departmental tours (for example, complete tour of the pharmacy), participation in small groups (such as a group class for amputees), attendance at departmental meetings and conferences, and hospital rounds with a number of health professionals, including a surgeon, administrator, social worker, enterostomal therapist, chaplain, and physical therapist.
Occasionally a student encountered more than the "ordinary" in her hours with another health professional. In the midst of the student's day with the hospital administrator, an alarm summoned the fire department in force for what turned out to be a minor fire. Another student, on her way to an early morning beginning of a day with the pediatric surgeon, found herself becoming dyspneic. Within a short time, she herself was admitted to the surgical service with a spontaneous pneumothorax. Thus, her "real world" observation experience was postponed as she had her own real life experience as a surgical patient!
At times there were scheduling problems for the student in participating in an activity in another department which conflicted with our class or clinical schedule. But this usually worked out, eventually, as happened with the student who wanted to make rounds with the infectious disease team. During one of our clinical days, this team arrived on the pediatric unit where the student was assigned. The physician director announced to me that the student was welcome to accompany the team on rounds just beginning. As the student was about to decline because of her patient assignment, I offered to take over care of two charming, immobilized fouryear-olds until her return. Instructors can also be flexible!
For the interdisciplinary seminars, we selected three dates which the students presented and asked each health professional to choose one. Thus, we did not plan which persons would come together for each seminar. This worked well. In some instances, it was interesting to note that the health professionals were meeting each other for the first time. In fact, I believe that certain instances of real interdisciplinary collaboration began through these meetings.
After an introduction by the individual student, each person presented educational requirements, his or her own background, unique focus of the particular profession, and considerations about interdisciplinary collaboration generally and with nursing particularly. In the discussion following (which often was lively!), there was opportunity for input and questions from students as well as from professional panel members.
As part of our welcome for these persons who had so warmly welcomed the students to their respective departments, we provided refreshments (usually "homemade") for each seminar. One of the health professionals who now returns each semester asks the student (in a teasing fashion) if there will be coffee and doughnuts before saying "yes" to coming to the interdisciplinary seminar.
In order to evaluate this project, I distributed questionnaires to the students and health professionals involved in it the first semester. The following quotations are taken from those questionnaires:
From the students. . .
I felt the experience was both positive and worthwhile. Not only does it enlighten the student nurse about the role of another health professional, but it also presents the student with the opportunity to describe her present and future role Ito that person).
Thought it was a great idea. Made me more aware of what goes on with other team members in the hospital.
I enjoyed it a great deal, especially since we. ..chose areas which interested us.
...it was a very beneficial experience. It definitely broadened my understanding of interdisciplinary collaboration.
Good to have responsibility of choosing professional, and then. . . to make contact with him or her.
Keep this in the senior practicum by all means. We need to know what services are available in the hospital so we can work with them and not against them.
Excellent idea! Chance to actually see what other health professionals do.
And from the health professionals' viewpoint. . .
I think it is essential for nursing students to develop an awareness of other health professionals with whom they will come in contact. It is an essential part of their learning experience. Therefore, we are always willing to have other team members observe and participate in treatment of their patients (this in the occupational therapy deapartment).
Should be done more often.
Excellent. Perhaps the student should spend more time with the indvidual service.
Enjoyed it. Gave opportunity to explain our role directly to another discipline.
A pleasure and a mutually satisfying experience.
On the questionnaire, I asked for evaluation of the interdisciplinary seminarformat itself as part of the total experience. Included in the student evaluations were the following comments:
I thought the interdisciplinary seminars were excellent. It enabled me to learn of the different professionals within the health care system and how they see their role and how we can work together to provide total health care.
Great idea. It's a good idea to learn what other health professionals think of the nursing student (although it may be something you don't want to hear) and to let others know what you think of yourself.
From the health professionals. . .
It was an interesting and valuable experience for me as well. I think of such seminars as a growth experience for myself.
I learned from the other participants as I am sure they learned from me.
I enjoyed the seminar, the students' observations and questions. It was interesting to listen to the other participants.
In my own practice and in reading related to interdisciplinary collaboration, I find an emphasis on the importance of a professional person's ability and willingness to communicate with other health professionals in providing comprehensive health services. I found it of note that several of the students' comments on the questionnaire related to the experience of communicating with another health professional. One student spoke of being frightened about contacting a physician - and then the positive outcomes of actually doing it. Describing her experience of contacting a member of another health profession, one student wrote:
I was excited and a little nervous. After I talked to him (a physician), I was relieved and looking forward to talking to him again. Went on rounds with him, met all of his clients, talked in his office for a long time about where he is as a professional and where 1 am.
In a paper written about her interdisciplinary project, another student described her hesitancy in early encounters with another health professional, again a physician:
... I must confess that at the beginning of my collaboration with Dr _____ I had the stereotypical image of the doctor and the nurse in my head. I now realize that this was a result of my summer experience working on a unit where the nurses and doctors behaved in the. . . "traditional" manner. I remember doing such things as getting off my chair when a doctor entered the nurses' station and remaining very quiet around one at all times. During the early weeks with Dr. _____, I felt this same attitude and uncomfortable just the same.
In her communication with this physician over several weeks, the student made a grand discovery - "I saw that he was human just like me. . ." This discovery made the communication process for her much more comfortable, open, and growing with this particular physician, and I trust with others in the future.
Continuing the Project
All who responded to the questionnaire (students and health professionals) recommended continuing the interdisciplinary learning experience. Several suggested ways to expand it in future semesters. Since my own evaluation was also positive, I certainly have continued to incorporate this experience into the practicum and it has grown in interesting dimensions.
All of the health professionals chosen by the students originally (with one or two exceptions) continue to be chosen by each new group of seniors in my practicum. We also have additional professions or roles represented. One of these is a nursing administrator. Originally, 1 contacted the Assistant Director of Nursing Service responsible for the clinical areas in the hospital to which my students are assigned and asked her to attend a separate seminar in which she would speak to "nursing in the health care delivery system" from the perspective of a nursing leader. In a followup discussion to her visit to our class, we planned to include her the next semester in the group of health professionals with whom my students spent a day (or more) in the medical center. This did happen the following semester, with the Assistant Director of Nursing now also a participant in our interdisciplinary seminars. On her own part, she has extended the opportunity of spending a day with her at work to any senior student in our program.
From the first semester of the interdisciplinary project, several of the health professionals expressed a wish to extend the student's observation experience with them in both scope and time. This initiative also came from several students. Now the interdisciplinary focus is built in as a more formal course requirement, but with wide opportunity for each student to plan the experience according to her own interests and learning needs.
Two experiences especially reflect the growth of the interdisciplinary focus in the practicum. Two physicians, both specialists in their own profession - a child psychiatrist and a pediatric surgeon - offered their own suggestions and willingness to develop further the nursing student projects with them.
The child psychiatrist offered the opportunity for the students to share in a number of his professional activities, including those beyond the ordinary work day. During one semester, two students spent several hours with him in such activities as consultation with the nursing specialist in the Intensive Care Nursery, participation in teaching rounds, and attending programs related to ethical issues in the health care delivery system. Certain other of a psychiatrist's activities, by their very nature, do not allow for student observation, as for example, individual psychotherapy sessions.
The pediatric surgeon offered to expand the senior student experience in the operating room itself, if the students so chose. Now the student who elects to have her interdisciplinary project in pediatric surgery also coordinates surgical followthrough experiences for the other students in our group. The patients they have observed have ranged from the smallest premature infant to the adult-sized adolescent, with thus a wide range of nursing and medical problems. The latest student to work with the pediatric surgeon developed this interdisciplinary focus into the major project required for this five-credit nursing course. In her paper she wrote:
My experience in this interdisciplinary project turned out to be a learning and growing process for me over the course of the semester. I realize this more now, as I write this paper and I am really glad I chose this topic. . . Interdisciplinary teams are fairly new to me. . . The fact that they are so necessary in a health care setting has been displayed to me through my rotations in pediatric settings and through my work with Dr _____ A big contributing factor to this positive experience was the university hospital setting. The teaching focus and environment is provided and available to all students, nursing and medical, not only through the medical center and its facilities, but also through professionals like Dr _____, who make it their responsibility to share their specialty with those who seek them out. . .
Working with Dr _____ this past semester and observing the various roles of members of an interdisciplinary team has given me many insights as to what I would like to do as a professional nurse in the future. . .
One final point that I want to bring up is that of my opportunity to get involved independently in an interdisciplinary project as a student. This was most fulfilling to me as a senior and I can see great value in incorporating this into the practicum. . .
Perhaps we should go a step further and design courses where collaboration can take place in conjunction with the medical school or where nursing and medical students work together in a clinical setting. If the interdisciplinary team is becoming responsible for the health of many in the future, then we must start now to prepare nursing and medical students for whatever lies ahead!
It does seem obvious that the optimal place to begin interdisciplinary collaboration of the two most numerous health professionals - nurses and physicians - is during their educational programs, especially in centers where both schools are found. The challenge is up to us as faculty to move from mere coexistence to real collaboration in education of nursing and medical students. We ourselves need to develop working models. I believe that our students are ready and capable of assisting us to develop exciting new models of interdisciplinary education and practice.
Nursing has a long tradition of a focus on the self-care abilities and an individual's personal responsibility for health. Obviously in a system with rapidly escalating costs and little improvement in actual health, nursing has a real contribution to make individually and in collaboration with other health professions.
Most graduates of baccalaureate programs in nursing still begin their professional careers in acute care settings. If nursing is to move forward in such settings, part of the nurse's readiness for beginning practice there is understanding of the nature of each other health profession, capability in communication with other health professionals, and at least foundational competence in interdisciplinary collaboration. The project described facilitates this readiness.
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