Teaching and Learning in Nursing (2011) 6, 97–101

www.jtln.org

Developing interprofessional communication skills1

Janet Wagner RN, PhDa,⁎, Beth Liston MD, PhDb, Jackie Miller RN, c-OB, MSc

a Columbus State Community College, P.O. Box 1609, Columbus, OH 43216, USAb Departments of Internal Medicine and Pediatrics, The Ohio State University College of Medicine, Columbus, OH 43210, USAc Columbus State Community College, Columbus, OH 43216, USA

1 Presented as: Developing Interdi2009 National Organization for AssocAnnual Convention in Orlando, FL.

⁎ Corresponding author.E-mail addresses: jwagner@cscc.edu

jmiller@cscc.edu

1557-3087/$ – see front matter. Publishdoi:10.1016/j.teln.2010.12.003

Abstract Interprofessional collaboration is a key component to patient safety and health professioneducation. This article will describe the development and implementation of a pilot educational teaching/learning simulation exercise designed to promote teamwork and collaboration between medical studentsand nursing students. This pilot simulation was an effective and well-received educational intervention.This is a beginning step toward the development of a culture that fosters interprofessional teamworkthroughout health care.Published by Elsevier Inc. on behalf of National Organization for Associate Degree Nursing.

KEYWORDS:Interprofessionaleducation;Quality and safety;Simulation

1. Introduction

The changes within the health care system arenecessitating that multiple competencies be taught in allhealth education programs. Quality and safety concernscontinue to emerge as the system evolves (Kohn, Corrigan,& Donaldson, 2000). Points of possible error in providingsafe patient care have grown underlining the need for allmembers of the health care team to work collaboratively,communicate effectively, and make joint decisions that arepatient centered and promote positive outcomes (Kohn etal., 2000). In particular, the fields of medicine and nursingare intertwined, and their responsibilities overlap; however,each group traditionally uses both similar and dissimilartypes of knowledge (Stein-Parbury & Liaschenko, 2007) tojustify their clinical work. This must be recognized and

sciplinary Communication Skills,iate Degree Nursing (N-OADN)

, beth.liston@osumc.edu,

ed by Elsevier Inc. on behalf of Nationa

understood in order for real communication and collabo-ration to occur.

The nursing student must learn how to develop andpresent a cogent contextual clinical picture that supports hisor her clinical assessment (Benner, Tanner, & Chelsa, 2009).The medical student must learn the meaning and value of thisalternative perspective. Both must learn negotiation andconflict-resolution skills. This needs to happen regardless ofdiffering professional perspectives, past historical realities,education–practice gap issues, and new quality imperatives.These are the new practice realities. They must be attended toin both nursing and medical education. Patient safetydemands it.

This article will describe the development and imple-mentation of a pilot educational teaching/learning simula-tion exercise designed to promote teamwork andcollaboration between medical students and nursing stu-dents. A clinical scenario was developed. Ten nursingstudents and 10 medical students were placed randomly inteams and asked to work together in conjunction with astandardized patient family member to develop next steps inthe care of an end-of-life patient whose written advancedirectives were not available to the team. The available

l Organization for Associate Degree Nursing.

98 J. Wagner et al.

options were intubation or comfort care. Each team memberreceived different information and therefore had a differentperspective. To form a reasonable and acceptable plan ofcare, the doctor and the nurse had to communicateeffectively between themselves as well as with thestandardized patient family member.

2. Quality and safety

Reports from the Institute of Medicine have called intoquestion patient safety, the quality of health care, and theefficacy of the educational system (Greiner & Knebel,2003; Kohn et al., 2000). The Joint Commission onAccreditation of Healthcare Organizations sentinel eventreporting demonstrates that 70% of preventable medicalerrors are due to communication errors. Through thesereports, core competencies have been identified as neededby all health care workers including physicians and nurses(Greiner & Knebel, 2003).

Leaders in the nursing profession have taken these reportsseriously, and the response has been the Quality and SafetyEducation for Nurses initiative (Cronenwett et al., 2007). Inthis initiative, six core competencies for nursing have beendefined. They include: patient-centered care, teamwork andcollaboration, evidence-based practice, quality improve-ment, safety, and informatics. Nurse educators have beenchallenged to create curricular offerings that support thedevelopment of these competencies.

3. Teamwork and collaboration

Physicians and nurses, although probably the mostclosely aligned health care workers regarding patient care,have had a tumultuous history in terms of communication,cooperation, and joint decision making. Perhaps, the mostwell-known description of this phenomenon was depictedin an article by Leonard Stein, where he describes a “game”played between the doctor and the nurse (Stein, 1967). Inthis article, he explicates a system where dominantphysicians receive subtle cues about patient needs givenby a submissive nurse in somewhat coded language. Thenurse gives soft respectful suggestions and thereby covertlyparticipates in clinical decision making without everappearing to do so. The physician, in a similar way, asksfor advice. Except in very rare instances, there is little overtconflict, but if the rules of the game are violated evensubtly, there is very little cooperation.

This communication pattern was reflective of the roles ofthe physician and the nurse. The physician was male, bettereducated, and by virtue of societies regarded in a highersocial class. He issued the orders. The nurse was female, hadless education, and was less valued in society andtheoretically followed his orders. The doctor was clearlycenter stage and in charge of patient care, whereas the nurse

was subservient and a handmaiden of the physician.Collaboration in decision making for the patient was notthe norm. The relationship between the groups becamestrained as nurses became better educated, the female role inAmerican society changed, and the patient populationbecame more complex. Nurses quite naturally began totake a more assertive role in patient care.

Although there have been substantive changes in theinteractional style between these two groups (Sirota, 2008),there are still remnants of this pattern, and often, neithergroup is comfortable with the other. Very little has been donein either professional school to help bridge this chasm. A1995 survey suggested that fewer than 15% of medicalschools and nursing schools had interprofessional programs(Larson, 1995). A recent survey of medical schools indicateslittle change in the last 15 years (Liston 2011). Socializationinto each profession is discipline specific, and each groupfunctions as if they were in a silo. Collaboration is really notfostered within the educational experiences of either group.Their socialization is mostly independent of the other and attimes can be subtly negative. Sometimes, what nursingstudents are taught is a “submissive and permissive mentalitythat instills feelings of powerlessness and victimization,undermining interprofessional teamwork” (Kenner, Finkel-man, Weatherby, Long, & Kupperschmidt, 2010). On theother side, medical schools sometimes “instill in theirgraduates a hierarchical model of teamwork with thephysician at the top of the hierarchy” (Chitty & Black,2007). Neither education system teaches students to workwith the other group.

In addition, nursing education is struggling to keep upwith the changes in the health care arena and to implementthe urgently needed curricular improvements to meet the newrequirements of tightened quality and safety standards.However, change in academia can be slow and boggeddown by the presence of an education–practice gap. Nursingeducators and administrators at times appear to view nursingpractice in differing ways. Berkow, Virkstis, Stewart, andConway (2008) reports that only 10% of hospital and healthsystem executives believe that their new graduate nurses arefully prepared to provide effective and safe care. In contrast,90% of academics believe their graduates to be well preparedfor the world of practice.

The reality however is that nursing practice continues toevolve, and nursing education must continue to evolve aswell. New techniques highlighting the Quality and SafetyEducation for Nurses competencies must be developed andimplemented reasonably. Didactic coverage of these topicsmay not lead to the desired competencies that nurses need.Realistic practice opportunities must be developed.

Currently, the coordination and mobilization of institu-tional resources for timely intervention and rescue areextremely important nursing functions for quality andsafety (Aiken, 2005). To fully execute these functions,particularly the latter, collaboration with other members ofthe health care team is necessary. The individual nurse must

99Developing interprofessional communication skills

be skilled in collaboration and making a persuasive clinicalcase. Benner et al. (2009) indicate that nurses must usepractical narrative reasoning that encompasses both timeand context parameters. The development of this skillshould not be left to chance and cannot effectively takeplace in a classroom. Experiences for medical students andnursing students to work together must be provided.Simulation experiences between nursing and medicalstudents are one way to accomplish this. One way ofdoing this simulation is through the use of a standardizedpatient. This is a time-honored teaching strategy inmedicine and is being used more frequently in nursing.This type of simulation does not involve technologynecessarily but rather uses a trained actor/actress to portraya patient or family member involved in a clinical situation(Rowles & Russo, 2009).

4. Simulation

Simulation involves the presentation of a close represen-tation of a clinical scenario using technology, computersoftware, actors (Rowles & Russo, 2009), and games. Thisallows the students to practice in safe situations where thereis no possibility of harm to a patient. Student confidenceincreases, and the behaviors learned this way become part oftheir repertoire of useful interventions. The use of these typesof teaching tools reduces the need to rely wholly on theavailability of the experience in the clinical setting.

5. Development of the scenario

The patient scenario was created collaboratively bynursing education and medical school faculty as well aspersonnel from the Ohio State University (OSU) ClinicalSkills Center. Volunteers were solicited from fourth-yearmedical students at the OSU College of Medicine and fromsenior nursing students at Columbus State CommunityCollege and the OSU College of Nursing. Standardizedactresses were trained at the Clinical Skills Center at theSchool of Medicine regarding the details of the scenario andtheir role as a family member.

6. Scenario

In this teaching/learning simulation, 10 teams consistingof a fourth-year medical student, a senior nursing student,and a patient family member (portrayed by standardizedpatient actress) were randomly assigned to participatetogether in the standardized clinical scenario. The scenariopresents a critically ill patient admitted via the emergencyroom (ER) with shortness of breath who has just beentransferred onto a unit. She was stabilized, alert, and orientedwhen received but since that time experienced a rapid

deterioration in vital signs, oxygen saturation, and sensori-um. The daughter has been called and is coming to consultwith the team and see her mother.

Reflective of real-life practices in an inpatient setting,each member of the team receives the information typical oftheir profession. Each one therefore received differentinformation. The medical students received a brief synopsisof the current diagnosis, patient history, chief complaint, andER chart. The recent diagnosis of metastatic cancer was notincluded in this information. They were told that the patient'scondition was worsening, and they had just been paged bythe nursing staff to see the patient and talk with an arrivingfamily member.

The nursing students were given an introduction to thepatient that included the initial nursing assessment andnursing note with the added information about themetastatic cancer diagnosis as well. They were also toldthat they themselves had spoken with the patient while thepatient was alert and oriented. The patient had indicated tothem that she knew she had metastatic cancer, had refusedchemotherapy in the past, and did not want any life support.Her written advanced directives were at the long-term carefacility where she lived. The nursing student first met withthe family member to provide comfort before the medicalstudent entered.

The standardized patients were instructed to say (whenasked) that they knew that their mother had metastaticcancer, had refused chemotherapy, and was looking intohospice care. However, they (as the daughter) had not yetcome to terms with this decision, and they should initiallyinsist that everything be done to “save” their mother. Theywere made aware of the information the nursing student andthe medical student had received. These actresses wereinstructed to allow the team to lead them to a conclusion(either intubation or comfort care) as long as they hadeffectively communicated with her and each other, acting asan interdisciplinary team.

The medical student, nursing student, and familymember worked together to develop a plan of care. Atthe end of a predetermined length of time, a patient “codeblue” was called and a plan of action was required fromboth student team members. Interdisciplinary communica-tion and teamwork were essential to effectively determineappropriate next steps, that is, either intubation or comfortcare. At the end of the session, all team membersparticipated in a feedback session including the patientfamily member to discuss this experience and evaluate thecommunication between team members. Students weregiven an evaluation form to complete to allow formalizedinput on the educational program.

6.1. Mechanics of the scenario

Simulations were done in a room in the Clinical SkillsCenter of the OSU College of Medicine. All rooms for thisscenario were set up as a typical clinic with an examination

Table 1 Nursing student feedback

Questions Averageresponse

Standarddeviation

1. The standardized patient scenario was avaluable learning.

4.7 0.48

2. The feedback session was a valuablelearning exercise.

4.7 0.48

3. I will be better prepared to discuss advanceddirectives as a result of this session.

4.4 0.52

4. I will be better able to work on amultidisciplinary team as a result ofthis session.

4.4 0.52

5. I would recommend this to other students. 4.8 0.42

100 J. Wagner et al.

table and three chairs. Rooms are equipped with two-waymirrors, video equipment, and two doors. Instructions andinformation were posted on the door outside of each room.

Nursing students and medical students arrived at the sametime but were kept in separate areas within the Clinical SkillsCenter. Nursing students were given 3 minutes to review thedoor instructions, nursing assessment, and nursing notes.They entered the room from the front, and the standardizedactress entered from the back entrance asking for informationregarding her mother and voicing her desire “for everythingto be done.” Nursing students were given 5 minutes tocomfort and communicate with the standardized actress,during which time the medical student was given their doorinstructions and ER chart to review.

After this time, the medical students entered the room tocommunicate with the nursing student and family member.They were instructed to exit the room when a plan of carehad been determined. Five minutes into the session, anannouncement was made, “Attention medical team, yourpatient's oxygen saturation is now 85% on 100% oxygen.”At 10 minutes, a code blue was called, and the teams wereasked to leave the room and determine a course of action.Medical students were given 5 minutes to document theirassessment and plan. Nursing students were then given 5minutes to document their response to the medical student'sassessment and plan.

Table 2 Nursing student comments

1. It did help in learning what my weaknesses are in communication withothers. It was a good learning tool.

2. Good opportunity to practice speaking to family and physician onadvanced directives. It gave me a chance to use my communicationskills in a way that really helped me learn and see what I can do betterin the future.

3. I feel this was a good experience and I learned a lot. Seeing how eachgroup handled the same situation differently and how differentperspectives can sometimes come into play.

4. It's interesting to see the routes everyone took. I felt very comfortabledetermining intubation as a life support measure for this patient. Irelied a lot on the medical student to present the options to the familymembers.

5. As the nurse I would feel more confident in my assessment of patientnot wanting advance life support if I have asked follow-up questionsto specify exactly what life support the patient did not want:intubation, CPR…what level of intervention the patient would want tostop at….

7. Feedback

All medical, nursing, and standardized patient teamsparticipated in a feedback session immediately after thescenario. Faculty were also present. During this time, allparticipants were asked about their immediate response tothis exercise. Responses were overwhelmingly positive,with each group sharing their ideas and their critiques oftheir own and their team members' responses. Standardizedfamily members were also encouraged to indicate how theybelieved the medical and nursing students functioned as ateam. Both groups of students indicated that they not onlyenjoyed the experience but also believed it to be helpful indeveloping rapport with the other group. Nursing studentsindicated that they had never spoken to a medical studentthrough their educational experience. Medical students hadthe same experience. Each student was given access to thevideo from this experience and asked to reflect andcomment on the experience.

6. This was really good practice for the nursing students who areapprehensive about speaking with family members. It allows the nurseand the physician to work together and come up with a plan.

7. Very beneficial! Great opportunity. This instilled faith in myselfbecause I initially thought I was doing a poor job. After the scenario, itwas apparent that it was a “gray situation” and not my incompetency.Great way to dissect communication between nurse and physician.

8. Both exercise and discussion were insightful.9. This was a great experience. I think med students and nursing students

should have more collaborative learning experiences.

8. Evaluation

All teams developed a plan of care for their critically illpatient that was accepted by the standardized patient.Nursing students responded positively to items on a formalevaluation tool using a 5-point Likert Scale (Table 1).Nursing students indicated this was a valuable exercise and

would recommend this to future students. They felt betterprepared to discuss advanced directives as a result andbelieved the experience would better enable them to work onan interdisciplinary team in the future. Student commentsindicate that they not only enjoyed the experience but alsolearned from watching how each doctor nurse team workedthrough the situation during their feedback and reflectiontime (Table 2).

9. Lessons learned

This type of educational innovation is an appropriateexperience for both groups of students. Each group indicatedreceiving real benefit from this type of experience that would

101Developing interprofessional communication skills

help guide their practice in the future. Comments from bothgroups indicated misconceptions about the other group,which were resolved through the experience. In addition,many students indicated increased self-awareness and a reliefthat they had participated in a critical conversation during apractice exercise where it did not count. Almost universally,nursing and medical students thought other students wouldbenefit from this experience.

There were some barriers identified in this project. The firstwas the complexity of trying to schedule nursing and medicalstudents with their very different course commitments. Thisproject was designed to be a volunteer laboratory experienceattended by both nursing and medical school faculty inaddition to the students. It was challenging to try to get all thesegroups in one place at one time for a productive feedbacksession. The second barrier was money. To increase the realityof the simulation, actresses to play the part of the daughter werehired and trained. Pizza and drinks were supplied to allparticipants during the feedback session. The expenses for thisproject were paid for by the medical school. Facilities wereidentified as another possible barrier. For this project, thesimulation laboratory of the medical school was used for theactual intervention and the feedback session. In addition,nursing students attended a preconference at one of the nursingfaculty's homeswhere breakfast was available.Discussionwascentered on the role of the nurse as a patient advocate.

Professional attitudes and preconceptions were alsoidentified as barriers. In mainstream culture as reflected bythe media, there is the perception that the physician is theautomatic and unequivocal head of the team. Students mayalso believe in this and behave according to these expecta-tions. For example, it was noted that several of the nurseswere uncomfortable in participating in the decision making.By way of contrast, the physicians naturally assumed theleadership role. For example, one medical student indicatedafterward that he was surprised by the extent of the nurse'sknowledge of the patient. He indicated that he would neveragain assume that he had all the information.

10. Conclusion

In summary, this pilot simulation was an effective andwell-received educational intervention for nursing students.Clearly, this is a beginning step toward the development ofa culture that fosters interprofessional teamwork throughout

health care. Interventions of this nature are ways toimprove quality and safety through the development ofinterprofessional collaboration. More exercises of this typeare needed to allow each group to learn to interact witheach other in a manner that is helpful to the patient and tothe health care system.

References

Aiken, L. H. (2005). Policy challenges in modern health care. In D.Mechanic, L. Roget, D. Colby, & J. Knickman (Eds.), Improvingquality through nursing. Improving health and the health of allAmericans. (pp. 177−188). New Brunswick, NJ: Rutgers UniversityPress.

Benner, P., Tanner, C., & Chelsa, C. (2009).Expertise in nursing practice:Caringclinical judgement and ethics. New York: Springer Publishing Company.

Berkow, S., Virkstis, K., Stewart, J., & Conway, L. (2008). Assessing newgraduate nurse performance. Journal of Nursing Administration, 38(11), 468−474.

Chitty, K. K., & Black, B. P. (2007). Professional nursing: Concepts andchallenges. Missouri: W.B. Saunders Company.

Cronenwett, L., Sherwood, G., Barnsteiner, J., Disch, J., Johnson, J.,Mitchell, P., et al. (2007). Quality and safety education for nurses.Nursing Outlook, 55(3), 122−131.

Greiner, A. C., & Knebel, E. (Eds.) (2003). Health professionseducation: A bridge to quality (pp. 1−192). Washington, DC: TheNational Academies Press.

Kenner, C., Finkelman, A., Weatherby, F., Long, L. E., & Kupperschmidt,B. R. (2010). Nursing against whose odds? Commentary on Gordon(2005) as an example of teaching to the IOM reports. In A. Finkelman, &C. Kenner (Eds.), Teaching IOM: Implications of the Institute ofMedicine reports for nursing education, (p. 247)., 2nd ed. Silver Spring,MD: American Nurses Association.

Kohn, L., Corrigan, J., & Donaldson, M. S. (2000). To err is human:Building a safer health care system. Washington, DC: NationalAcademy Press.

Larson, E. L. (1995). New rules for the game: Interdisciplinary education forhealth professionals. Nursing Outlook, 43(4), 180−185.

Liston, B. L., Fischer, M. A., Way, D., Torre, D., & Papp, K. (2011).Interprofessional education in the internal medicine clerkship: Resultsfrom a national survey. Academic Medicine, in press.

Rowles, C. J., & Russo, B. L. (2009). Strategies to promote critical thinkingand active learning. In D. M. Billings, & J. A. Halstead (Eds.), Teachingin nursing; A guide for faculty (pp. 238−261)., 3rd ed. St. Louis, MO:Saunders Elsevier.

Sirota, T. (2008). Nursing 2008 nurse/physician relationships survey report.Nursing, 38(7), 28−31.

Stein, L. I. (1967). The doctor–nurse game. Archives of General Psychiatry,16(6), 699−703.

Stein-Parbury, J., & Liaschenko, J. (2007). Understanding collaborationbetween nurses and physicians as knowledge at work. American Journalof Critical Care, 16(5), 470−477.