Can Doctors and Nurses Be Taught to Get Along?

Michele Cohen Marill

February 03, 2020

Almost 20 years ago, toddler Josie King turned on the bathtub faucet and climbed in. By the time her mother heard her screams, scalding water had caused second-degree burns on more than half of the 18-month-old's body. After extensive treatment at Johns Hopkins Hospital in Baltimore, she was almost ready to be discharged when she became pale and unresponsive. Her unexpected death from septic shock prompted soul searching and became a catalyst for the patient safety movement.

A host of preventable factors contributed to Josie's death, including severe dehydration, a hospital-acquired infection, an opioid administration error, and a failure to respond appropriately to Josie's mother's concerns. Many of those issues appeared to stem from a toxic hospital work environment.

"Some nurses were scared to call certain doctors with concerns about patients," recalled Cheryl Connors, DNP, RN, NEA-BC, who was then a young nurse just starting her career. "The relationships were more hierarchical than collaborative." Nurses had tried to raise the alarm about Josie's rapidly changing condition, but physicians dismissed their concerns, Connors says.

Ultimately, as Hopkins anesthesiologist Peter J. Provonost told the Baltimore Sun , "Josie died of a third-world disease ― dehydration ― in the best hospital in the world."

Connors' career was shaped by that experience. She is now a patient safety specialist with the Johns Hopkins Armstrong Institute for Patient Safety and Quality, where she helps medical and nursing students acquire the skills needed to speak up, without hesitation, on behalf of their patients.

In that program and others like it across the country, students from different clinical pathways learn to work as a team. The goal is to encourage the new generation of clinicians to work collaboratively in ways that were missing when Josie King was being treated. "We're preparing them to walk into environments like that and to challenge that culture," said Connors.

Starting Early: Establishing a Positive Dynamic

In 2017–2018, 143 medical schools required some form of interprofessional education (IPE). National nursing organizations promote IPE in nursing education. The approach has been touted as an effective way to address patient safety risks created by the hierarchical structure that prevails among healthcare staff. Although nurses are no longer required to stand in the presence of a physician or refrain from speaking unless spoken to, as they once were, remnants of that long-ago culture of deference and obedience can still be found today.

To counter that, medical students need role models, says Michael Wilkes, MD, MPH, PhD, an internist and professor at the University of California, Davis. Wilkes developed a "doctoring curriculum" to help young physicians learn to work as partners with other healthcare professionals. He often invites nurses, pharmacy students, and others to joint sessions on collaboration and conflict management.

"It needs to be done early; it needs to be done regularly," he said. "And it can't be confined to just the classroom. The students need to be in environments where people are working together."

Evidence shows that early IPE intervention is effective. At Virginia Commonwealth University (VCU) in Richmond, Alan Dow, MD, MSHA, and colleagues studied power dynamics and team cohesiveness in IPE teams of medical and nursing students. The teams participated in three sessions of simulated cases and completed validated survey tools that measured "power distance" (comfort with hierarchy) and "psychological safety" (perception of the potential of negative consequences for speaking out). As power distance declined, psychological safety rose and students reported feeling more team cohesion.

"Clearly some foundational learning needs to happen when people are early in their health careers, getting concepts of how teams work together and understanding their roles and responsibilities," said Dow, an internist who is assistant vice president of health sciences for interprofessional education and collaborative care at VCU.

Do Students Find IPE Useful?

In 2009, the Interprofessional Education Collaborative, which now encompasses 21 different health professions, created core competencies for IPE. These include the ability to communicate in a "responsive and responsible manner" and to apply principles of team dynamics.

"It's very simplistic to think any educational intervention, in and of itself, is going to solve a problem," said Barbara Brandt, PhD, director of the National Center for Interprofessional Practice and Education at the University of Minnesota in Minneapolis. "But we know that people need certain knowledge and skills to be able to function in teams. That's what we promote."

The logistics of IPE can be daunting. Along with medicine, a university may offer a half dozen different degree programs for would-be health professionals — pharmacy, nursing, respiratory therapy, social work, physician assistant, and physical and occupational therapy. Academic calendars rarely align, and it can be difficult to fit these sessions into school curricula in a way that provides meaningful experiences for hundreds of students.

What's more, judging the success of IPE isn't straightforward. One pillar of effectiveness is whether the students themselves find team-building experiences in controlled environments useful. In a 2019 survey, 97% of medical school graduates agreed (71% strongly) that through IPE, they acquired the skills to work collaboratively on interprofessional teams.

But is such training clinically relevant?

Kolin Meehan, a third-year medical student at West Virginia University in Morgantown, recalls his first IPE session in a large conference room with students from various health professions. They worked in small groups on team-based exercises, such as building a house of cards without talking. The next year, the exercises included discussing hypothetical clinical scenarios, he said, but they still lacked a real-life, consequential aspect. "I didn't really get a whole lot out of it," he said.

More recently, Meehan participated in a simulation exercise with two nursing students and two pharmacy students. This was much more realistic, with an actor playing the role of a patient describing his symptoms. Even then, the scenario felt scripted, he says, particularly because they received laboratory and imaging results up front that already suggested the patient's diagnosis.

"A better scenario," suggested Meehan, "would be a doctor entering a patient's room with a limited amount of information, and you really do have to rely on the nurse and pharmacist to give you information and figure out the treatment plan. I think that would be practical and translate into our careers." Meehan's best IPE experiences have come naturally, he says, as he goes on rounds with multidisciplinary teams of residents, attending physicians, nurses, and pharmacists. "There's so much give and take. It's actually really cool to see that in action."

The Patient Perspective

On a recent fall day in Richmond, Virginia, three students knocked on the door of a patient with severe diabetes who had undergone a foot amputation. They were part of a "hotspotting" program at VCU that uses student teams to address the needs of patients with chronic medical conditions who experience frequent hospitalizations.

In the patient's living room, pharmacy student Will Mayville asked about her medications and learned that she was worried that her sleep medicine was too sedating. Brianne Oglesby, a nursing student in her final semester, talked about barriers to behavioral change and what the patient needed to do to keep living independently. Justin Riederer, a fourth-year medical student, asked about her goals for her care.

Their conclusion: Working together, they could do more to help the patient than they could by working independently. And they learned from each other, too.

"I can honestly say I don't think I would be as well prepared without having done this [hotspotting] course," said Oglesby. "It's helped me understand, aside from scope of practice, what everybody can bring to the table."

The experience gave Riederer an appreciation of the value of partnership. "When a primary care doctor has at most 20 minutes with a patient, they can't accomplish everything that needs to be done," he said.

Increasingly, research shows that collaborative care as practiced in IPE can improve patient outcomes. At the University of Kansas, about 200 students in various health professions rotate through the school's Interprofessional Teaching Clinic each year. Since 2011, the program has provided primary care for patients with complex medical needs, giving students from medicine, pharmacy, nursing, social work, and physical therapy the opportunity to work in small teams under the supervision of interprofessional faculty.

In surveys over 3 years, 91% of those patients said they were satisfied with their care, and almost three quarters (73.7%) said that being seen by a team of students improved their care, according to a 2019 study. Some clinical outcomes improved as well: A1c levels among patients with diabetes declined by 0.5%, and depression screening rose from 9% to 91%.

A Model for Collaborative Care

When Creighton University in Omaha, Nebraska, opened a redesigned family medicine clinic with a collaborative care model in 2017, it became possible to compare the outcomes of high-risk patients who received traditional care with outcomes of patients who received team-based care from 2016–2017.

In Creighton's collaborative model, teams work in a central pod bordered on three sides by exam rooms, making it easy for physicians to interact with other team members. Instead of relying on written referrals, the physicians personally introduce patients to other on-site providers. This direct interaction helps remove barriers to the transition — and has the effect of averting the perceived hierarchy of a doctor dispatching patients to seek help with others. A study published in the Annals of Family Medicine showed that with Creighton's collaborative model, emergency department visits and hospitalizations declined by about 17%, A1c levels of patients with diabetes dropped by 0.8%, and patient charges were cut almost in half.

As part of its efforts to promote effective teams, the Creighton clinic provides training in conflict management — not conflict avoidance. "There's a myth that teams are always happy and they just work," said Joy Doll, OTD, executive director of the Center for Interprofessional Practice, Education and Research at Creighton. "We come from different perspectives and we will have different opinions, and that's okay."

There's a myth that teams are always happy and they just work, Joy Doll, OTD

Twice a day — at 7:45 AM, before the first patient has been escorted to an exam room, and at midday — a team gathers at the Creighton clinic: physicians, nurses, pharmacists, physical therapists, other health professionals, as well as security and front desk staff. They give safety reminders, words of gratitude for someone who stepped up to help with a patient, and an opportunity to raise concerns. "There's definitely a sense of camaraderie," said Evangelos Giakoumatos, MD, a family medicine resident. "We are all in it together."

Michele Cohen Marill is a health and medical writer based in Atlanta and is a regular contributor to Wired and Health Affairs.

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