By 4 p.m. in the inpatient units at Fletcher Allen Health Care, the nurses have taken over. Day shift nurses have reported to the night shift nurses, and physician rounds and clinic hours are over or winding down. And as of Jan. 10, first-year medical students are beginning a two-hour stint shadowing these busy caregivers and learning invaluable information about not only their role in health care, but also how clear and consistent communication between physicians and nurses can ensure better patient outcomes and reduce errors.
The nurse is the person who receives the first communication regarding pain from the patient, but in the traditional health care system, the nurse needs an order for pain medication from a medical resident. Both the nurse and the physician want the patient to feel safe and comfortable, so clear and respectful communication is required to meet this goal.
Nurse shadowing and discussing the medical team is part of University of Vermont first-year medical students’ Professionalism, Communication and Reflection (PCR) course. The goal of incorporating this nursing piece, explains Lee Rosen, Ph.D., PCR course director, clinical assistant professor of psychology and lecturer in psychiatry, is that “we want our students to be doctors who collaborate well with nurses, admire nursing and have immense respect for nursing and how it holds everything together.” Rosen says there is an opportunity in the first year of medical school to “plant a seed” – students are at a stage of their careers where they have not yet acculturated to the role of a doctor. The program aims to provide students with the opportunity to gain a deep understanding of both the “triangle” between the nurse, patient and doctor and how a disconnect can create a “dysfunctional family.”
This new educational curriculum has evolved through a two-part process and involves collaboration between UVM’s College of Medicine, College of Nursing and Health Sciences and nurses and administrators at Fletcher Allen Health Care and Dartmouth. Dartmouth developed a nurse shadow program as an elective for more senior medical students that caught UVM’s eye. When approached by Rosen and colleagues, Dartmouth faculty members Joseph O’Donnell, M.D., professor of medicine and psychiatry, and Ellen Ceppetelli, M.S., B.S.N., instructor in community and family medicine and director of nursing education at Dartmouth-Hitchcock Medical Center, gave the UVM-Fletcher Allen group the go-ahead to model their program. O’Donnell served as a facilitator for small group learning in Dartmouth Medical School’s On Doctoring and Health, Society and the Physician courses and Ceppetelli has worked with UVM and Fletcher Allen on a variety of educational programs over the past 15 years. Other key collaborators include Jeanine Carr, Ph.D., R.N., UVM associate professor of nursing, Suzanne Goetschius, A.P.R.N.-B.C., M.S.N, director of nursing and education research at Fletcher Allen, and Hollie Shaner-McRae, D.N.P., R.N., F.A.A.N., coordinator of professional nursing practice at Fletcher Allen.
The pilot for the components of this new curriculum – the nurse shadowing and the “Doctors and Nurses” PCR session – took place during the 2009-10 academic year and included 25 medical students whom each shadowed a nurse for two hours. The students participated in small process-oriented groups that also included two to three nursing students. The group discussions created an exchange regarding training, philosophies, and readings that evolved based on experienced and observed evidence that communication between doctors and nurses is critical to good outcomes such as patient safety and health. “It seemed appropriate to have nursing and medicine share,” says Rosen, adding that “this project offers a rare chance for the nursing students to truly have the upper hand, because they have the clinical experience.” Once medical students go into clinical clerkships, admits Rosen, they are identified with the doctors.
Based on feedback from the pilot, Rosen and colleagues elected to run the PCR “Doctors and Nurses” session – a one-week unit – following the nurse shadow experience, allowing the medical students to bring more to the discussion with nursing students.
Shadowing sheds light on patient care
Maramawit Wubeshet’s eyes were truly opened by her shadow experience. “The nurses are spending more time with the patient than the doctors,” she says. “They know the patients very well – more than I thought they would – so in the future, I think it is important to consider their input in patient care.”
“It gets them out of the books and into the hospital where they can see patient care through the eyes of nurses,” says Rosen. “You can’t teach that didactically,” he admits.
First-year medical student Rola Khedraki agrees. “It was a great opportunity to transcend our textbook understanding of disease by seeing how it actually affects families,” she says. “The experience gave me great insight into the important role these health care professionals play for the patient and their loved ones.”
The second phase of the session will continue through Jan. 31 and will be followed by group discussions with nursing students on Feb. 1 and 3. “Our direction is different than Dartmouth’s,” says Rosen. At UVM, the curriculum involves first-year medical students and is mandatory for the entire class. Each member of the Class of 2014 will shadow a nurse at the hospital, thanks to the efforts of Goetschius, Shaner-McRae, and Carr. For the small group discussions with nursing students, course homework will include written reflections (medical students will write about their shadows). Nursing students created narratives in response to the 2009-10 pilot.
Rosen says they hope to expand the shadow to longer than its current two hours in the future. “We have a model that is simple and powerful,” Rosen says. According to Carr, the shadowing and interdisciplinary communication skills gained in the “Doctors and Nurses” session are “both steps in the right direction in promoting communication, collaboration, and teamwork between physicians and nurses, with the ultimate goal of delivering quality patient care.” She adds that the efforts are also timely, in light of a recent report from the Institute of Medicine’s Committee on the Robert Wood Johnson Foundation Initiative on the Future of Nursing, which underscores “interprofessional collaboration and care coordination” as a standard in its vision for the future health care system.
Ceppetelli, O'Donnell, Shaner-McRae and Rosen's pilot project findings were accepted for presentation at the International Council on Nursing Conference in Malta in July. Specifically, Ceppetelli's piece of the presentation abstract discusses the nursing perspective of the program and provides the program as an example of how nurses can help educate future doctors about what they do, and Shaner-McRae's piece focuses on the narratives completed by nursing students during the pilot.
“The nurses are really the ones on the front lines in medicine, and they handle the responsibility so gracefully,” says Adam Ackerman of the Class of 2014. "Administering drugs or putting in an IV does not preclude the wonderful small talk that goes hand in hand with adding the human touch to healthcare – it’s a great lesson.”
Examining the lessons learned, Rosen says, via the evaluation process, is the next step for the program. He and colleagues would like to look at the students’ reflections for themes and collect course evaluation data. In the near future, he also plans to submit an abstract for a professional medical education meeting, as well as an article for a medical education journal.
Nurses are on the front line with patients and now, with this new UVM College of Medicine course, on the front line with medical students, too.