Bridging Gaps in Interprofessional Teamwork

Bridging Gaps in Interprofessional Teamwork Gwen Sherwood, PhD, RN, FAAN Professor and Associate Dean University of North Carolina at Chapel Hill School of Nursing Gwen.sherwood@unc.edu Humber Institute of Technology, Toronto, Canada March 24, 2010

Greetings from the University of North Carolina - Chapel Hill School of Nursing 2

Seeking purpose: Reflecting in action What is my purpose in being here today? What did I give up to be here? What do I want to leave with? What am I willing to invest to achieve my goal?

Why is interprofessional education so important? US Institute of Medicine (IOM) series of Quality Chasm reports conclude that how well health professionals work together significantly impacts quality and safety. This recommendation out-strips our educational curricula.

So what is it about Interprofessional Education? What are the three words which come to your mind immediately? Write them on the post it notes. In groups, share in rounds, and determine the three key terms to share.

Debrief What do these words reveal about our beliefs and attitudes about interprofessional education? Consider our history in trying to achieve interprofessional education. Will the imperative for quality and safety lead to interprofessional education experiences?

Teamwork is an important foundation for interprofessional education. Challenges for integrating interprofessional education into health professions curricula. Faculty have not been confident of the knowledge, skills and attitudes that comprise teamwork as a competency nor pedagogies that will attract students.

There are some patients whom we cannot help. There are none whom we cannot harm. L. Bloomfield

Significance Although evidence indicates that miscommunication contributes to 70% of health care errors, health professionals rarely have interprofessional educational experiences. Complexity of care means no one discipline can provide the care required. Each needs to clarify and understand roles

We can t hope to make lasting change in the ability of health care systems to improve without changes in the way we develop future health professionals. Those changes require faculty and schools to change. Paul Batalden Dartmouth College QSEN Advisory Board

Health professionals are challenged to change outcomes by changing the way we communicate and relate across disciplines to coordinate care. What are the challenges for leading this change?

Teamwork contributes to quality. Health care is value based; quality is an essential value. When quality erodes, joy in work diminishes, contributes to disengagement and resignation. Health professionals are willing to help improve systems when they have what is needed to make quality improvement a part of daily work

Quality impacts the work force Working in systems with poor quality lowers satisfaction: relationships are the key to worker satisfaction American Association of Critical-Care Nurses (AACN), CQ HealthBeat Retention

Shaping organizational context Work takes place in a given context which influences our responses. Culture is the behavior and beliefs/values of the group Culture is built from the connection of consequences with behavior, what is valued and rewarded. Leaders create and manage the culture, and deconstruct when needed to change outcomes.

Contextual factors in quality and safety: which could be addressed in IPE? Workload fluctuations Interruptions Fatigue Multi-tasking Failure to follow up Poor handoffs Ineffective communication Not following protocol Excessive professional courtesy Halo effect Passenger syndrome Hidden agenda Complacency High-risk phase Strength of an idea Task (target) fixation

How do each of the contextual factors impact interprofessional work? Each factor represents set patterns of behavior. Our challenge is to interrupt and unfreeze with new behaviors. What are the new behaviors? How do we educate health professionals who can make these changes in organizations?

Changing conversations, Changing minds, Changing culture Creating transformation

Creating the backdrop for IPE: Collective wisdom 1: What is the ideal timing for interprofessional teamwork learning experiences? 2: What are goals and opportunities related to interprofessional teamwork in health professions education? 3: Who should be included in interprofessional teamwork education experiences?

Debrief: Iterative process 1: What is the ideal timing for interprofessional teamwork learning experiences? 2: What are goals and opportunities related to interprofessional teamwork in health professions education? 3: Who should be included in interprofessional teamwork education experiences?

Exemplar: educational change to integrate Quality and Safety 1990 s: U.S. hospitals launched quality improvement and safety science methods., Little content in Schools of Nursing on QI methods which require cross disciplinary teamwork Required longer and more costly orientations for hospitals to integrate nurses into QI processes.

Health Professions Education Redefined by IOM 2004 Continuous quality improvement Based on a culture of inquiry Investigates incidents from a system perspective Seeks evidence as the basis for practice Faculty development: faculty need to know how emerging quality and safety standards, regulations, and initiatives in practice settings are changing health care.

To focus on quality: 6 competencies All health professionals should be educated to deliver patient-centered care as members of interdisciplinary teams, emphasizing evidence-based practice, quality improvement, [safety], and informatics. Committee on Health Professions Education Institute of Medicine (2003)

2009-2012 Phase III Faculty Development in partnership with the American Association of Colleges of Nursing Quality and Safety Education for Nurses (QSEN: www.qsen.org) Funded by the Robert Wood Johnson Foundation for the University of North Carolina at Chapel Hill 2005-2007 Phase I Pre-licensure Education 2007-2009 Phase II Graduate Education and Pilot School Collaborative

Welcome to QSEN, a comprehensive resource for quality and safety education for nurses! Faculty members worldwide are working to help new health professionals gain the knowledge, skills, and attitudes to continuously improve the health care systems in which they work... www.qsen.org

Transforming Nursing Education National expert panel defined quality and safety competencies and knowledge, skills and attitudes required for nurses in health care organizations Based on IOM competencies for all health professions education Adopted by nursing education credentialing agencies

Cronenwett et al, Nursing Outlook, May-June 2007 (special topic issue) Patient centered care Teamwork and collaboration Evidence base practice Quality Safety Informatics

Teamwork and Collaboration Example Knowledge Skills Attitudes Describe examples of the impact of team functioning on safety and quality of care Explain how authority gradients influence teamwork and patient safety Identify system barriers and facilitators of effective team functioning Follow communication practices that minimize risks associated with handoffs among providers and across transitions in care Assert own perspective (using SBAR or other team communication models) Participate in designing systems that support effective teamwork Appreciate the risks associated with handoffs among providers and across transitions in care Value the influence of system solutions in achieving effective team functioning Nursing Outlook, May- June, 2007

What are ways to engage students in the new competencies?

What assumptions are embedded in health professions education that drive curriculum, student learning experiences, and the way we teach?

What are effective pedagogies for integrating IPE into curriculum? Can we thread through the curriculum to produce the behavior change required? Which courses: class, simulation, skills lab, clinical learning, modeling and coaching? Questions Narrative pedagogies Unfolding case studies Readings Web Modules PBL Papers Patient stories Reflection

QSEN Learning Collaborative Goals Pre and post curricular mapping of the integration of quality and safety KSAs into pre-licensure curriculum Evaluate one class of graduating students perceptions of competency achievement Develop, evaluate, and disseminate teaching strategies for classroom, clinical, and simulation/skills laboratories

3 member project teams had 2 meetings with QSEN faculty and Advisory Board Theory bursts: 10-15 minutes of essential concepts followed by Table Top discussion on each competency applied in Classroom, Lab, Clinical, and Interprofessional pedagogies Raises the question: How much teaching time is spent on content and how much on application? Is our teaching on the higher or lower end of the scale on Bloom s educational objectives taxonomy?

PopQuiz!! WHY?

1. According to the IOM how many deaths occur each year due to medical errors? A. 44,000 and 98,000 B. We do not know. C. 1 million D. 25,000 35,000

2. According to the IOM, what are the leading causes of unexpected deaths in health care settings? A. Cardiac arrest B. Stroke C. Emboli D. Medical errors

3. What percentage of patients experience a serious medical error while hospitalized? A. 3% B. 7% C. 1% D. 13%

4. Which accounts for the largest number of patient deaths? A. Breast cancer B. AIDS C. Adverse and sentinel events D. Motor vehicle accidents

5. The root cause of 65% of sentinel events is: A. Communication B. Lack of training C. Provider intention D. Lack of caring

6. What is the economic cost of medical error annually? A. $1,000,000 -$20,000,000 B. $1 billion to 10 billion C. $8 billion to 29 billion D. $500,000,000 to $800,000,000

7. What is the cost in human terms? A. Pain and suffering B. Moral distress and erosion of trust C. Disengagement D. All of the above

What are proposed interventions? What percentage of health professions educational programs have interprofessional education experiences? Why?

IPE Exemplar: IPSEC Project Purpose: Design and implement an experimental trial to compare the effectiveness of different training methods of interactive team coordination with nursing and medical students

Framework for the study Institute of Medicine Quality Chasm report on changes needed in health professions education Quality and Safety Education for Nurses (QSEN), a national study to define competencies and KSA s, definition for Teamwork and Collaboration

Project Aims: Interprofessional Safety Education Consortium (IPSEC) 1. Provide senior SOM & SON students an interdisciplinary patient safety focused teamwork experience 2. Randomized control design to evaluate interactive teamwork training scenarios 3. Engage and train faculty in teaching patient safety and teamwork skills

Developing the Curriculum: QSEN Competency Definition Teamwork and collaboration: Function effectively within nursing and inter-professional teams, fostering open communication, mutual respect, and shared decision-making to achieve quality patient care Nursing Outlook, May-June 2007

Study Curriculum: Team Strategies and Tools to Enhance Performance and Patient Safety TeamSTEPPS: a multimedia, evidence based public domain curriculum from AHRQ/DoD to improve team coordination knowledge, skills, and attitudes First student use

Team Competencies and Outcomes Knowledge, cognitive Shared Mental Model Attitudes, affective Mutual Trust Team Orientation Performance, skills Adaptability Accuracy Productivity Efficiency Safety

Effective Team Leaders Organize the team Articulate clear goals Base decisions on collective member input Empower members to speak up and challenge, when appropriate, call a huddle Skillful at conflict resolution Team Activities: Briefs planning Huddles problem solving Debriefs process improvement

Question What is the impact of four pedagogies on interdisciplinary team training knowledge and attitudes of medical and nursing students in two universities?

March 6, 2007 Duke & UNC-CH 438 students 70 faculty 90 volunteers 12 temporary workers

Four Cohorts N = 438 Matched nursing (196) and medicine (233) Small Groups, 2 strategies Large Groups, 2 strategies 10 High Fidelity Human Simulation (n = 80) 10 Role-Play (n = 79) Lecture & Audience Response (n = 139) Traditional Lecture (n = 140)

4 Assessment Tools 12- item teamwork knowledge test 36-item teamwork attitudes instrument 10-item standardized patient (SP) evaluation of four-student teamwork skills 10-item modification of Malec et al. (2007, Sim Healthcare 2:4-10) Mayo High Performance Teamwork Scale (HPTS).

Teamwork Knowledge Results Knowledge test results 12 10 8 6 Pre-test Post-test 4 2 0 Simulation Role play ARS Lecture Training condition

Results 1. Interactive training in a high fidelity environment did not demonstrate more effective results in promoting team coordination skills than training in a low fidelity environment. 2. Participation in interactive training in small groups did not present as more effective than in large groups. 3. Large group interactive training exercises did not show as more effective than training with only lectures without interactive exercises.

Differences in student responses Evaluation by student satisfaction measures revealed differences across cohorts. Nursing students had previous experiences with role play and high fidelity simulation. Medical students had previous experiences with standardized patients used in the video taping in afternoon demonstration sessions, as well as ARS.

Even a single day made a difference but what is the long term impact?

Theory Burst: Teamwork and Collaboration Components of a Patient Safety Program

TeamSTEPPS competencies Knowledge, cognitive Shared Mental Model Attitudes, affective Mutual Trust Team Orientation Performance, skills Adaptability Accuracy Productivity Efficiency Safety

Situation Monitoring: individual skill Introduction Actively scanning behaviors and actions to assess elements of the situation or environment Mod 1 05.2 06.2 Page 4 Fosters mutual respect and team accountability Includes cross monitoring the actions of team members to share workload, watch each other s back: TEAMSTEPPS 05.2 Situational Awareness: individual outcome Shared mental model (team outcome) : One s perception of current environment accurately mirrors reality. We re all in the same Movie 4

Shared Mental Models help teams know what to expect, be on the same page to synchronize care and avoid errors. Structured Communication Situation Background Assessment Recommendation (SBAR) Call-Out Check-Back Handoff Who on the team has critical information needed for team decisions? Are they empowered to share?

Call-Out: communicates critical information to all team members during urgent situations so all can anticipate next steps. Check Back: I need 3 mg. epinephrine. Three mg. epinephrine, here. Mutual Support: cross monitor and help overloaded team member, redistribute tasks, verbal support, encourage, share information and safety alerts.

Improving communication to improve care: Handoffs The transfer of information (along with authority and responsibility) during transitions in care across the continuum. Include opportunity to ask questions, clarify, and confirm

Critical Language: key phrases are understood by all team members to mean, STOP. We may have a problem. CUS: I need some CLARITY. I am UNCERTAIN. I have a SAFETY concern. The team member is responsible for assertively voicing a concern at least two times to ensure that it has been heard using the three C s I m curious I m concerned. I m still uncomfortable, let s consult with a third party.

Introduction What are examples. Of teamwork across disciplines Of opportunities to include the client and family as members of the team Of unclear communication contributing to poor outcomes Of ways to influence communication in your area? Mod 1 05.2 06.2 Page 9 TEAMSTEPPS 05.2 9

Reflection as a learning activity Critically consider beliefs or knowledge Raise awareness about what we do to make better choices in the future. Monitor reactions for intentional, conscious, deliberate actions. Learn from experience to create change.

Transformative Teaching: our best strategy! What are your best moments as faculty in which you felt you made a difference?

The questions we ask are significant. Inquiry, asking questions is the first step to change. Reflection for Transformation: Moving to Change The conversations we have shape how we see the world, how we behave, and what we see as reality. Stories illustrate our reality; stories are defined by our reflections. We act based on how we perceive reality and what we imagine will happen in the future, forming our mental models.

Reflective practice: bridging theory and practice by reflecting on didactic and experiential learning Change behavior to improve practice Promote individual accountability Increase self awareness Progress novice to expert (Benner)

Changing views of the same reality How do we share our mental models of reality with others? How can we use shared mental models to shape culture and context? When do we try to see other views of the same situation so that we can be open to change?

Self-Reflection: A window to the soul Do you spend more time thinking about what worked in team experiences or what did not? Reflect on specific examples. What are your feelings when you work well with others? What feelings result from poor working relationships?

Creating our reality Building and sustaining momentum for change requires large amounts of positive affect.... Hope, excitement, inspiration, camaraderie, urgent purpose. Wholeness (inclusiveness) brings out the best in people and organizations. We must be the change we want to see.

Reflective Leadership: journey of the self towards transformation Emotional intelligence is basis for reflection. Begins with uncomfortable feeling about something. Critically reflect on the action. Look for meaning within what happened. Integrate into context to change perspective to act from one s internal compass of what is right.

3 R s of Reflection Reaction: Affective Domain Examine the evidence, including how you feel, and cite an example Relevance: Cognitive Domain How is the evidence related? Add your own understanding; give alternative viewpoints; Cite examples Responsibility: Psychomotor Domain How is the knowledge used? Give examples What are any remaining questions?

1 page Reflective learning activity When today did you feel unsure of what to do? How did you feel? What steps did you take to be able to make an informed decision? What were safety issues? What would you do differently in the future? Evaluation using rubrics

Unfolding Case Studies Students respond at varying stages of the case as it unfolds, whether low or high fidelity simulation or written. In writing the case, consider each set of details included and what details are omitted, reasons for each question, and provider roles. Describe significant relationships for the patient that may influence the case. What are goals for evidence based responses? Have students condense patient teaching or discharge instructions to only three paragraphs to demonstrate synthesis and time limitations.

Collective Wisdom: IPE for change Group 1: What are strategies that promote sustained behavior change over time? Group 2: Which are the best matches for level of education across the health professions? Group 3: What are assessment or evaluation measures? How will we know we were successful?

Debriefing Group 1: What are strategies that promote sustained behavior change over time? Group 2: Which are the best matches for level of education across the health professions? Group 3: What are assessment or evaluation measures? How do know we were successful?

8 Steps of Change John Kotter

How have you responded to the session today? Reflect on your expectations. Reflect on the commitment you made to attend this session. Reflect on what you will take with you from this session. Write one sentence that summarizes your participation in this session today, that describes your feeling as you leave.