My colleague shook his head skeptically as he said, “I’m not sure the students know what nurses actually do.” The fall semester was coming to a close, which often prompts faculty members to wax philosophical about our nursing students. Despite hours of lecture and intensive work in the skills lab and on hospital rotations, we can never be sure that all students have gained an appreciable understanding of what being a nurse means—clinically, intellectually, and emotionally. Our university graduates hundreds of new nurses every year, many of them second-degree students. The program is built for speed—in 15 months our prospective nurses must be ready to sit for the NCLEX licensing exam. Apart from my colleague’s worries about emotional and intellectual preparation, I wonder if 15 months is enough time for students to understand the complicated culture of the US hospital system. The week after my colleague shook his head, a chance assignment opened a door for exploring how the use of interdisciplinary rounds can help prepare students for the work ahead.
On the last day of the students’ hospital rotation, I assigned two second-degree freshmen to take care of a 73-year-old man who was actively dying. Mr. S. had complications from a previous hip surgery that included a postoperative infection, Vancomycin-resistant enterocci in his urine, and respiratory failure. A past medical history included hepatitis C and chronic obstructive pulmonary disease. I had reservations about assigning the patient to relatively inexperienced students and was not at all confident they were ready to handle this involved case, let alone manage an end-of-life experience. Only a few weeks ago they were working in jobs light years from nursing; one young woman came from the public relations world and the other from a job as a sales associate at a large chain department store. The night nurse, who appeared tired and overwhelmed, whispered that Mr. S. would probably die on our shift. When I learned he had no family or visitors, my decision was made. I could not bear the idea of a patient dying alone.
My goals for the students that morning were to provide comfort, monitor vital signs and intake/output, be responsible for his general care and, possibly, observe postmortem care. The patient’s code status was do not resuscitate, with no plan for hospice care. The RN case manager was wringing her hands, trying to chase down the attending to write an order for hospice care. Complicating the situation was the fact that Mr. S. had been placed on the orthopedics floor, and the nurses wanted to transfer Mr. S. to a medical unit.
Nervously, the students tied filmy blue gowns around their waists, struggled into plastic gloves, and approached our patient. His eyes were dry and staring as we entered the room. A bag of normal saline dripped into a vein keeping him hydrated, along with several piggybacked antibiotics to treat the infections overwhelming his body; a Venturi mask covered his face pushing air into lungs that no longer worked on their own. We were told he was responsive to pain only.
We talked to Mr. S. as we cleaned and bathed his face, body, and wounds. We adjusted his breathing mask, placing cotton gauze under strategic areas to prevent the plastic ties from biting into fragile skin. We put saline drops into dry eyes, massaged hands and feet with moisturizer, and applied barrier cream to a reddened sacrum. The students took vital signs. His temperature was 94.6 F degrees, and we rushed to cover him with extra blankets. We turned and positioned him carefully, relieving stress on a body that could no longer move on its own. Mr. S. had been a professional musician, so we turned the radio to a classical music station. As the notes of a piano concerto begin, we snipped and replaced wristbands that had grown tight around his swollen arms. We reattached sequential compression devices, which had been lying on the floor, to the patient’s legs.
The students barely left the patient’s side the entire morning. At some point, a resident entered the room, and stood at the foot of the bed. “Mr. S.,” he shouted, “How are you today? Are you in pain?” Mr. S. remained silent. “Well, no change I see.” He quickly left. Any reservations I had about assigning the patient to freshmen evaporated.
The students went back to caring for Mr. S., cleaning his mouth with a soft swab and mouthwash solution. By the end of our shift, he proved the nurses wrong. His vital signs improved. He was able to squeeze our hands when we said goodbye, and his eyes followed us as we left the room.
Reflection to resolution
In the postclinical conference, the freshmen were tired but quietly exhilarated. Apart from the primary nurse hanging the antibiotics and saline infusion, they had taken complete care of their patient. They spoke with some surprise, a little awe, and finally pride because they saw first-hand how their care significantly influenced their patient’s clinical outcomes that morning. They talked about how nursing goes beyond simple tasks and following medical orders. Ultimately, they were taken with the incredible power nursing has to change the course of a person’s outcomes. They experienced first-hand how nurses should respect the needs of all patients, and never more so than when those lives are nearing death.
I was pleased with the students’ work and appreciative of their sensitive reflections on a challenging day. As novice nurses they excelled in performing tasks, monitoring vital signs, and reporting changes. They were able to discuss larger issues surrounding those tasks. I thought back to the last faculty meeting, and the skeptical teachers. I told my students that I was proud that they learned not just what nurses do, but what nurses are capable of doing.
Unfortunately, our conference was running late, and we still needed to talk about what did not go right, but the students had to leave. If they had stayed, I would have talked about how the busy night nurse missed providing basic care to Mr. S. and how the preoccupied day nurse administered medications then left the room without talking or touching her patient and without talking to us. I would have pointed out that from a distance of 6 feet, the resident ascertained his patient was still dying: a caricature of poor bedside manners. He stereotypically ignored the nurses taking care of his patient – the students and me. There were other issues I needed to address with the students. We had not followed up on the missing hospice care order. We had not effectively communicated our concerns to the primary nurse. Perhaps most importantly, we missed interdisciplinary rounds.
While I had no regrets assigning Mr. S. to my novices, I realized I cannot teach any students without showing them how to manage patients in a healthcare culture that is in itself ailing and overly complicated. These are enormous issues to tackle, and I think I am partly to blame for what I saw as the failure to help Mr. S. on the many levels that needed care and attention. We should have engaged the medical team, tried to talk to the physician who left so abruptly. We should have followed up with the primary nurse, the RN case manager, and hospice care. Perhaps most importantly, because it could have answered many questions regarding Mr. S.’s care, we missed attending the unit’s interdisciplinary rounds.
The next week, I went back to the hospital, determined to change the way I manage the students’ day and our patients’ plan of care. Interdisciplinary rounds are held at 10:00 am, and I made sure we were there. A large group of people gathered by the nursing station, led by the nurse manager. Floor nurses, the social worker, the case manager, physicians, a nutritionist, and two nurse practitioners make up the team. Seventeen beds, 27 discussions, and many questions raised—some answered, some left unresolved. The topics ranged from moving a patient with newly diagnosed Clostridium difficile to an isolation room, to finding available rehab beds, to discussing how to best deal with a patient with Alzheimer’s disease who was pulling out her nasogastric tube to a psych consult for a young woman with metastatic breast disease. After rounds, the students began to see how critical interdisciplinary care is to managing a patient’s hospital stay. They began to understand the roles of the varied disciplines in the hospital with each discipline playing a vital part in the management of their patients.
What the research shows
Interdisciplinary rounds (IDR) have been widely used in the hospital setting for a number of years, and studies have shown their benefits in improving clinician efficiency, quality of care, and improved teamwork climate. Moreover, research shows the importance of interprofessional collaboration. The quality of healthcare provided by the hospital staff is affected by how clinicians communicate and interact with each other, and poor communication can influence patient outcomes, length of hospital stay, and costs. An informal review of the literature reveals few studies examining student involvement in IDRs. One Danish study showed that interprofessional training can offer students the chance to use new clinical expertise while teaching them about other professional roles; the study found more positive attitudes were fostered between the professions using this model. The use of interprofessional training has been championed by the Robert Wood Johnson Foundation, and a number of training grants and research studies have been funded.
Students who participate in IDRs are taking a step toward interprofessional collaboration, and this early training may prove critical on both a personal and clinical level after graduation. The suggested benefits of student participation in IDRs include:
- Opportunities to obtain an understanding of other disciplines
- Appreciation for alternative health care approaches
- Increased student participation in patient care
- Exploration of the values and challenges of each discipline
- Improved interprofessional relationships
Time to learn
Fifteen months may not be a long time to learn how to become a professional nurse. Nevertheless, it can be enough time to instill in new nurses an appreciation of how to effectively manage and collaborate patient care. Instructors who have access to interdisciplinary rounds can speed a student’s understanding of how best to achieve those goals.
Karyn Lee Boyar is a family nurse practitioner and a faculty instructor of nursing at New York University College of Nursing in New York City.
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Jacobsen F, Fink A, Marcussen V, et al. Interprofessional undergraduate clinical learning: results from a three year project in a Danish Interprofessional Training Unit. J Interprof Care. 2009;23(1):30-40.
Naylor M. Promoting rigorous interdisciplinary research and building an evidence base to inform health care learning, practice, and policy. Commentary; Institute of Medicine, Washington, DC. Nov 15, 2013; http://iom.edu/interdisciplinaryresearch. Accessed September 5, 2014.