What does Interprofessional
communication look like in an inner city emergency room? Some observations and
reflections
Christine Holland, MMS, PA-C
Instructor at Rush University PA Program
Contact: Christine_S_Holland@rush.edu
Introduction
It
is well-accepted that good interprofessional communication is a precondition
for optimal care and treatment for patients in addition to good cooperation
between healthcare providers (e.g. Berry, 2007). Healthcare providers are
facing a complicated healthcare system where team communication is increasingly
even more essential due to this complexity of collaboration between caregivers
(King et al., 2012).
While great progress has been made in the areas of interprofessional practice
and interprofessional education (IPE), the literature continues to report a
number of challenges related to interprofessional communication (Foronda et al., 2016). The aim of this
paper is to report observations of interprofessional team communication with patients
in an inner-city emergency department during a physician’s shift. What I witnessed
was surprising and disheartening, especially in relation to the fact that the
attending physician would state to every patient that they would be treated by
an interprofessional team. As a PA myself, and a Interprofessional Studies PhD
student, I greatly appreciate the importance of an interprofessional team. The whole
PA profession was birthed from the notion of building a team relationship with
physicians. It is this team approach that the PA-MD team cares for patients. It
is through these lenses, both as a PA and an Interprofessional Studies PhD student,
that I have made the following documentation and some thoughts for improvement.
Context
My
observations were gathered from an inner-city emergency room which contained 60
beds. There were four pods, each covered by an attending physician, two residents,
a physician assistant student and a nurse. There was also a “pit doctor” and
one nurse who triaged patients, ensuring: (1) emergent cases were addressed
immediately, (2) low acuity patients were seen by the pit doctor and then
released (3) or appropriate labs or x-rays were ordered and completed prior to
the patient being seen by the emergency room physician. The team also included two
social workers, administrative staff, and a nurse manager. These providers worked
either a nine or 12-hour shift. There was no formal communication training that
these providers received prior to working in the emergency room. The physicians
did reference some team training, but could not tell me what it stood for nor
what they learned from it. Thus, this ‘training’ did not seem to play an
important role in impacting how these providers worked. Also, it is worth noting
that none of these providers had received any form of IPE to help support their
interprofessional teamwork.
Observations
During
my time in the emergency room various patients presented ranging from those
with congestive heart failure, head laceration, loss-of-consciousness,
shortness of breath, possible seizure, vertigo, back pain to headache and more.
The average amount of time the physician and I spent with a patient was between
3-5 minutes, during which there was no interprofessional team communication evident.
Rather, the physician would advise the patient to get the nurse if they had any
questions. The nurse would then address the patient’s question(s). There was however,
a whiteboard in each examining room where the physician would circle orders
he/she wanted (i.e. labs, x-ray, CT scan) as a means of communicating about
patient needs.
Once
the physician saw the patient for the second (and usually final time) to
communicate the diagnosis and treatment plan, the communication with the
patient was a one-sided conversation (i.e. “your dad has water on his lungs. We
gave him Lasix so he can urinate. He has to be admitted.”). During one case, the patient (a 78-year-old,
Hispanic, Spanish speaking man) did not know what was being said by the
physician. The physician did not even address the patient until the very end of
the conversation, only communicating with the family who were surprised by the
diagnosis. Unfortunately, the physician did not seem to notice any of her body
language. Rather, he continued stating his plan for their father never asking
the family or patient if they had any questions until the very end. The
physician also was not at eye level with anyone in the room when he was
speaking to them. He stood while everyone else sat putting him in an
authoritative position. He also introduced me as a “team member,” stating
patients’ are seen by teams in this emergency room. After my time there,
however, the interprofessional team communication appeared fragmented.
Discussion
This
inner-city emergency room experience provided a useful example of the gap
between what is taught about interprofessional communication in classrooms and
what is happening in clinical practice. While this was only a single observational encounter relating to interprofessional
communication, my findings were concerning given it was a very busy emergency
room, impacting thousands of patients’ lives on an annual basis. Therefore,
even these few observations provide some indication about the possible
difficulties with interprofessional communication.
In
regards attempting to enhance this situation, one improvement would be to make
sure nurses are present while students and or residents are giving their clinical
presentations to the attending physician. This will allow the nurse to be
involved with the patient’s interprofessional plan and if anything was
forgotten or overlooked by the resident/student, the nurse can add to the
details.
In
addition to having nurses present during medical case presentation, implementing
an interprofessional communication skills lab is another action that can be
taken to improve interprofessional communication. Salvatori et al (2006) for
example, introduced a mandatory IPE curriculum for all their health profession
programs at McMaster University in Canada. In this curriculum,
competency-based, small group, problem-based learning, IPE competencies were
identified. One of these competencies was making team decisions (which seemed
to be lacking in my emergency room observations). Their findings indicated that
communication skill labs were not only a positive experience for the
participants, but they were effective in providing exposure to collaborating
with other healthcare professionals. Interprofessional simulation has also been
recognized as a crucial step to incorporate into healthcare students’ training
to better prepare them to practice in the clinical setting (Sanfey et al., 2011). I would further suggest
incorporating this interprofessional simulation in existing emergency rooms to improve
interprofessional team communication between providers and with patients.
My
last suggestion is to train interprofessional team members about basic
inter-personal and body language skills along with the sociological and
psychologic elements of teams. By providing these type of training, providers
would better understand about the nature of communication and how language can
be perceived by others. Not only should interprofessional teams learn about
their members and communication styles, but more importantly learn how to
adjust their communication styles when communicating with one another. This can
be better achieved with DISC training (Disc
Profile, 2017) that
teaches a common language for people to use when adapting their behavior with
others in addition to better understanding themselves. In combination with DISC
training, a simple body language course may serve to be quite beneficial toward
improving interprofessional team communication when interacting with patients. With
this said, the best communication will fall short if teams do not understand
the sociological and psychological elements of working together. Stereotypes and
hierarchical positions of professions need to be broken or at least discussed since
they can result in an imbalance of power (Sharma et al., 2011; Boet et al., 2014).
Furthermore, as noted by Boet et al
(2014) emotional and psychological safety need to be maintained during team
simulation debriefings. Buhler et. al. (2016) noted certain professions tend to
have more of particular personality types than others. These professional
personality differences may set-up a challenging situation for
interprofessional team members where the less dominant personality may feel
their opinion is not welcomed or valued as an equal team player. This triad of
communication, sociological, and psychological elements is crucial to maintain
balanced when teaching how to work as a productive interprofessional team.
Concluding comments
Team
communication is a crucial part of any clinical team that can lead to better
delivery and access to care (e.g. Brock et al., 2013). This experience suggests
there is still a long way to go in relation to providing effective interprofessional
and patient communication. However, as suggested above, the use of number of
interprofessional learning activities could be implemented to help improve this
situation, and begin closing the gap between what is taught in the classroom
and what actually happens in practice.
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