From Interprofessionalism Lite to the Real Thing

health care team

By: Jessica Early, a nurse practitioner fellow at the West Haven Veterans Affairs Center of Excellence in Primary Care Education (CoEPCE)

During my time in nursing school, the constant refrain was that interprofessional teamwork is the foundation of patient-centered care. In lectures and seminars, we were told that, as nurse practitioners (NPs), our effectiveness depended on collaboration with all members of the health care team—social workers, RNs, physicians, and specialty providers. Ironically, we were encouraged to develop the communication and teamwork skills needed for this collaboration in a classroom full of nursing students, led by a nurse faculty member, in a building only serving students pursuing a nursing degree.

In my three years of school, I had exactly one day of interprofessional education. My university’s third-year medical school class and my first-year graduate nursing class attended a lecture on hierarchy and power dynamics in a large medical school auditorium where my own educational cohort sat, clustered together, in a section of the hall separated from our medical school counterparts by a few empty rows of seats.

After the lecture, we were divided into smaller combined nursing and medical student groups for a breakout discussion. Both the lecture and discussion were thought-provoking and involved greater exposure to interprofessional education than most nursing students ever get. Unfortunately, a few hours of group learning with some medical students—who I would never learn alongside or even talk to again—did not make me feel prepared to successfully contribute to interprofessional teams in the future.

Similarly, in my clinical rotations, I had very limited interprofessional exchanges. In the inpatient setting, “collaboration” often consisted of an RN ducking into medical rounds to give a one- or two-minute “nursing” assessment of a given patient. The nurse then would quickly return to his or her duties while the attending physicians, residents, medical students, or other participating professionals (from nutrition, psychiatry, etc.) developed the patient’s plan of care for the day. Typically, the same nurse would implement this plan.

Meaningful interprofessionalism was also a rarity in my outpatient, primary care clinical rotations (in the private health sector). In this setting, my “interprofessional” experience involved watching overworked NPs and primary care physicians (PCPs) wrangle with specialists over criteria for patient referrals via faxes, letters, emails and—less frequently—telephone calls.

Fortunately, as a first-year licensed NP, I am now working in a drastically different setting. At the West Haven, Connecticut VA CoEPCE, described in a recent Academic Medicine article, I am actively engaged in truly collaborative primary care practice and learning. At the CoEPCE, our team RN leads “team huddles”—our version of morning rounds—in which health techs, NP fellows, physician and NP faculty, and residents and medical students all discuss patient and work delegation concerns and priorities for the day ahead. Together, we generate a plan to best address these issues. Then each team member plays the role that was specifically identified and assigned to her or him. We also cooperate to troubleshoot any other issues as they arise throughout the clinic day.

Our recent care of a complex patient with multiple comorbidities illustrates how personally rewarding CoEPCE-style collaboration can be. When this patient presented, his primary physician (a resident member of my clinical team) was on an inpatient unit. Rather than delay this patient’s care until his PCP returned, I saw the patient to address his pressing need for home oxygen therapy for rapidly worsening COPD.

Our team’s RN then involved the respiratory and home oxygen departments to secure both a temporary oxygen tank for the patient to take home and same-day delivery of a permanent home and portable oxygen set-up. A couple weeks later, when I saw the patient again, he reported that he was no longer grappling with the shortness of breath that had been impairing his daily functioning.

Shortly after this follow-up appointment, I discussed the patient in-person with his PCP who had just returned from his inpatient rotation. Together we recapped the patient’s history and developed a plan to transfer care to ensure that my colleague—the provider with the closest and most continuous relationship with this patient—could address the patient’s future needs.

This experience working collaboratively with a medical resident, an RN, and professionals from our VA specialty services demonstrated the depth of the CoEPCE’s commitment to interprofessional health care. The knowledge and skills of the other team members helped me grow professionally. More importantly, the patient had his urgent health needs met and was re-engaged in his patient-provider partnership for long-term management of his chronic conditions.

At a time when fundamental change in graduate medical education and health care delivery is needed, paying lip service to interprofessionalism in the classroom and in the workplace just won’t suffice. I feel privileged to be part of a program where I can learn, with others, to care for patients in the way that I hoped would be possible when I originally decided to become a nurse.