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
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.
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.
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.
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.
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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