http://informahealthcare.com/jic ISSN: 1356-1820 (print), 1469-9567 (electronic) J Interprof Care, 2014; 28(5): 475–477 ! 2014 Informa UK Ltd. DOI: 10.3109/13561820.2014.907558
SHORT REPORT
Attitudes of nursing staff toward interprofessional in-patient-centered rounding Umesh Sharma1 and David Klocke2 1
Department of Hospital Medicine, Mayo Clinic Health System, Franciscan Healthcare, La Crosse, WI, USA and 2Hospital Internal Medicine, Mayo Clinic Rochester, Rochester, MN, USA Abstract
Keywords
Historically, medicine and nursing has had a hierarchical and patriarchal relationship, with physicians holding monopoly over knowledge-based practice of medical care, thus impeding interprofessional collaboration. Power gradient prevents nurses from demanding cooperative patient rounding. We surveyed attitudes of nursing staff at our tertiary care community hospital, before and after implementation of a patient-centered interprofessional (hospitalist– nurse) rounding process for patients. There was a substantial improvement in nursing staff satisfaction related to the improved communication (7%–54%, p50.001) and rounding (3%–49%, p50.001) by hospitalist providers. Patient-centered rounding also positively impacted nursing workflow (5%–56%, p50.001), nurses’ perceptions of value as a team member (26%–56%, p ¼ 0.018) and their job satisfaction (43%–59%, p ¼ 0.010). Patientcentered rounding positively contributed to transforming the hospitalist–nurse hierarchical model to a team-based collaborative model, thus enhancing interprofessional relationships.
Attitudes, hospital rounds, interprofessional care, interprofessional collaboration, nursing, patient-centered care
Introduction Historically, medicine and nursing has had a hierarchical and patriarchal relationship, with physicians holding monopoly over knowledge-based practice of medical care, thus impeding interprofessional collaboration (Price, Doucet, & McGillis Hall, 2013). Power gradient prevents nurses from demanding cooperative patient rounding, and physicians are more likely to have deliberate patient care-related conversations with other physicians, rare and terse conversations with other health professionals with a tendency to overlook their observations (Zwarenstein, Rice, Gotlib-Conn, Kenaszchuk, & Reeves, 2013). Yildirim et al. (2005) study undertaken at public hospitals in Istanbul, Turkey, indicated that nurses more than physicians, residents (trainees) more than permanent physicians and male physicians more than female physicians reported more positive attitudes toward interprofessional collaboration. This finding was attributed to cultural and hierarchal norms and conflict caused by the position of women physicians in a male-dominated occupation (Yildirim et al., 2005). Hospitalist providers (six attending hospitalist physicians and two associate providers – a nurse practitioner and a physician assistant) typically round independently on their patients at our 152-bed tertiary care community hospital with an average of 8000 inpatient admissions per year, return to their work desk to write progress notes and orders and then inconsistently communicate care plans to the patients’ nurses.
History Received 16 July 2013 Revised 15 February 2014 Accepted 19 March 2014 Published online 8 April 2014
Our pre-survey workflow did not encourage team-based participation of nursing staff in bedside rounds by hospitalists or promote interprofessional communication between them. Lack of awareness of patient care plans led to confusion, frustration and barriers to quality patient care. The negative effect on nursing staff workflow efficiency, potential for patient harm and having received multiple requests from the staff to improve our rounding and communication prompted us to choose them as the study group.
Methods The main purpose of this pilot study was to study and improve the perceived communication and interprofessional care provided by the hospital medicine providers with the medical floor nursing staff. We surveyed attitudes of nursing staff before and after fourmonth implementation of a patient-centered physician–nurse rounding process for inpatients on three medical units. During these collaborative rounds, the hospitalist, bedside nurse, patient and their family (when present) discussed the patient’s condition and mutually formulated the care plan for that day. This pilot study focused specifically on the medical floor nursing staff–hospitalist provider interprofessional interactions, hence data on hospitalist providers, other groups or patient outcomes were not collected. The emphasis on collaboration for patient care rather than physician or nurse’s preferences make this a patient-centered intervention. Data collection
Correspondence: Umesh Sharma, Department of Hospital Medicine, Mayo Clinic Health System, Franciscan Health Care, 700 West Ave S, La Crosse 54601, WI, USA. E-mail: [email protected]
A total of 90 medical floor nurses were asked to complete a five-question baseline and four-month follow-up survey.
476
U. Sharma & D. Klocke
J Interprof Care, 2014; 28(5): 475–477
Table I. Pre/post rounding survey findings. Before rounding Survey parameter In-patient rounding Valued as a healthcare team member Interaction/communication Positive effect on workflow Job satisfaction
None + somewhat satisfied 59 45 57 58 35
(97%) (74%) (93%) (95%) (57%)
This survey was created by authors to specifically address historically problematic aspects of interprofessional care: rounding, communication skills, work-flow, involvement and jobsatisfaction. Questions were close-ended with none, somewhat and extremely as the possible answers. This survey and rounding was initially piloted with a small group of nurses and eventually spread to nurses on all medical floors. To encourage participation and confidentiality, this survey was anonymous, and data such as nursing staff age and years of experience were not collected. We also received voluntary and solicited feedback from nursing staff and supervisors with regards to their experience, concerns and recommendation with regards to new form of rounding. Data analysis Data were analyzed using online statistical software (chi-square test – http://www.graphpad.com). We compared survey-based staff responses before and after initiation of patient-centered rounding with respect to percent of staff that were or not fully satisfied with various aspects of rounding. p Value50.05 were considered statistically significant. Qualitative feedback data and opinions were noted, not statistically analyzed and were used to reinforce the momentum of the process by providing frequent positive feedback to involved staff.
Results The response rate for the nurses was 61/90 (67%) to both the pre- and post-surveys (only first 67 of 69 total surveys were included to ensure comparability of the data analyzed). Compared with baseline pre-rounding data, nursing staff satisfaction related to the communication and rounding by hospitalist providers significantly improved after the patient-centered inpatient rounding model was implemented (Table I). Nursing workflow, nurses’ perceptions of value as a team member and their job satisfaction was also positively impacted. Daily feedback confirmed that staff found rounds to be interactive, educational and conducive to improving partnership in collaborative patient care. Documentation of the patient care helped nurses to effectively review the care plan with patients, their families, transition patient care to colleagues and adequately answer any subsequent questions. Staff felt that the team-based ‘‘rounding time’’ was a great investment that made them an equal partner in patient care with a valued opinion, thus improving their morale. Hospitalists were perceived to be more accessible for face-to-face communication. Some instances of potential harm to patients such as medication errors and timely removal of indwelling catheters were prevented because of the improved interprofessional communication.
Discussion Professionalism of medicine has suffered from a crisis of public confidence due to acceptance of high levels of ambiguity in
After rounding
Completely satisfied 2 16 4 3 26
(3%) (26%) (7%) (5%) (43%)
None + somewhat satisfied 31 27 28 27 25
(51%) (44%) (46%) (44%) (41%)
Completely satisfied 30 34 33 34 36
(49%) (56%) (54%) (56%) (59%)
p Value 50.0001 0.0018 50.0001 50.0001 0.1031
practice, medical errors, patient-centeredness and need for accountability. Traditionally, physicians, nurses and other health providers work in silos leading to nurses’ perception of not being valued in physician’s decision-making process and hurting interprofessional collaboration (Gotlib-Conn, Reeves, Dainty, Kenaszchuk, & Zwarenstein, 2012). Modern medicine has been evolving from a physician-dominated autonomy to a team-based interprofessional practice with expansion of nurse’s role from being handmaidens to doctors to practicing medicine (Bleakley, 2013). As a result, there is a rising need for a ‘‘social contract’’ to clarify professional roles and responsibilities: medicine for managing and curing diseases and nursing for supporting and caring patients, thus creating a therapeutic alliance. Collaboration between these professions is central for effective patient care delivery (Reeves, van Soeren, Macmillan, & Zwarenstein, 2013). Patient-centered care places patient at center of care and consists of a comprehensive, collaborative, responsive and therapeutic alliance between healthcare professional and patients to find strategies to tailor treatments consistent to patient’s needs and preferences (Sidani & Fox, 2013). Patient-centered inpatient rounding gives physicians and nursing staff a real-time opportunity to understand and clarify issues on patient care, hence improving nurses’ perception as a team member and jobsatisfaction, and workflow. Patient-centered rounding positively contributed to transforming the hospitalist–nurse hierarchical model to a team-based collaborative model, thus enhancing interprofessional relationships. This study helped improve accessibility and face-to face communication between hospitalists and nurses, which is shown to be essential for effective interprofessional communication. The key elements of effective interprofessional collaboration are availability for interprofessional communication, relationship-building and a move from physician-lead to a team-based approach to patient care (Gotlib-Conn et al., 2012). Interprofessional collaboration can be improved by strategies that improve interprofessional relationships like training workshops, interprofessional rounds, journal clubs, special interest groups and improving interprofessional education (Price et al., 2013). This is even more important in an era of health informatics and the use of electronic medical records and computerized order entry, which reduces the time physicians spend on medical floors or interacting with nurses. Aging and high prevalence of chronic diseases leads to hospitalization of these medically complex patients with acute medical conditions. Hence, there is a need for designing an interprofessional communication and collaboration system that prioritizes information, improves workflow, promotes patient autonomy and improves relationships and scalability across various platforms and institutions (Wu et al., 2012).
References Bleakley, A. (2013). The dislocation of medical dominance: Making space for interprofessional care. Journal of Interprofessional Care, 27, 24–30.
DOI: 10.3109/13561820.2014.907558
Gotlib-Conn, L., Reeves, S., Dainty, K., Kenaszchuk, C., Zwarenstein, M. (2012). Interprofessional communication with hospitalist and consultant physicians in general internal medicine: A qualitative study. BMC Health Services Research, 12, 437. Price, S., Doucet, S., McGillis Hall, A. (2013). The historical social positioning of nursing and medicine: Implications for career choice, early socialization and interprofessional collaboration. Journal of Interprofessional Care, 28, 103–109. Reeves, S., van Soeren, M., Macmillan, K., & Zwarenstein, M. (2013). Medicine and nursing: A social contract to improve collaboration and patient-centered care? Journal of Interprofessional Care, 27, 441–442. Sidani, S., & Fox, M. (2013). Patient-centered care: Clarification of its specific elements to facilitate interprofessional care. Journal of Interprofessional Care, 28, 134–141.
Patient-centered in-patient rounding
477
Wu, R., Lo, V., Rossos, P., Kuziemsky, C., O’Leary, K., Cafazzo, J., Reeves, S., et al. (2012). Improving hospital care and collaborative communications for the 21st century: Key recommendations for general internal medicine. Interactive Journal of Medical Research, 1, e9. Yildirim, A., Ates, M., Akinci, F., Ross, T., Selimen, D., Issever, H., Erdim, A., & Akgun, M. (2005). Physician-nurse attitudes toward collaboration in Istanbul’s public hospitals. International Journal of Nursing Studies, 42, 429–437. Zwarenstein, M., Rice, K., Gotlib-Conn, L., Kenaszchuk, C., & Reeves, S. (2013). Disengaged: A qualitative study of communication and collaboration between physicians and other professions on general internal medicine wards. BMC Health Sciences Research, 13, 494.
Notice of Correction: A correction was made to the affiliation of the second author as well as to headings in Table 1 since this article’s original online publication date of April 8, 2014.
Copyright of Journal of Interprofessional Care is the property of Taylor & Francis Ltd and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
SHORT REPORT
Attitudes of nursing staff toward interprofessional in-patient-centered rounding Umesh Sharma1 and David Klocke2 1
Department of Hospital Medicine, Mayo Clinic Health System, Franciscan Healthcare, La Crosse, WI, USA and 2Hospital Internal Medicine, Mayo Clinic Rochester, Rochester, MN, USA Abstract
Keywords
Historically, medicine and nursing has had a hierarchical and patriarchal relationship, with physicians holding monopoly over knowledge-based practice of medical care, thus impeding interprofessional collaboration. Power gradient prevents nurses from demanding cooperative patient rounding. We surveyed attitudes of nursing staff at our tertiary care community hospital, before and after implementation of a patient-centered interprofessional (hospitalist– nurse) rounding process for patients. There was a substantial improvement in nursing staff satisfaction related to the improved communication (7%–54%, p50.001) and rounding (3%–49%, p50.001) by hospitalist providers. Patient-centered rounding also positively impacted nursing workflow (5%–56%, p50.001), nurses’ perceptions of value as a team member (26%–56%, p ¼ 0.018) and their job satisfaction (43%–59%, p ¼ 0.010). Patientcentered rounding positively contributed to transforming the hospitalist–nurse hierarchical model to a team-based collaborative model, thus enhancing interprofessional relationships.
Attitudes, hospital rounds, interprofessional care, interprofessional collaboration, nursing, patient-centered care
Introduction Historically, medicine and nursing has had a hierarchical and patriarchal relationship, with physicians holding monopoly over knowledge-based practice of medical care, thus impeding interprofessional collaboration (Price, Doucet, & McGillis Hall, 2013). Power gradient prevents nurses from demanding cooperative patient rounding, and physicians are more likely to have deliberate patient care-related conversations with other physicians, rare and terse conversations with other health professionals with a tendency to overlook their observations (Zwarenstein, Rice, Gotlib-Conn, Kenaszchuk, & Reeves, 2013). Yildirim et al. (2005) study undertaken at public hospitals in Istanbul, Turkey, indicated that nurses more than physicians, residents (trainees) more than permanent physicians and male physicians more than female physicians reported more positive attitudes toward interprofessional collaboration. This finding was attributed to cultural and hierarchal norms and conflict caused by the position of women physicians in a male-dominated occupation (Yildirim et al., 2005). Hospitalist providers (six attending hospitalist physicians and two associate providers – a nurse practitioner and a physician assistant) typically round independently on their patients at our 152-bed tertiary care community hospital with an average of 8000 inpatient admissions per year, return to their work desk to write progress notes and orders and then inconsistently communicate care plans to the patients’ nurses.
History Received 16 July 2013 Revised 15 February 2014 Accepted 19 March 2014 Published online 8 April 2014
Our pre-survey workflow did not encourage team-based participation of nursing staff in bedside rounds by hospitalists or promote interprofessional communication between them. Lack of awareness of patient care plans led to confusion, frustration and barriers to quality patient care. The negative effect on nursing staff workflow efficiency, potential for patient harm and having received multiple requests from the staff to improve our rounding and communication prompted us to choose them as the study group.
Methods The main purpose of this pilot study was to study and improve the perceived communication and interprofessional care provided by the hospital medicine providers with the medical floor nursing staff. We surveyed attitudes of nursing staff before and after fourmonth implementation of a patient-centered physician–nurse rounding process for inpatients on three medical units. During these collaborative rounds, the hospitalist, bedside nurse, patient and their family (when present) discussed the patient’s condition and mutually formulated the care plan for that day. This pilot study focused specifically on the medical floor nursing staff–hospitalist provider interprofessional interactions, hence data on hospitalist providers, other groups or patient outcomes were not collected. The emphasis on collaboration for patient care rather than physician or nurse’s preferences make this a patient-centered intervention. Data collection
Correspondence: Umesh Sharma, Department of Hospital Medicine, Mayo Clinic Health System, Franciscan Health Care, 700 West Ave S, La Crosse 54601, WI, USA. E-mail: [email protected]
A total of 90 medical floor nurses were asked to complete a five-question baseline and four-month follow-up survey.
476
U. Sharma & D. Klocke
J Interprof Care, 2014; 28(5): 475–477
Table I. Pre/post rounding survey findings. Before rounding Survey parameter In-patient rounding Valued as a healthcare team member Interaction/communication Positive effect on workflow Job satisfaction
None + somewhat satisfied 59 45 57 58 35
(97%) (74%) (93%) (95%) (57%)
This survey was created by authors to specifically address historically problematic aspects of interprofessional care: rounding, communication skills, work-flow, involvement and jobsatisfaction. Questions were close-ended with none, somewhat and extremely as the possible answers. This survey and rounding was initially piloted with a small group of nurses and eventually spread to nurses on all medical floors. To encourage participation and confidentiality, this survey was anonymous, and data such as nursing staff age and years of experience were not collected. We also received voluntary and solicited feedback from nursing staff and supervisors with regards to their experience, concerns and recommendation with regards to new form of rounding. Data analysis Data were analyzed using online statistical software (chi-square test – http://www.graphpad.com). We compared survey-based staff responses before and after initiation of patient-centered rounding with respect to percent of staff that were or not fully satisfied with various aspects of rounding. p Value50.05 were considered statistically significant. Qualitative feedback data and opinions were noted, not statistically analyzed and were used to reinforce the momentum of the process by providing frequent positive feedback to involved staff.
Results The response rate for the nurses was 61/90 (67%) to both the pre- and post-surveys (only first 67 of 69 total surveys were included to ensure comparability of the data analyzed). Compared with baseline pre-rounding data, nursing staff satisfaction related to the communication and rounding by hospitalist providers significantly improved after the patient-centered inpatient rounding model was implemented (Table I). Nursing workflow, nurses’ perceptions of value as a team member and their job satisfaction was also positively impacted. Daily feedback confirmed that staff found rounds to be interactive, educational and conducive to improving partnership in collaborative patient care. Documentation of the patient care helped nurses to effectively review the care plan with patients, their families, transition patient care to colleagues and adequately answer any subsequent questions. Staff felt that the team-based ‘‘rounding time’’ was a great investment that made them an equal partner in patient care with a valued opinion, thus improving their morale. Hospitalists were perceived to be more accessible for face-to-face communication. Some instances of potential harm to patients such as medication errors and timely removal of indwelling catheters were prevented because of the improved interprofessional communication.
Discussion Professionalism of medicine has suffered from a crisis of public confidence due to acceptance of high levels of ambiguity in
After rounding
Completely satisfied 2 16 4 3 26
(3%) (26%) (7%) (5%) (43%)
None + somewhat satisfied 31 27 28 27 25
(51%) (44%) (46%) (44%) (41%)
Completely satisfied 30 34 33 34 36
(49%) (56%) (54%) (56%) (59%)
p Value 50.0001 0.0018 50.0001 50.0001 0.1031
practice, medical errors, patient-centeredness and need for accountability. Traditionally, physicians, nurses and other health providers work in silos leading to nurses’ perception of not being valued in physician’s decision-making process and hurting interprofessional collaboration (Gotlib-Conn, Reeves, Dainty, Kenaszchuk, & Zwarenstein, 2012). Modern medicine has been evolving from a physician-dominated autonomy to a team-based interprofessional practice with expansion of nurse’s role from being handmaidens to doctors to practicing medicine (Bleakley, 2013). As a result, there is a rising need for a ‘‘social contract’’ to clarify professional roles and responsibilities: medicine for managing and curing diseases and nursing for supporting and caring patients, thus creating a therapeutic alliance. Collaboration between these professions is central for effective patient care delivery (Reeves, van Soeren, Macmillan, & Zwarenstein, 2013). Patient-centered care places patient at center of care and consists of a comprehensive, collaborative, responsive and therapeutic alliance between healthcare professional and patients to find strategies to tailor treatments consistent to patient’s needs and preferences (Sidani & Fox, 2013). Patient-centered inpatient rounding gives physicians and nursing staff a real-time opportunity to understand and clarify issues on patient care, hence improving nurses’ perception as a team member and jobsatisfaction, and workflow. Patient-centered rounding positively contributed to transforming the hospitalist–nurse hierarchical model to a team-based collaborative model, thus enhancing interprofessional relationships. This study helped improve accessibility and face-to face communication between hospitalists and nurses, which is shown to be essential for effective interprofessional communication. The key elements of effective interprofessional collaboration are availability for interprofessional communication, relationship-building and a move from physician-lead to a team-based approach to patient care (Gotlib-Conn et al., 2012). Interprofessional collaboration can be improved by strategies that improve interprofessional relationships like training workshops, interprofessional rounds, journal clubs, special interest groups and improving interprofessional education (Price et al., 2013). This is even more important in an era of health informatics and the use of electronic medical records and computerized order entry, which reduces the time physicians spend on medical floors or interacting with nurses. Aging and high prevalence of chronic diseases leads to hospitalization of these medically complex patients with acute medical conditions. Hence, there is a need for designing an interprofessional communication and collaboration system that prioritizes information, improves workflow, promotes patient autonomy and improves relationships and scalability across various platforms and institutions (Wu et al., 2012).
References Bleakley, A. (2013). The dislocation of medical dominance: Making space for interprofessional care. Journal of Interprofessional Care, 27, 24–30.
DOI: 10.3109/13561820.2014.907558
Gotlib-Conn, L., Reeves, S., Dainty, K., Kenaszchuk, C., Zwarenstein, M. (2012). Interprofessional communication with hospitalist and consultant physicians in general internal medicine: A qualitative study. BMC Health Services Research, 12, 437. Price, S., Doucet, S., McGillis Hall, A. (2013). The historical social positioning of nursing and medicine: Implications for career choice, early socialization and interprofessional collaboration. Journal of Interprofessional Care, 28, 103–109. Reeves, S., van Soeren, M., Macmillan, K., & Zwarenstein, M. (2013). Medicine and nursing: A social contract to improve collaboration and patient-centered care? Journal of Interprofessional Care, 27, 441–442. Sidani, S., & Fox, M. (2013). Patient-centered care: Clarification of its specific elements to facilitate interprofessional care. Journal of Interprofessional Care, 28, 134–141.
Patient-centered in-patient rounding
477
Wu, R., Lo, V., Rossos, P., Kuziemsky, C., O’Leary, K., Cafazzo, J., Reeves, S., et al. (2012). Improving hospital care and collaborative communications for the 21st century: Key recommendations for general internal medicine. Interactive Journal of Medical Research, 1, e9. Yildirim, A., Ates, M., Akinci, F., Ross, T., Selimen, D., Issever, H., Erdim, A., & Akgun, M. (2005). Physician-nurse attitudes toward collaboration in Istanbul’s public hospitals. International Journal of Nursing Studies, 42, 429–437. Zwarenstein, M., Rice, K., Gotlib-Conn, L., Kenaszchuk, C., & Reeves, S. (2013). Disengaged: A qualitative study of communication and collaboration between physicians and other professions on general internal medicine wards. BMC Health Sciences Research, 13, 494.
Notice of Correction: A correction was made to the affiliation of the second author as well as to headings in Table 1 since this article’s original online publication date of April 8, 2014.
Copyright of Journal of Interprofessional Care is the property of Taylor & Francis Ltd and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
