Kanter, Steven L. MD
Everyone agrees that better teamwork leads to better patient care. But those who work every day at academic health centers recognize that there are very significant challenges to building interprofessional* teams and to educating learners to function effectively in such teams.
Such challenges in patient care range from system-based barriers to differences in individual skills and traits that impede effective communication and collaboration. In interprofessional education, logistic issues—like trying to coordinate the schedules of nursing students in semester-based courses with those of medical students in modular courses—along with differences among learners in experience, age, and professional and personal maturity combine to present intractable barriers.
The academic health professions community clearly has recognized the critical importance of interprofessional care and education and has responded with a variety of initiatives, projects, and events aimed at surmounting barriers, addressing challenges, and improving the effectiveness of teams. For example, foundations have offered funding to catalyze the development of new interprofessional efforts, major health professions associations have partnered to facilitate the implementation of new projects, and new professional organizations have formed to facilitate the sharing of new ideas, best practices, and important research questions.
As a result, there is, I believe, a general sentiment that things are headed in the right direction. But I also think that all of us wish we could move even faster. We see the tremendous potential of high-functioning, efficient teams, and so we see the need to discover new and better ways to address challenges more effectively, to surmount existing barriers more rapidly, and to implement change more efficiently. But is it really possible to do all this more quickly?
A few years ago, my mother discovered, albeit somewhat accidentally, a strategy that effectively and immediately improved team-based patient care at the hospital where she was a patient. She demonstrated that, with sufficient motivation, barriers can be surmounted in a single bound, and that seemingly intractable problems can be replaced, overnight, with rational solutions.
Here is what happened.
My mother, who lived in a nursing home, was admitted to the hospital early one day with a urinary tract infection and sepsis. She also had significant back pain.
The doctor who admitted her wrote orders for antibiotics and pain medication to be administered immediately, vital signs to be taken on admission and again one hour after she was medicated for pain, and blood to be drawn for laboratory testing once she was settled in her hospital room. As is common practice, the doctor placed his orders in the chart and left the hospital floor without having a conversation with the nurse or anyone else assigned to my mother's room.
The nurse administered the antibiotics intravenously and then got caught up doing other things. After an hour or so, my mother pressed the “nurse button” to request pain medicine. In fact, during the course of the day, she asked for pain medicine a few times. Each time she waited 45 minutes to an hour for the nurse to arrive with the medicine. When she complained, the nurse apologized and said that she was busy, that she had too many patients assigned to her, and that she really was doing the best she could.
Later on the same day, while I was driving from Pittsburgh to Washington, D.C., to attend a meeting with the editorial staff of this journal, I called my mother to see how she was doing. My mother told me that she was having a lot of pain and was waiting at least 45 minutes for pain medicine. She asked me to call the head nurse to see if she could get pain medicine on a more regular schedule. It always has been my understanding that when your mother asks you to do something, she really is telling you to do it. So, I called the head nurse immediately.
The first thing that the head nurse told me was that the pain medicine took a while to come up from the pharmacy, using the classic strategy of shifting blame, at least partially, to another profession. She then added, in a comforting and supportive voice, that while the pharmacy might be delaying things somewhat, it was also the case that my mother was a little confused, and that she really was getting her pain medicine quite promptly, and that I could rest assured that my mother was receiving good care.
I have spoken with many nurses over the years, and I could tell that this nurse was a good person who cared about her patients. Her words and the intonation of her voice convinced me that she was dedicated to her job and that she sincerely wanted me to feel comfortable about the care that my mother was receiving. She seemed to me like the kind of head nurse who had been around for a while and who knew that to do her job well, she had to use her well-honed interpersonal skills to negotiate the various obstructions, impediments, and hurdles imposed by a complex health care enterprise. And I got the impression that she knew the ins and outs, the shortcuts, the modus operandi that every good nurse learns so she can provide good care for her patients and protect them from the inadequacies of the health care system.
So, I called my mother to report back to her and to reassure her, but she insisted that she was waiting too long for pain medicine. So, while we were on the phone together, my mother pressed the button for the nurse and requested pain medicine. I noted the time on the clock in my car and we waited together as I continued to drive to D.C. Sure enough, it took the nurse a little over 45 minutes to show up with the pain medicine. My mother—i.e., the patient—was right.
The nurse gave my mother the medication and, after a bit, my mother started to get groggy, so we agreed that I would call the head nurse again in the morning to see if my mother could get the pain medicine more quickly.
The events that followed were synthesized from conversations that took place the following day with hospital administrators, nurses, other hospital staff, my siblings, and my mother. Here is a summary of what we believe occurred.
Later that night, the next shift of nurses arrived, and my mother's new nurse dutifully and carefully reviewed her orders. The new nurse realized that the vital signs and the blood work had not been done. He was not sure that they still needed to be done, or that they should be done while my mother was asleep, but he did not want to disturb the physician at night. So, he called for the phlebotomist, went in to my mother's room, and measured her blood pressure, pulse, and respiration rate.
It takes a while for elderly people to wake up and orient to their surroundings, especially if they are in new or unfamiliar places. So when the nurse, moving quickly, put the blood pressure cuff on my mother's arm, my mother woke up only a little bit—she knew someone was hurting her bad arm—but fell back asleep when the nurse removed the cuff and left the room.
Next, the phlebotomist showed up to draw blood. The phlebotomist, also overworked and moving quickly, did not give my mother adequate time to fully wake up. Rather, the phlebotomist slapped on a tourniquet, pulled it tight, and jabbed my mother's arm with a needle. In fact, the phlebotomist had to stick my mother's arm three times to get blood. The phlebotomist finished and left the room with my mother partially, but never fully, awake.
Because of the three attempts required to gain venous access, and because my mother had been taking an anticoagulant and the phlebotomist probably did not compress the puncture site long enough, a hematoma started to form in my mother's antecubital fossa. Most likely, my mother began to feel more and more pain in her arm and, ultimately, woke up. Of course, it was dark and she was not in her usual environment. Thus, while her sensorium was not perfectly clear, she was awake enough to know that at least two people came into her room and hurt her for no reason that she could discern.
Having recently watched a documentary about elder abuse that encouraged people to report such events, she picked up the phone and called 9-1-1. She told the dispatch operator that she was in a strange room and that at least two people had hurt her.
When the 9-1-1 dispatch office traced the call to a hospital room, I can only imagine that they must have thought they had an interesting story on their hands—perhaps, even, an exposé of elder abuse at a respected hospital.
A few minutes later, in the wee hours of the morning on the quiet and dimly lit hospital ward, three paramedics came barging through with their equipment, waking up other patients on the way, and entered my mother's room. Of course, the nurses came running, someone brought a “crash cart,” and there was all manner of commotion.
It took several hours and a lot of discussion among the paramedics, the on-duty nurses, the head nurse, and a few hospital administrators who were unaccustomed to being awakened in the middle of the night, to figure out what had happened.
The next morning, as I was leaving my hotel for the journal office, I received a call on my cell phone from the hospital's chief nursing officer. “Dr. Kanter,” she said, “I promise you that your mother will get her pain medication and anything else she needs or wants in a timely and prompt manner, if you promise me that she will never call 9-1-1 again while she is in our hospital.” The nurse went on to tell me that they had to fill out reams of paperwork, respond to calls from concerned family members of other patients on the floor, and convince a reporter not to run a potentially embarrassing story in a local newspaper.
And then she told me something very interesting. She said that she and the hospital president were going to hold a meeting with a couple of their physicians, a few nurses, a laboratory supervisor, and someone from the hospital pharmacy to figure out how to communicate more effectively, how to respond more rapidly to patient concerns, and how to function better as a team.
I said, “Wow, that's fantastic,” and I commended her for choosing to pursue a constructive response to a difficult and complicated situation.
My mother's call to 9-1-1 from a hospital bed had brought into sharp focus a seemingly disparate set of occurrences in which good people, acting with good intentions, contributed to suboptimal patient care. In a poetic sense, she sounded the alarm for the emergent need for better interprofessional, team-based care everywhere. And, perhaps most important of all, her call demonstrated that the health care ship—as cumbersome as it may be—can be turned quickly in the night, so that by morning it is headed in a better direction.
As I continued walking to the journal office I found myself thinking that, with commitment that starts from the top and includes all stakeholders, and with sufficient motivation, it is possible to quicken the pace of progress in team-based care. And this underscores the urgency to improve our ability to provide high-quality and effective interprofessional educational experiences for all residents and students.
Of course, significant challenges still lie ahead including, but not limited to, framing the next set of key research questions, implementing team-based care and interprofessional education on a larger scale, and understanding how these educational interventions and team strategies affect patient outcomes. I just hope we don't have to call 9-1-1 to get it done.