WHEN MANAGING patient care in acute care settings, physicians and nurses sometimes lack a sense of collaboration due to perceived barriers, including issues related to communication, mutual respect, and limited availability.1 This article details the implementation of a nurse shadowing program and its impact on the relationship between resident physicians and transitional care nurses (TCRNs) at University of Colorado Health.
It had become clear to the TCRNs within the adult medicine service of the family medicine residency program that the institution's resident physicians lacked an understanding of the role of nurses at the bedside. This was evidenced by growing resentment between the residents and nurses and demonstrated in fragmented communication regarding orders or plans of care, resulting in confusion and discontent.
The residents were frustrated with how often they were being paged with seemingly trivial or unnecessary questions. The nurses, on the other hand, did not want to be viewed in a vacuum without the attribution of critical thinking and assessment skills outside of carrying out orders and administering medications.
In a 2016 study, over half of the nurses surveyed confirmed that a physician's attitude affected how likely they were to ask questions or report changes in a patient's condition.2 This underscores why developing collegial relationships is essential for safe patient care.
In the trenches
Part of a TCRN's role includes educating new physicians about nursing workflows in the hospital and the nursing staff's depth and breadth of clinical knowledge. Empowered by the shared governance model and inspired by an essay in JAMA by Rafelson and Brown that explored the obstacles and eventual benefits of including nurses in clinical rounds, the TCRNs proposed the integration of a nurse shadowing program into the residency curriculum.3 The concept was then adopted by an attending physician and incorporated into the hospital portion of the residency curriculum.
In 2016, six first-year residents were assigned to nurses in the oncology, medical-surgical, telemetry, and neurology units. Seasoned nurses were handpicked by their managers for the shadowing experience. In preparation, the residents read Rafelson and Brown's essay and were assigned the following goals:
- understand the logistics of how orders are carried out by observing medication administration, patient monitoring, therapies, and general patient care
- become familiar with RN roles, responsibilities, and workflows
- experience improved patient care firsthand by witnessing nurses as they inquire about the rationale behind orders and advocate for patients
- identify the various roles of interdisciplinary care team members (such as physical, occupational, speech, and respiratory therapists and certified unlicensed assistive personnel) and see them in action
- formulate plans of care from orders available on the electronic health record (EHR).
For 2 hours, the residents observed the nurses during patient handoffs, physical assessments, and other associated duties during the morning shift. They were not permitted to write orders, provide patient education, or act as a physician during this time. Two TCRNs and an attending physician floated between the units to check in.
Afterward, the residents regrouped and recounted their experiences during a guided reflection, which was facilitated by a TCRN and an attending physician. The residents discussed something they learned, challenging situations and how they were handled, and the implications of their experiences on future practice. Each resident also completed a postexperience survey to capture additional data (see Postexperience survey questions).
The residents uniformly reported an increased awareness of and appreciation for the role of nursing at the bedside (see Impact of the nurse shadowing program on resident physicians). Many participating residents described the experience as humbling, given the number of responsibilities tasked to the nursing staff. One resident noted that acknowledging a new order in the EHR, carrying it out, documenting it, and explaining it to the patient took significantly more time than expected.
Residents were also surprised by the range of nursing responsibilities and placed greater value in nurses' expertise following the experience. One resident commented, “I didn't know nurses did such thorough physical assessments. I thought they just listened to the patient's heart and lungs. I could use that information later in the day when I have a lot going on to see how the patient is doing.” Another noted being surprised by how many patient questions the nurses fielded and how well they were prepared to answer each of them.
Respect for the level of patience the nurses demonstrated was a common theme as well. Whether it was having to administer medications one at a time, dealing with difficult patients, or assisting patients at high risk for falls in the restroom, the residents described scenarios that had changed their perspectives on the amount of work behind the nursing documentation in a patient's medical record.
As for obstacles in communication, the residents observed the challenges of limited physician interactions due to more time spent entering electronic orders in the physician call room and less time spent on the nursing units. They commented on the hurdles many nurses face when acting as a middleman between providers and patients. One resident pointed out the disparity between physician-nurse communication compared with the communication between nurses and other hospital departments. Another described similarities in pre-rounding and medical record review and noted the need for improved collaboration between physicians and nurses.
What happened next
The nurse shadowing program has led to a shift in attitudes and daily workflows at University of Colorado Health. With a better understanding of the role of nursing in patient care, the residents have demonstrated more patience and less frustration with pages or calls from nurses. With a better understanding of nursing processes, the residents also put workflows into practice to make things easier for the nursing staff, such as entering orders into the EHR in groups for efficiency. This type of collaboration shows consideration and care for each party involved, building mutual respect between residents and nurses.
Recognizing the need for better communication, daily bedside rounding with the entire inpatient healthcare team, including the clinical nurse, was initiated approximately a year after the first nurse shadowing program. This lets the nurse provide real-time data regarding the patient's clinical status, discuss any concerns to be addressed immediately, and advocate for the patient. The resident can then utilize the in-room computer to make any changes, and the patient feels that the entire team is on the same page. Additionally, because the nurse is present, he or she can address any questions the patient asks afterward. Inpatient unit staff, nursing managers, and directors view bedside rounding as a win for everyone involved.
Implementing a standard practice for opportunities to increase physician-nurse collaboration placed more emphasis on teamwork. In the cardiac unit, for example, charge nurses place the nurse's name and phone number on the patient's door, offering a quick means of communication between the residents and the nurses. Each of these changes is conducive to a more unified approach, leading to optimal patient outcomes, a more effective team, and more satisfied patients and families.
Both nurses and residents who have gone through the shadowing program at University of Colorado Health feel it has broken down what was previously an “us versus them” mentality between the disciplines. Residents feel more comfortable approaching nurses in a collaborative fashion, and nurses are less hesitant to contact residents with questions or concerns about their patients.
Communication has also been streamlined. Previously, residents would call nurses to ask for updated patient information that was already available in the nursing documentation in the patient EHR. Now that they are more familiar with nursing workflows and have a better understanding of where to find nursing documentation regarding their patients, the residents are more likely to review nursing flowsheets for information before contacting a nurse with their questions. With challenging patients, the disciplines work together to determine the best way to deal with the situation.
At University of Colorado Health, the nurse shadowing program has provided the opportunity to develop an effective professional relationship between residents and the nursing staff and has set the foundation for how these physicians will interact with nurses for the rest of their careers. The experience changed the participants' perspectives, increased understanding, and provided a more complete picture of healthcare delivery in acute care settings. Additionally, bedside rounding has improved the quality of communication and collaboration within the healthcare team.
Since its inception in 2016, the nurse shadowing program has continued to thrive in the oncology, medical-surgical, telemetry, and neurology units, with shadowing times extended from 2 to 3 hours. Resident presurveys have been added and are required, and postsurveys are completed as part of the guided facilitation to assure 100% participation. Nurses who participated in the experience have also been included and complete their own postsurveys. These interventions have helped overcome previous challenges in the level of participation and the effects of a small sample size. The surveys are undergoing evaluation to make improvements for the purposes of obtaining quantitative data. The next step would be to explore the impact of nurse shadowing programs in larger physician residencies in different geographical areas.
Other considerations include expanding the facilitation of guided reflection to include nurses involved in the shadowing experience. Although the nursing staff has expressed interest in shadowing residents as a second part of the program, this has not been a consideration yet. Additionally, the effects of increased professional collaboration between nurses and residents could be extended to include data on patient satisfaction using surveys or other hospital metrics.
Postexperience survey questions
Below are questions from a 2016 survey to assess a resident physician's understanding of how orders are carried out on the unit, the amount of communication present between RNs and MDs, and his or her takeaways from the nurse shadowing program.
- Did the shadowing experience help you understand the logistics of how orders get carried out on the unit?
- By observing the RN workflows, did this help with how you will communicate urgency or rationale of orders in the future?
- In your opinion, did this shadowing experience increase ease of dialogue between residents and nurses?
- From this experience, do you agree that patient care is improved by more dialogue between the resident and the nurse?
- As a result of this experience, do you view the nurse and resident as a team instead of with an “us and them” mentality?
- After shadowing a nurse, can you see how increased nurse and resident interactions on the floor can help decrease compassion fatigue for challenging patients?
- Please identify two things you learned from shadowing a nurse.
- How will these two things change the way you interact with a nurse?
- Please list three lasting impressions of this experience.
- Please include any feedback, criticisms, suggestions.