Adapting to Change: Ensuring Nursing Competence in ...



Adapting to Change: Ensuring Competence in Teamwork and Collaborative CareMegan GreenwayFerris State UniversityAbstractThe lack of interdisciplinary collaboration and efficient teamwork in healthcare has been under scrutiny long before the release of the Institute of Medicine’s (IOM) To Err Is Human report in 1999. Although quality and safety initiatives such as Quality and Safety Education for Nursing (QSEN) competencies have been developed to combat this national epidemic, rapid changes in the healthcare environment continue to challenge the efforts of QSEN and other quality and safety initiates. Nursing educators are faced with the responsibility of validating teamwork and collaboration competence of nursing students and established nurses without adding additional content to already saturated courses and programs. High fidelity simulation exercises enable interdisciplinary participants to practice working as a collaborative team and also give instructors the opportunity to evaluate the knowledge, skills and attitude (KSA) required for professional communication and respect for all individuals in a variety of medical disciplines. Adapting to Change: Ensuring Competence in Teamwork and Collaborative CarePatient safety and preventable medical errors has gained a significant amount of attention since the report, To Err Is Human: Building a Safer Health System was released by the Institute of Medicine (IOM) to the public in 1999. Suddenly the reality of preventable medical errors and subsequent harm to patients was in the public eye requiring several government agencies, insurers and professional agencies to investigate the cause of these errors and devise a plan to reduce the number of negative patient outcomes caused by human error (Donaldson, 2008). Recent changes in the healthcare environment has made it necessary for nursing educators to alter their approach in implementing quality and safety standard training and competency assessment in order to accommodate these changes and reduce the occurrence of adverse events. The purpose of this paper is to discuss the challenges associated with interdisciplinary collaboration in patient care, the nurse’s role in this relationship, and a strategy to implement evaluation of the knowledge, skills and attitude (KSA’s) necessary to validate the Quality and Safety Education for Nursing (QSEN) competency of Teamwork and Collaboration. Quality and Safety Initiative – Teamwork and CollaborationThe need to improve quality and safety education for nursing became evident after the IOM declared the focus of error prevention should be on the system as a whole and not necessarily on the individual making the error (Institute of Medicine [IOM], 1999). The United States Health Care System was, and continues to be challenged by the IOM’s theory that medical errors are an epidemic rather than individual incidences. This theory quickly changed the responsibility of the medical error from a single individual’s negligence to an individual’s role and responsibilities as a member of an interdisciplinary collaborative team who allowed the error to occur. Organizations now had to change a system of assigned blame to a process that analyzes the gaps in processes that allowed the individual to make an error (Keepnews, 2000). This new school of thought challenged nursing as a whole to define new competencies designed to assess the learner’s ability to seek out means to improve quality and safety in patient care. Since then, the QSEN initiative has answered with six quality and safety competencies designed to measure the KSAs of both pre-licensure nursing students, and those individuals working as a nurse pursuing graduate level degrees (Dolansky & Moore, 2013). Among these competencies are the KSAs associated with Teamwork and Collaboration. The concept of teamwork and collaboration was explored and defined long before it was made public by the IOM. Advances in interdisciplinary healthcare education, along with individual and societal benefits of a team approach to healthcare, has been documented as early as the 1960’s and 1970’s when Dr. Lowell T. Coggeshall first advocated for the team approach to healthcare. Shortly thereafter, Dr. Jerome P. Lysaught advocated for the advancement of nursing education (Interprofessional Collaboration, 2013). Since 1972 the IOM has been working toward building a safer healthcare environment by researching, supporting, and recommending advances in a team and collaborative approach to improve quality and safety in the healthcare system (Clancy, 2009).The Changing Healthcare EnvironmentAlthough the healthcare environment has gone through substantial historical changes, societal and demographic changes in the United States has made significant impact on the United States Healthcare System resulting in rapid changes to the healthcare environment. Now more than ever, the concept of interdisciplinary collaboration and teamwork in patient care is vital to the success of modern healthcare delivery and positive patient outcomes (Bankston & Glazer, 2013). The healthcare delivery team now consists of a large variety educated individuals specializing in specific areas of expertise as opposed to an era where physicians acted alone to diagnose and treat an individual’s medical condition. With today’s growing population, institutions are required to expand and grow in order to keep up with the number of individuals requiring medical care. Typically, more specialized care is needed the longer an individual lives, resulting in an increased number of care givers providing specific care expertise (Edmondson, 2015). The implementation of the Affordable Care Act (ACA) has enabled over 16.4 million Americans to have access to affordable healthcare were previously they were uninsured (U.S. Department of Health and Human Services website, 2015). The increased number of individuals who now have access to affordable medical treatment increases the demands of the healthcare workforce. To increase efficiency in the health care delivery process, healthcare worker responsibility can become concentrated to one or two specific tasks in order to manage the increased workload from an increased patient volume requiring their service of expertise. Efficiency is achieved when an individual is able to complete their task in a timely manner so they can move on to a new and similar task (Edmondson, 2015). However, if the process is flawed by lack of proper communication, leadership, and teamwork preventable medical errors, or never events, can occur putting the subsequent costs of these errors back on the healthcare facility (Humphreys, 2009). The Impact on Nursing EducationPerhaps the most compelling piece of evidence demonstrating the need to improve safety culture in the current healthcare system is not a recent change in healthcare, but a rather a known issue that has shown little improvement since the release of the IOM’s To Err Is Human. Although some positive changes have occurred in the last ten years, reports have shown that errors are still occurring at an alarming rate (Clancy, 2009). The Joint Commission shows that a lack of or inefficient communication between members of the healthcare team continues to expose gaps in the healthcare process and is to blame for the majority of preventable medical errors (O’Daniel & Rosenstein, 2008). In order to improve communication between healthcare team members, the relationship between healthcare disciplines must contain elements of trust in each other’s abilities and contributions to the team. Unfortunately, literature shows that the barriers between nurses and physicians are some of the most difficult to overcome largely because of the perceived hierarchal status of physicians and nurses’ perceived inability to exude the role of leader in the relationship (O’Daniel & Rosenstein, 2008). In order to overcome these professional relationship obstacles, nurses and physicians need opportunities to develop emotional intelligence (Lindeke & Sieckert, 2005). According to Segal and Smith (2016), when an individual’s possess emotional intelligence, daily interactions are pleasant and fulfilling because each party is able recognize the emotional state of themselves and each other, which aides in effective communication, problem solving, conflict resolution, and reduced stress. However, teaching someone emotional intelligence and social maturity is not an easy task to accomplish and could perhaps be a reason why a lack of interdisciplinary collaboration and teamwork continue to be a serious issue in healthcare today. Today, nursing educators need to be aware of the potential patient safety issues that can arise when the interdisciplinary team fails with collaboration, communication and coordination of care. The educational process is transforming to a learner-centered focus where the needs of individual students must be considered when teaching. This may require an educator to adjust the method of teaching to ensure each student is obtaining the knowledge, skills, and most importantly with the development of emotional intelligence. In the learner-centered environment, learning autonomy lies within the student, and the instructor takes on the role of facilitator and mentor in the learning process (Gunderman, Williamson, Frank, Heitkamp, & Kipfer, 2003). The relationship between the student and the instructor is collaborative so the emotional intelligence of the instructor can influence the beliefs and attitudes of the students in the early stages of the relationship (Lindeke & Block, 1998). Therefore, it is imperative that today’s nursing instructors lead by example, and influence the development of emotional intelligence in each and every student and staff member in the educational environment. Incorporation into Instructional Design, Assessment and EvaluationCollaboration, including interdisciplinary collaboration, and teamwork are vital components to safe and high quality patient care. However, the difference between individuals possessing the information on this concept and the ability to demonstrate compliance continues to be a struggle in today’s healthcare environment. Additionally, the implantation of the ACA has dramatically increased the number of individuals, especially those who are in poor health, to seek medical treatment where previously they would have delayed or avoided treatment (Sommers, Buchmueller, Decker, Carey, & Kronick, 2013). These changes, whether new or ongoing, validates the importance of nurses (and all members of the healthcare team) to demonstrate the ability to effectively collaborate with all disciplines of the healthcare team through proper communication, awareness of other’s knowledge, skills and abilities, and overall emotional intelligence. Both pre-licensure and graduate KSAs of the QSEN competency Teamwork and Collaboration were designated to assist nursing faculty members develop these attributes both nurses and nursing students (American Association of Colleges of Nursing: Advancing Higher Education in Nursing, 2016). Incorporating KSAs of Teamwork and Collaboration, while stressing how the changes in the healthcare environment effect patient care and safety, can be a challenge and even more difficult to assess and evaluate so they are often times avoided when building curricula. According to the American Association of Colleges of Nursing (AACN) (2016), socialization of nurses into the interprofessional team needs to occur early in the educational program (American Association of Colleges of Nursing: Advancing Higher Education in Nursing, 2016). Placing nursing students into a live clinical situation with physicians and other experienced individuals can be intimidating and perhaps create the opposite outcome that is desired from the experience. Research has shown that clinical training utilizing recorded high fidelity simulation in a lab type environment enables nurses to rehearse and eventually develop skills required for interdisciplinary collaboration and teamwork such as communication, transformational leadership and professional management of high stress situations (Lewis, Strachan, & Smith, 2012). Simulation provides an opportunity for participants, both as a team and as individuals, to evaluate the collaborative performance of the team in a clinical scenario during the debriefing or discussion session immediately following the simulation. Individual participants are able to reflect on their own personal actions and reactions without fear of harming a patient, punitive actions, or disruptive behavior (O’Daniel & Rosenstein, 2008). Research shows that a more accurate formative assessment of individual student performance by the instructor is possible following a recorded simulation exercise because the natural actions and reactions of the student are not influenced by the presence of the assessor (Imperial College London, 2013). Therefore, evaluation of the students KSAs for teamwork and collaboration competence has a better likelihood of real work performance success if simulation, especially interdisciplinary simulation, is utilized often during the educational program.Traditionally different disciplines in medicine, specifically physicians and nurses, operate under vastly different philosophies, principles and underlying values which are implemented during the educational process (Lindeke & Block, 1998). Simulation exercises that include physician and nurse participation enables both disciplines to share a learning experience in a safe environment where individual contribution and skills can be recognized and analyzed in a safe environment (Rhodes, 2016). By incorporating multidiscipline simulation exercises into current educational programs, especially in the early phases of education, interdisciplinary collaboration concepts and skills are more likely to achieve success when the participants are able to reflect on their performance and attitude in an environment where there is no direct impact on patient care. ConclusionRecent changes to the healthcare system and environment continues to effect quality and safety initiatives designed to reduce medical errors. Implantation of the ACA has given millions of Americans the financial means to access medical care creating an increased volume of patients seen every day. Although struggles with interdisciplinary teamwork and collaboration are not new to the United States Healthcare System, recent data has shown that medical errors continue to occur at an alarming rate. Nurse educators continue to search for methods to reinforce and evaluate the KSAs that are so vital for the success of a well-functioning interdisciplinary collaborate healthcare team. Research has shown that by incorporating interdisciplinary high fidelity simulation exercises into nursing curriculum, students are able to reflect on their own personal actions and reactions to stressful situations moving QSEN safety initiatives closer to success. ReferencesAmerican Association of Colleges of Nursing: Advancing Higher Education in Nursing. (2016). aacn.nche.eduAmerican healthcare education services [Database record]. (2013). Retrieved from . , K., & Glazer, G. (2013). Legislative: Interprofessional collaboration: What’s taking so long? The Online Journal of Issues in Nursing, 19(1). , C. M. (2009). Patient safety: One decade after To Err Is Human. Patient Safety & Quality Healthcare. Retrieved from , M. A., & Moore, S. M. (2013). 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Emotional intelligence (EQ): Key skills for raising emotional intelligence. Retrieved from , B. D., Buchmueller, T., Decker, S. L., Carey, C., & Kronick, R. (2013). The Affordable Care Act Has led to significant gains in health insurance and access to care for young adults. Health Affairs, 32(1), 165-174. . Department of Health and Human Services website. (2015). ................
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