Doctors and nurses: We work as a team – why not train as a team?

Maria Delaney

Mr Lloyd is angry! His elderly mother is getting no treatment for her metastatic lung cancer, and he doesn’t want to hear what the doctors and nurses are saying…

…A different approach by a new face. They understand why he is angry. Their rationale make sense. His anger fades…

“What is happening now?” facilitator Anne Arber, cancer and palliative care lecturer at the University of Surrey, asks the participants. They are a mixture of oncology nurses and registrars, and have been asked give feedback on the method that their colleagues used to communicate to the relative. They are then asked to put themselves in the place of the patient’s son. Denial to acceptance. Anger to sadness. Suggestions come in from across the semi-circle of seats facing the mock consultation room.

The facilitator then turns to ‘Mr Lloyd’. “And is that how you feel?” Christopher Webber, an actor-facilitator who assumed the angry relative role twenty minutes before, answers in detail. His 25 years of experience enables him to immerse the nurse or doctor sitting opposite him in the interaction. He is acting, so that they don’t have to.

This communication skills session was part of the masterclasses in clinical oncology (ESO–ESMO), and oncology nursing (ESO–EONS), which took place jointly and in parallel in Switzerland in March. The participants come up with the role that the actor plays. Common themes are breaking bad news to a patient, dealing with an angry relative, and interacting with a difficult colleague.

This sort of multiprofessional training works well for communication skills, according to Andrew Hoy, retired UK-based palliative medicine physician, who facilitated a session at the same time as Arber. “Although some of the detail may be different for different professional groups, the generality of skills and attributes is much the same,” he says, adding that, “the professional groups learn from each other.”

Instead of ‘Mr Lloyd’, the participants in Hoy’s session were interacting with ‘Mrs Jones’, a cancer patient, played by actor Debbie Manship. She agrees with Hoy. “Because it is communication- skills based, the difficulties for the participants, regardless of what their profession is, are very often common,” she explains.

Lena Sharp, president elect of the European Oncology Nurses Society (EONS), and co-chair of the nursing masterclass is a big believer in interprofessional learning – the term used, she says, to describe two or more professions learning with and from each other. Interaction is key, she explains. “It’s not sharing the same lecture room. That’s not enough.”

Sharp feels that it’s an issue in healthcare that, once you finish your education, you’re supposed to be very good at interprofessional communication, despite not having been educated together. It’s a real problem, she says, and she would like to see more interprofessional training developed.

The concept is not a new one. The WHO first identified interprofessional education as an important component of primary healthcare as far back as 1978, and issued its technical report on this subject in 1988.

The report made a number of recom-mendations, including that communication between health professionals at all levels should be encouraged and improved, and continuous joint in-service training should be provided for all members of the health team, with a view to strengthening the team approach in the field.

“I’ve seen progress but it’s too slow,” says Sharp, who adds that only a few universities have developed medical education that encompasses interprofessional learning. When it is added, it is often voluntary or only a small part of the curriculum, she says.

This fact is evident in the ESO oncology masterclass. It is the first time that many of the doctors and nurses have trained with other professions, despite years of medical training. “It’s not a common practice. I’ve only seen it here,” says Cypriot nurse participant Loizos Hadjulois. He feels that it should be more common because they are part of the same team and need to cooperate all the time. “But for some reason, we don’t train together.”

“It was useful in the communication skills session to get input from the nurses,” says English oncologist participant Michael Davidson. He believes that there is scope in medical school to include other professions.

Benefits of interprofessional education

The WHO advocates interprofessional development to improve the education of health professionals and consequently health outcomes.
WHOIts 2010 report, Framework for Action on Interprofessional Education and Collaborative Practice 2010, identifies key benefits accruing from health professionals learning together. It also presents strategies and ideas that have been designed to help health policy makers implement the elements of interprofessional education and collaborative practice that are likely to be most appropriate for their particular setting.

Educational benefits

□ Students have real world experience and insight
□ Sta from a range of professions provide input into programme development
□ Students learn about the work of other practitioners

Health policy benefits
□ Improved workplace practices and productivity
□ Improved patient outcomes
□ Raised staff morale
□ Improved patient safety
□ Better access to healthcare

Source: WHO Framework for Action on Interprofessional Education and Collaborative Practice 2010 (www.who.int/hrh/resources/framework_action/en/)

ESO’s Scientific Director, Fedro Peccatori, says the ‘silo culture’ in oncology, and other specialties, where “the doctor is the doctor, the pharmacist is the pharmacist, the nurse is the nurse” needs to be changed. He argues that, from the last year of medical school, “it would be best to have the notion and the idea that multi-professionality is the way that medicine is going.”

A specialist in women’s cancers, Peccatori feels that, while the practice of medicine has changed dramatically over the past few decades, and there is a strong feeling in the medical community that integration is a positive thing, much more progress is needed in this area. “The knowledge and capabilities are there, but the integration is still something that happens in some [areas] but not everywhere,” he says.

Ahead of the field

One university in southern Sweden embraced interprofessional learning thirty years ago. The dean of the Linköping medical faculty was inspired by a WHO conference where he learnt about multiprofessional education, as they called it then. The different professions in the department began working with each other, and it was integrated into the curriculum in 1986. Tomas Faresjö, professor in the Department of Medical and Health Sciences at Linköping University, explains that they made the change, “because the challenge for future healthcare needs cooperation between disciplines and occupations.”

Faresjö distinguishes between what they do, and ‘multiprofessional education’, which he defines as different professions attending a course or lecture together, and is, he says, quite common. “We decided that we should have more integration, and that’s why we call it ‘interprofessional education’.”

Each group has three weeks to identify a quality improvement
in healthcare, in a challenge set by clinics
in primary care or at the university hospital.

The interprofessional education of undergraduates is divided into three stages. In each of these, all professions in the medical department work together. This includes medics, nurses, physiotherapists, occupational therapists, and biomedical science students.

“In the first semester, 30 years ago, we devoted a lot of time,” says Faresjö. All students in the medical department attended courses together for 10 weeks. “We’re breaking down borders early, and I think that’s important.”

The department then decided that more shared learning was required further into the undergraduate education. After two years, the professions once again work together. This time as part of a base group of eight students and one tutor.

Each group has three weeks to identify a quality improvement in healthcare, in a challenge set by clinics in primary care or at the university hospital. “What is interesting is that they go very quickly into their roles and work together in teams,” says Faresjö, who is a tutor on these challenges.

Finally, at the end of their time as undergraduates, they move onto a training ward, where they practice working together professionally, as a team, with supervisors. “They are responsible for finding their own roles in the team, for example supporting elderly people in the orthopaedic clinic,” says Faresjö. He proudly reports that they were the first in the world to start this programme of clinical wards for student training.

Sharp has been to Linköping and says that she can see a difference in the hospital. “This is impacting healthcare a lot, because you don’t have the strong hierarchical structures [in Linköping] that you have in other hospitals,” explains the nurse trainer. This is because the staff train together, she says, so they know the competencies of the other groups, which improves collaboration.

“If you can educate people early on in their training, then it’s natural,” says Sharp. She adds that there are traces of this type of education in other universities in Sweden, but Linköping is the only university to do it so systematically.

Oncology education

Shared training can be seen in action at the ESO oncology masterclass. Here the two professions work together during interactive interprofessional sessions such as communication training, and they also share many lectures. They are trained separately for more technical sessions, which are geared towards either doctors or nurses.

Team work. Doctors and nurses discuss how to handle difficult conversations with patients, relatives or colleagues, after watching a role play at the ESO masterclass
Team work. Doctors and nurses discuss how to handle difficult conversations with patients, relatives or colleagues, after watching a role play at the ESO masterclass

This method is also used by the École de Formation en Cancérologie (EFEC), which offers training to healthcare professionals caring for patients with cancer in France.

The majority of their courses are interprofessional. These include courses related to supportive care – nutrition and cancer, sexuality and cancer, fatigue and cancer, psychological social and intercultural aspects of care, palliative care – as well as communication skills and organisation of supportive care. Other courses are aimed at a single profession, because the learning outcomes are different and specific to that profession.

For some courses which address the organisational aspect of care, such as setting up the patient pathway, it is strongly recommended that two healthcare professionals from the same hospital but different professions attend the course, according to Françoise Charnay-Sonnek, president of the European Specialist Nurses Organisation (ESNO) and education head of the EFEC School for Continuing Training, specialising in cancer. She explains that this is because the aim of the course is to facilitate the implementation of the new organisation in the hospital.

Charnay-Sonnek says that it is difficult to attract doctors to these interprofessional courses, as three days may be too long for physicians, and some of them can be a little reluctant to be mixed with nurses. She adds, however, that when they do attend, their feedback is very positive, as this kind of course offers them the opportunity to get know other professions and be more open to listening to them. Doctors and nurses have a very rich experience, says Charnay-Sonnek. “They gain knowledge, and can exchange tips and tricks.”

The school runs courses in setting up patient pathways, and learning from error. For these, doctors, nurses and other healthcare professionals attend from the same hospital. Charnay-Sonnek says that when participants are out of the hospital and in the training venue, they are much more open to listening to other professions.

Sharp argues that subjects such as communication, safety, ethics, and some disease topics can be adapted well to shared training. “You can’t say that safety is the responsibility of one profession – it’s everybody’s,” she says.

To encourage different professions to interact, she suggests a method called the ‘flipped classroom’, where a student or participant presents to their peers. Case methodology is a good way of doing this, she says.

Peccatori agrees. Case presentations are currently done by each profession separately at the ESO masterclass. However, he feels that, when discussing a case, “there are some nuances that you can only get if you have a multiprofessional discussion.”

Challenging hierarchies

Routine evaluation of the impact of interprofessional education on health outcomes and service delivery are rare. However, a WHO questionnaire that elicited almost 400 responses from 42 countries, highlighted a number of benefits (see box on top). These include raised staff morale, improved patient outcomes, and students having real-world insight.

The Linköping way. Interprofessional learning is built in to the curriculum of this Swedish teaching hospital, fostering mutual respect and breaking down hierarchies
The Linköping way. Interprofessional learning is built in to the curriculum of this Swedish teaching hospital, fostering mutual respect and breaking down hierarchies

This questionnaire was part of a 2010 follow-up report, the Framework for Action on Interprofessional Education and Collaborative Practice. The WHO report identifies interprofessional collaboration in education and practice as an innovative strategy that will play an important role in mitigating the global health workforce crisis.

Hoy, who facilitates communication sessions, cites another benefit: removal of status differences between the professions. Hoy believes that “it’s a great mistake to feel that some healthcare professionals are intrinsically lower status than others.” Shared education, he says, is one of the ways around this.

Sharp knows people in management positions
who say they will not question doctors directly

Lack of confidence, especially among nurses, is a big issue, says actor-facilitator Webber. When people are empowered to stand up independently, and come out with an opinion in a role play situation, he says, “You quite often see a bit of light dawning in people’s minds.”

Being unable to speak up can be tackled through shared training, says Sharp, who knows people in management positions who say they will not question doctors directly. “That is really important to lift… especially in healthcare, when we are handling life or death situations.”

Improvements in self-confidence and perception have been shown in a small study of medical and nursing students who participated in a three-hour interprofessional learning session (Nurse Educ Today 2014, 34:259–64). Separate research (J Hosp Med 2014, 9:189–92) has also shown that it improves knowledge and teamwork.

There are also many challenges faced by those implementing or teaching interprofessional education. The main one is the attitude of both doctors and nurses, says Sharp.

In France, you still have physicians who feel superior to nurses, according to Charnay-Sonnek, who says that some doctors prefer not to train with nurses, but those who do “are always very happy, and come back with new ideas… not only knowledge, but also a new multiprofessional vision in all of their care.”

Retired doctor, Hoy, believes senior professionals, particularly doctors, may feel more inhibited if other professionals are present during training. “They take some comfort from a uni-professional group,” he explains, but he thinks this attitude is quite rare.

When facilitating groups with more than one profession, he says, it’s important to be as inclusive as possible to encourage the quieter members to contribute. Erika Juhlin, a nurse participant from Sweden, said that she would have preferred it if there was one case for nurses and one for doctors, because they often had different perspectives. She thinks it would be a learning experience for the doctors to see how her nurse colleagues would handle it, “because they are rarely in the room together with a nurse and a patient without being in control of the conversation.”

Making the change

Many points voiced about interprofessional learning by the participants of the ESO masterclass agreed on one thing – that more time was needed so that all participants from all professions got the opportunity to contribute, and voice their opinion.

Despite providing many weeks of interprofessional training,
Linköping came out best in Sweden in every type of test

Securing enough time for interprofessional education is a challenge the medical department in Linköping had to address from the very beginning. “The main criticism is that you’re taking a lot of time from the normal curriculum, especially for medical students,” says Faresjö.

He looks to national evaluations to prove the critics wrong. Despite providing many weeks of interprofessional training, he says that Linköping came out best in Sweden in every type of test. “That speaks for itself. It can’t be true that we are taking a lot of knowledge away from the normal curriculum, and [the students] get less education,” says Faresjö, who argues that the reverse is true. “They get more education.”

So where could a medical department start? Boundaries within the department need to be broken down, according to Faresjö, as every faculty within the department has its own system of education which, “like a guardian, they want to protect.” This often means starting from the beginning with a new curriculum, rather than trying to add time slots into an already full schedule.

Most medical faculties might say that they can’t devote a day, perhaps only an afternoon, warns Faresjö, when asked about barriers to implementation. In order to get around such obstacles, he recommends looking at existing subjects that could be integrated.

The communication training at the ESO masterclass was first given just to oncology nurses. “It was quite provocative to even suggest that we do the communication skills together,” says Sharp. “When we first raised it, we were met with, not resistance, but questions: Could we really do that? Can we really mix these two groups?” Sharp said that these queries were answered when some of the doctors observed the nurse-only session. The mixed session is now in its third year.

“In oncology, this masterclass is important because we are getting further and further,” explains Sharp, who welcomes the advances in interprofessional learning being made each year, and says that they need to keep pushing forward with it.

Though some progress has been made across the world, there is still much to do to achieve the goals that the WHO recommended almost thirty years ago. Peccatori, who is in charge of shaping ESO’s educational programme, says that “innovation in education is really difficult to achieve in a short time, and it takes almost a generation to do that, but it is changing.”

Awareness of the problem is key, according to Peccatori. “If there is more awareness of the need for integration between the different professionals, I think that this will become easy to implement.”

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