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University Gazette

The University of North Carolina at Chapel Hill

Collaborative class helps health-care students learn to lean on teams

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Kelly Scolaro, sets up a problem in the simulation lab as UNC health-care students huddle in the background at the School of Nursing.

Patients are in pain, machines are buzzing and alarms are going off. Families are upset, shifts are changing and information is quickly exchanged amid the chaos. It’s the kind of situation health professions often find themselves in, and one where medical errors easily can occur.

In “Interprofessional Teamwork and Communication: Keys to Patient Safety,” Carolina’s nursing, medical and pharmacy students are given a chance to practice how they’ll work as a team in clinical situations like this to keep patients from harm.

Through simulated patient settings, the students use mannequins and role-playing exercises as they learn to value the collective expertise of the different professions involved in patient care, said Carol Durham, clinical professor of nursing, who helps lead the class.

If that mutual respect gets lost in translation, it could be the patient who loses.

“It’s important that these students understand the prevalence of medical and health-care errors and that they have to be part of the solution,” Durham said. “Most of them will work in situations where they have someone from the other professions on their team, and it makes sense to have them rehearse that.”

Kelly Scolaro, director of the Pharmaceutical Care Laboratory at the Eshelman School of Pharmacy, and Benny Joyner, clinical assistant professor of pediatrics in the School of Medicine, join Durham in leading the class.

“We three have a passion about working together,” Durham said. “We’re modeling for the students the kinds of interactions they’ll have from the very first day of work.”

Learning by immersion

The first assignment isn’t graded. There’s a reason for that.

After an introduction on teamwork and collaboration, the students are put directly in a patient-care simulation with someone from each school on the team. Inevitably, Durham said, they approach the exercise individualistically as doctors, nurses and pharmacists.

“After the exercise, we ask them where the teamwork occurred, and it’s a real ‘a-ha’ moment for them. They’d listened, and they’d bought into it, so they wonder why they didn’t do it,” she said.

It’s in that moment where the students realize that knowing the roles of other health-care professionals and fully understanding what they contribute are two different things.

“The teamwork from the first simulation to the second is amazing in how the students have realized to trust each other, lean on each other and appreciate what the other does,” said Scolaro.

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Carol Durham looks on as student Katie Zachary evaluates a patient in the simulation lab.

Durham said physicians are seen as team leaders by default. While that’s often the right fit, she said, it’s important for everyone on the team to recognize when it isn’t.

“Our simulation exercises show that sometimes the pharmacist needs to be the lead because he or she knows more about the drug regimen. Sometimes the lead should be the nurse, who has been with the patient for 12 hours,” Durham said.

In one exercise, medical student Robert Wiggins had to disclose a medical error to a crying patient. He said the insight of the nurse and pharmacist in his group relieved some of the pressure.

“As a member of the medical community, I want to be a champion for patient safety and quality care,” he said. “After working with students from three different professions, I can now be a better member of the team because I understand the gifts and abilities that each profession brings to the table.”

Pharmacists, nurses and doctors are trained differently, not to make them adversaries, but to complement one another, Joyner said. The goal is that students go into clinical practice with the confidence that no matter who is in the lead, that person is part of a trusted team.

“The reality of medicine is that it’s not feasible for any one individual to do it all or know it all,” he said. “What it’s really going to come down to, as these different innovations in health care come out, is that you will have to rely on the quality of your team and how well they communicate.”

‘Giving a voice’ to team members

One of the most common times for a medical error to occur is during a patient hand-off, Durham said. It’s more likely an issue of poor communication than a lack of care.

“Key information is not transmitted, picked up and continued in the care of a patient,” she said.

Medication errors, failing to recognize when a patient is in distress and neglecting to involve patients and their families in the care are other ways in which patient safety can be compromised.

This is where pharmacists, doctors and nurses need to listen to one another, think before they speak and provide feedback. Often, to get there, they have to get past stereotypes, Durham said.

“The attending physician may know more about disease states, but the pharmacist will know more about drug interaction, and the nurse will know more about the patient’s hour-by-hour condition and responses to care,” Durham said.

In the class, students are trained with what Joyner calls CUS words. CUS is an acronym for “I am Concerned, I am Uncomfortable, and I feel it is a Safety issue.”

“This isn’t necessarily about who has the medical knowledge; it’s about how to speak,” he said. “How does the pharmacist or nurse get the physician’s attention? How can the physician come back to the nurse with a concern? CUS words take out the blame.”

If someone on your team doesn’t hear you the first time, Durham said, it’s important to realize they might not be ignoring you. “We’re teaching our students that they might not hear you or they may have competing priorities,” she explained.

The training also empowers students to prevent medical errors in current educational situations where they might be less likely to speak up.

“Students don’t necessarily want to speak out to the attending physician or pharmacist, or the charge nurse or preceptor, when they feel that they see something wrong,” Scolaro said. “This is giving students a voice that I don’t think they realized they had.”

Setting an example

The Carolina course is based on national standards that are part of accreditation and TeamSTEPPS (Team Strategies and Tools to Enhance Performance and Patient Safety), an evidence-based teamwork system designed for health-care professionals.

The course, which has been offered for four years, predates the Core Competencies for Interprofessional Collaborative Practice, said Scolaro. “We were ahead of the game,” she said.

Scolaro, Durham and Joyner team-teach the class with a level playing field. They use only their first names and encourage students to see themselves as equals with different strengths.

“Our common thread is that we recognize the value of simulation and real-world experiences over a passive didactic presentation of information,” Joyner said. “Our students see all of us in one place training them in such a way that’s going to be applicable to the real world in a year.”

Durham said she hoped the collaboration among the instructors set an example that reinforced the lessons of the simulation exercises.

“Many times practitioners go out feeling that the burden of care is totally on their shoulders, and we want to show them how sharing that burden helps,” she said.

Understanding that they have a team to share the burden of care is a powerful outcome of the class, she said. “Most importantly, we are equipping the students to be better positioned to improve the quality and safety of patient care.”