Interdisciplinary collaboration, patient education

The importance of interdisciplinary involvement by the total health care team is central to effective patient care and is an area of JCAHO focus. Although some agencies have achieve excellent interdisciplinary collaboration, lack of communication among disciplines often creates barriers. Inadequate communication can lead to disagreements over “turf” and an inability to collaborate, both between individuals and in team conferences. Patients are often baffled by various team members who repeat instructions already taught by someone else. The need to move patients through the health care system in an effective and cost-effective way means that nurses and other health care professionals must learn ways of providing patient teaching collaboratively.

Because of nursing’s continuous and visible presence at the patient’s side, nurses are in the unique position to provide leadership for patient education and to capitalize on the strengths of each discipline for the patient’s ultimate benefit. Understanding the significant contributions that other health care professionals can make to patient teaching is an important part of the nurse’s knowledge base. To do this, the nurse needs an accurate understanding of the expertise of each member of the team.

Physicians help patients understand the health care problem and the treatment plan. Physicians report that they depend on nurses to help reinforce the teaching they do. Nurses are often asked follow up questions by patients and families, especially when physician explanations are not in terms the patient understands or when patients and families have additional questions. Collaboration with physicians increases with good communication and effective documentation. Physical therapists teach patients and families about mobility and how to perform functional activities safely. Occupational therapy teaching focuses on how to make adaptations that enable patients to be as independent as possible in activities of daily living. Physical and occupational therapists depend on nurses to educate patients about their disease condition and to reinforce instructions they give, particularly regarding carrying through with positioning, transfers, and the use of adaptive devices. Nurses’ active participation in formal team meetings and informal meetings on patient units or by telephone maximizes the contributions of both disciplines. Dietitians teach patients and families about therapeutic diets. They assess the patient’s usual dietary patterns and plan with the patient and family how the customary diet can be modified to achieve health management goals. Dieticians depend on nurses to reinforce the importance of following the dietary plan and providing feedback about patient participation. Pharmacists teach patients how drugs work in their bodies, what the medications are for, why it’s important to take them, how to store them, and how to avoid drug interactions with other medications and food. Pharmacists often depend on nurses to reinforce information they have given patients. Social workers serve as an important liaison between the hospital staff and the community. Social workers coordinate referrals to many different agencies and resources, and provide emotional support to patients and families. The efforts of social workers are maximized when nurses are able to provide specific information about the patient’s home situation.

In well-functioning interdisciplinary teams, team members view nurses as their “eyes and ears”- to provide feedback about patient participation, to share information that may help team members plan and adjust goals, and to reinforce and follow through with teaching they have provided. In turn, nurse members of top performing teams communicate superbly, both orally and in writing. They keep communication channels open, are active participants in team conferences, and provide excellent and current progress notes about patient teaching results so that other team members are kept continuously informed. Effective teams often cite specific characteristics that allow them to work well together. Some of the characteristics of effective interdisciplinary teams include:

  • Good communication, both verbal and written, facilitated by planning meetings, patient care conferences, telephone consultation, good documentation, and the willingness to go “out of the way” to make sure communication takes place
  • Mutual respect among disciplines, recognizing respective areas of expertise, knowing one’s limits, and teaching each other
  • A desire to work as a team and recognition of a common goal

What does the future hold?