Getting doctors and nurses to work together at patient bedsides
The structure of health care systems helps determine how doctors and nurses collaborate during hospital rounds, according to Penn State College of Medicine researchers. A greater understanding of such team-based treatment in hospitals could help improve patient care.
Collaboration among different types of health care professionals, like doctors and nurses, is good for patients because it provides greater communication, coordination of care and patient-centered decision making.
One way to promote this type of team-based care is by having a mix of providers visit hospital patients together, called "rounding." Although significant research has been conducted on bedside rounds, little has been done on interprofessional collaboration during these patient visits, said Jed D. Gonzalo, assistant professor of medicine and public health sciences, Penn State College of Medicine.
The limited existing research on the topic finds that the amount of interprofessional bedside care that goes on in hospital settings — such as internal medicine, pediatrics or intensive care — can vary widely, ranging from 1 to 80 percent. Until now, no study has looked at how frequent this practice is across a variety of units in a single hospital. Also, little data exists on what prompts bedside interprofessional rounds in hospital units.
Based on the benefits of collaborative care, Penn State Health Milton S. Hershey Medical Center conducted a hospital-wide initiative starting in 2012 to increase bedside interprofessional rounds. The goal was for at least 80 percent of patients at the hospital to receive collaborative care at their bedsides.
To determine how common bedside interprofessional rounds became following this effort, researchers from the College of Medicine analyzed data from nurses working in 18 of the hospital's units.
Of 29,173 patients treated in those units during the study period, 21,493 — 74 percent — received bedside interprofessional rounds.
The researchers also examined the factors associated with the shift toward collaborative care. They considered unit characteristics such as number of beds and square feet per bed; staffing characteristics, such as nurse-to-patient ratios; patient-level characteristics, such as length of stay; and nurses' perceptions of team collegiality and the use of scripts to guide bedside rounding.
Gonzalo and his team found several factors associated with greater incidence of bedside interprofessional rounds. Patients who were in the intensive care or intermediate care unit, or who were hospitalized for five or more days, were more likely to be seen by a nurse and a doctor together. These units generally have more nurses for every patient, Gonzalo said, increasing the likelihood of a nurse being available for bedside rounds when an attending physician sees patients. A longer hospital stay may also provide more opportunities for doctors and nurses to sync up when visiting patients, he added. It is also possible that patients with shorter stays may present cases that do not require as much collaborative care.
The use of scripts and nurses' perception of staff support for this type of team-based care was also linked to higher use of rounds.
Gonzalo, who is also associate dean for health systems education at the College of Medicine, said the study suggests that institutional and relationship factors drive collaborations between doctors and nurses. These "structural factors increase the odds of this process actually occurring," Gonzalo said. "When it comes to interprofessional collaborative care, structure drives behavior."
Rather than simply telling doctors to integrate nurses into their bedside rounds more frequently, hospital administrators must understand the underlying challenges and work to overcome them.
"My hope would be that we increasingly think about the structure of our systems rather than 100 percent of the time saying it's just about the people," Gonzalo said. "People are the operators, but they're operating in a system and how we design things matters. Better structural and process designs that are more conducive to collaboration and bringing providers together and patients together matter."
The study, recently published in the journal BMC Health Services Research, was itself an example of interprofessional collaboration, Gonzalo added, involving the internal medicine, nursing, quality and public health sciences departments.
Other researchers on this project were Judy Himes, chief nursing officer; Brian McGillen, hospitalist director, Division of General Internal Medicine; Vicki Shifflet, General Medicine Acute Care Unit; and Erik Lehman, Public Health Sciences.
The Penn State College of Medicine Department of Medicine funded this study.