A Deliberate Strategy

AN ADVOCATE FOR COLLABORATIVE INTENTIONALITY, DR MARIE MORRIS’ WORK IS FOCUSED ON THE EMPOWERMENT OF MULTIDISCIPLINARY TEAMS r Marie Morris PhD, Senior Lecturer in Postgraduate Surgical Education, RCSI has over 35 years’ experience in health sciences, holding both clinical and education posts. e focus of Dr Morris’ work for many years has been on interdisciplinary team collaboration and she is an advocate for collaborative intentionality, the empowering of teams by instilling a mindset of deliberately seeking out collaboration.

For the rst half of her career she worked in acute and critical care as a clinical nurse specialist and postgraduate nurse educator in the UK. She then moved into undergraduate medical education in Ireland. A er over a decade of teaching undergraduate medical students, she completed a PhD in Surgical Education and led the masters degree in Surgical Science and Practice at RCSI Dublin in collaboration with the Programme Director, Professor Oscar Traynor.

“When I was working in intensive care,” says Dr Morris, “I noticed that the junior doctors starting their jobs were like ducks out of water. ere’s no doubt that anyone nishing a medical degree has expertise in medical information, but what was missing was translational transferability. Medical school didn’t teach them how to be a doctor. ey had a head full of knowledge of respiratory disease and how to do a respiratory assessment and how to read arterial blood gases, but at two o’clock in the morning when they were standing in front of Mr O’Brien in acute respiratory distress they would freeze because suddenly they had to pull all this information together and do something fast. Observing this gap between the young doctors’ academic learning and how they were poorly prepared for stressful clinical situations, I set up an outreach programme where the senior nurses in intensive care started teaching and supporting the junior doctors in relation to the step down of ICU patients. I am a strong advocate for senior nurses crossing traditional hierarchical boundaries to share their expertise with junior doctors to ensure patient safety.”

On returning to Ireland, Dr Morris considered postgraduate entry to medicine but felt that she could make more of an impact by bringing her experience as a senior nurse into undergraduate medical education by reforming the medical curriculum to improve junior doctors’ preparation for clinical practice. A er a masters in Clinical Medicine in Trinity College Dublin, she was appointed to lead the undergraduate clinical skills programme in the School of Medicine there.

“I could see very quickly that what was missing was communication skills training. We know from all the human factors literature that doctors are generally very well trained, and don’t tend to make technical errors, but that major errors generally result from a breakdown in communication. My masters thesis therefore focused on the design and implementation of an undergraduate curriculum on communication skills training and assessment.

“I always feel that we train medical students as if they are only children. e system in medical school whereby medals and the choice of internships goes to those who perform best in exams makes them highly competitive, so that their peers are their competition, not their support network. And then we put them through an internship, and it’s as if mummy and daddy have suddenly adopted four children – a nurse, a physiotherapist, a pharmacist, and an dietician – and we tell them to go and play nicely. ey are suddenly expected to communicate and collaborate and become part of a ‘team’ with unfamiliar people, unsure of the exact roles and scope of knowledge of other disciplines.”

Dr Morris believes that training doctors and surgeons in isolation is wrong, and may lead to poorer outcomes for patients.

“Patient care is like a jigsaw or puzzle. As the junior medical/surgical person in the team, the doctor generally has the most pieces of the puzzle, but they won’t nish the puzzle properly if they don’t have a piece from the nurse, the physiotherapist, the pharmacist and the dietitian. And where they don’t get all those pieces to make the big picture, that’s where error happens and the patient su ers.”

Dr Morris designed and introduced a simulation-based module to her undergraduate teaching of clinical skills, so senior medical students could rst learn and come to understand their strengths and limitations in a psychologically safe environment.

“ ey need to know when to ask for help. To learn that even if it feels really uncomfortable, and even if the other person on the end of the phone says you should know the answer, their responsibility is to the patient and also to themselves is to ask for help early.”

When Dr Morris took up the role of leading the new masters degree in Surgical Science and Practice at RCSI in 2019, e ectively a one-year simulated intern job, it was an opportunity to introduce the missing interdisciplinary dimension to medical education and to implement a totally new way of doing things. In collaboration with Professor Walter Eppich, Chair, RCSI SIM Centre, she explored ways of promoting collaborative intentionality into simulation-based education.

With the support of the simulation team in 26 York Street, the students had their theatre practice, ward rounds and clinics, they undertook a simulated clinical post in a psychologically safe and supervised setting.

It was the optimal opportunity for instilling a mindset of intentional, deliberate interdisciplinary collaboration: “I reached out to the Schools of Physiotherapy, Pharmacy and Nursing and we worked together, taking a top down and bottom up approach. I wanted to instil the concept of deliberately, intentionally communicating and collaborating outside your own discipline into all the students. e support and involvement of cardiac surgeon consultant, Mr Simon MacGowan, legitimised the importance of and the essential contribution other disciplines make to clinical decision making and safe patient care.”

Each cohort of students shared the responsibilities of their role, so each group could better understand the other disciplines – learning with, from and about each other. ey were then placed in multidisciplinary groups. When they went to meet simulated patients, they observed each other take histories to gain a better understanding of the information required by each discipline. As a team they wrote up each case, and presented it to the consultant and received feedback from their discipline faculty.

“ e intention was to build a community of interdisciplinary learners,” explains Dr Morris. “ ey went to co ee together, stayed together and didn’t silo o into their own disciplines. It worked out very well in terms of starting to instil a new mindset or cultural change. It’s going to take time, but it’s about re-iterating to all disciplines that they each have accountability for patient safety and that by working together in collaboration they will achieve better outcomes for their patients, something they all obviously care deeply about as healthcare professionals.”

Feedback from the doctors revealed that, before commencing the masters, they had underestimated how much knowledge the nurses had, and they also observed that in terms of discharge planning, if on Day 1 they had collaborated with a pharmacist and physiotherapist for their input, the patient probably would have gone home a lot sooner. Scholars of the programme have reported meeting physiotherapists and pharmacists in clinical posts since their training and are continuing their interdisciplinary collaboration in the workplace.

“ ey got to see the dynamics of the whole team in action,” explains Dr Morris. “And from the systematic review we published, we saw that nurses sometimes struggle to cross a traditional professional boundary and speak up either because it feels intimidating or unsafe. So we designed scenarios around courageous conversations to promote traditional boundary crossing to share discipline speci c expertise within the team. e development of advanced nurse practitioner roles also helps with the challenging of traditional boundaries.”

Simulated nights on call were part of the award-winning masters programme, with senior nurses from Dublin hospitals working unscripted as they would on an actual night shi .

“ is was really powerful learning,” says Dr Morris. “ e doctors reported the sense of being alone and isolated was petrifying. It was just them, the patient and the nurse, and they said that without the nurse, they wouldn’t have known what to do. ey just were lost. e exercise promoted nurses to be their authentic selves, step into their power and cross traditional boundaries for the better good, share their expert discipline knowledge to support their doctor and suggest when to escalate to senior sta in order to keep their patients safe.” e masters programme is now paused as Dr Morris and her colleagues evaluate everything they have learned, to prepare to deliver this programme using a hybrid approach, and to explore how it could be integrated into the undergraduate curriculum.

“ e dream for me would be that from the start of health science education we train every discipline together as much as feasible. We instil a mindset of collaborative intentionality and build up this community of interdisciplinary learners. From this training, the professional identity of an inclusive team member can then be fostered to transfer into the clinical workplace. is team approach and mutual respect for one another then contributes to the best care of the patient.” ■

The Power Of Interdisciplinary Surgical Ward Rounds

Limited yet encouraging evidence in the literature points to the positive effects of interdisciplinary surgical ward rounds on behaviour change, organisational practice and patient bene ts. The evidence from medical rounds suggests that this form of clinical practice can improve collaborative attitudes, perceptions, knowledge, and skills. Many healthcare disciplines support the bene ts of interdisciplinary surgical ward rounds to improve communication, collaboration and patient safety, however logistical and nancial barriers restrict planning and implementation.

Future research should focus on key aims as follows:

• to establish an evidence-based clinical and educational model for designing and implementing interdisciplinary surgical ward rounds to support clinicians and ensure patient safety; and

• to prioritise addressing the barriers in surgical rounds through implementation of deliberate interdisciplinary collaborative training to ensure the mandated clinical competencies and capabilities are achieved.

Research Findings

• Longstanding structures, with doctors teaching doctors and nurses teaching nurses, hamper learning across professional boundaries.

• Boundary-crossing between CoHP (Community of Healthcare Practitioners) represents particularly fertile ground for learning through occasional forays either across borders or through membership of two or more communities.

• Collaborative intentionality requires deliberate connectedness and thoughtful collaboration through adaptation, exibility and tolerance from all team members.

• We advocate for early introduction of a boundary-crossing approach in health professional education (HPE) to promote collaborative intentionality and deliberate team engagement.

• Cross-Professional Educators (CPEs), such as nurses teaching in medical schools, are uniquely positioned to challenge uni-professional siloed approaches to HPE and atten hierarchies.

M Morris, C Mulhall, PJ Murphy and WJ Eppich, ‘Interdisciplinary collaborative working on surgical ward rounds: reality or rhetoric?

A systematic review’, Journal of Interprofessional Care, 2022. DOI: 10.1080/13561820.2022.2115023.

To link to this article: https://doi.org/10.1080/13561820.2022.2115023