A deer in the headlights.
That’s how Stuart Carter, a MS3 student at the Perelman School of Medicine, described feeling when he began his first clinical rotation at HUP in early 2011. “It was scary, trying to navigate the system ... especially Founders 14, which is a fast moving, well-oiled machine,” he recalled.
In a sense, this new program is an extension of Penn Medicine’s unit-based clinical leadership. These interdisciplinary groups have demonstrated the immense benefits of health-care professionals working as a team instead of in side-by-side silos. The mentoring program brings them together as well but at an earlier stage … and it’s a win-win situation for everyone.
Betty Ann Boczar, BSN, nurse manager of Founders 12 and 14, and Kate FitzPatrick, MSN, RN, clinical director, Nursing Operations and Women’s Health, were brought into this program early in the planning process but both credit Victoria Rich, PhD, chief nurse executive, UPMC, as “the visionary” who kick-started the initiative with Stanley Goldfarb, MD, associate dean for Curriculum, and other medical school faculty and administration.
“Medical students had no idea of the various roles of nurses, and nurses didn’t know how much the students knew – what their background would allow them to do,” Goldfarb said. “It’s two different worlds coming together.”
Input from groups of nurses and med students helped shape the structure of the mentoring program, said Anna Delaney, chief administration officer of Academic Programs. “We asked them, ‘What is it you don’t understand about each other? What has worked well and what hasn’t?’”
From that feedback, “we developed a checklist of nursing actions that we felt were important for a medical student to see,” said Jennifer Kogan, MD, of Internal Medicine. This included patient admission and discharge, wound care, medication administration, and the nurse-to-nurse shift report.
What Does a Nurse Do?
Medical students receive classroom training in clinical areas, but their knowledge about the flow of the hospital and how a patient unit works is minimal. “Diana was the point person I could direct questions to,” Carter said. “She showed me the structure of the floor, the different roles of nurses, support staff.… I had a much better perception of who to go to for answers and as a result I was a more helpful med --student.”
The biggest surprise, Santangelo said, was how little medical students seem to know about the role of the nurse in patient care. “Sometimes I feel like they think things magically happen!” she said, laughing. “I tell them, ‘These are the steps we have to do to prepare for a discharge … so be nice to me when you’re an intern and I call you 15 times!’”
“The process from the doctor typing an order into the computer to its execution is like an algebra equation; many factors play into it,” explained Ian Villarreal, BSN, nurse mentor on Founders 14. For example, for medication administration, “we have to know ‘Can the patient swallow? If there are two meds, are they compatible?’ ... There are a lot of subtleties to be learned.”
A Treasure Trove of Information
Wound care on a patient with diabetic foot ulcers. Pulling together information for a patient discharge. “These are things you never see when you’re with a resident or attending,” said Ivor Asztalos, second-year medical student at Penn. But, what’s even better, he said, is knowing where all that information is charted online. “It’s a treasure trove of information. And it’s not only great information but there’s also electronic charting for information that’s frequently difficult to acquire, like a patient’s daily intakes and outtakes or weights.”
The nurse’s information can also help confirm findings, Asztalos said. “Pre-rounds with residents are directed at information pertinent to the organ systems involved. For example, if it’s a heart patient, we look for edema, check the heart and lungs. But nurses do a head-to-toe assessment every day,” he said. “This information can help confirm a finding but the average med student may not know this information even exists … or how to find it.”
Asztalos also learned about the Navicare tracking system. “If patients aren’t in the room, where are they? With Navicare I know if a patient is in transit, on the way back.… I don’t have to waste time trying to find out.”
Villarreal mentors his assigned med student but will take other students under his wing when he’s tackling one of the checklist items. “I just call out, ‘Hey, want to watch an interesting wound change?’ and two or three eager students will follow me.”
The biggest challenge, he said, is finding a time when nurses are performing their patient-care activities and med students have the time to watch. “We’re hoping to get a day where a med student will only shadow you – no other responsibilities. Right now we try to grab them when we’re doing something on the checklist but they’re not always available.”
Others in the program have found the timing to be a challenge as well. “We’re going to recommend that time be set aside on all mentoring units so students can spend several hours with their mentor,” said Keith Hamilton, MD, associate director of the Internal Medicine Clerkship.
Success Leads to Expansion
The mentorship program recently won the Dean’s Award for Excellence in Medical Student Teaching by an Allied Health Professional but this is not stopping its leadership from making it even better. “It’s is an ongoing process,” Kogan said. “We have to remain flexible and willing to make changes.” Boczar and FitzPatrick will receive the award at the Perelman School of Medicine commencement next month.
Based on the positive feedback, Hamilton said that every student who does a rotation in internal medicine will now participate in this interdisciplinary process. Since the program was piloted last year on Founders 12 and 14, it has expanded to include Founders 8 (the CCU) and Labor & Delivery, as well as the Acute Care for Elders unit at Penn Presbyterian and one of its general internal medicine floors. “Each unit we choose brings something unique to the table,” Hamilton said. “For example, CCU nurses have expertise in reading telemetry, and the ACE unit demonstrates the nuances in caring for the elderly.”
“Eventually we want to roll this program out throughout the Health System,” Boczar said. “We’re already getting requests from the surgical units.”
“Now that health care is a team sport, it’s crucial for medical students to understand the roles of other members of the team,” Hamilton said. “When they graduate, they will be helping to lead these teams. It’s important to ‘grow up’ in this environment.”