A new nurse mentor program helps medical students learn the ropes.
From Penn Medicine, Summer 2012
By Sally Sapega
Like a deer in the headlights.
That’s how Stuart Carter, a student at the Perelman School of Medicine, described how he felt when he began his first clinical rotation at the Hospital of the University of Pennsylvania in early 2011. “It was scary, trying to navigate the system,” he said. “Especially Founders 14, which is a fast-moving, well-oiled machine.”
Enter Diana Santangelo, B.S.N., R.N., a clinical nurse who participates in a new program that focuses on interdisciplinary education and pairs nurses with medical students coming to clinical rotations. Remembering the fear that she felt on her first clinical rotation as a student nurse, Santangelo took the time to show Carter not only the ins and outs of the unit but also the important roles nurses play in patient care. Looking back, said Carter, “It was nice to have someone help ease my burden. Now I feel much more comfortable interacting with the nursing staff.”
To a great extent, the new program is an extension of Penn Medicine’s Unit-Based Clinical Leadership initiative, which began in 2007. The UBCLs are three-way partnerships that manage quality in the Health System’s hospital units, led by a physician leader, a nurse leader, and a project manager for quality. These interdisciplinary groups have demonstrated the immense benefits when health-care professionals work as a team instead of in side-by-side silos. The mentoring program brings them together as well, but at an earlier stage – and the results show great promise for the patients and for the professionals themselves.
Structuring the Program
Betty Ann Boczar, B.S.N., nurse manager of Founders 12 and 14 and one of the first nurse managers to implement the UBCL model, and Kate FitzPatrick, M.S.N., R.N., clinical director of Nursing Operations and Women’s Health at HUP, were brought into the mentoring program early in the planning process. Both credit Victoria Rich, Ph.D., chief nurse executive of UPMC, as “the visionary” who initiated the program with Stanley Goldfarb, M.D., associate dean for curriculum in the School of Medicine, as well as other medical school faculty members and administrators.
As Rich put it at a recent campus symposium on interprofessionalism, in programs like UBCL, “we role-model what we believe in.” In the past, she noted, there was sometimes insufficient trust among the hospital practitioners, and some professionals who worked side by side did not know each other’s expertise.
According to Goldfarb, “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. It’s two different worlds coming together.”
Input from groups of nurses and medical students helped shape the structure of the mentoring program, said Anna Delaney, chief administrative officer of academic programs at the School of Medicine. “We asked them, ‘What is it you don’t understand about each other? What has worked well and what hasn’t?’”
Based on the responses, “we developed a checklist of nursing actions that we felt were important for a medical student to see,” said Jennifer Kogan, M.D. ’95, associate professor of medicine. The actions included admitting and discharging patients, caring for wounds, and administering medications.
What Does a Nurse Do?
Although medical students receive classroom training in clinical areas, their knowledge about the flow of the hospital and how a patient unit works is often minimal. “Diana was the point person I could direct questions to,” said Stuart Carter. “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.”
In Santangelo’s view, the biggest surprise 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, B.S.N., nurse mentor on Founders 14. For example, when administering medication, “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, a Penn medical student who was in the mentor program. 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.”
As Asztalos learned, the nurse’s information can also help confirm findings. “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 serves as a mentor for his assigned medical student but will take others 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, said Villarreal, is finding a time when nurses are performing their patient-care activities and medical students are able 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 also found the timing to be a challenge. “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, M.D., associate director of the internal medicine clerkship.
Success Leads to Expansion
The mentor program recently won the Dean’s Award for Excellence in Medical Student Teaching by an Allied Health Professional, one of the School of Medicine’s annual teaching awards. According to the school, the program is “perhaps the only in the country” of its kind. Boczar and FitzPatrick received the award at the graduation ceremonies of the Perelman School of Medicine in May. Receiving the honor certainly has not stopped its leaders from trying to make the program even better. “It’s an ongoing process,” said Kogan. “We have to remain flexible and willing to make changes.”
Based on the positive response, Hamilton said that every student who does a rotation in internal medicine will now take part 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 floors devoted to general internal medicine. “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.”
J. Larry Jameson, M.D., Ph.D., dean of the Perelman School and executive vice president of the University of Pennsylvania for the Health System, lent support for initiatives like the mentoring program at the recent symposium on interprofessionalism. He began his welcoming remarks with what he thought would be a familiar story to some of members of the audience. He recounted his first night on call as a resident, acutely aware of what he didn’t know. When the nurse came to him and informed him that Mrs. Smith was having chest pains, he said, “I’ve read about this!” And when the nurse made a suggestion for the patient’s treatment, he said, “Great idea!” His own experience, he implied, supported a mentoring program that would better equip medical students and new residents, and he acknowledged the promising efforts of Boczar and FitzPatrick.
From Boczar’s perspective, there is certainly room for expansion. “Eventually we want to roll this program out throughout the Health System,” she said. “We’re already getting requests from the surgical units.”
As successful health care becomes increasingly dependent on teamwork, said Hamilton, “it’s crucial for medical students to understand the roles of other members of the team. When they graduate, they will be helping to lead these teams. It’s important to ‘grow up’ in this environment.”