A novel nurse-inteRN mentorship program to improve nurse-physician communication and teamwork in the emergency department

Abstract

Background

Communication between nurses and physicians is essential to providing patient care in the emergency department. The American College of Graduate Medical Education includes interpersonal and communication skills as one of six core competencies for residents. There is a known correlation between poor communication and negative patient outcomes. Yet, formalized training programs in doctor-nurse communication are lacking and literature reports that physicians may view collaboration as less important than nurses. To address this gap, we developed and implemented a novel, pilot “Nurse-InteRN Mentorship Program”. The program aimed to improve trainees’ communication with nurses and enhance emergency department collaboration. We then evaluated the impact of this program on participant perception of nurse-physician communication, efficacy and overall benefit.

Methods

We used Kern’s Six-step approach to develop and implement this program. We then evaluated the program’s impact with a pre-program and post-program 12-question survey to evaluate participation, perceived benefit, and efficacy of the program using a 1–5 Likert scale. Nurse vs. intern responses were compared using Fisher’s exact and Wilcoxon rank sum tests. Pre- and post- intervention responses were paired by respondent and compared using marginal homogeneity tests.

Results

13 interns and 22 nurses participated in the program. All 13 interns and 19 of 22 nurses completed the pre-program survey. 10 of 13 interns and 11 of 22 nurse mentors completed the post-program survey. Nurses showed greater interest in providing feedback on communication skills than interns showed in receiving feedback (p < 0.001). Interns rated themselves higher in communication skills with patients than nurses rated them (p = 0.004). Perceived benefit among nurses and interns decreased after completion of the program.

Conclusion

We were able to successfully implement a one-year nurse-intern mentorship program aiming to promote communication, collaboration and professional development. Our results show differing attitudes between nurses and interns around interns’ communication skills. There was some perceived benefit, but unfortunately this decreased over the course of the program. Further studies are needed to determine how this program impacts communication, teamwork, and patient care. We hope that given the novelty of such a nurse-intern mentorship program, this study may serve as a pilot for future programs.

Introduction

Providing excellent care in the high acuity emergency department requires trust and communication between nurses and physicians. There is a known correlation between poor communication and negative patient outcomes. In the Joint Commission’s 2022 report, miscommunication was the leading factor contributing to sentinel events [1]. Errors arising from miscommunication led to 210,000–440,000 US patient deaths in 2013 and are the second leading root cause of diagnostic errors in the emergency department (ED) [2, 3]. In addition, poor communication has been linked to decreased job satisfaction and burnout, further highlighting its importance in clinical medicine [4, 5].

The American College of Graduate Medical Education (ACGME) includes interpersonal and communication skills as one of six core competencies for residents. Formalized training programs for nurse-physician communication are lacking. A recent review found only four interventional studies that involved the implementation of educational programs to improve nurse-physician communication, most of which were initiated by nurses [6]. Two of these studies showed improved collaboration [7, 8]. Additionally, other investigations reported that physicians viewed collaboration as less important than nurses [9,10,11].

To address this gap, we created a novel, pilot Nurse-InteRN Mentorship program in our ED. The objectives of the program were to improve trainees’ communication and enhance collaboration with the ultimate goal of improving patient care. We evaluated the impact of this program on participant perception of communication skills, collaboration and perceived benefit.

Methods

We developed and implemented a novel, pilot year-long multidisciplinary “Nurse-InteRN Mentorship Program” at a large urban academic medical center, home to a three-year emergency medicine residency. We used Kern’s six-step approach as a conceptual framework for developing, implementing and evaluating our program [12] [Figure 1].

Fig. 1

Kern’s six step approach as applied to our novel nurse-intern mentorship program

We performed a literature review and discovered few publications on nurse-mentorship programs. Prior communication initiatives include interdisciplinary simulation and clinical rounds, communication curriculum and shadowing programs, all of which were perceived as beneficial [6]. We did not find reports of a mentorship program involving nurse mentors and intern mentees and no program has been described in emergency medicine. We also conducted a targeted needs assessment in our ED through discussions with nursing and residency leadership, residents and nurses. Initial feedback from all parties was that this program could be feasible and beneficial.

Participants in the program included all 13 emergency medicine interns and 22 nurse mentors. Participation was required of interns and voluntary among nurses and was only open to full-time nurses to guarantee enough overlap working together with their intern mentees. Interns were the target subjects as developing interprofessional communication skills early was thought to be an effective way of improving communication long-term. The pilot program spanned one academic year, July 2020 to June 2021. We introduced the program during orientation and assigned mentor-mentee pairings. All 13 interns were assigned one or two nurse mentors based on the number of nurses who volunteered to participate. Pairs were expected to meet at least quarterly in person or virtually. Nurses were expected to provide feedback on communication and teamwork skills. Beyond regularly scheduled meetings, pairs were expected to communicate to via text, phone, or method of their choice. We also held several group social events at local restaurants. The ultimate objectives of the program were to improve intern communication and teamwork skills, enhance departmental collaboration and ultimately improve patient care.

To assess the program, we developed a 12-question survey to evaluate participation, perceived benefit, and efficacy of the program based on best practices in educational research. Items included demographic information, interns’ performance in communication and teamwork, and perceived benefit of the program using a 1–5 Likert scale [Appendix] [13]. The survey was field tested by several education faculty and modified based on feedback. Institutional Review Board exemption was obtained. We administered the survey using Qualtrics, an online data collection platform, and distributed it via email including an anonymous link. The initial survey was administered at the beginning of the academic year prior to program participation. The follow-up survey asked the same questions at the end of the year after program completion.

Descriptive statistics were used to characterize the study population. Continuous data were reported as medians with interquartile ranges (IQR)s and categorical data was reported as counts with frequencies. Between-group comparisons were made using Fisher’s exact test for categorical or dichotomous data and Wilcoxon rank sum test for continuous data. In order to test the impact of the intervention, responses were paired by respondent and median scores were compared using marginal homogeneity tests. These analyses were stratified by intern vs. nurse. Analyses were performed using Stata 17.

Results

Table 1 Pre-program and Post-program Survey responses from nurse mentors and intern mentees

All 13 interns and 19 of 22 nurses (86%) completed the pre-program survey. Both groups preferred a combination of text/email/phone to communicate and preferred communication between nurses and physicians as a topic of interest. Most nurses (63%) listed feedback on performance of communications skills as a topic of most interest compared to zero interns (p < 0.001). When asked “How comfortable are you interacting with nurses/interns?,” more nurses than interns indicated a higher comfort level. When asked “How strong are interns’ communication skills with patients?,” interns rated themselves higher than nurses did (p = 0.004). Lastly, when asked “How often are you able to teach/share knowledge with nurses/interns?,” nurses reported they are able to teach/share knowledge more often than interns (p = 0.003). Full results are shown in Table 1.

Eleven of 22 nurse mentors and 10 of 13 interns completed the follow-up survey. Post-program, there was a statistically significant decrease in nurses’ and interns’ ratings on its benefit (nurses p = 0.016, interns p = 0.035), with a larger decrease in perceived benefit among interns compared to nurses. There was no significant improvement in ratings of interns’ communication and teamwork abilities.

Discussion

We successfully developed and implemented a novel, one-year pilot “Nurse-InteRN Mentorship Program.” Interestingly, nurses anticipated the program to be more beneficial pre-program and found it to be more beneficial post-program compared to interns. This is consistent with previous studies showing that nurses place higher value on physician-nurse collaboration compared to physicians [6, 14]. It is also important to note the statistically significant increased number of nurses compared to interns who selected “feedback on intern communication” as a topic of interest. Reasons for this discordance are unclear. Power dynamics, preassigned designation of mentor/mentee and prior experience may play a role. Different models of education may also account for this. Nurse training often emphasizes a narrative style of communication to relay information to physicians throughout the course of patient care to facilitate shared decision-making. Physician training emphasizes organized, succinct communication and focuses on development of technical skills, diagnosis and treatment [9, 15, 16]. Further investigation is warranted to explore this and other differing perspectives. Unfortunately, both groups found the program to be less beneficial after completion than anticipated. This may be due to inadequate structure, unclear expectations, nursing turnover, or increased burnout amidst the pandemic leading to decreased engagement [17]. Lastly, this pilot program was designed to be flexible, with participants meeting via varying platforms and frequencies. This does introduce several confounding factors that may have impacted results.

There are several limitations to this study. First, this was a single center pilot study conducted over one year with a small sample size of 13 interns and 22 nurses. Some interns had two mentors rather than one. This may have affected perceived impact of the program. Additionally, while the pre-program survey response rate was high, several participants, mostly nurses, were lost to follow-up. Most nurses were female, whereas interns included four female and nine males meaning gender discordance in several mentor/mentee pairs. This may have had an impact due to personal relationships, affection or conflict. A major limiting factor was the Covid-19 pandemic. This led to decreased opportunities for in-person meetings, nursing turnover, and difficulty for nurses and interns to get to know each other longitudinally, as well as a decreased post-program survey response rate due to turnover. Lastly, there are many confounding factors over the course of intern year that may also impact interns’ communication and collaboration skills making it difficult to determine how much impact is attributable to the intervention itself.

To improve upon this program for future years, we plan to increase structure with clear expectations of nurse-intern pairs. Survey feedback indicates quarterly meetings are most desired and feasible. We will have each pair meet quarterly and send reminder emails with outlined discussion topics for these meetings. We will make clear that feedback will be given to all involved parties in order to improve communication and help overcome the difference in attitudes we found. Lastly, given nurse turnover was a considerable limitation to our pilot program, we will select nurse mentors with longstanding history at the hospital at lower risk for leaving and implement a protocol to pair interns with a new mentor if their mentor leaves.

Conclusion

We were able to successfully implement a one-year nurse-intern mentorship program to promote mentorship, professional development and collaboration. Results showed a decrease in perceived benefit among nurses and interns after completion of the program. While this is unfortunate, results did show an interesting difference in attitudes around communication between nurses and interns and evidence that nurses are interested in providing feedback on communication to interns. This indicates that improving this intervention for future implementation may have benefit for enhancing the physician-nurse relationship. We plan for systematic improvement to the program based on initial feedback. Further studies are needed to determine how such a program impacts communication and teamwork skills or if there is any impact on patient care. We hope that given the novelty of such a nurse-intern mentorship program, this study may serve as a pilot for future programs.

Appendix: pre- and post-program survey questions

• 1. Age.

• 2. Gender.

• 3. How many years of prior experience do you have working as an RN (nurses)? –OR- in a clinical setting (EMT, scribe, CAN, etc.)? ***do not include nursing/medical school** (interns).

  0.

  1.

  2.

  3+.

• 4. (interns only) If you worked in a clinical role previously, what did you do for work?

• 5. How beneficial do you think a nurse/intern mentorship program will be to improving teamwork, communication, and camaraderie and knowledge in the emergency department?

  Not at all beneficial.

  Slightly beneficial.

  Moderately beneficial.

  Very beneficial.

  Extremely beneficial.

• 6. How often would you be interested in meeting with your mentor/mentee during the 2020–2021 academic year?

  a. fewer than 3 times.

  b. quarterly.

  c. monthly.

  d. more than once per month.

• 7. How would you like to communicate primarily with your nurse mentor/intern mentee outside of meeting in person (or via zoom)?

  a. email.

  b. text.

  c. phone.

  d. combination of all of the above.

• 8. What topics would you like to discuss with your nurse mentor/intern mentee? (select all that apply)

  a. communication between MDs and RNs.

  b. feedback on performance.

  c. clinical knowledge.

  d. clinical skills/procedural skills.

  e. life/interests/wellness.

• 9. How comfortable do you feel interacting with nurses/interns?

  1.very uncomfortable.

  2. slightly uncomfortable.

  3. neither uncomfortable nor comfortable.

  4. somewhat comfortable.

  5. very comfortable.

• 10. How strong do you feel your ability to work as a team with nurses/interns is?

  1. very weak.

  2. weak.

  3. neither strong nor weak.

  4. strong.

  5. very strong.

• 11. How strong do you feel interns’ communication skills with patients are?

  1. very weak.

  2. weak.

  3. neither strong nor weak.

  4. strong.

  5. very strong.

• 12. How often are you ale to teach/share knowledge with nurses/interns?

  1. never.

  2. rarely (a few times a year).

  3. sometimes (about once per month).

  4. often (about once per week).

  5. all the time (about every shift).