Teaching and Learning in Nursing (2011) 6, 97–101

www.jtln.org

Developing interprofessional communication skills1

Janet Wagner RN, PhD a,⁎, Beth Liston MD, PhD b , Jackie Miller RN, c-OB, MS c
a
Columbus State Community College, P.O. Box 1609, Columbus, OH 43216, USA
b
Departments of Internal Medicine and Pediatrics, The Ohio State University College of Medicine, Columbus, OH 43210, USA
c
Columbus State Community College, Columbus, OH 43216, USA

KEYWORDS: Abstract Interprofessional collaboration is a key component to patient safety and health profession
Interprofessional education. This article will describe the development and implementation of a pilot educational teaching/
education; learning simulation exercise designed to promote teamwork and collaboration between medical students
Quality and safety; and nursing students. This pilot simulation was an effective and well-received educational intervention.
Simulation This is a beginning step toward the development of a culture that fosters interprofessional teamwork
throughout health care.
Published by Elsevier Inc. on behalf of National Organization for Associate Degree Nursing.

1. Introduction understood in order for real communication and collabo-

The changes within the health care system are
necessitating that multiple competencies be taught in all
health education programs. Quality and safety concerns
continue to emerge as the system evolves (Kohn, Corrigan,
& Donaldson, 2000). Points of possible error in providing
safe patient care have grown underlining the need for all
members of the health care team to work collaboratively,
communicate effectively, and make joint decisions that are
patient centered and promote positive outcomes (Kohn et
al., 2000). In particular, the fields of medicine and nursing
are intertwined, and their responsibilities overlap; however,
each group traditionally uses both similar and dissimilar
types of knowledge (Stein-Parbury & Liaschenko, 2007) to
justify their clinical work. This must be recognized and
1
Presented as: Developing Interdisciplinary Communication Skills,
2009 National Organization for Associate Degree Nursing (N-OADN)
Annual Convention in Orlando, FL.
⁎ Corresponding author.
E-mail addresses: jwagner@cscc.edu, beth.liston@osumc.edu,
jmiller@cscc.edu
ration to occur.
The nursing student must learn how to develop and
present a cogent contextual clinical picture that supports his
or her clinical assessment (Benner, Tanner, & Chelsa, 2009).
The medical student must learn the meaning and value of this
alternative perspective. Both must learn negotiation and
conflict-resolution skills. This needs to happen regardless of
differing professional perspectives, past historical realities,
education–practice gap issues, and new quality imperatives.
These are the new practice realities. They must be attended to
in both nursing and medical education. Patient safety
demands it.
This article will describe the development and imple-
mentation of a pilot educational teaching/learning simula-
tion exercise designed to promote teamwork and
collaboration between medical students and nursing stu-
dents. A clinical scenario was developed. Ten nursing
students and 10 medical students were placed randomly in
teams and asked to work together in conjunction with a
standardized patient family member to develop next steps in
the care of an end-of-life patient whose written advance
directives were not available to the team. The available

1557-3087/$ – see front matter. Published by Elsevier Inc. on behalf of National Organization for Associate Degree Nursing.
doi:10.1016/j.teln.2010.12.003
98
options were intubation or comfort care. Each team member
received different information and therefore had a different
perspective. To form a reasonable and acceptable plan of
care, the doctor and the nurse had to communicate
effectively between themselves as well as with the
standardized patient family member.
2. Quality and safety
Reports from the Institute of Medicine have called into
question patient safety, the quality of health care, and the
efficacy of the educational system (Greiner & Knebel,
2003; Kohn et al., 2000). The Joint Commission on
Accreditation of Healthcare Organizations sentinel event
reporting demonstrates that 70% of preventable medical
errors are due to communication errors. Through these
reports, core competencies have been identified as needed
by all health care workers including physicians and nurses
(Greiner & Knebel, 2003).
Leaders in the nursing profession have taken these reports
seriously, and the response has been the Quality and Safety
Education for Nurses initiative (Cronenwett et al., 2007). In
this initiative, six core competencies for nursing have been
defined. They include: patient-centered care, teamwork and
collaboration, evidence-based practice, quality improve-
ment, safety, and informatics. Nurse educators have been
challenged to create curricular offerings that support the
development of these competencies.
3. Teamwork and collaboration
Physicians and nurses, although probably the most
closely aligned health care workers regarding patient care,
have had a tumultuous history in terms of communication,
cooperation, and joint decision making. Perhaps, the most
well-known description of this phenomenon was depicted
in an article by Leonard Stein, where he describes a “game”
played between the doctor and the nurse (Stein, 1967). In
this article, he explicates a system where dominant
physicians receive subtle cues about patient needs given
by a submissive nurse in somewhat coded language. The
nurse gives soft respectful suggestions and thereby covertly
participates in clinical decision making without ever
appearing to do so. The physician, in a similar way, asks
for advice. Except in very rare instances, there is little overt
conflict, but if the rules of the game are violated even
subtly, there is very little cooperation.
This communication pattern was reflective of the roles of
the physician and the nurse. The physician was male, better
educated, and by virtue of societies regarded in a higher
social class. He issued the orders. The nurse was female, had
less education, and was less valued in society and
theoretically followed his orders. The doctor was clearly
center stage and in charge of patient care, whereas the nurse
J. Wagner et al.
was subservient and a handmaiden of the physician.
Collaboration in decision making for the patient was not
the norm. The relationship between the groups became
strained as nurses became better educated, the female role in
American society changed, and the patient population
became more complex. Nurses quite naturally began to
take a more assertive role in patient care.
Although there have been substantive changes in the
interactional style between these two groups (Sirota, 2008),
there are still remnants of this pattern, and often, neither
group is comfortable with the other. Very little has been done
in either professional school to help bridge this chasm. A
1995 survey suggested that fewer than 15% of medical
schools and nursing schools had interprofessional programs
(Larson, 1995). A recent survey of medical schools indicates
little change in the last 15 years (Liston 2011). Socialization
into each profession is discipline specific, and each group
functions as if they were in a silo. Collaboration is really not
fostered within the educational experiences of either group.
Their socialization is mostly independent of the other and at
times can be subtly negative. Sometimes, what nursing
students are taught is a “submissive and permissive mentality
that instills feelings of powerlessness and victimization,
undermining interprofessional teamwork” (Kenner, Finkel-
man, Weatherby, Long, & Kupperschmidt, 2010). On the
other side, medical schools sometimes “instill in their
graduates a hierarchical model of teamwork with the
physician at the top of the hierarchy” (Chitty & Black,
2007). Neither education system teaches students to work
with the other group.
In addition, nursing education is struggling to keep up
with the changes in the health care arena and to implement
the urgently needed curricular improvements to meet the new
requirements of tightened quality and safety standards.
However, change in academia can be slow and bogged
down by the presence of an education–practice gap. Nursing
educators and administrators at times appear to view nursing
practice in differing ways. Berkow, Virkstis, Stewart, and
Conway (2008) reports that only 10% of hospital and health
system executives believe that their new graduate nurses are
fully prepared to provide effective and safe care. In contrast,
90% of academics believe their graduates to be well prepared
for the world of practice.
The reality however is that nursing practice continues to
evolve, and nursing education must continue to evolve as
well. New techniques highlighting the Quality and Safety
Education for Nurses competencies must be developed and
implemented reasonably. Didactic coverage of these topics
may not lead to the desired competencies that nurses need.
Realistic practice opportunities must be developed.
Currently, the coordination and mobilization of institu-
tional resources for timely intervention and rescue are
extremely important nursing functions for quality and
safety (Aiken, 2005). To fully execute these functions,
particularly the latter, collaboration with other members of
the health care team is necessary. The individual nurse must
Developing interprofessional communication skills
be skilled in collaboration and making a persuasive clinical
case. Benner et al. (2009) indicate that nurses must use
practical narrative reasoning that encompasses both time
and context parameters. The development of this skill
should not be left to chance and cannot effectively take
place in a classroom. Experiences for medical students and
nursing students to work together must be provided.
Simulation experiences between nursing and medical
students are one way to accomplish this. One way of
doing this simulation is through the use of a standardized
patient. This is a time-honored teaching strategy in
medicine and is being used more frequently in nursing.
This type of simulation does not involve technology
necessarily but rather uses a trained actor/actress to portray
a patient or family member involved in a clinical situation
(Rowles & Russo, 2009).
4. Simulation
Simulation involves the presentation of a close represen-
tation of a clinical scenario using technology, computer
software, actors (Rowles & Russo, 2009), and games. This
allows the students to practice in safe situations where there
is no possibility of harm to a patient. Student confidence
increases, and the behaviors learned this way become part of
their repertoire of useful interventions. The use of these types
of teaching tools reduces the need to rely wholly on the
availability of the experience in the clinical setting.
5. Development of the scenario
The patient scenario was created collaboratively by
nursing education and medical school faculty as well as
personnel from the Ohio State University (OSU) Clinical
Skills Center. Volunteers were solicited from fourth-year
medical students at the OSU College of Medicine and from
senior nursing students at Columbus State Community
College and the OSU College of Nursing. Standardized
actresses were trained at the Clinical Skills Center at the
School of Medicine regarding the details of the scenario and
their role as a family member.
6. Scenario
In this teaching/learning simulation, 10 teams consisting
of a fourth-year medical student, a senior nursing student,
and a patient family member (portrayed by standardized
patient actress) were randomly assigned to participate
together in the standardized clinical scenario. The scenario
presents a critically ill patient admitted via the emergency
room (ER) with shortness of breath who has just been
transferred onto a unit. She was stabilized, alert, and oriented
when received but since that time experienced a rapid
99
deterioration in vital signs, oxygen saturation, and sensori-
um. The daughter has been called and is coming to consult
with the team and see her mother.
Reflective of real-life practices in an inpatient setting,
each member of the team receives the information typical of
their profession. Each one therefore received different
information. The medical students received a brief synopsis
of the current diagnosis, patient history, chief complaint, and
ER chart. The recent diagnosis of metastatic cancer was not
included in this information. They were told that the patient's
condition was worsening, and they had just been paged by
the nursing staff to see the patient and talk with an arriving
family member.
The nursing students were given an introduction to the
patient that included the initial nursing assessment and
nursing note with the added information about the
metastatic cancer diagnosis as well. They were also told
that they themselves had spoken with the patient while the
patient was alert and oriented. The patient had indicated to
them that she knew she had metastatic cancer, had refused
chemotherapy in the past, and did not want any life support.
Her written advanced directives were at the long-term care
facility where she lived. The nursing student first met with
the family member to provide comfort before the medical
student entered.
The standardized patients were instructed to say (when
asked) that they knew that their mother had metastatic
cancer, had refused chemotherapy, and was looking into
hospice care. However, they (as the daughter) had not yet
come to terms with this decision, and they should initially
insist that everything be done to “save” their mother. They
were made aware of the information the nursing student and
the medical student had received. These actresses were
instructed to allow the team to lead them to a conclusion
(either intubation or comfort care) as long as they had
effectively communicated with her and each other, acting as
an interdisciplinary team.
The medical student, nursing student, and family
member worked together to develop a plan of care. At
the end of a predetermined length of time, a patient “code
blue” was called and a plan of action was required from
both student team members. Interdisciplinary communica-
tion and teamwork were essential to effectively determine
appropriate next steps, that is, either intubation or comfort
care. At the end of the session, all team members
participated in a feedback session including the patient
family member to discuss this experience and evaluate the
communication between team members. Students were
given an evaluation form to complete to allow formalized
input on the educational program.
6.1. Mechanics of the scenario
Simulations were done in a room in the Clinical Skills
Center of the OSU College of Medicine. All rooms for this
scenario were set up as a typical clinic with an examination
100
table and three chairs. Rooms are equipped with two-way
mirrors, video equipment, and two doors. Instructions and
information were posted on the door outside of each room.
Nursing students and medical students arrived at the same
time but were kept in separate areas within the Clinical Skills
Center. Nursing students were given 3 minutes to review the
door instructions, nursing assessment, and nursing notes.
They entered the room from the front, and the standardized
actress entered from the back entrance asking for information
regarding her mother and voicing her desire “for everything
to be done.” Nursing students were given 5 minutes to
comfort and communicate with the standardized actress,
during which time the medical student was given their door
instructions and ER chart to review.
After this time, the medical students entered the room to
communicate with the nursing student and family member.
They were instructed to exit the room when a plan of care
had been determined. Five minutes into the session, an
announcement was made, “Attention medical team, your
patient's oxygen saturation is now 85% on 100% oxygen.”
At 10 minutes, a code blue was called, and the teams were
asked to leave the room and determine a course of action.
Medical students were given 5 minutes to document their
assessment and plan. Nursing students were then given 5
minutes to document their response to the medical student's
assessment and plan.
7. Feedback
All medical, nursing, and standardized patient teams
participated in a feedback session immediately after the
scenario. Faculty were also present. During this time, all
participants were asked about their immediate response to
this exercise. Responses were overwhelmingly positive,
with each group sharing their ideas and their critiques of
their own and their team members' responses. Standardized
family members were also encouraged to indicate how they
believed the medical and nursing students functioned as a
team. Both groups of students indicated that they not only
enjoyed the experience but also believed it to be helpful in
developing rapport with the other group. Nursing students
indicated that they had never spoken to a medical student
through their educational experience. Medical students had
the same experience. Each student was given access to the
video from this experience and asked to reflect and
comment on the experience.
8. Evaluation
All teams developed a plan of care for their critically ill
patient that was accepted by the standardized patient.
Nursing students responded positively to items on a formal
evaluation tool using a 5-point Likert Scale (Table 1).
Nursing students indicated this was a valuable exercise and
J. Wagner et al.
Table 1 Nursing student feedback
Questions Average Standard
response deviation
1. The standardized patient scenario was a 4.7 0.48
valuable learning.
2. The feedback session was a valuable 4.7 0.48
learning exercise.
3. I will be better prepared to discuss advanced 4.4 0.52
directives as a result of this session.
4. I will be better able to work on a 4.4 0.52
multidisciplinary team as a result of
this session.
5. I would recommend this to other students. 4.8 0.42
would recommend this to future students. They felt better
prepared to discuss advanced directives as a result and
believed the experience would better enable them to work on
an interdisciplinary team in the future. Student comments
indicate that they not only enjoyed the experience but also
learned from watching how each doctor nurse team worked
through the situation during their feedback and reflection
time (Table 2).
9. Lessons learned
This type of educational innovation is an appropriate
experience for both groups of students. Each group indicated
receiving real benefit from this type of experience that would
Table 2 Nursing student comments
1. It did help in learning what my weaknesses are in communication with
others. It was a good learning tool.
2. Good opportunity to practice speaking to family and physician on
advanced directives. It gave me a chance to use my communication
skills in a way that really helped me learn and see what I can do better
in the future.
3. I feel this was a good experience and I learned a lot. Seeing how each
group handled the same situation differently and how different
perspectives can sometimes come into play.
4. It's interesting to see the routes everyone took. I felt very comfortable
determining intubation as a life support measure for this patient. I
relied a lot on the medical student to present the options to the family
members.
5. As the nurse I would feel more confident in my assessment of patient
not wanting advance life support if I have asked follow-up questions
to specify exactly what life support the patient did not want:
intubation, CPR…what level of intervention the patient would want to
stop at….
6. This was really good practice for the nursing students who are
apprehensive about speaking with family members. It allows the nurse
and the physician to work together and come up with a plan.
7. Very beneficial! Great opportunity. This instilled faith in myself
because I initially thought I was doing a poor job. After the scenario, it
was apparent that it was a “gray situation” and not my incompetency.
Great way to dissect communication between nurse and physician.
8. Both exercise and discussion were insightful.
9. This was a great experience. I think med students and nursing students
should have more collaborative learning experiences.
Developing interprofessional communication skills
help guide their practice in the future. Comments from both
groups indicated misconceptions about the other group,
which were resolved through the experience. In addition,
many students indicated increased self-awareness and a relief
that they had participated in a critical conversation during a
practice exercise where it did not count. Almost universally,
nursing and medical students thought other students would
benefit from this experience.
There were some barriers identified in this project. The first
was the complexity of trying to schedule nursing and medical
students with their very different course commitments. This
project was designed to be a volunteer laboratory experience
attended by both nursing and medical school faculty in
addition to the students. It was challenging to try to get all these
groups in one place at one time for a productive feedback
session. The second barrier was money. To increase the reality
of the simulation, actresses to play the part of the daughter were
hired and trained. Pizza and drinks were supplied to all
participants during the feedback session. The expenses for this
project were paid for by the medical school. Facilities were
identified as another possible barrier. For this project, the
simulation laboratory of the medical school was used for the
actual intervention and the feedback session. In addition,
nursing students attended a preconference at one of the nursing
faculty's homes where breakfast was available. Discussion was
centered on the role of the nurse as a patient advocate.
Professional attitudes and preconceptions were also
identified as barriers. In mainstream culture as reflected by
the media, there is the perception that the physician is the
automatic and unequivocal head of the team. Students may
also believe in this and behave according to these expecta-
tions. For example, it was noted that several of the nurses
were uncomfortable in participating in the decision making.
By way of contrast, the physicians naturally assumed the
leadership role. For example, one medical student indicated
afterward that he was surprised by the extent of the nurse's
knowledge of the patient. He indicated that he would never
again assume that he had all the information.
10. Conclusion
In summary, this pilot simulation was an effective and
well-received educational intervention for nursing students.
Clearly, this is a beginning step toward the development of
a culture that fosters interprofessional teamwork throughout
101
health care. Interventions of this nature are ways to
improve quality and safety through the development of
interprofessional collaboration. More exercises of this type
are needed to allow each group to learn to interact with
each other in a manner that is helpful to the patient and to
the health care system.
References
Aiken, L. H. (2005). Policy challenges in modern health care. In D.
Mechanic, L. Roget, D. Colby, & J. Knickman (Eds.), Improving
quality through nursing. Improving health and the health of all
Americans. (pp. 177−188). New Brunswick, NJ: Rutgers University
Press.
Benner, P., Tanner, C., & Chelsa, C. (2009). Expertise in nursing practice:Caring
clinical judgement and ethics. New York: Springer Publishing Company.
Berkow, S., Virkstis, K., Stewart, J., & Conway, L. (2008). Assessing new
graduate nurse performance. Journal of Nursing Administration, 38
(11), 468−474.
Chitty, K. K., & Black, B. P. (2007). Professional nursing: Concepts and
challenges. Missouri: W.B. Saunders Company.
Cronenwett, L., Sherwood, G., Barnsteiner, J., Disch, J., Johnson, J.,
Mitchell, P., et al. (2007). Quality and safety education for nurses.
Nursing Outlook, 55(3), 122−131.
Greiner, A. C., & Knebel, E. (Eds.) (2003). Health professions
education: A bridge to quality (pp. 1−192). Washington, DC: The
National Academies Press.
Kenner, C., Finkelman, A., Weatherby, F., Long, L. E., & Kupperschmidt,
B. R. (2010). Nursing against whose odds? Commentary on Gordon
(2005) as an example of teaching to the IOM reports. In A. Finkelman, &
C. Kenner (Eds.), Teaching IOM: Implications of the Institute of
Medicine reports for nursing education, (p. 247)., 2nd ed. Silver Spring,
MD: American Nurses Association.
Kohn, L., Corrigan, J., & Donaldson, M. S. (2000). To err is human:
Building a safer health care system. Washington, DC: National
Academy Press.
Larson, E. L. (1995). New rules for the game: Interdisciplinary education for
health professionals. Nursing Outlook, 43(4), 180−185.
Liston, B. L., Fischer, M. A., Way, D., Torre, D., & Papp, K. (2011).
Interprofessional education in the internal medicine clerkship: Results
from a national survey. Academic Medicine, in press.
Rowles, C. J., & Russo, B. L. (2009). Strategies to promote critical thinking
and active learning. In D. M. Billings, & J. A. Halstead (Eds.), Teaching
in nursing; A guide for faculty (pp. 238−261)., 3rd ed. St. Louis, MO:
Saunders Elsevier.
Sirota, T. (2008). Nursing 2008 nurse/physician relationships survey report.
Nursing, 38(7), 28−31.
Stein, L. I. (1967). The doctor–nurse game. Archives of General Psychiatry,
16(6), 699−703.
Stein-Parbury, J., & Liaschenko, J. (2007). Understanding collaboration
between nurses and physicians as knowledge at work. American Journal
of Critical Care, 16(5), 470−477.