Nurse/Resident Reciprocal Shadowing to Improve Interprofessional Communication

This prospective mixed-methods multisite study consisted of sequential surveys administered before and after a 4-hour nurse–resident shadowing experience. To provide a preshadowing framework, participants at site 1 received a checklist of possible observable activities, developed with input from nurses and chief residents (Supplemental Information). Site 2 participants received shadowing objectives and reflection questions to frame the experience (Supplemental Information). Developed with input from nurse and physician study team members, reflection questions were focused on building role understanding. The institutional review board at each site approved this study as exempt from full review.

C.S. Mott Children’s Hospital, Michigan Medicine (MM) is a 250-bed children’s hospital with >2000 admissions to hospital medicine annually. This study occurred on a 32-bed acute care unit. The interprofessional study team included the unit medical director, pediatric residency director, a chief resident, and unit clinical nurse specialist. Nurse participation was voluntary. Residents in their first year of training participated in the shadowing experience during a required professional development week. Nurses and residents were paired on the basis of schedule and staffing availability. Nurses shadowed as staffing allowed, typically occurring during scheduled shifts. Resident shadowing occurred primarily during day shift.

Cincinnati Children’s Hospital Medical Center (CCHMC) is a 600-bed children’s hospital with >7000 admissions to hospital medicine annually. This study occurred on a 41-bed acute care unit. The interprofessional study team included the unit medical director and pediatric residency associate program director, hospital medicine attending physicians and fellows, a chief resident, nursing unit leadership, and the unit nurse educator. Existing unit nurses could volunteer to participate; newly hired nurses participated as part of their orientation process. Residents in their first year of training shadowed during 1 morning of their required ambulatory pediatrics rotation. Whereas residents partnered with a nurse to shadow one-on-one, nurses shadowed a resident team during family-centered rounds and morning activities.

A survey was developed that included both quantitative and qualitative elements. Quantitative questions were derived from the Interprofessional Collaborative Competency Attainment Survey (ICCAS), a retrospective pre–post survey tool with validity evidence designed to assess differences in interprofessional collaboration competencies after training interventions. The 20-item tool asks participants to self-assess skills in 6 domains: communication, collaboration, roles and responsibilities, collaborative patient and family-centered approach, conflict management and resolution, and team functioning (Table 1).³⁶  Responses are based on a 7-point Likert-scale (1 = strongly disagree, 7 = strongly agree).³⁷  An additional question related to previous health care experience was added to the preshadowing survey for both groups. The nurse preshadowing survey included a question regarding years in nursing practice. Qualitative open-ended questions related to interprofessional communication, role understanding, and collaboration were derived from the Interprofessional Collaboration Competency Domains³⁸  and piloted among interprofessional study team members (Supplemental Table 4). Postshadowing surveys also assessed perceived impact of the shadowing experience.

Surveys were administered via an electronic survey platform before shadowing, immediately postshadowing, and at least 6 months later. Respondents were identified by role and clinical site and entered a unique 6-digit username for deidentification. At MM, respondents received a $5.00 gift card after completion of each survey. No incentive for survey completion was offered at CCHMC. Participants were included in the study if they completed the shadowing intervention and completed at least 1 survey. If 2 surveys for 1 time point were submitted, the most-complete survey was included for analysis.

The ICCAS survey responses were grouped and analyzed separately by respondent role (nurse or resident). Linear mixed models were fit to each ICCAS question with the Likert-scale response as the dependent variable, with fixed effects for hospital location and study phase, and a random intercept at the respondent level. The 3 study phases (before, immediate after, and 6 months after) were treated as a categorical variable, with preshadowing survey as the reference category. Postshadowing and 6-month postshadowing surveys not matched to a preshadowing survey identification number were treated as independent identification numbers. The P values for the coefficient for immediate postshadowing and 6-month postshadowing surveys were used to assess statistical significance of the change in response from preshadowing survey. Previous health care experience and years of experience were evaluated by including their main effects and interactions with the phase variable. P values ≤.01 were considered statistically significant. Analysis was performed by using R version 0.0.2³⁹  and the package nlme version 3.1-148.

Responses to open-ended questions were collated by survey administration and respondent role and thematically analyzed by using inductive coding. Three study members (K.K.M., J.L.K., and L.E.H.) independently coded each transcript and combined codes to create the initial codebook. The codebook was iteratively revised through peer debriefing and review of coded transcripts. The codes were combined into categories, and main themes were identified. Themes and subthemes were chosen to be mutually exclusive and exhaustive. Themes and representative quotes were shared with the study group to achieve consensus. Member checking was completed with 2 to 4 resident and nurse study participants from each site; all agreed that the analysis reflected their shadowing experience.⁴⁰ 

Eight nurses and 21 residents shadowed at MM, whereas 25 nurses and 32 residents shadowed at CCHMC (Table 2). Both nurses and residents demonstrated statistically significant improved scores from the preshadowing survey to immediate postshadowing survey in all 6 ICCAS domains (nurses = 12 questions, residents = 19), with some lasting improvements on the delayed postshadowing survey (nurses = 6 questions, residents = 17) implying sustainability (Fig 1). Only the collaborative patient- and family-centered approach and conflict management and resolution domains had no questions with statistically significant changes for nurses on the 6-month postshadowing survey. Previous health care experience was not associated with significant differences in survey responses. Nurses with <1 year of experience demonstrated greater improvements from preshadowing to 6-month postshadowing for questions communication 2 (P = .009), communication 5 (P = .004), and team functioning 2 (P = .007).

We used thematic analysis of responses to open-ended survey questions to identify 5 major themes with associated subthemes (Table 3).

Nurses and residents at both sites shared that effective communication contributes to building and maintaining interprofessional relationships and providing safe patient care. Drivers of effective communication included open communication, accuracy of communication, mode of communication, shared mental models, empowerment and speaking up, and communication style. Participants identified open communication (ie, clear lines of consistent communication) with accurate information as important to maintaining effective, collaborative working relationships. Many modes of communication exist within hospitals, such as numeric pages, text pages, secure text messaging, phone calls, and face-to-face communication, with each method valued differently by interprofessional team members. Face-to-face communication and phone calls were identified as preferred methods of communication over text-based messaging; both nurses and residents noted making more effort to have direct conversations because of the shadowing experience. Shared mental models of patient status and care plans can ensure that “everyone [is] presenting consistent information, as well as catching potential medical errors” (resident). After shadowing, nurses and residents described feeling more empowered to raise concerns, ask questions, and share opinions with each other. One nurse stated that after shadowing she felt “more confident in sharing my opinions, as the team made it clear that our opinion is needed.” Participants acknowledged that individual communication style can also support or hinder effective communication.

Collaboration was identified as another major theme related to the shadowing experience, with the following subthemes: personal relationships, same team, and trust. Participants shared that personal relationships formed through shadowing facilitated collaboration and communication. A resident noted that the intervention “formed a bond with a nurse that I could go to with issues and vice-a versa.” Nurses at both sites reflected that through time spent shadowing and “getting to know” residents, they felt more comfortable expressing ideas and concerns. Participants noted both groups can collaborate more effectively by remembering that they are “on the same team.” A resident acknowledged that nurses and physicians “both have the patient’s best interest in mind.” Participants further identified trust as a key element in collaborating with each other and with patients and families.

Subthemes identified under the role understanding theme included respect perspectives, understand unique contributions, responsibilities, and education and training. Before shadowing, a resident shared: “I get the sense that nursing feels frustrated when they don’t feel heard or appreciated.” After shadowing, numerous residents reflected that nurses spend more time in patient rooms, noting that information nurses gather from those interactions supports developing optimal plans for the patient and family. Both respondent groups appreciated the opportunity to shadow and learn more about each other’s responsibilities, noting there is sometimes “a lack of understanding when it comes to the respective roles and what they include.” Nurses commented on appreciation for “how busy the interns and physicians stay! They are constantly answering pages, modifying orders, updating notes, and admitting patients.” Having more patience when expecting a response from a resident in a nonemergent situation and understanding that residents are caring for “a lot of patients” was shared as being important to improving communication. Both groups acknowledged a general lack of understanding of the education requirements for each other’s profession. A resident recognized how “unfamiliar I am with describing the training that goes into being a nurse, and on the other side, how unfamiliar nursing can be with the training and what it means to be a pediatric intern.”

Team process included subthemes of workflow, workload, setting, and accessibility and availability. Respondents reflected on gaining a better understanding of their colleagues’ workflow because of shadowing. One resident commented “physician and nursing workflows are very different, so quick response time is challenging if a nurse is feeding a baby or a physician is actively rounding on another patient and unable to be at bedside . . . it is helpful for us to understand the other perspective and workflow by shadowing.” Participants identified new perspectives on how busy workloads may contribute to communication and recognized that being in physically different spaces could serve as a barrier to communication. Accessibility to care team members was identified as essential. Nurses described challenges when they had difficulty identifying the correct physician to contact regarding a patient question or issue. Residents identified the importance of “everyone being available in order to get on the same page. All members are very busy but ensuring that everyone is available for rounding is the best way to get on the same page.”

Both nurses and residents identified that effective communication and collaboration can improve the patient-family experience and patient outcomes. Residents noted that openly communicating and working together to develop care plans can optimize the plan for a patient. Both groups highlighted the importance of using rounds as an optimal time to communicate needs, issues, or questions to improve patient care. A resident commented that “by keeping the nurse in the loop of the care plan, the nurse can better serve the patients. Moreover, nurses may be more attune to minute by minute changes with the patient. Listening and collaborating will benefit patients much more than disagreeing or ignoring.” Participants frequently commented on putting patient needs first and the importance of working as a team to improve care delivery.

This multicenter prospective study of a reciprocal nurse–resident shadowing experience revealed positive impact on interprofessional competencies. Improvements in ICCAS components were sustained over 6 months postshadowing in almost all domains. Qualitative analysis of open-ended questions revealed 5 themes related to optimal nurse–resident engagement: effective communication, collaboration, role understanding, team process, and patient-centeredness. Although other studies have revealed similar findings,^{15,21,25–28}  this is the first multisite study that reveals the value of reciprocal shadowing between nurses and residents.

Residents demonstrated significant improvements on more ICCAS survey items than nurses. Nurse experience may be a factor; 64% of nurses had >1 year of experience at the time of the study, compared with the residents, who were in their first year of training. Experience may have affected the perceived impact of the shadowing intervention by 2 mechanisms. We hypothesize that the earliest phases in a professional role, when one has the least understanding of other roles and the most to learn, are often accompanied by more-rapid information transfer.^28,41  Additionally, residents shadowed nurses who generally had more experience in their role and, therefore, may have been better equipped to share their experiences. Although almost all questions on resident surveys revealed sustained improvements at 6 months, nurse responses with sustained improvements were primarily in the communication, collaboration, roles and responsibilities, and team functioning domains. Because our intervention was primarily focused on interprofessional communication and collaboration, the shadowing interventions did not directly address patient and family involvement in decisions or conflict management, which may explain lack of significant change in these domains.

Our qualitative findings closely align with the Interprofessional Education Collaborative core competencies for interprofessional collaborative practice. These competencies include teamwork and team-based practice, interprofessional communication, roles and responsibilities for collaborative practice, and values and ethics.³⁸  Interprofessional education is an important part of medical and nursing accreditation standards and is necessary for the collaborative growth needed to attain better health outcomes.^42–47  Although interprofessional education learning activities have demonstrated positive learning outcomes, there are barriers to sustainability, such as scheduling logistics and generalizability to different settings.²⁵  Our reciprocal nurse–resident shadowing experience demonstrated growth in these competency areas in a short time period.

Participants noted that the shadowing experiences revealed a new, deeper understanding of their partner’s role. This outcome supports previous work in which health professions students participated in 1-time interprofessional shadowing experiences. Postexperience reflective writings revealed themes similar to many identified in our study, a focus on individual and team member roles, and a patient-centered focus.²⁵  Walsh et al¹⁵  assessed a resident shadowing experience at a single site; with their qualitative analysis they found themes supporting an overarching principle of improving communication between nurses and residents. In our study, we expand on this resident shadowing concept by including reciprocal nurse shadowing and incorporating a quantitative assessment component via the ICCAS.

Improved communication and understanding of roles and responsibilities fostered by these shadowing experiences may also contribute to increased team SA, “the shared understanding of a situation among team members at one point in time.”⁴⁸  Improving team SA enhances team effectiveness; more robust SA can improve patient safety and quality of care.^48–52  Our shadowing intervention positively impacted participants’ assessment of their interprofessional collaboration and communication, which is a critical component to team SA.⁵³  These strengthened interprofessional working relationships may lead to improvements in patient safety and quality of care. Further research should investigate the relationship between reciprocal shadowing experiences and the impact on patient safety, patient satisfaction, and objective patient-level outcome measures.

Although this is a multisite study, both sites were large academic centers, which may limit generalizability, particularly in clinical settings without trainees. Shadowing implementation, participant numbers, and survey response rates differed for each site. Although this demonstrates the shadowing intervention can be adapted to different practice environments, we could not control for all the differences between settings. Our intervention only included nurses and residents, which may not be generalizable to other health care professionals. Recall bias may have occurred because some responses were >6 months postshadowing; 3 6-month postshadowing surveys at MM occurred up to 1 year after the intervention. Bias may also be introduced on the basis of which survey(s) were completed, because not all participants completed all 3 surveys. In addition, as acknowledged by Archibald et al³⁷  in validating the ICCAS, response shift bias could be present because the pre- and postintervention surveys were not administered retrospectively. Statistical comparisons were not adjusted for multiple testing. Although we chose a lower significance level of 0.01 to counteract multiple testing effects, the family-wise type I error rate is likely to be somewhat higher than what is implied by the comparison-wise significance level of 0.01; a larger sample would be needed to be confident that all comparisons represent the true population differences. Finally, using an electronic survey format may have limited our ability to explore the qualitative responses in more detail. Identification number entry error was also possible and may have affected the mixed model results if repeated measures from the same respondent were counted as separate identification numbers.

This reciprocal nurse–resident shadowing experience led to a significantly better understanding of roles, workflow, and barriers to communication for interprofessional team members. Surveys and qualitative assessment identified opportunities for future interventions to improve communication and promote safe patient care.

The authors thank Lori Launius, Resident Assistant, C.S. Mott Children’s Hospital Administration and Jennifer L. Hemberg, MD.