Previous sections of this chapter discussed IPEC competencies required for effective interprofessional collaboration and methods for managing conflict. In addition to demonstrating these competencies, nurses also have many other responsibilities related to interprofessional collaborative practice. Nurses plan and participate in interdisciplinary care conferences; assign, delegate, and supervise nursing team members; educate clients and staff; act as client advocates; make client referrals; ensure continuity of care; and contribute to the evaluation of patient outcomes. These responsibilities of the nurse are further described in the following subsections.
Planning and Participating in Interdisciplinary Care Conferences
The nurse identifies clients who would benefit from interdisciplinary care conferences. are meetings where interprofessional team members professionally collaborate, share their expertise, and plan collaborative interventions to meet client needs. As the interprofessional team member likely to spend the most time at the client’s bedside, nurses are key members for advocating for client needs during interdisciplinary care conferences. The nurse utilizes effective communication techniques by expressing and advocating for client needs, listening attentively to suggestions of other team members, formulating a collaborative plan of care, and documenting it in the client’s nursing care plan.
View the following YouTube video illustrating an interdisciplinary care conference as a patient’s plan of care is designed and implemented.
- As you watch the video, notice how the professionals from different health disciplines communicate and interact with each other to formulate the plan of care for a patient and how the care is continued through multidisciplinary involvement.
- Assess interprofessional collaborative practice of the health care team using the following PDF:
Assigning, Delegating, and Supervising
Nurses assign, delegate, and supervise care of other members of the nursing team, such as licensed practical/vocational nurses (LPN/VN) and assistive personnel (AP). Appropriately assigning and delegating care with appropriate supervision are strategies that ensure quality client care is completed efficiently.
Read more about assigning and delegating in the “Delegation and Supervision” chapter.
Educating Clients and Staff
Nurses provide patient education, train staff, and serve as a staff resource. For example, an RN serves as a resource to assistive personnel (AP) floating to their unit. The RN provides a general orientation of the unit, explains the pertinent needs of the clients as they pertain to the AP’s assigned tasks, and shares how the staff interact and communicate within the unit. The RN ensures the AP understands the orientation information, is competent in their assigned/delegated tasks, and utilizes the RN as a resource throughout the shift.
Acting As a Client Advocate
Nurses advocate for client needs with family members, interprofessional team members, health care administrators, and, in some cases, health insurance companies and policy makers. Nurses protect and defend the rights and interests of their clients and ensure their safety, especially if the client is unable to advocate for themselves. For example, clients who are unconscious, developmentally disabled, illiterate, or experiencing confusion often require assertive advocacy with the interprofessional team to effectively meet their needs and preferences.
Read more about nurse advocacy in the “Advocacy” chapter.
Making Client Referrals
Nurses assess clients, determine their needs, and make referrals based on potential or actual problem(s). If the assessed needs of the client cannot be met by the collaborative nursing interventions, the nurse seeks out other resources to fulfill the client’s needs. For example, nurses often advocate for referrals to community resources such as home health care, support groups, social services, respite care, emergency shelters, transportation, elder day care, and parenting groups. After needed referrals are identified, the nurse obtains necessary provider orders and completes applicable referral forms. This information is shared confidentially with the client and the referral resource.
Ensuring Continuity of Care
Nurses serve a vital role for maintaining and making any client transition of care smooth and unfragmented. Continuity of care is defined as “the use of information on past events and personal circumstances to make current care appropriate for each individual.” Transitions of care include admission to a facility, transfer from one unit to another within the same facility, transfer from one facility to another, or discharge to their home or a long-term care facility. For example, a transfer occurs when a client is moved from a medical unit bed to the intensive care unit.
There is high risk for medical errors during transitions of care. Nurses help make transitions seamless with good handoff reports and documentation while effectively collaborating with the interprofessional team. Read about preventing medication errors during transitions of care in the following box.
Preventing Medication Errors During Transitions
Key strategies for improving medication safety during transitions of care include the following:
- Implementing formal structured processes for medication reconciliation at all transition points of care. Steps of effective medication reconciliation are to build the best possible medication history by interviewing the patient and verifying with at least one reliable information source, reconciling and updating the medication list, and communicating with the patient and future health care providers about changes in their medications.
- Partnering with clients, families, caregivers, and health care professionals to agree on treatment plans, ensuring clients are equipped to manage their medications safely, and ensuring clients have an up-to-date medication list.
- Where necessary, prioritize clients at high risk of medication-related harm for enhanced support such as post-discharge contact by a nurse.
Safely Admitting and Discharging Clients
refers to an initial visit or contact with a client. refers to the completion of care and services in a health care facility and the client is sent home (or to another health care facility).
Admissions and discharges are more than just the physical movement of an individual. They require a great deal of confidential information sharing to maintain continuity of care. During an admission, nurses use the nursing process to thoroughly assess the client, diagnose nursing problems, establish expected outcomes, and create a nursing care plan. Referrals for other inpatient services, such as a dietician, wound care nurse, chaplain, social worker, or other interprofessional team members, may be initiated. Additionally, the client and their family members are oriented to the setting, and information is provided regarding HIPAA and patient rights and responsibilities; medications are reconciled; and other admission tasks are completed based on agency policy.
During discharge, there is also a great deal of information shared with clients regarding follow-up appointments with interprofessional team members, medication reconciliation, and patient education.
Reporting New Information and Changing Conditions
The nurse is often responsible for reporting new information to the interprofessional team regarding inpatients, such as newly reported laboratory or diagnostic results or changes in a patient’s condition. Here are some examples of a nurse reporting and following up on issues:
- A client receiving BiPAP therapy has worsening oxygen saturation levels and respiratory status. The nurse reports these changes to the respiratory therapist, who reassesses and adjusts the positive pressure settings as needed.
- An inpatient receiving furosemide has new abnormal potassium levels. The nurse reports the newly reported lab results to the provider.
- A client receiving an antibiotic for the first time develops a rash and shortness of breath. The nurse reports the client’s adverse reaction to the prescribing provider and the pharmacist and ensures the allergy is noted in the client’s chart.
- A family member shares a recent change in a client’s living arrangements that is concerning. The nurse reports updates to the social worker to assist in making alternative living arrangements.
Contributing to the Evaluation of Client Outcomes
In today’s complex health care system, data regarding patient outcomes is constantly documented and analyzed. This data drives management decisions and is also reported to insurance companies as a component of “pay for performance” reimbursement processes. The nurse is directly involved in this data by establishing expected outcomes customized to the client, evaluating these outcomes, and documenting data supporting outcomes related to collaborative nursing interventions.
- Interprofessional Professionalism Collaborative. (2018, August 15). IPC case scenario for Mr. Jones part I. [Video]. YouTube. All rights reserved. https://youtu.be/woHaclEtLFw ↵
- Interprofessional Professionalism Collaborative. (2019). IPA tool kit. http://www.interprofessionalprofessionalism.org/toolkit.html ↵
- Gerber, L. (2018). Understanding the nurse's role as a patient advocate. Nursing, 48(4), 55-58. https://journals.lww.com/nursing/Fulltext/2018/04000/Understanding_the_nurse_s_role_as_a_patient.15.aspx ↵
- Kim, S. Y. (2017). Continuity of care. Korean Journal of Family Medicine, 38(5), 241. https://doi.org/10.4082/kjfm.2017.38.5.241 ↵
- Medication Safety in Transitions of Care by World Health Organization is licensed under CC BY-NC-SA 3.0 ↵
Meetings where interprofessional team members professionally collaborate, share their expertise, and plan collaborative interventions to meet client needs.
The use of information on past events and personal circumstances to make current care appropriate for each individual.
Refers to an initial visit or contact with a client.
The completion of care and services in a health care facility and the client is sent home (or to another health care facility).