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The Interdisciplinary Team

Vol. 9 •Issue 16 • Page 19
The Interdisciplinary Team

Nurses on community based collaborative teams face uniquechallenges in meeting complex patient needs

By Lolita M. Carter, MSN, CPNP, Rhonda L. Draper, ND, Dorothy A. Dickens, MSW, LISW-BCD, & Faith Dickens, MSN

It's Friday morning, the workweek has been full of pediatric patients with both acute healthcare, and immediate social support needs. The reprieve comes from the anticipated weekly interdisciplinary team meeting each Friday to address set-forth issues. All members are present, armed with clipboards, notes and coffee in the expectation of a lengthy meeting.

Your patient is the first to be reviewed; you take a deep breath and begin.

Briefly, Mrs. J brought her 14-year-old daughter M. to the clinic as a walk-in with the chief complaint of persistent vaginal itching for 2 months with discharge. A review of systems is within normal limits. Vital signs are stable, urinalysis along with HCG are negative.

Mom denies any concerns. However, the girl discloses mom has a new boyfriend who recently moved in and is 6 years younger than the mother. M. has been spending more time outside the home; her grades have dropped significantly.

As the central primary care triage nurse you request to speak one-on-one with M.; mom is reluctant. M. is seen by the provider with the mother in the room and scheduled for a follow-up visit within a week. As the nurse you are concerned and would like the team to develop interventions that would foster information gathering for M.

Coordination Even More Important

Interdisciplinary collaboration is becoming increasingly important as the complexity and cost of healthcare require an efficient and well-coordinated service delivery system. Historically the nursing profession has embraced a holistic approach to promoting health, healing and comfort for the individual. The nurse doesn't regard the patient as a disease process, but recognizes the impact of a health crisis on the mind, body, spirit and family of the affected individual.

The prevalence of patients with co-medical and psychiatric diagnosis require an interdisciplinary approach to treatment as well as management in order to achieve stabilization and optimal functioning of the patients. Socioeconomic circumstances include lack of healthcare insurance, inadequate and/or lack of housing, and unemployment impact on access to services.

In the hospital setting social workers and nurses often work jointly within the multidisciplinary healthcare team to provide services to their patient. Discharge planning coordinated by social work and nursing concentrate on assisting the client to regain an optimal level of health and well-being.

Nursing Role & Community

Today, the nursing role and its relation to the community-based interdisciplinary team is multifaceted. Various functions and responsibilities include: development of individualized plans of care, program and outreach development, education, social service support, consultation and fostering partnership with community based resources to maximize services.

However, nurses must be aware of potential challenges that arise in community based interdisciplinary teams that may not present themselves within the tertiary setting — specifically, role diffusion and delayed service delivery.

The role of the nurse deals with assessment, interventions, maintenance and evaluation. Interventions implemented by the social worker include supportive services, crisis intervention and accessing financial assistance with regard to the well being of the individual from psychological/emotional and socio-economic conditions.

Frequently, interventions overlap hindering services because of ineffective communication. Specifically, communication related to professional expectation, interventions and outcomes are not uniform. For example, the nurse triages in the area of vital signs, obtaining urine samples, dietary information, history of any new prescribed and non-prescribed medications. Going back to M's situation, communication would break down if the nurse opted not to assess the home environment, mother-daughter relationship, financial changes or pending criminal issue. If the nurse suspects any issues outside the medical role a referral should be made to the social worker.

During the nursing assessment if the family identifies basic needs, e.g., housing, utilities or unmet financial needs, it is the nurse's responsibility to call the social worker instead of addressing those needs herself. In addition, if mental health needs are addressed, nurses must consult the social worker. Nursing's role as part of the interdisciplinary team is to the medical needs of their clients; social work attends to environmental needs.

Assessment Includes Much More

The dynamic roles of nurses and social workers together are client centered and goal directed to provide interventions which address the comprehensive needs of clients. Today's healthcare system is facing its greatest challenges due to an increase in underinsured and uninsured and medical conditions within the populace. The interdisciplinary team is a model to address these issues. Nursing interventions within the interdisciplinary team must include prompt referral to social work when complex environmental issues are evident.

Assessment must include review of systems as it relates to the home environment, financial status and mental health needs. Interventions can be guided by the nurse with support from social workers for case management and follow-up.

Both nursing and social work must maintain their perspectives and boundaries yet work collaboratively to meet the complex physical, psychosocial and economic needs of the families assigned to their care.

Lolita M. Carter is a pediatric primary care NP adolescent health specialist at the Greater Philadelphia Health Action, Philadelphia. Rhonda L. Draper is associate professor of nursing, Case Western Reserve University, Cleveland. Dorothy A. Dickens is a social work coordinator at Metro Health Medical Center, Cleveland. Faith Dickens is founder of David's Challenge, a non-profit organization in Cleveland.


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