The Leaflet Article
Medical and Nursing Education in the Healthcare Reform Period
Patty Looker, Associate AIA, FACHE, EDAC, Principal
VOA Associates Incorporated
In these days when healthcare provider leadership is compelled by huge changes in care provision, as well as looming deadlines for implementation of reform and difficult decisions about capital needs, it is easy to lose sight of parallel transformations taking place. What is always clear is that all transformations are grounded in the fact that our current US healthcare system is not sustainable. From every conference podium across the country since PPACA was passed, the keynote message is that “the train has left the station”. Change is underway. And every part of the healthcare sector is involved.
Context for reform’s improvement initiatives is grounded in the goal of quality care from providers better linked to patient responsibility and wellness maintainance. Historical care fragmentation has contributed to excessive cost, waste and patient dissatisfaction. Almost 10 years ago, a 2004 J.D. Power and Associates study of 2,350 patients found that satisfaction with the hospital experience was driven (in order of importance) by “dignity and respect, speed and efficiency, comfort, information and communication, and emotional support”. In 2004 and 2005, the Agency for Healthcare Research and Quality (AHRQ) and CMS convened 16 focus groups in six cities to find out what consumers perceived as important attributes of care in hospitals (Sofaer et al. 2005). Consumers responded:
- Doctor communication skills
- Responsiveness of hospital staff
- Comfort and cleanliness of the hospital environment
- Nursing and hospital staff communication skills
Better health outcomes through better communication and care continuity. Need we say more?
Transformation is Underway
The transformation of medical and nursing practice is foundational to healthcare reform and underlies trust in our healers. In VOA’s conversations with clients who are experts in healthcare provision and medical/nursing education, we are currently drawing conclusions about the developing 'gestalt’ for the future:
- Medicine and nursing are both “art and science”
- The internet and new communication devices provide tremendous future opportunities. Among many examples are posting metrics of daily monitoring by patients themselves, telemedicine and other web-based medicine strategies
- “Postmodern” medicine (coined by futurist David Ellis in H&HN, March 2013) will be “personalized, regenerative, bionic and digital”
- Attributes of physicians are changing: The medical profession is increasingly female (though still 32% of doctors and surgeons - 2011 US Bureau of Labor Statistics, Modern Healthcare, 4/8/13). They may be willing to work for less money, have a strong priority for work/life balance and may be more open to working as primary care physicians than specialists. Many more physicians are becoming employed by hospitals. Most doctors who enjoyed independence and high levels of control in their practices are no longer able to be the entrepreneurial, “cottage industry” physicians of the past.
- Nurses will need to work “at the top of their licensure”. As Donna Shalala said during her MacEachern Memorial Lecture at the 2013 Annual Congress of the American College of Healthcare Executives (ACHE) in March, nurses must be the backbone of care provision through the reform period and beyond. In order to meet the demand for primary care, RNs and advanced degree nurses will need to work even more broadly within physician standing orders, such that outpatient primary care can meet the demand. For many years, nurses themselves have sought this latitude in practice.
- Both expertise and respect will need to be enhanced for the multi-disciplinary teams that will provide the healthcare of the future.
While the above is evolving, the optimal mix of evidence-based medicine and nursing and better communication between clinician and patient remains to be maximized. Enlightened clinicians and educators are seeking to capitalize on this fertile moment to improve training. Drivers behind these new opportunities include:
- Improved communication skills by clinicians with patients
- Training in “narrative medicine” that probes for personal stories that illuminate a patient’s proper diagnosis and successful treatment
- A more holistic/broad-based approach to patient care and support
- Focus on chronic disease and how to improve outcomes, which necessarily relies on psychological support and partnering with care givers
- Knowledge about and acceptance of clinical pathways and care guidelines
- Advancing skill sets of physicians and nurses to work at the top of their licenses
Built Environment Strategies to Support Educational Reform
So how do these medical and nursing education opportunities get optimized during reform and how do built environment strategies become the platform for high quality practice that yields improved health outcomes? Medical and nursing education programs provide the clinical settings for training. Based on a team philosophy, allied health professionals should also be included in these educational settings. This type of education center would provide classroom, simulation lab, meeting/conference space for graduate medical education, nursing, occupational therapy, and physical therapy training in a single facility. Associated with the teaching spaces, there should be facilities for recreation and social spaces for both intentional and unintentional co-mingling. Two VOA projects speak to the future of medical education and nursing training and the leading edge philosophies behind them.
Louisiana State University (LSU) Medical Education and Innovation Center
Baton Rouge, LA
The LSU Medical Education and Innovation Center is designed to support the core competencies of quality patient care. The 4-story, 35,000 square foot graduate medical education facility, with a project cost of approximately $19 million, is located on the campus of Our Lady of the Lake College in Baton Rouge, Louisiana and is expected to be completed in August 2013. The building also contains spaces intended to foster learning about and the practical skills for interprofessional communication, patient interface, whole team integration, medical knowledge, patient-based learning and capacity building.
On the first floor, state-of-the-art classrooms are featured with a student commons, resource center and café. The Innovation Center on the second floor contains space for procedure simulation, patient interface, professional interaction and peer review. The upper floors are dedicated to faculty and resident offices. Exterior terraces at the first and second floors support classes held outdoors and feature a reflective garden featuring medicinal plants, providing a place of respite for faculty and residents alike.
The LSU program is built on the philosophy of Internal Medicine physician Dr. George Karam, who oversees the residency program, and is carried forward by his dozens of protégés. As articulated by Dr. Dean Lauret, assistant professor of clinical medicine and one of those protégés:
“When it comes to taking care of patients, we have to teach in black-and-white because that’s what you can easily communicate…the reality is, when you take care of sick people at their bedside, the practice is in the gray. The LSU program provides a relaxed educational atmosphere, understanding that to promote the learning process there must be opportunity for humor, casual interactions, self-reflection and constructive criticism.” (Business Report, August 21, 2012)
Inside the building, this multi-faceted approach to learning is supported by flexible spaces that promote this kind of interaction and philosophies of Competency-based Medical Education, adhering to mandates of Outcomes-based Training that standardize learning outcomes and individualize the learning process.
A key driver behind the training curriculum at the LSU Center is the value of the “narrative medicine’ philosophy. Facilitation of reflection also offers a formative aspect of professional development. Since design of the built environment can be a contributor to diagnostic listening, VOA created a platform for three educational opportunities: personal reflection, recording of thoughts and intra-personal dialogue. Skills learned in this special environment form the ability to narrate a patient’s story as a therapeutically central act, giving shape and control over the issues, as noted in Rita Charon’s important article on narrative medicine in JAMA (October 2001). Perhaps behind the search for a patient’s narrative in a calm, focused yet personable manner, where diagnosis and successful treatment can be discerned, is the bigger question: “How can we expect our future physicians to nurture if they are not nurtured?” (Levonson, 1970 concept)
Nursing Simulation Laboratory, School of Nursing, North Park University Chicago, Illinois
The mission of North Park University’s School of Nursing is to prepare its students for lives of service. The School offers a pre-licensure baccalaureate nursing program, an RN-completion program for registered nurses to obtain a bachelor’s degree, and a Master’s degree program that prepares nursing graduates to be nurse executives, community specialists and nurse practitioners.
In fall 2011, the program was enhanced by the opening of the Nurse Training Center, a 3,000 square foot facility that features four nursing simulation laboratories, with a project cost of approximately $1.1 million. Two of the four are dedicated to general nursing education; the other two simulate an Intensive Care Unit and the Labor/Delivery/Recovery birthing environment. All simulation labs are fully equipped with functional hospital equipment, simulation dolls and video recording equipment to capture and play back student performance in real life treatment situations.
Space and Place as the “Silent Curriculum” that complements and increases engagement
Use of simulation centers enhances training and builds confidence in young practitioners, as they and their mentors review video and begin to correct technique in harmless settings. Simulation centers have multiple advantages:
- A variety of learning styles and intensities are supported
- Multi-sensory experiences engage and stimulate
- Visual, auditory and kinesthetic experiences influence memory and the intake of information
- Diverse stimulation raises mental awareness and allows people to absorb information and ideas that the environment facilitates
- New ideas emerge from social interactions and “intellectual collisions”
Whether in medical education or nursing education, the ultimate goal of designers is to align the pathways of learning to a variety of spaces that engender intellectual curiosity, broad conceptual understanding, try-and-learn environments and space where inter- and intra-personal understanding develops. What is ahead in the new healthcare reform world provides a chance to do better than we have done so far, in medicine, in nursing and in design.
About the Authors:
Brenda M. Bush-Moline, AIA, LEED AP, EDAC
VOA Associates, Incorporated
Ms. Bush-Moline is an Associate Principal in the Chicago headquarters office of VOA Associates Incorporated. She is a leader within the Chicago healthcare practice and for VOA’s healthcare clients is inspired to translate design and planning intentions into architecture that reflects the mission and vision of her clients. She has been practicing architecture for 20 years, is a licensed architect, serves on the National Advisory Board for the Healthcare Facilities Symposium, and holds evidence-based design accreditation and certification status with the Center for Health Design.
Patty Looker, Assoc. AIA, FACHE, EDAC
VOA Associates Incorporated
Ms. Looker has led VOA’s Healthcare Practice Group for ten years. She is responsible for executive management, oversight of all healthcare projects and business development. She is a Principal and Partner at VOA, as well as a Fellow in the American College of Healthcare Executives (ACHE) and certified in Evidence-based Design (EDAC). Patty has led over 100 hospitals nationwide to achieve market leadership, improve healing environments and increase revenue margins. Prior to joining VOA, she spent 15 years as a consultant to hospitals nationwide and provided strategy and governance expertise to 50 nonprofit health and human service organizations in metropolitan Chicago. Her knowledge of the healthcare sector and public health spans nearly 35 years, with a special emphasis on women’s health.