Patient-Centered Care: CRNAs and the Interprofessional Team

Formerly Position Statement Number 1.12

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In order to optimize patient health outcomes, modern healthcare delivery requires patient-centered care and interprofessional collaboration among healthcare practitioners. Fractured and disconnected healthcare delivery models are no longer acceptable. The AANA recognizes the importance of interprofessional collaboration and the interprofessional team on patient-centered care, care coordination and health outcomes.  The AANA is committed to supporting its members in providing safe and effective anesthesia care. According to the Institute of Medicine (IOM) report titled "The Future of Nursing," "nurses must be involved in decision making about how to improve the delivery of care."In addition to nurses serving as strong patient advocates, the report also recognizes the scope of practice of advanced practice registered nurses (APRNs) and their value in promoting quality, cost-effective healthcare. This document describes the critical aspects of patient-centered care, collaboration, interprofessionality, and the role of the Certified Registered Nurse Anesthetist (CRNA) in the interprofessional team.

Patient-centered care is based on the concept of shared decision making by establishing a patient partnership through sharing information and evidence, acknowledging patient preferences and ideas, identifying choices, and negotiating decisions and agreeing upon an action.2  CRNAs should seek to engage the patient in decision-making discussions while being respectful of patient preferences for anesthesia care services. The concept of collaboration entails five characteristics: sharing, partnership, power, interdependency and process. Collaboration should occur across all disciplines and requires respect for the skills and knowledge that a particular healthcare professional contributes to the patient care environment. Interprofessionality refers to a practice that is integrated and cohesive, involving continuous interaction and knowledge between professionals with shared values and codes of conduct while incorporating patient participation.4

These concepts as described above often are experienced or interpreted differently by the medical and nursing disciplines. Sexton et al. surveyed 60 U.S. hospital operating room (OR) staff members (i.e., surgeons, OR nurses, surgical technicians, anesthesiologists, and CRNAs) focusing on the teamwork climate domain featured in the Safety Attitudes Questionnaire (SAQ).5 Of the 2,135 respondents, the researchers found that surgeons and anesthesiologists provided overall higher ratings for teamwork and physician-nurse collaboration than operating room nurses and CRNAs.  When further probed about the discrepancy, the nurse respondents characterized "good collaboration" as having their input respected, while the physician respondents characterized "good collaboration" as having their instructions followed.5 This study demonstrates the possible incongruent understanding of professional scope of practice and roles and responsibilities between disciplines. It is these differences in understanding that frequently pose a significant barrier to true interprofessional collaboration and team-based care.

The concept of interprofessional team-based healthcare is very different from the anesthesia team model where CRNAs are medically directed by an anesthesiologist. Medical direction is solely a reimbursement concept and has no relationship to quality of care delivery. Within the construct of the broader interprofessional team, anesthesia delivery may be viewed as one activity within the team and may be accomplished by a solo anesthesia professional or more than one anesthesia professional working together. In this situation, the anesthesia team model may be viewed as a subgroup within the larger interprofessional team. The provision of anesthesia services by an anesthesia team involves at least two or more anesthesia professionals working in collaboration with patients and their other caregivers to achieve shared goals and anesthesia patient-centered care. Interprofessional teams do not require medical direction by an anesthesiologist.  As such, patient care needs should dictate appropriate anesthesia personnel resources (e.g., the number of anesthesia professionals needed), rather than a predetermined numerical ratio that inefficiently uses the anesthesia workforce.   There is no difference in patient outcomes when CRNAs provide anesthesia services without the supervision of a physician. In addition, arbitrarily requiring medical direction of CRNAs contributes to increasing anesthesia service cost ineffectiveness7 without demonstrable benefits to patient outcomes.  CRNAs deliver safe, cost-effective anesthesia services.6,7

Barriers to achieving team-based healthcare are current clinical workplace models and professional educational programs.  Additionally, poor teamwork skills stem from a lack of defined roles and responsibilities in the workplace setting, a lack of unified healthcare ethics and values, and poor communication practices among healthcare professionals.Several expert panels suggest that healthcare professionals need education, either formal or in the workplace, for instruction on how to work in collaborative teams to improve healthcare delivery.8-11

Currently the Council on Accreditation (COA) of Nurse Anesthesia Educational Programs is ensuring that nurse anesthetists are educated in leadership skills that facilitate interprofessional collaboration in addition to healthcare improvement.12  Additionally, the National Board of Certification and Recertification for Nurse Anesthetists (NBCRNA) believe that "nurse anesthetists are leaders in interprofessional teams working to improve patient outcomes and the quality and safety of anesthesia care within the healthcare system."  The NBCRNA has defined interprofessional teams to "include all disciplines involved in determining the standard of healthcare provided in the institution."13  Similar undertakings to promote interprofessional collaboration have taken place among medical accrediting and certification bodies.14,15

CRNAs engaged in anesthesia team-based healthcare should use their expertise and skills in anesthesia care as described by their scope of practice while collaborating with other team members to promote safe, patient-centered care.   As such, CRNAs should also adhere to the characteristics of teamwork10 (i.e., shared goals, shared decision-making, and adaptability) by applying relationship-building values to plan and deliver anesthesia care throughout the perioperative process.   In addition, all team members should incorporate the Institute of Medicine’s principles of safe, timely, efficient, effective, equitable, and patient-centered care.16  Lastly, all anesthesia professionals and trainees (i.e., student registered nurse anesthetists, physician anesthesia residents, physician anesthesia fellows, and anesthesiologist assistant students) have an obligation to accurately identify themselves to other members of the team, patients and family members as well as define their role in patient care (i.e., supervision, direct patient care, training).

The AANA believes that patients are best served when healthcare professionals work in a collaborative fashion that promotes safe, high-quality, value-driven, patient-centered care.  The AANA also believes that safe, high-quality, value-driven, patient-centered care is not a value held by one profession or the responsibility of one healthcare professional, but rather is a process that occurs throughout a patient’s care experience under the auspices of team-based healthcare.  The AANA strongly encourages interprofessional collaboration by incorporating team-based healthcare, team values and ethics, interprofessional communication practices, and defined roles and responsibilities for interprofessional collaboration.8

References

  1. IOM (Institute of Medicine). The Future of Nursing: Leading Change, Advancing Health. Washington, DC: The National Academies Press; 2011.
  2. Godolphin W. Shared decision-making. Healthc Q. 2009;12 Spec No Patient:e186-190.
  3. D'Amour D, Ferrada-Videla M, San Martin Rodriguez L, Beaulieu MD. The conceptual basis for interprofessional collaboration: core concepts and theoretical frameworks. J Interprof Care. May 2005;19 Suppl 1:116-131.
  4. D'Amour D, Oandasan I. Interprofessionality as the field of interprofessional practice and interprofessional education: an emerging concept. J Interprof Care. May 2005;19 Suppl 1:8-20.
  5. Sexton JB, Makary MA, Tersigni AR, et al. Teamwork in the operating room: frontline perspectives among hospitals and operating room personnel. Anesthesiology. Nov 2006;105(5):877-884.
  6. Dulisse B, Cromwell J. No harm found when nurse anesthetists work without supervision by physicians. Health Aff (Millwood). Aug 2010;29(8):1469-1475.
  7. Hogan PF, Seifert RF, Moore CS, Simonson BE. Cost effectiveness analysis of anesthesia providers. Nurs Econ. May-Jun 2010;28(3):159-169.
  8. Core competencies for interprofessional collaborative practice: Report of an expert panel.   Interprofessional Education Collaborative Expert Panel (IPEC). 2011. http://www.aacn.nche.edu/education/pdf/IPECReport.pdf  Published 2011.  Accessed September 7, 2011.
  9. Frenk J, Chen L, Bhutta ZA, et al. Health professionals for a new century: transforming education to strengthen health systems in an interdependent world. Lancet. Dec 4 2010;376(9756):1923-1958.
  10. Thistlethwaite J, Moran M. Learning outcomes for interprofessional education (IPE): Literature review and synthesis. J Interprof Care. Sep 2010;24(5):503-513.
  11. Framework for action on interprofessional education and collaborative practice. World Health Organization: Reference  WHO/HRH/HPN/10.3.64. http://whqlibdoc.who.int/hq/2010/WHO_HRH_HPN_10.3_eng.pdf  Published 2010.  Accessed September 7, 2011.
  12. Standards for Accreditation of Nurse Anesthesia Educational Programs. Council on Accreditation of Nurse Anesthesia Educational Programs 2012; http://home.coa.us.com/accreditation/Documents/Standards%20for%20Accreditation%20of%20Nurse%20Anesthesia%20Education%20Programs.pdf  Revised January 2012. Accessed May 4, 2012.
  13. National Board of Certification and Recertification for Nurse Anesthetists. Continuing Competence for Nurse Anesthetists. 2011; http://www.nbcrna.com/Documents/Continuing%20Competence%20for%20Nurse%20Anesthetists.pdf  Published July 10, 2011.  Accessed September 29, 2011.
  14. MOC compentencies and criteria. Maintenance of Certification (MOC): American Board of Medical Specialties 2011; http://www.abms.org/Maintenance_of_Certification/MOC_competencies.aspx  Accessed September 7, 2011.
  15. Common program requirements. Accreditation Council for Graduate Medical Education 2011; http://www.acgme.org/acgmeweb/Portals/0/dh_dutyhoursCommonPR07012007.pdf  Published July 1, 2011.  Accessed September 7, 2011. 
  16. IOM (Institute of Medicine). Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academy Press; 2001.
 

Adopted by AANA Board of Directors June 2012.