Three C’s: Reflections for Lessons Learned in our Changing World

By Gwen Sherwood (@gwensherwood)

For almost everyone, the familiar world that we knew made a sharp pivot in early spring 2020. The COVID19 global pandemic called into question almost every process for how we live our lives and for how we conduct our work. Life put us in unfamiliar territory.  Every day was a new experience that left us with new mental models of how we are to do things.

Now in the fall of 2020 as we find new ways to cope with a new worldview, comes the question: what have we learned?

John Dewey famously said we do not learn from experience; we learn by reflecting on experience through cycles of interpretation and reinterpretation over time (Dewey, 1933).

Reflecting on the stories and news accounts of the impact of COVID19 on our healthcare systems, it became clear that a mindset for interprofessional collaboration as defined by the Interprofessional Education Collaboration (IPEC) helped form the response to the challenges of the COVID19 global pandemic while maintaining healthcare quality and safety.

In so many ways, COVID19 became the catalyst for how we work together with healthcare providers uniting to combat a common threat. What can we learn from this reversal of working in silos, sticking with one’s own tribe, and communicating through hierarchy?

Interprofessional Collaboration, Coordination, and Communication.

These three C-words can be discussed within the framework of the core competencies for interprofessional collaborative practice (IPEC, 2016) and provide lessons for keeping patients safe and improving work environments. 

As COVID19 consumes every aspect of healthcare, successful organizations recognized that if leaders worked together on common goals and purpose that quality of care could be maintained.

The Three C’s

Collaboration

Interprofessional Collaboration is the overarching construct that encompasses the four original competency domains guiding interprofessional practice:

• values and ethics
• roles and responsibilities
• teams and teamwork
• communication.

From the onset, COVID19 challenged long held healthcare values posing new ethical questions: how would they allocate the limited supply of PPE? Who would get ICU beds and ventilators? How could front line workers remain uninfected? Do previously held beliefs about nurses’ and advance practice nurses’ scope of practice make sense?  While there continues to be opposition to full scope practice (https://www.ama-assn.org/practice-management/payment-delivery-models/ama-successfully-fights-scope-practice-expansions ), the pandemic push us to evaluate our tightly held beliefs and brought all disciplines, units, and services together for unprecedented exemplars of working together. The continuing flow of new evidence had to be examined and synthesized for the impact on every part of the system and how the various roles would apply.

Coordination

Coordination, another C, featured teamwork that brought together all units of a facility.

Housekeeping, security, quality improvement, dietary, chaplains, pharmacy, nurses, physicians—every microsystem of the larger system became a key part of effective COVID19 management.

Team members who had been invisible and taken for granted, suddenly were recognized as visible and in demand. For example, housekeeping had essential infection prevention roles thus were key to managing bed availability as well as safety.

In some systems, an Incident Command Center met daily and sometimes twice to coordinate actions, keep patients and staff safe, and consider resource allocation.

The question is whether these changes are permanent as part of daily business, or applicable only in times of crisis?

Interprofessional teams, necessary to manage the complexity of COVID19, continuously monitored the daily flow of evidence to update standards, operating procedures, and practices. Each change had to be evaluated for impact on every part of the system and how the various roles would apply.

Interprofessional teams collaborated in caring for complex patients with COVID19 to attend to physical, emotional, social, mental and spiritual needs of patients, families and caregivers.

 While all team members helped patients and families cope with separation during traumatic circumstances, innovative nurses found ways to engage family with patients via window visits, social media, and multiple technologies  This was particularly evident when patients approached end of life alone, separated from family; nurses were the surrogate.

Communicate

Communicate, Communicate, and Communicate!

The third “C” word is one that always arises in times of crisis yet lags during routine times. Transparent, coordinated, respectful, and honest communications were evident in institutions who reported best practices even in the face of daunting circumstances and lack of resources.

 Innovative ways of maintaining communication safely such as virtual rounds, helped to communicate the synthesis of ever-changing evidence to guide practice, source personal protective equipment and other resources, and offer support to frontline caregivers who worked amid the risks, hour after hour.

Units convened interprofessional huddles when situations changed to realign shared goals, sort resources, and determine next steps. Each shift ended with debriefings of what went well, what we can improve, and what we learned to share with the team to keep the process going. 

Reflection

All healthcare professions share the story of COVID 19, and all suffer emotional exhaustion.  

Taking time to reflect does not come easily in the frantic reshuffling of priorities but can help to preserve the future of quality healthcare. 

Reflection helps us make sense of confounding experiences, to review contradictions, and to reconsider responses in future situations. Reflection is not a haphazard process we play over in our mind as we jog. 

It is a careful and analytical process that brings together what we know, interpreted within what we have done previously creating a pathway to deep learning that is key to changes in behavior and attitudes. This is a mark of a professional, a mindset of continuous learning to improve our being and doing (Horton-Deutsch and Sherwood, 2017).

Every healthcare worker remains an essential part of effective teams in managing the threats posed by the COVID pandemic, and all should be persons of the year.

It so happens, however, that last December the World Health Organization and the International Council of Nursing declared 2020 as the Year of the Nurse and Midwife. As part of the COVID19 management team, nurses have indeed been a 2020 headline story but in unexpected ways. Through this pandemic, nurses have demonstrated how they touch almost every microsystem in healthcare facilities and are key to coordination of the entire care team.

Nurses have essential roles in Interprofessional Collaboration, Coordination, and Communication.

Thinking back to those early days of pivot as the reality of COVID hit, what are the key moments that stand out in building resilient systems? Reflecting on the role of the three C’s, what stories have emerged in your system on how interprofessional teams made the difference?  What can you learn from these stories? What examples of communication, coordination, and collaboration can offer new ways to continue to move out of routine tribes and silos to maintain interprofessional relationships that we know contribute to better care, access, and healthier work environments?  What barriers limit Interprofessional teams from working to their maximum potential?  How do COVID19 stories illustrate reorganized roles and responsibilities to transform systems for better outcomes?

Make 2020 the year that we all collaborated, coordinated and communicated together through a global pandemic to change healthcare to make it better for now and forever.

References

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About the author: Gwen Sherwood, PhD, RN, FAAN, ANEF is Professor Emeritus at the University of North Carolina at Chapel Hill School of Nursing. She was co-PI for launching QSEN, the Quality and Safety Education for Nurses project to define a competency model to improve quality and safety, which she has taught globally. She has been a frequent faculty for the Interprofessional Education Collaborative and is editor of four books on safety and on reflective practice.

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