As she began her residency at the Brigham, Marina Zambrotta, MD, MEd, often thought of the advice her mother, a nurse, had given Zambrotta while she was in medical school: Listen to the nurses.
She carried those words with her daily — and nightly, as it turned out.
“I remember being on nights in the ICU as an intern at the Brigham and learning just as much, if not more, from my ICU nurse colleagues as I did from my attendings, fellows and co-residents,” said Zambrotta, now an internist with the Indian Health Service in Shiprock, N.M., and an affiliate physician for the Brigham.
So, when Zambrotta was awarded a medical education fellowship in her second year of residency and tasked with conceptualizing and designing a new medical education program, she didn’t have to think twice about her proposal: Invite nurses to share their expertise with residents in a more structured way.
That kernel of an idea turned into the Nurse-Doctor Co-Teaching Program, which pairs staff nurses with attending physicians to co-lead educational sessions on various clinical topics for residents and other interested staff. First launched as a pilot in the General Medicine Service (GMS) in 2019, the program has since expanded to Medical Oncology and the Emergency Department.
“There’s a historic hierarchy in medicine, and it’s something doctors get exposed to starting in medical school. We need to prioritize breaking down that hierarchy by listening to all of the valuable experience and knowledge that nurses have to share,” Zambrotta said. “It’s really important to emphasize this as early as possible in medical training so that interns who are told and expected to listen to their attendings also listen to and equally value nurses’ input.”
Marly Diallo, BSN, RN, a staff nurse in GMS on Braunwald Tower 14CD who has co-taught several sessions, said participating in the program provided an opportunity to expand her own skills while also strengthening interdisciplinary relationships on the unit.
“I enjoy teaching, and it’s something I do almost every day precepting new nurses, so I thought this was a good opportunity to do more of that and improve the way that we communicate as doctors and nurses,” she said. “As we get new interns and residents throughout the year, that mutual respect is something we always want to reinforce so that we continue to have a culture where we approach each other in the same way.”
Hospitalist Bill Martin-Doyle, MD, who co-teaches sessions on caring for patients exhibiting symptoms of alcohol withdrawal, agreed that the program has been a shining example of enhanced multidisciplinary collaboration.
“It was immediately apparent to me, right from the start, what a great idea this was and the kind of thing that makes you think, how come this hasn’t been happening the whole time?” he said. “There are so many clinical topics where we might have different viewpoints and understandings of the nitty-gritty details, and it’s been fantastic to get everybody in the same room and speaking the same language.”
In the process of preparing for and conducting the sessions with her physician co-instructors, Diallo said she felt it was an informative experience for both clinicians — and one that can ultimately enhance care in the long run. For instance, in co-teaching a session on arterial blood gas tests, Diallo said she received a greater understanding about the thought process behind a physician ordering the test and interpreting the results.
“For me, it wasn’t just about teaching residents. It’s a learning opportunity for all of us. Let’s say I’m back on the unit and another nurse or nursing student has a question about arterial blood gases, I feel like I can provide a more informed answer,” Diallo said. “It always comes back to the patients, too. The more I know, the better I can communicate with my patients about their care.”
‘We Insisted on Equality’
While the content of the sessions is rigorously evidence-based, the program seeks to cultivate a relaxed atmosphere and create a fun learning environment that bucks convention, explained Helen Shields, MD, a faculty member of the Division of Medical Communications and the Division of Gastroenterology, Hepatology and Endoscopy, as well as the program’s course director.
In place of dry PowerPoint presentations, attendees participate in interactive activities, including Family Feud-style competitions to test their knowledge and contests to redesign catheters. The sessions are also intentionally kept brief — 30 minutes, as opposed to the typical hour-plus format of an academic lecture — to keep everyone engaged.
But behind the breezy exterior is a serious commitment to achieving the program’s original vision of presenting nurses’ and physicians’ unique viewpoints, Shields said.
“The big value was showing the equality of the knowledge and skillsets, but we had to tease out what were the expert areas of the nurse versus the doctor, then unify them and link them — not just the nurse lectures here and the doctor lectures here. They go back and forth in a complementary manner,” she said. “We insisted on equality from the get-go, and the nurse’s name always comes first in the list of presenters as a sign of that respect.”
Madelyn Pearson, DNP, RN, NEA-BC, senior vice president of Patient Care Services, chief nursing officer and the Beth V. Martignetti Distinguished Chair in Nursing, said this kind of interdisciplinary exchange is invaluable to all members of a care team.
“Nurse-doctor co-teaching teams are one important way we can bring disciplines together, learn from one another’s perspectives and ultimately enhance the care we deliver,” Pearson said. “This kind of collaboration is more important than ever, given the intense challenges that we continue to face in health care.”
Holli Murray, MSN, RN, PCCN, a staff nurse on 14CD who co-taught the session on alcohol withdrawal with Martin-Doyle, said the program has helped improve collegiality between the two disciplines. While physicians and nurses may work on the same unit, differing shifts and rotations can mean that they don’t have much time to get to know one another. Coming together for these sessions provides an important opportunity to mingle in a more casual setting, Murray said.
“Anytime I can, I try to interact more with the doctors to build those relationships so that later I’m more comfortable speaking up about something,” she said. “I also don’t necessarily feel like I’m instructing the doctors, but I think it’s helpful for them to understand that, as a nurse, I might have different concerns around the patient’s safety and comfort.”
For Zambrotta, it has been exceptionally rewarding to see her original vision come to life. In addition to its expansion to units beyond GMS, the program has also been spun off into a Harvard Medical School course, “Nurse-Doctor Co-Teaching,” to train future medical educators in developing nurse-doctor co-teaching programs. (The next course will be held virtually on Sept. 23.) Zambrotta also hopes to expand the Brigham program to include additional allied health professionals as co-instructors.
“What I was hoping with the initial pilot study on GMS was that interns and residents would feel more comfortable seeking out knowledge and teaching from the nurses on the floor and, vice versa, that the nurses would feel comfortable going up to the interns and saying, ‘Hey, I have a question about this order,’” she said. “Rather than coming from a place of ‘one more page I have to respond to,’ it opens up a more friendly line of communication.”