Reid-Ponte: Can you start by telling me about your program of research?
Manojlovich: My program of research seeks to advance patient safety by improving communication among interdisciplinary teams. Communication is usually defined as information exchange between a sender and a receiver, but I view communication more broadly as the development of shared understanding, which is based on the cognitive and social sciences. Through my own practice as a CCRN-certified ICU nurse, I realized early on that communication among healthcare team members was critical to high-quality, safe patient care. I've learned through my research that each member of the team sees and hears things through his/her own lens. Each of us constructs our own reality of what is happening in a given situation. The aim of my research is to establish mechanisms for team members to build a shared understanding of what's happening in a clinical situation.
I'll give you an example from one of my studies. In a feasibility study aimed at testing the utility of a novel method called "video-reflexive ethnography," we videotaped interactions between clinicians on an inpatient medical-surgical unit. In 1 case, a nurse who was caring for an oncology patient with an extreme case of thrush reported the situation to the physician. The physician immediately ordered a higher dose of nystatin to increase the likelihood of diminishing the level of thrush. The nurse then asked the physician to also order a powerful opioid for pain.
When the nurse and the physician reviewed the videotape together, they each realized that from their own lens they were approaching the situation appropriately: the physician ordering medication to treat the disease and the nurse requesting medication to treat the patient's pain. This was an "ah-ha" moment for both clinicians-a shared understanding that ultimately resulted in a more inclusive, holistic approach to the patient situation and to their team's communication effectiveness. Video reflexive ethnography was developed by Dr Rick Iedema, PhD, a social scientist from Australia.
Reid-Ponte: What led you to this important work?
Manojlovich: Soon after graduating from a local community college (part of a larger university system), I began practicing in an inpatient ICU. I made an almost fatal error for one of my patients. It was a defining moment for me in my life and my career. I asked myself whether nursing was the right place for me to be. After much reflection and now many years later, I know that my error was not only a function of my actions. None of us wakes up in the morning thinking we will harm someone when we are at work that day. Errors happen every day and most often are a result of system problems, not the individuals or teams of people who make the errors.
I realized I needed to attain my graduate degree and subsequently attended the Rush University program from associate degree in nursing to MS program and became a clinical nurse specialist in the ICU of the University of Chicago Medical Center. That role was a milestone in my career.
I later moved to Michigan and taught as a clinical instructor at a community college in Dearborn. I soon realized that although I loved teaching in the clinical setting, I would not be able to keep the pace of such a physically and emotionally draining job into the 2nd half of my working life. More importantly, I saw many opportunities to improve what happens in interdisciplinary teams to ensure patient safety.
Because of these reasons, I pursued a PhD in the school of nursing at the University of Michigan, where I worked most closely with the late Prof Heather Laschinger, PhD, RN, FAAN, who was the dominant researcher nationwide in workplace empowerment. I felt so fortunate to have been guided by this exemplary nurse scientist.
Reid-Ponte: Tell me about your funding and current projects
Manojlovich: My major funding source has been the Agency for Healthcare Research and Quality. I have had R01 and R03 funding, and recently I submitted another R01. I work closely with a medical anthropologist, Molly Harrod, PhD, at the Ann Arbor VA, as well as another nurse researcher Sarah Krein, PhD, RN, who has a joint appointment at the Ann Arbor VA and the University of Michigan. Of course, I work with physician colleagues as well. In my current study, I am assessing the usefulness and potential impact of video reflexive ethnography to improve medication education delivered by pharmacists to cancer patients taking oral oncolytic therapy. Up to 30% of patients reported medication nonadherence to oral oncolytic therapy with symptoms as the primary reason, despite receiving education from oncology clinicians on evidence-based symptom management strategies. We do not know whether symptom management strategies are being taught effectively or how well patients incorporate strategies into their daily lives. Video reflexive ethnography may help us improve the education patients receive so that they adhere to an oral oncolytic therapy regimen.
My major goal is to develop novel methods to intervene in the communication process within teams and dyads. In my view, which is substantiated by evidence, most medical errors have poor communication as their root cause.
I mentioned earlier the work of Rick Iedema, PhD, a social scientist who designed and tested the video reflexive ethnography method for changing clinical practice. This method has the power of potentially changing how clinical care happens. It has the potential to change our paradigm of working together in teams.
Reid-Ponte: There certainly is user-friendly technology that could help teams learn together, whether it be short podcasts or agreed-upon tapings of interactions followed by quick debrief sessions, or even the headset technology of learning in a virtual realm.
Manojlovich: Absolutely. We need to use the technology to innovate. One example in the literature1 has nurses and physicians agreeing to be videotaped while engaging in infection control practices. Through watching videotapes in teams, clinicians learned about subtle (eg, scratching an itch on one's face with gloved hands) and not so subtle (eg, carrying a clipboard into an isolation room, putting it down, and then carrying it out again) differences in approaches used while caring for patients in isolation. Using this video-based method, nurses and physicians can work together in teams to create a best practice standard based on the literature and the practice. It can really be quite a powerful yet simple way to learn and set standards. It's also applicable to developing best practices to interacting with patients, families, and teams in the context of a given unit, practice, or organization.
Reid-Ponte: What would you want JONA readers to consider about this important area of health services research, practice, and education?
Manojlovich: We need to change the paradigm of communication that has existed for more than 50 years in healthcare delivery and think about communication as more than information exchange. We need to be more proactive and less reactive by advancing important evidence-based strategies for effective communication within teams all aimed at meeting the needs of a highly diverse patient population and their families. The competing and complex demands of clinicians and support staff put leaders in a crucial role of ensuring that communication standards and systems support these teams and position them to have every opportunity for shared understanding and open, effective communication, which increases the likelihood of high-quality, safe patient and family-centered care.
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