A term you will hear a lot in nursing school is “the interdisciplinary team.” It wasn’t until I was working as a nurse in the ICU that I truly understood the importance of this team, who it entails, and the roles of everyone involved.

So in this article, we’ll be talking about the key components of the interdisciplinary team and how or when you would utilize each one of these team members for your patient.

Nursing Team Members

RN: The RN is the coordinator of care for the patient. It is the RN’s role to assess the patient, implement MD orders, and perform nursing interventions to move the patient toward achieving their goals…all while ensuring patient safety and taking steps to avoid complications.

LVN/LPN: The LVN/LPN has similar duties as that of an RN, and the scope of practice can vary greatly state-to-state. In some states, the LVN/LPN may be supervised by an RN. To see the scope of practice for LVN/LPNs in your state, simply google “LPN scope of practice _____” and type in your state.

Case Manager: One of the key roles of the case manager in the clinical setting is to start working on the patient’s discharge needs as soon as they are admitted. Will they need to go to a skilled nursing facility or rehabilitation? Will they need specific equipment at home or even a home health nurse? In addition, case managers work with patients to develop long-term plans for managing chronic conditions in hopes of avoiding frequent hospitalizations. They also act as a liaison between patients and insurance providers as a way to optimize patient care while also controlling costs.

  • Example of when to call the case manager RN: In most cases, the patient will have a case manager from the outset if one is needed. But if your patient, who is about to be discharged with both arms in casts, says “I live alone, I have no support system and I am the sole caregiver for my children,” you’re going to be calling the case manager to ensure the patient gets what they need for a safe and timely discharge.

Palliative Care RN: These nurses work with patients to ensure pain relief and comfort are top priorities of care. Often confused with hospice care, palliative care can include curative treatment for the patient.

  • Example of when to call the palliative care RN: A typical situation is a patient who is critically ill who has a very poor prognosis. The palliative care RN can talk through options with the family, educate them on the role of palliative care and hospice, act as a case manager for issues surrounding end of life, and provide resources and guidance with complex decision making.

Hospice RN: Similar to the palliative care RN, hospice nurses work to provide comfort and pain relief at end of life. The key difference is hospice patients are not pursuing curative treatments of any kind. Some patients will receive hospice care inside the hospital (if symptoms cannot be managed at home), but most go home or to a skilled nursing facility. The hospice RN works to ensure the family and patient have the necessary items needed for their care at home, such as hospital beds, oxygen (if using) and medications.

  • Example of when to call the hospice RN: The patient or DPOA no longer desire to pursue treatment and wish to take the patient home or shift the plan of care to comfort measures only.

Stroke Coordinator RN: Hospitals that are Designated Stroke Centers will have a nurse who works to ensure stroke protocols and best practices are followed on all stroke patients.

  • Example of when to call the stroke RN: Most likely you won’t have to. They’ll call you to ask you the patient’s NIH score (among other things). They’re incredibly valuable resources and so very knowledgeable about stroke care. Count yourself lucky if your hospital has a dedicated stroke RN.

WOCN: The wound-ostomy-continence nurse is a specially trained nurse in all things wounds and ostomies. These RNs develop protocols for pressure ulcer prevention, stage pressure ulcers and develop plans of care for patients who have pressure injuries. They also work with patients who have ostomies and do a lot of patient education for new ostomates.

  • Example of when to call the WOCN: A common scenario is the development of a new pressure injury or you have a newly admitted patient who comes in with an existing wound. If your patient has a new ostomy, the WOCN will already be consulted. For an existing ostomy, you may need to call them for complex issues such as skin breakdown around the ostomy site.

Dialysis RN: Typically the dialysis RN is employed by a dialysis company such as Davita, and contracted to provide in-patient dialysis in the hospital setting.

  • Example of when to call the dialysis RN: Most of the time, they’ll call you or simply show up to perform dialysis. If you have a newly-admitted patient, try to find out where they get dialysis and on what days. It’s nice to call the center and let them know so they can anticipate performing inpatient dialysis as needed. These nurses also get to know their patients, so when a patient doesn’t show up for dialysis, they tend to worry.

Physician/Advanced Practice Team Members

Physicians: Physicians are the ones diagnosing and developing treatment plans for your patient. This could be a resident, hospitalist (an MD employed by the hospital) or a specialist. When you are assuming care of a patient, it’s important to know which physicians are on the patient’s care team so you know who to call (and who you call can vary depending on what is going on with the patient).

  • MD: Medical doctor
  • DO: Doctor of osteopathy (Same level of authority as MD)
  • Intensivist: A critical care physician who works with patients with complex illness or who are in the ICU. Usually the intensivist is a pulmonologist but this can vary.
  • Specialists: Name a body system and there’s a specialist who has dedicated years (and years and years) of study to it. If your patient has specialists on the care team, you typically will alert him/her to any changes in condition as well as the attending physician or hospitalist.
  • Surgeon: Surgeons can be general surgeons or specialize to very specific areas. You’ll notify the surgeon if there are any issues related to the patient’s specific surgery.
  • Anesthesiologist: This is a specialist that administers anesthesia to patients for surgery but will also perform pain management procedures such as epidurals and other types of blocks. Most of the time, calls to the anesthesiologist will stem from the patient’s time in PACU, but could also extend further if specific orders are in place (such as those with a long-acting block or a PCA).
  • Example of when to call the physician: When you have a concern about your patient, notice a change in condition, have questions about an order, or need to report any instances where you are unable to implement MD orders (such as held medications or patient refusals).

PA or NP: Your facility may utilize PAs (Physician Assistant or Physician Associate) or NPs (Nurse Practitioners) who are advanced level practitioners ​​who can assess patients, develop plans of care and write orders. Many times you will be calling the NP or PA who can handle all but the most complex of issues (generally speaking).

Other Disciplines

Physical Therapist: The PT works with patients to improve strength and mobility. They also assess patients for any mobility aids that may be needed for discharge. In some facilities, PTs perform complex wound care.

  • Example of when to utilize PT: PT will be utilized for patients who have orthopedic surgery, have been on bedrest for even a short period of time, have suffered a stroke, are intubated in the ICU or for anyone who is a significant fall risk due to weakness or gait issues. The physician or NP/PA will need to write an order for physical therapy, but that doesn’t mean you can’t advocate for it!

Occupational Therapist: The OT works with patients to maximize functional capacity.

  • Example of when to utilize OT: You’ll see occupational therapists used the most with patients who’ve had a stroke or who’ve had significant surgeries such as back surgeries that require very specific activity limitations or long-term braces.

Respiratory Therapist: RTs work with patients who have respiratory disorders requiring intervention. They manage ventilators, assist with bronchoscopies, and manage the airway during codes. RTs also work with patients to administer standard inhaled medications and perform respiratory assessments.

  • Example of when to call the respiratory therapist: The most common scenario is the patient with asthma or COPD exhibiting wheezes or saying, “I’m having difficulty breathing” so you call RT to administer the bronchodilators and perform a focused respiratory assessment.

Speech Language Pathology Therapist: In the clinical setting, SLPs work almost exclusively with stroke patients and any patient who has dysphagia. They perform assessments to determine the level of the dysphagia and prescribe specialized diet textures and feeding guidelines to minimize aspiration risk and maximize nutrition.

  • Example of when to utilize the SLP: If your patient has had a stroke or shows any signs of swallowing difficulty, you’ll want to advocate for the physician to write orders for a SLP consultation.

Dietician: Dieticians in the clinical setting work to maximize nutrition for patients, especially those who come in malnourished or who have complex illness. In addition to making recommendations for nourishment boosters, dieticians also determine the proper tube feeding formulas and rates for those who rely on enteral nutrition. They also work to educate patients who must follow specialized diets, especially when newly diagnosed (such as patients with diabetes or renal failure).

  • Example of when to utilize the dietician: If your patient is on tube feeding, has a poorly managed or newly-diagnosed condition such as diabetes, or is underweight, you’ll want to make sure there’s an order for a dietician consult in the chart.

Social Work: Social workers (LCSW or LMSW), help patients and families navigate the healthcare system, connect them to resources that may help them manage psychosocial concerns such as homelessness, assist them in managing complex illnesses, and also provide emotional support and counseling during times of crisis.

  • Example of when to utilize the hospital social worker: Anytime your patient has complex psychosocial issues including substance abuse disorder, you’ll want to make sure the MD has an order for social work in place.

Spiritual Care/Chaplain: Many acute care settings employ spiritual care advisors or chaplains who work with patients and families to ensure their spiritual needs are being met.

  • Example of when to call the spiritual care team: The most likely scenario is you have a patient who is near end-of-life or who has received a devastating diagnosis.

Supportive Roles

CNA or PCT: These individuals (often called “unlicensed personnel”) perform a variety of vital patient care tasks. In some hospital settings, the PCT is a hybrid role of “unit secretary” and CNA, which expands the role even further. PCTs or CNAs will help patients with ADLs, may obtain vital signs if facility allows, set up trays at mealtime, bathe patients, answer call lights and so much more. As the RN or LVN/LPN you can delegate tasks to unlicensed personnel, but you must follow the guidelines of appropriate delegation.

  • Example of when to utilize the CNA or PCT: Your patient needs help with positioning, toileting or feeding (provided it is safe to do so).

Interpreter: If your patient does not speak your language fluently enough to understand the plan of care, a certified medical interpreter must be used. Sometimes the interpreter will be in-person, but could also be via a phone line or video chat.

  • Example of when to utilize an interpreter: Your patient is Punjabi speaking and you need to perform an assessment or provide patient teaching.

Does your facility utilize these team members differently or ones I didn’t mention? I’d love to learn more!

References:

NurseRegistry. (2019, February 19). What is the difference between an RN and an LVN? NurseRegistry. https://www.nurseregistry.com/blog/difference-between-rn-and-lvn/

Purdue University Global. (2021, January 14). What is a nurse case manager? Purdue University Global. https://www.purdueglobal.edu/blog/nursing/what-is-nurse-case-manager/

Schneider, R. (2021, July 30). Palliative care nurse careers and salary outlook. NurseJournal. https://nursejournal.org/careers/palliative-care-nurse/