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The woman had come in for a kidney transplant. Her nurse knew that the sort of immunosuppressants given to prepare the patient for surgery could lead to complications, so she watched her charge closely. The two ended up talking about … contraception choices.

"They were the sort of questions she would never have asked her doctor," recalled Judith Lewis, RN, editor of National Academies of Practice Forum: Issues in Interdisciplinary Care and associate professor of nursing and director of information systems in the School of Nursing at Virginia Commonwealth University, years after the conversation. "But it was easy to talk to me; I didn't have that physician's mystique. It was another example to me of how nurses can do things for patients that physicians can't."

Interdisciplinary approaches to care are critical to good patient outcomes in the 21st century, Lewis said. When a team of several physicians, physical therapists, respiratory therapists, nutritionists, nurses, social workers, occupational therapists, chaplains and counselors is working on one case, each member has to talk to one another and know exactly where he or she fits into the overall care model.

The National Academies of Practice, a Washington, D.C.-based organization made up of 10 academies that promote interdisciplinary models of health care (the 10 care professions are social work, dentistry, veterinary science, nursing, podiatry, psychology, medicine, optometry, osteopathic medicine and pharmacy) has been raising awareness of overall care since 1981.

But, simple as it sounds, "talking to each other" still doesn't happen often enough, said Jean Ann Seago, Ph.D., RN, assistant professor at the University of California, San Francisco School of Nursing.

"Nurses tend to talk to doctors or other nurses, while other specialists tend to stick to members of their own fields," Seago said. "We just don't talk enough across the disciplines; even if that respiratory therapist is right there in front of you, you'd rather talk with someone you're comfortable with, who speaks the same jargon and understands medical care the way you do.

"Hospitals today are huge places where you're not going to know everybody, especially those who belong to other disciplines. But different members of a team need to talk about the patient. It's critical."

In order to keep lines of communication open, hospitals need to organize committees and meetings with representatives from several fields. Disciplinary territoriality, or "silos" of specialization, as Seago calls them, only increases the chances of error. Following a set procedure-writing orders, keeping logs up to date and legible, even having everyone speak English when discussing work-will help cut down on errors.

Such approaches figure prominently in hospice and home care, transplant operations, foster services, hospitals and many other areas that require various specialties to act as a coherent whole for effective patient outcomes. Nursing has evolved right along with this model of care in recent decades, Lewis said.

"I liken it to a child growing up. Our profession was very dependent early on, very passively doing whatever the grown-ups said. Then came the teen-age years: As RNs got more educated, they started demanding different models of care and more responsibility, whether they were ready for it or not. Now we've reached the adult stage, not independent, but interdependent-working as part of a team for the total benefit of the patient."

An RN's contribution to a well-rounded team involves his or her capacity to straddle two worlds: the medical and the social, said Sarena Seifer, MD, administrator for Community-Campus Partnerships for Health, an interdisciplinary, service-learning educational program affiliated with the University of Washington-Seattle, the UCSF Center for Health Professions and Health Professions Schools in Service to the Nation, a nationwide initiative to build partnerships between health professions schools and communities.

As part of Seifer's program, students in different disciplines worked at a Seattle homeless shelter for men run by the Salvation Army. More so than those in other fields, the RNs could address the men's concerns about alcohol and drug abuse and other issues, in language that was medically sound but accessible.

"Nurses are the best at translating this important information into lay discussions, because they have that clinical background but are still very approachable," Seifer said. "That adds value to any team. The other students-future pharmacists, dentists, physicians-learn a lot from nurses' rolling up their sleeves and getting down and dirty with a patient. They learn you don't have to hide behind a white coat or clinical lingo."

Nurses, in turn, learn from social workers how to maneuver bureaucratic hurdles and from pharmacists which new drugs to investigate, and so on. Such teamwork and burden-sharing has led managed care, a model of belt-tightening and (in theory) maximizing efficiency, to embrace interdisciplinary approaches.

"Managed care has brought a focus on cost benefit, on value for the dollar, and nurses are a good value," Lewis said.

Part of a wider cultural shift, this new appreciation also has led to changes in the perceived role of nurses and other care providers. Even something seemingly as minor as changing the wording in government health care legislation from "physician" to "provider" or "clinician" (which Lewis helped pioneer as a member of an advisory committee to former Secretary of Health and Human Services Donna Shalala) makes a big impact, because it underscores that now not only doctors can prescribe medication.

This, in turn, can result in a backlash: a redoubled effort to police disciplinary borders. Witness the hostile reaction of many physicians to the emergence of the nurse practitioner as a primary caregiver.

"Where the model breaks down is when people are not explicit about the practice, about what the team is doing, and toes get stepped on," Seifer said. "You need to be very explicit with your team about duties: Now that we've hired a new nurse practitioner, how does my own role change? Don't just assume you know what the new social worker will be doing."

The hospice model of care, with nurses, social workers, chaplains, counselors, physicians, volunteers, home aides and the patient's loved ones working in tandem, shows how such teamwork can work miracles on a daily basis, easing a family's burden in a time of personal tragedy: the death of one of its members.

"The essence of hospice care is interdisciplinary; it's the gold standard. We must function as a team. It isn't and shouldn't appear to be nurse-driven," said Linda Blum, PHN, RN, clinical supervisor at Sutter Visiting Nurse Association & Hospice in San Mateo, Calif., a nonprofit home-based and hospice care agency headquartered in Emeryville, Calif.

"Naturally, our territories overlap and sometimes you can get your toes stepped on," Blum added. "You've got to wear boots, so to speak. But on the other hand, there is some strict division of labor."

One possible drawback to the interdisciplinary team model Blum does see: confusion over billing. Insurance providers must keep a flexible structure to pay so many different specialists all serving the patient.

But Hedy Dumpel, RN, chief director of nursing practice and patient advocacy at the California Nurses Association, sees more serious problems with interdisciplinary care-too much blurring of the nurse's role could lead to a fraying of the vocation itself, and the undoing of some hard-fought rights and respect.

"This is bringing about the de-skilling of care and of the nursing profession," Dumpel said. "It intensifies work and leads to an underutilization of nursing resources. This can result in nurses burning out and leaving the profession altogether."

In response, Seifer said, "I start with the patient and work backward from there. Who has the skills to address these concerns? That's the driving force, not 'I have XYZ responsibility and only I can do this.' People do get defensive about their profession when disciplinary boundaries start to blur, but if someone at that moment can do the job for the patient, then why not do it? Redundant skills only make for better care."

Things have come a long way from the days when nurses were not even allowed to take a patient's blood pressure readings, but deferred to physicians in all things medical, Lewis said. Today, she advocates a different model-nursing and medical students learning together in a classroom, understanding each other's roles before the disciplinary boundaries become too rigid.

"In the past, some have looked at it in terms of 'a nurse can do 50 percent of what a doctor can do,' or 'a doctor can do 70 percent of what a nurse can do,' " Lewis said. "But the interdisciplinary approach gets you away from looking at the numbers; you have two complementary providers whose roles somewhat overlap. The patient wins: He gets 130 percent care. No provider has to be all things to all people."