Nurse-Physician Communication for Patient Safety

1. Nurse –to-Physician Communication Connecting for Safety MEDHEALTH CAIRO /EGYPT HOTEL SAMIRAMIS INTERCONTINENTEL 12-13 MARCH 2014 10/22/2014 1

2. 10/22/2014 2  Communication problems can affect everything from business and politics to military operations and personal relationships , and in health care facilities  Poor communication between nurses and other medical practitioners can be leading not to grave errors influencing patient recovery time and even their mortality.

3. 10/22/2014 3 Hospital nurses do not work in isolation ; rather they collaborate and interact with other members of the healthcare team to provide quality safe patient care. Nurses and physicians make up the largest group of healthcare providers, and both daily confront complex problems with no easy solutions. However, communication between the professions does not flow as it should.

4. 10/22/2014 4 In a study on outcomes of intensive care, communication between nurses and physicians was the single factor most significantly associated with excess hospital mortality.

5. 10/22/2014 5  Administration of medications is primarily a role of nurses , and the second largest group of medication -related errors has been attributed to administration of drugs by nurses.  Most medication errors are due to unsafe systems rather than to mistakes by individuals, but they tend to be underreported.

6. 10/22/2014 6  As part of its National Patient Safety Goals, The Joint Commission mandates health care organizations to improve communication effectiveness among caregivers by reading verbal orders , creating a list of abbreviations NOT to use, timely reporting of critical tests and critical results and managing handoff communications.  each aspect is still a struggle for many caregivers, including nurses.

7. Communication in patient handoffs The handoff of patients is a chief area of concern. In a 2008 survey conducted by the Agency for Healthcare Research and Quality (AHRQ), 49% percent of hospital staff members reported that “important patient-care information is often lost during shift changes ,” 42% percent agreed that “problems often occur in the exchange of information across hospital units ” and 41% percent admitted that “things ‘fall between the cracks’ when transferring patients from one unit to another.” 7 10/22/2014 7

8. 10/22/2014 8  It’s a human factors problem,”  “ The human brain has to absorb information on 8 - 16 patients--sometimes even more--and it can’t keep that much information in short-term memory

9. 10/22/2014 9  Reviewing over 11 years of data pertaining to nursing handoffs from medical facilities across the United States for a study published in the American Journal of Nursing in April 2010.  found that minimal research is available on best practices, despite The Joint Commission’s requirements .

10. Communication between nurses and physicians 10/22/2014 10  While communication errors during nurse-to-nurse handoffs are common, exchanges between nurses and physicians also contribute to medical challenges.  In the intensive care setting, 37% percent of errors were linked to verbal communication challenges between physicians and nurses, according to a 2003 report in Quality and Safety in Healthcare .

11. 10/22/2014 11  And in a 2007 study published in the American Journal of Critical Care , Nursing, stated that communication between nurses and physicians may be the most significant factor associated with excess hospital mortality in critical care settings.

12. 10/22/2014 12  High workload,  Interruptions,  lack of leader support , contributing factors in communication difficulties between nurses and physicians, as well as interpersonal factors , like hierarchical differences and nurses not being able to articulate their contributions to patient care.

13. 10/22/2014 13 In their 2007 publication, Improving Handoff Communication , The Joint Commission drafted several guidelines that nurses can use to improve interactions with physicians , including:  Addressing the physician by name ;  Having each patient’s information and chart immediately available;  Clearly expressing concerns about the patient and reasons for those concerns; suggesting a follow-up plan; focusing on the patient’s problem rather than extenuating circumstances;  acting professional, not aggressive;  and continuing to monitor the patient problem until a resolution has been reached

14. 10/22/2014 14  Social science analyst for patient safety at AHRQ, suggested practicing “ closed loop” communication, used in roughly 500 hospitals across the United States to improve communication. This method involves acknowledgment and repetition.  After a physician gives an order, such as the administration of medicine, a nurse repeats, receives confirmation and, when administering the medication, repeats once more.  “If there’s a disconnect there, you recognize the disconnect and you address it immediately,”

15. Causes of the Communication Disconnect Causes of the Communication Disconnect 10/22/2014 15 Healthcare is by its very nature complicated, dynamic, and unpredictable. Patient needs often arise unexpectedly , requiring unplanned communication among busy healthcare providers.  Professionals from a number of different disciplines frequently care for a patient at different times of day , sometimes at different locations , which limits the opportunities for face-to-face or other synchronous communication.  In addition, several factors make effective communication between nurses and physicians particularly difficult to achieve .

16. 10/22/2014 16 Historic Tension and Hierarchy The relationship between nurses and physicians has been characterized historically by hierarchy, power differential , and avoidance of open disagreement (Stein, 1967).  Fundamental problems persist in many healthcare environments, including disruptive behaviour by physicians , attitudes about nurses , and power and gender issues (Sirota 2007).  Patient safety experts have pointed out the dangers that are associated with strict hierarchies in which individuals refrain from communicating concerns to those higher in the decision-making structure (Sexton, et al., 2000; Walton, 2006), healthcare providers will need to collaborate and function effectively on teams.

17. 10/22/2014 17 Professional education for nurses and physicians sets the stage for divergent views and perspectives.  Nurses and physicians are trained to define well-being and its attainment differently (Arford, 2005).  They taught to communicate very differently .  Nurses are trained to relate information in narratives,  whereas physicians are trained to provide the most concise, top-level communiqué possible.  The fact that nurses and physicians are trained to communicate so differently can be a source of ongoing friction ( Joint Commission, 2009).

18. 10/22/2014 18  In addition, nurses and physicians are trained under distinctly separate care models, which sometimes involve the use of different terminology to describe similar events .  An essential first step was developing a common language for describing the events.

19. Existing Inefficient Communication Processes 10/22/2014 19 The existing infrastructure for communication between nurses and physicians is often inefficient, leading to reduced staff productivity , frustration, and reduced staff satisfaction . In many organizations, nurses are challenged to identify which physician to contact and the preferred means with which to do so. One of the most common barriers to communication with physicians cited by a sample of 375 nurses working in long- term care facilities in Connecticut was difficulty reaching physicians and receiving call backs from them ( Tjia et al., 2009).

20. 10/22/2014 20 A study of communication between nurses and physicians in an urban hospital found that approximately 40 %percent of the time that nurses spent communicating with physicians was “ problematic time,” in which they searched for contact information or attempted, but failed, to communicate with the correct provider (Dingley, et al., 2008). These inefficient processes can hinder collegial and collaborative relationships between physicians and nurses .

21.  In the current system, nurses often must hunt for an on-call list , place a call, and wait for a call back.  In the meantime, they may be called away from the nurses’ station to attend to patient needs or other tasks.  In addition, if a manual on-call list is used, the nurse may mistakenly contact a physician who is not currently responsible for coverage.  If there is a significant delay or a failure to respond , he or she may escalate the problem to the nurse manager, who may intervene with a call to another physician or a department chair, but in the interim the patient experiences a delay in care—which may result in worsening of his or her clinical condition, staff frustration, and reduced productivity 10/22/2014 21

22. Solutions to Bring Nurses and Physicians Togethe r 10/22/2014 22 A three-pronged strategy is needed to improve ineffective communication between nurses and physicians:  Culture change,  Use of structured communication tools,  And supportive technology. No one of these interventions, no matter how successfully applied, is sufficient. All three must be effectively implemented to optimize nurse- physician communication and avoid communication gaps that can lead to patient harm .

23. Culture Change 10/22/2014 23 The most fundamental intervention for improving nurse- physician communication is :  Fostering an organizational culture that is patient-centric, safety-focused , and supportive of open communication and teamwork .  Leaders play a crucial role in culture transformation by setting expectations, enabling and investing in specific structural supports, and modelling desired behaviours.

24. As a means for improving nurse-physician : communication , the Joint Commission recommends encouraging physicians to view their patients as primary customers and their role as partners in delivering the most effective and safe care (Joint Commission, 2009). Focusing on the patient can bring purpose and meaning to the work of all clinicians and help reinforce the natural synergy between the nurses’ and physicians’ roles (Bujak & Bartholomew, 2001) . 10/22/2014 24

25. 10/22/2014 25 Leaders can support open communication and teamwork through several interventions:  First step is ensuring that adequate Policies are in place for addressing disruptive physician behaviour , a significant barrier to effective communication .  Second is Flattering the hierarchy within the organization and fostering respect among the various disciplines providing patient care.  Regular teaching experiences provided by nurses for physicians and vice versa can help to personalize the nurse-physician relationship (Bujak & Bartholomew, 2011 ).  In addition, specifically addressing the conflict between nurses and physicians can help prevent negative interpersonal dynamics (Joint Commission, 2009).

26. 10/22/2014 26 A third important intervention for open communication and teamwork is :  Fostering the empowerment of nurses: By facilitating continuing education , participation on multidisciplinary committees , pursuit of specialty certification, and focused communication training, leaders can support nurses in communicating more confidently with physicians and other health professionals. Organizational leaders should consider pursuing Magnet® designation as a means for improving the work environment for nurses. Nurses who work in hospitals that have achieved Magnet designation report higher quality relationships with physicians than peers who work in hospitals without Magnet status (Schmalenberg & Kramer, 2009).

27. 10/22/2014 27  Finally, creating interdisciplinary patient care teams with a designated team manager sets the stage for teamwork and fosters improved communication.  For example, an advanced practice nurse can serve as team manager; as such he or she is accountable for fostering timely communication between all care providers and the patient (Joint Commission, 2009).

28. Structured Communication Tools 10/22/2014 28 Specific communication tools have proven successful at improving communication among care providers. Developed by the Department of Defence and the Agency for Healthcare Research and a Quality Team, STEPPSteamwork ) that focuses on the ) development training program of four core competencies:  leadership,  situation monitoring,  mutual support,  and communication (Agency for Healthcare Research and Quality, n.d.; Joint Commission, 2009). Pratt, et al., 2007 ).

29. 10/22/2014 29 SBAR (Situation, Background, Assessment, and Recommendation )  Is a structured communication tool that standardizes communication between health professionals (Institute for Healthcare Improvement, 2011).  It can be especially effective when a nurse is contacting a physician with a concern about a change in patient status.  By clearly spelling out his or her concerns , observations , interpretation , and recommendations , the nurse using SBAR provides the physician with a more complete picture of the clinical situation than might be the case without the tool.  In this way, the use of SBAR can prevent the scenario in which the physician underestimates the significance of a clinical finding conveyed via telephone .

30. 10/22/2014 30  Similarly, tools such as a daily goals worksheet can be helpful in bridging the communication gap between busy nurses and physicians.  Use of this tool in the ICU was associated with a significantly improved understanding of patient care goals among both nurses and physicians—and shorter ICU stays (Narasimhan, et al., 2006).

31. Supportive Technology 10/22/2014 31 Technology solutions are essential for supporting effective communication between nurses and physicians. Two types of solutions are available:  tools that enable a particular aspect of communication and software-based communication platforms that coordinate and standardize clinical communication. both types of solutions are essential for effective nurse-physician communication. .

32.  To communicate effectively, clinicians must have reliable, secure communication tools .  Email, text messages, and notes in the electronic medical record (EMR) facilitate asynchronous communication between nurses and physicians.  An advantage of asynchronous communication, or communication between individuals who are not present at the same time, is that it may reduce interruptions, which have been shown to increase medical errors (Westbrook, et al., 2010) . 10/22/2014 32

33. 10/22/2014 33  Other tools facilitate direct, synchronous communication between nurses and physicians.  A wireless, voice-controlled communication system enables nurses to contact physicians or other staff located within the hospital while remaining at the bedside.  Worn as a badge pinned to the uniform or lab coat , the device can also send secure text messages and mobilize care teams. Use of H andheld Phones also allows nurses to remain at the bedside with the added benefit of being able to place calls to individuals outside the hospital .

34.  The combination of a communication platform that standardizes contact through reliable processes and secure, effective communication tools streamlines communication.  For example, pairing a communication platform with handheld or smart phones allows nurses to quickly contact physicians—and await return calls—without leaving the bedside. 10/22/2014 34

35. Conclusion 10/22/2014 35 The problem of ineffective nurse-physician communication is both common and complex.  The problem of ineffective nurse-physician communication is both common and complex.  Multiple interrelated factors propagate the dynamic, which has clearly documented adverse effects on patient safety and other outcomes.  Multiple interrelated factors propagate the dynamic, which has clearly documented adverse effects on patient safety and other outcomes.  Improving organizational culture, using structured communication tools, are critical for addressing effective nurse- physician communication.  Improving organizational culture, using structured communication tools, are critical for addressing effective nurse- physician communication.  All three solutions are necessary for true improvement.