Nurses, Communication and Patient Safety
By Brook Larios, contributor
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 especially perilous, leading not only to distrust and resentment among cohorts, but also to grave errors influencing patient recovery time and even their mortality.
Clear communication is imperative to patient safety and workplace success, and there are several practices nurses can employ to achieve it.
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. Yet each aspect is still a struggle for many caregivers, including nurses.
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.”
“It’s a human factors problem,” said Lee Ann Riesenberg, Ph.D., RN, director of medical education research and outcomes, Christiana Care Health System, Newark, De., and research assistant professor, Jefferson School of Population Health, Thomas Jefferson University. “We rely on the human brain to absorb information on eight to 16 patients--sometimes even more--and we can’t keep that much information in short-term memory; it’s not possible.”
Riesenberg reviewed 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. She found that minimal research is available on best practices, despite The Joint Commission’s requirements.
In addition to using the many technological solutions that are available, she pointed out that nurses must set aside time to ask and answer questions during handoffs. She also cited the need for structured handoff training prior to entering the nursing field.
“We, by and large, have an apprentice model, where you watch other nurses give a report and then you emulate what they’ve done,” Riesenberg contended. “You may have watched a good example, a bad example or multiple ones and then picked your own system. That’s not an educationally sound way to learn how to give a safe, efficient and effective report.”
Communication between nurses and physicians
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.
And in a 2007 study published in the American Journal of Critical Care, author Milisa Manojlovich, Ph.D., RN, CCRN, assistant professor at the University of Michigan School of Nursing, stated that communication between nurses and physicians may be the most significant factor associated with excess hospital mortality in critical care settings.
One way for nurses to mitigate these issues, according to Manojlovich, is to focus on the importance of what they bring to the health care setting and speak up when necessary.
“Nurses need to think about those unique contributions they make and make sure doctors and others know about what those are,” she said.
Manojlovich cited high workload, interruptions, lack of leader support and the inability to effectively role model as 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.
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.
James B. Battles, Ph.D., social science analyst for patient safety at AHRQ, suggested practicing “closed loop” communication, a key facet of the organization’s TeamSTEPPS curriculum used in roughly 500 hospitals across the United States to improve communication. This method involves acknowledgment and repetition. For instance, 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,” said Battles.
Barbara Sorbello, Ph.D., RN-BC, NEA-BC, administrative director for professional development at Bon Secours St. Francis Medical Center in Midlothian, Va., recommended using SBAR (Situation, Background, Assessment, Recommendation), a standardized way of communicating with physicians, to minimize error.
“It organizes your thinking in terms of what’s going on right now, the background of the situation and what the purpose is of the communication so you have effective handoff,” she said, adding that crafting your communication before approaching a physician can save time and increase credibility.
Listening and accepting responsibility for effective communication
Sorbello also suggested relationship building for enhanced communication and learning how to address conflict. Of equal importance, she said, is exercising authentic and intentional listening.
“We all multi-task. [We need to] really zero in on what the patient is saying or what my colleague, this physician, is saying, or a family member is saying,” she said. She encourages nurses to stop multi-tasking long enough to understand both the verbal and non-verbal messages, allowing themselves to “be really authentic, here in the minute.”
Deborah M. Nadzam, Ph.D., FAAN, project director, Joint Commission Resources’ AHRQ Knowledge Transfer Contract and researcher on nursing communication, stressed the importance of setting expectations and understanding that disagreement isn’t to be taken personally.
“We need to hear those expressions of concern with the understanding that it’s the patient’s safety in mind that is driving the person to ask it,” she said. “[We must learn] how to speak up in non-confrontational ways that are focused on the best interests of the patient. We’re not used to doing it. Some individuals have a harder time hearing those sort of messages. Those individuals also need to be coached in how to receive those messages.”
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