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Hughes RG, editor. Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Rockville (MD): Agency for Healthcare Research and Quality (US); 2008 Apr.

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Patient Safety and Quality: An Evidence-Based Handbook for Nurses.

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Chapter 32Professional Communication

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Jean Ann Seago, Ph.D., R.N., associate professor, Department of Community Health Systems, School of Nursing, University of California, San Francisco. E-mail: ude.fscu.gnisrun@ogaes.nna.naej

Background

Instructing nurses on communication is a bit like instructing birds on flying. All nurses have been taught communication skills as a basic part of a prelicensure nursing program and then retaught communication skills in postlicensure programs, continuing education programs, workshops, and meetings. Some nurses would be insulted that anyone would even raise the issue of communication since raising the issue implies that they are deficient in one of the most basic aspects of nursing care. However, the problem with good communication is that it is, ironically, easy to talk about but hard to put into practice. In the literature, there are numerous articles that provide opinion, both expert and otherwise, about communication,1–7 but there is very little evidence about communication practices that have demonstrated an impact upon patient outcomes. The purposes of this chapter are to discuss evidence of professional communication practices or strategies that have been tested empirically and have a relationship with patient outcomes or patient safety, and to provide communication tools that might help practicing nurses maintain and improve patient outcomes and patient safety.

This chapter will focus on communication strategies in hospitals and those related to communication between nurses and physicians. Studies related to communication between physicians and patients or nurses and patients were included if they were determined to be sufficiently methodologically rigorous and had a direct relationship with patient outcomes or patient safety. There is a large body of research on communication in other health care settings and among other professionals, which was not included in this chapter.

Historical Context

The history of communication between doctors and nurses is well documented. A series of publications begun in 1967 describing the “doctor-nurse game” provides insight into the way nurses have historically made treatment recommendations to doctors without appearing to do so, the way doctors have historically asked nurses for recommendations without appearing to do so, and how both participants strive to avoid open disagreement.8–27 Although some nurses have argued that much has changed—and improved—in the relationships between doctors and nurses since that initial 1967 article, there is little evidence, although much wishful thinking, to support that view.28–31 Additionally, over the years, the literature has contained descriptions of verbal abuse of nurses by physicians,32–35 disruptive physician behavior,36, 37 and advice on how nurses can better “handle” physicians.38–41 So, in spite of much discussion, communication between doctors and nurses often remains contentious and obscure.

Theoretical Foundations

Many professional groups study communication among humans, and a wide range of theories guides the work. For the purpose of this review, a sample of theories used to describe or study nurse-physician communication will be presented in brief. Habermas’ critical theory has been used to identify successful nurse-physician collaborative strategies, including a willingness to move beyond basic information exchange and to challenge distortions and assumptions in the relationships.42 Theories of Foucault and other poststructuralists that have guided concept analysis of collaboration and explored the notion that the relationship between power and knowledge (knowledge and power are not fixed, meaning not stable, and the idea that there is a hidden or “real” discourse) help explain the relationships between nurses and doctors.43, 44 Various perspectives from the field of organizational behavior, including the structural (behavior is rational) perspective, the human resource (human needs and motivation) perspective, the political (competition for resources) perspective, and the cultural (organizational culture and climate) perspective, have been used to guide activities to improve nurse-physician communication.45

Feminists and scientists have used oppressed-group behavior theory to explain much of nurses’ work and its structure in hospitals, including nurse-physician relationships.34, 46–54 Many scientists and writers have evoked the issue of gender as it relates to the work of nurses and the relationship between nurses and doctors. Early literature related to gender tends to emphasize nurse image, and later work focuses more on nurse job satisfaction; job retention; and differences in decisionmaking, attitudes, perceptions, and ethical or moral dilemmas.55–73 Mark and colleagues argue for theory development related to nurse staffing and patient outcomes, maintaining that one of the important and unexplored areas is the “why” of the nurse-physician relationships and the hypothesis that “enhanced” nurse-physician communication would “result in early recognition and intervention of potentially hazardous patient situations”74 (p. 13).

With the recent emphasis on patient safety, hospital error, and adverse events, some hospital executives have embraced human factors science and training ideas taken from the aviation industry (Crew Resource Management)75 to try to address the issue of patient safety and the lack of collaboration or teamwork in hospital settings. One of the most intriguing recent ideas is the use of the leader-member exchange theory76–88 to describe the interactions between nurses and doctors in hospitals. Hughes and colleagues89, 90 used leader-member exchange theory to create a nurse-physician exchange relationship scale and discussed the relationship between nurses and doctors in terms of a supervisor-employee relationship. The physician can be thought of as being the leader or supervisor of patient care, and the nurse can be thought of as being one of the members or employees providing care. This conceptualization will undoubtedly be challenged by nurses and nurse leaders who advocate for nurse autonomy or nurse independence, but Hughes and colleagues make a compelling argument for viewing the hospital nurse-physician relationship through this theoretical lens. There exists a long and varied history between nurses and doctors, making it difficult to use only one theory to explain all the subtleties of the relationships or to hold the key to improving those relationships.

Significance—Why Do We Care About Nurse-Physician Communication?

Over the years, there have been repeated cries and admonitions for improving nurse-physician communication and questioning why it is so difficult to achieve.1, 63, 91, 92 Some research has shown that the lack of interpersonal and communication skills of physicians and nurses is associated with errors, inefficiencies in the delivery of care, and frustration.93 There is evidence, though conflicting, that links better collaboration with better patient outcomes, specifically reduced medication errors,45, 94 reduced risk of inpatient mortality,95–98 improved patient satisfaction,99 and some support for efficiency measures such as shorter hospital length of stay.100–103 However, several major reviews and studies found no relationship between nurse-physician collaboration and patient outcomes such as mortality or self-reported health status.100, 102, 103 Physician satisfaction is generally not related to perceived increased collaboration; most frequently the evidence links perceived increased collaboration with nurse satisfaction.4, 36, 104, 105 Additionally, nurses and physicians view the level of collaboration very differently, with nurses typically perceiving less collaboration and poorer communication than physicians.70, 106–108 So, even though the descriptive evidence for improved patient outcomes and improved hospital efficiency is conflicting, it does not clearly negate the premise that better communication and collaboration could have an impact on patient outcomes.

In the nursing literature, nurse-physician communication is discussed or studied using terms such as empowerment, autonomy, collaboration, coordination, teamwork, transitioning, organizational culture, climate, and relationships. Assessment of the descriptive studies listed in the evidence table and references from other studies provide results, information, and opinion about nurse-physician communication, but they are not interventional studies. Some of the more compelling descriptive studies are included in the evidence table but do not meet the rigor required of randomized controlled trials. The setting of much of the descriptive or interventional work is intensive care units, emergency departments, or operating rooms and is often focused on nurse change-of-shift report;109–112 physician/resident handoff/sign-off;113–115 nurse-physician interaction, both routine and emergent;91, 116–118 foreign language use by physicians and nurses;119–124 and communication with patients.125–131

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Table

Evidence Table

One of the recurring themes in the literature is the difference in perceptions between nurse and physician.36, 69, 70, 106–108, 132–134 Nurses are typically less satisfied than physicians with the communication or interaction patterns and express the need for their opinions to be heard by physicians.133 Areas of particular difference involve those of ethical decision-making and the moral dilemmas confronted by nurses related to these decisions.135–137 There is also a body of literature on the differences between patient and provider (both nurses and physicians) in perceptions of care, quality, or comfort.138–143 Although these papers provide important descriptions and information about nurse, physician, and patient communication, they are only briefly mentioned to provide context for this chapter. The focus of the chapter is on communication between physicians and nurses and whether there is a relationship with patient safety or other patient outcomes.

Research Evidence

There is no shortage of manuscripts in the literature that advocate, based only on opinion, for one or another method of building teamwork, collaboration, or communication, including recognizing corporate culture,144 quality improvement,145 continuous assessment and regular communication,146 and reducing conflict.147 Other publications detail the experience of one institution or unit in improving communication or teamwork using strategies such as the Comprehensive Unit-Based Safety Program developed at Hopkins,148 Surgical Morning Meetings149 using daily goals in an intensive care unit,150 or interdisciplinary rounds.151 These individual experience descriptions typically report varying outcomes or lack measured outcomes.

Evidence for Interventions That Improve Positive Communication—What Works?

This review found no randomized controlled trials(RCTs) that investigated communication interventions between nurses and physicians that had a patient outcome as a measure of interest. The RCTs included in the evidence table tested whether various communication training sessions for physicians improved communication with patients.152–157 The evidence indicates that communication training is effective in improving physician attitudes, beliefs, and communication ability. There is also evidence that an intervention called peer leader education155 can result in fewer symptom days, lower oral steroid rates, and reduced cost for children with asthma. In general, longer training programs (2–3 days) had greater positive effects, and the effects were longer lasting. Two RCTs tested the effect of training patients about care using information or technology and found slight improvement in patient perceptions of care.158, 159

Four systematic literature reviews were found that evaluated aspects of communication. One review of 14 studies measured the effect of communication training on physicians, using self-rating of the training effects, but provided no evidence of a relationship between the training and patient compliance or health status, and ambiguous effects on patient psychosocial health.160 The second review of 26 studies concluded that various interventions had no effect on patient expectations, had conflicting lung-function outcomes, improved systolic blood pressure with any interaction, and decreased pain with improved patient-practitioner interaction.161 The third review of 89 studies found no patient outcome changes (health status, disease incidence, cure rates, mortality rates, complication rates) with implementation of interprofessional education versus single-discipline education.162 The fourth review, covering two studies, concluded that after communication training, team development meetings, or weekly rounds, there was no difference in patient mortality rates; but staff satisfaction increased, and there were conflicting results on length of stay.100

The literature search provided three nonrandomized controlled trials (NRCTs) with control groups related to interventions aimed at improving effective communication.163–165 One study described a communication training intervention, a second added personnel (nurse practitioners and hospitalists) and multidisciplinary rounds to the environment, and the third used weekly meetings to discuss role relationships. The first study improved hospital employee work satisfaction and perception of opportunities and decreased information overload.163 The second study improved physician perception of collaboration between nurses and doctors, but produced no change in nurse perception of collaboration.164 The third study decreased consumers’ belief in shared responsibility for care versus a physician-dominated responsibility for care, and increased consumers’ belief that powerful individuals influence a consumer’s health status.165

Included in the evidence tables are seven quality improvement projects without a control or comparison group. These projects are included as examples of the numerous studies in the literature that essentially describe the experience of one or two institutions in implementing an organizational change to improve doctor-nurse collaboration or communication. Dechairo-Marino and colleagues166 report on a teamwork training program that produced no differences in self-reported collaboration or satisfaction; McFerran and colleagues167 describe implementation of a structured communication technique known as Situation-Background-Assessment-Recommendation (SBAR), changing policies, debriefing, and multidisciplinary reports in four Kaiser Permanente sites. No long-term measures are reported, and only the short-term expectations for the “communication initiative” were met. Leonard and colleagues168 report on another Kaiser study of various groups in the organization trained in SBAR, assertion checklists, and briefings. Reported outcomes associated with the intervention include reduced wrong-site surgery, decreased nurse turnover, and improved employee satisfaction; however, no specifics on the measurement of these outcomes are provided. Lassen and colleagues169 describe development and education of a collaborative practice (primarily physician specialists) decisionmaking protocol that was associated with a decrease in rule outsepsis diagnosis, use of antibiotics, patient days, costs, and readmissions in one neonatal intensive care unit (NICU).

Dutton and colleagues170 reported that daily discharge multidisciplinary rounds were related to decreased length of stay in the emergency department and emergency department closures in one trauma center. Copnell and colleagues134 reported no difference in perception of doctor-nurse collaboration after introduction of a nurse practitioner in two NICUs. Boyle4 reported an increase in perceived doctor-nurse communication skills, nurse leadership skills, and problem-solving, and a decrease in nurse stress after a six-module training session called Collaborative Communication Intervention. The designs of these quality projects were too weak to allow any sort of conclusions to be drawn.

Practice Implications

There is insufficient empirical evidence to recommend any specific communication strategy or technology device to improve doctor-nurse communication. However, there is mixed or weak evidence to support using some of the techniques described in the cited literature. It is likely that focusing an organization on any strategy and persisting in that focus will be associated with, at least temporarily, a change in doctor-nurse communication patterns (e.g., Hawthorne effect). Given the paucity of available evidence, the following suggestions are offered for possible consideration in efforts to improve professional communication:

  • Carefully evaluate various strategies for doctor-nurse communication using measurable outcomes that are important to your organization; plan to use a strategy that meets the needs and culture of your organization.
  • Select a strategy, focus training, and provide organizational support and sufficient resources toward improving doctor-nurse communication.
  • Slowly implement the change using sufficient resources and sufficient time.
  • Do not implement multiple changes simultaneously.
  • Persist in that strategy for an extended period of time (years, not weeks or months).
  • Critically and rigorously evaluate the strategy using patient outcomes and worker satisfaction.
  • After allowing sufficient thought and time for implementation and evaluation, be willing to publicly eliminate the strategy if it does not improve the outcomes.

Hospitals have used many communication tools such as written and verbal orders, reports, rounds, and team meetings. As the United States shifted to the “business model” for hospitals, organizations have tried to change culture or climate, create transformational leaders and knowledge workers, implement continuous quality improvement or total quality management, form quality circles, and train the one-minute manager. Some hospitals have used and are currently using technology ranging from pencil and paper, medication rooms and carts, orange vests for the medication nurse so she will have fewer interruptions, Pyxis or other automatic medication dispensers, landline telephones, fax machines, beepers, e-mail, personal digital assistants (PDAs), cellular telephones, wireless devices, direct information transfer, and Web access.

Other recent technology includes mobile communication systems such as Vocera, electronic medical records, computerized physician order entry, and bar-coding for medication administration. A number of organizations are also trying SBAR, organizational support structures such as Rapid Response Teams or techniques such as customer relationship management from business or crew resource management from aviation. Other organizations are trying systems such as Situation-Trajectory-Intent-Concern-Calibrate (STICC) using the Hands-on Automated Nursing Data System Method from the University of Illinois at Chicago and funded by AHRQ, or Gerontology Interdisciplinary Team Training from the Hartford Foundation and the American Geriatrics Society. Few, if any, of these methods or devices have been empirically tested. Without careful consideration and evaluation, efforts to improve communication problems that exist in present-day hospitals may lead to implementation of strategies that will be ineffective.

Research Implications

Based on the literature review, future research is needed to assess the following:

  • What should be the communication competencies of physicians and nurses; and should these competencies be assessed periodically?
  • How can health information technologies be used to ensure effective communication between physicians and nurses, across settings and among the various care delivery models?
  • What is the impact of effective communication strategies on hospitalized patient outcomes and medical errors?
  • What is the impact of effective communication strategies on nurse and physician job satisfaction, and how does provider satisfaction relate to patient outcomes?
  • How can communication skills training for practicing physicians and nurses have a career-long impact on their communication skills?

Conclusion

Within health care, there have been and will continue to be many approaches to professional communication. Unfortunately, the body of evidence is very limited, and the research findings to support professional communication and the relationship with patient safety and quality are not available at this time. There were limited studies that tested specific interventions aimed at changing nurse-physician communication, and there is some evidence that focusing on a doctor-nurse communication may have a positive effect. Health care organizations and providers will be challenged as they seek to improve the effectiveness of professional communication, given all the subtleties of the nurse-physician relationships.

Search Strategy

Search strategies employed includedthe use of the electroni c databases PubMed®, CINAHL®, the Cochrane Collection, and relevant AHRQ reports. Keywords included physician, nurse, relationships, communication, coordination, collaboration, autonomy, teamwork, MD, RN, patient, outcome, safety, and adverse event. Reference lists of select publications were investigated for potential manuscripts, and literature related to relevant measurement instruments was sought.

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Appendix

Measurement Instruments

SourceMeasurement InstrumentConceptsNumber of Items & Response Style
Shortell 1991172ICU Nurse-Physician Questionnaire; 48 items selected from the Organizational Culture Inventory (OCI)Organizational culture, leadership, communication, coordination, problem-solving48 items; 1–5 point Likert scale
Roberts 1974173Organizational CommunicationCommunication35 items; 7–10 point Likert scale
Choi 2004174Perceived Nursing Work Environment (PNWE)Nursing management, nursing process, RN/MD collaboration, nursing competence, scheduling climate42 items; 4 point Likert scale
Weiss 1985175Collaborative Practice ScalesRN/MD interaction and influence on patient care9 items RN & 10 items MD; 6 point Likert scale
Aiken 2000176Nursing Work Index-Revised (NWI-R)Autonomy, RN/MD relationships, control of practice57 items; 4 point Likert scale
Temkin-Greener 2004177PACE team performance questionnaireInterdisciplinary team performance59 items; 5 point Likert scale
Baggs 1994178Collaboration and Satisfaction About Care Decisions (CSACD)RN/MD collaboration14 items; 7 point Likert scale
Dougherty 2005179A review of instruments measuring RN/MD collaborationRN/MD collaborationCollaborative Practice Scale, Collaboration and Satisfaction About Care Decisions, ICU Nurse-Physician Questionnaire, Nurses Opinion Questionnaire, and the Jefferson Scale of Attitudes Toward Physician-Nurse Collaboration
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