Professional Communication

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, 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. 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. Additionally, over the years, the literature has contained descriptions of verbal abuse of nurses by physicians, disruptive physician behavior, and advice on how nurses can better “handle” physicians. 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. 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. 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.

Feminists and scientists have used oppressed-group behavior theory to explain much of nurses’ work and its structure in hospitals, including nurse-physician relationships.  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. 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” .

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 theory  to describe the interactions between nurses and doctors in hospitals. Hughes and colleagues^89, 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.  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.  There is evidence, though conflicting, that links better collaboration with better patient outcomes, specifically reduced medication errors,  reduced risk of inpatient mortality, improved patient satisfaction, and some support for efficiency measures such as shorter hospital length of stay. 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. Additionally, nurses and physicians view the level of collaboration very differently, with nurses typically perceiving less collaboration and poorer communication than physicians. 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; physician/resident handoff/sign-off;¹  nurse-physician interaction, both routine and emergent;  foreign language use by physicians and nurses; and communication with patients.

Evidence Table

One of the recurring themes in the literature is the difference in perceptions between nurse and physician. 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. Areas of particular difference involve those of ethical decision-making and the moral dilemmas confronted by nurses related to these decisions. 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. 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, quality improvement,¹⁴⁵ continuous assessment and regular communication, 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,  Surgical Morning Meetings using daily goals in an intensive care unit, or interdisciplinary rounds. 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.  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 education  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.

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. 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.  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.  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.

The literature search provided three nonrandomized controlled trials (NRCTs) with control groups related to interventions aimed at improving effective communication. 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. The second study improved physician perception of collaboration between nurses and doctors, but produced no change in nurse perception of collaboration. 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.

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 colleagues report on a teamwork training program that produced no differences in self-reported collaboration or satisfaction; McFerran and colleagues 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 colleagues 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 colleagues  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 colleagues 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 colleagues  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.

·                    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.

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?

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 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.

 

If you could change any element of the communication that occurs in an OT what would it be?

There was an overwhelming response that respect, common courtesies and manners were essential and often absent.

That it doesn't matter what level you are, what hierarchy, whether you are a sister or not, you speak to everybody civilly. Participant 2

One nurse stated that the decisive non-verbal communication act "throwing instruments on to the floor" should stop. Most nurses nodded in agreement and when asked how often this occurred, there was agreement that this happened up to four times a year.

Organisational issues impacted communication. Although nurses acknowledged the importance of induction programmes, they strongly urged that the programme for medical staff be reviewed so that the frequent turnover of juniors (every 3 to 6 months) would not take up their time. Nurses were adamant that they did not want medical induction to form part of their role.

... you know we have to go through the rigmarole... you get juniors (trainee surgeons) come up and say I don't know how to use this, I wasn't shown how to, I don't know what to do. 

Participant 1

...we already take on a lot of their roles and some things that we don't know about it's only their colleagues who know how to do it and they need to speak to their colleagues and it's their colleagues who need to train them how to do it and not us because we do not know ourselves. It's like booking patients on the computer that you know they have to teach themselves or teach each other how to do that.

 Participant 3

3. What do you perceive to be the key communication skills for surgeons (and trainees) to carry out their roles?

In response to the questions about communication skills for different professional groups, common themes emerged as well as repetition from earlier questions. Nurses were especially vocal and energetic in responding to this question. Common courtesies and respectful behaviours were identified as key. These were illustrated with examples that questioned professional competence, over running schedules, starting late and sending for patients.

I have, I have surgeons that turn round to me and say that I have never seen this nurse before. I do not know what she can do. I don't want her. Participant 5

Certainly there should be a discussion so that if you are going to overrun...they say, send – and it's like quarter to four or something, like that you know you're going to overrun and it's just assumed that you are going to stay and it's just nice common courtesy to actually ask the staff is everyone is willing to stay. Participant 1

Sometimes, operations don't go to time, you can never time an operation. Therefore it's going to overrun. Therefore, you know the patient is not going to get done. I mean it's happened this week and the patient, to my knowledge, has still not been operated on because he can't get allocated time in that theatre. Participant 7

It's like when you're trying to start a list in the morning you have the patient there, you have the anaesthetist there, you have the nurses there, they're (surgeons) doing a ward round. There is no common courtesy to ring to say they are going to be late. You are waiting to start so therefore you are delayed in the morning. Therefore, it's going to be a knock on effect in the afternoon

.Participant 2

Nurses reported inadequate communication between surgeons. Nurses were often expected to act as a "go between." There was frustration with the experience that surgeons could be courteous to one another but not to nurses even within the same communicative event.

So what we are saying is that consultants don't communicate well with each other. They have some sort of etiquette going on whereby the language that they use towards each other is totally different... I'll give you a prime example is that I was running a list in which we were using the x-ray. Another consultant came, I walked out to the door. He shouted at me about why we were using the equipment at that time of the day. I pushed the door open and said "Don't tell me, tell the surgeon". The way that he spoke to him was totally different and it was almost as though "it's okay" right I don't mind you using it and we need to come to some sort of arrangement but he is shouting at me as if it his right to use the equipment now. So the way that they interact with each other is totally different. They are not honest with each other. They will slate each other behind their backs but they will not say anything to their face, never. 

Participant 7

Nurses thought it important that accurate (e.g. the names of instruments) and complete information be provided.

When we when we are given specimens you say they might say "specimen" you might say "for histology" they might want it dry, frozen sections they might not always tell you in formalin sometime you have to keep prodding for bacteriology, cytology all these, why can't they say the appendix for histology in formalin or whatever. Yes we know that some junior nurses might not know not always those sorts of things as well they assume you know and mistakes can happen. Specific instructions so it's a two way thing they're saying now that they want us to acknowledge their commands but they're not acknowledging ours as well so it's a two way game. It's a team.

Participant 1

Discussion extended to several related topics that are likely to influence communication and included notions of effective teams.

I truly believe that we are working our damndest to work as a team. Doctors are still, and this is consultant all the way down, are still working to their own agenda and they do not believe that they are part of our team and they are part of our team but they don't believe. I am sure they don't believe that they are, they're a stand alone team and we're a team here and they're a team there and they'll pick up what they need but we can't take anything from them. Does that make any sense?

 Participant 4

This theme was elaborated in discussions about roles and responsibilities of members of the OT with emphasis on perceptions of the role of an OT nurse. Many of these views were expressed with intense frustration and illustrated with specific examples (e.g. draping patients, cleaning the theatre, answering mobile telephones).

... expect us to be secretaries in the theatre as well as doing the work ...

Participant 3

We know what our professional role is, we know what our professional role is but they don't.

Participant 7

I'm sorry to say that it is the surgeon's responsibility to make sure that a patient is positioned the way you want it and the way it's been draped. It is the operating surgeon's responsibility. It is actually not a nurse responsibility because a nurse can only provide you with the equipment and the necessary tools for you to perform the surgery and assist you but she is actually not there to know how you are going to approach the operative procedure.

 Participant 5

I tell you what they are talking about the waiting time is what they don't understand is when they've walked out of the operating theatre the nurses still have to clean the floor of all the operating theatres, empty the bags, you know these things take time, it doesn't happen its' not a miracle you know we are supposed to clean the tables and the trolleys and they may see it as a natural break. 

Participant 2

There are other factors like mobile 'phones. You are probably the only person in the theatre...bleeps going maybe... You are expected to be hands here, there and everywhere. Like, can you answer my mobile phone? And while you are, you know concentrating on that, that's when he wants the diathermy.

 Participant 4

Nurses distinguished themselves from surgeons in relation to patient advocacy. This was illustrated in examples of sending for patients and leaning on patients.

You see I think I think we look at the patient, we're the patient's advocate. When they are leaning all over the patient, they don't care and if you tell them please that is a body under there that is, I mean how would you like it if that was your wife you know you should not lean on the patient. I had a surgeon and when they had finished leaning on the patient the towel clip was actually imprinted on that patient's skin. 

Participant 1

Nurses also identified strongly expressed emotions.

The only problem is if they don't tell us in advance and it is something we haven't got in the department. I mean it's beyond our control we can't give it to them. Again if we have it in the department and it's not clean and they have to wait for it to be sterilised so it might compromise time again and they might get angry as well you know being impatient you know, shouting "When is it going to be ready?" "How long is it going to take?

 Participant 7

Nurses expressed some frustration with their constant adaptation to circumstances beyond their control in relation to taking breaks (or not).

Can I just say, can I just say the majority of the people in this room will turn to you and say that half of us never get a proper break during the day because we'd rather do the operating and try and finish the list. Participant 5

Power, hierarchy and acknowledgement were sources of frustration for nurses.

We've moved away from Yes sir, we've moved away from that a long time ago. We do anticipate, we do give them what they need. We don't always get acknowledgement from, from our point of view and if we felt that we needed to say something to them i.e. yes that's done then we will tell them that but if we don't we won't.

 Participant 2

A sense of helplessness was expressed in relation to training opportunities.

I think it's to be a bit more patient and compassionate especially when we are trying to train nurses up to be as competent as they want them to be and you know it is to give them that opportunity to develop that role that they're put in there to do. Not sort of just brush them aside and say you know, I'm too busy you know I don't want this because you know, I mean it is a teaching hospital and we are supposed to teach people and to train them and that opportunity is not given with compassion then it's you know, its never ever going to work. 

Participant 6

Nurses were adamant in their views that trainees should not follow the examples of consultant surgeons. The nurses also identified "a bit of a barrier if they do not speak English as their first language." Nurses also suggested that consultants do not communicate well with trainee surgeons and this has implications for nurses' roles.

4. What do you perceive to be the key communication skills for anaesthetists to carry out their roles?

Unlike the response to questions about surgeons, anaesthetists did not generate as much discussion nor was the response as energetic. They were described as "more approachable" than their surgeon colleagues. Nurses reported that anaesthetists sometimes seemed isolated from the rest of the OT team.

They don't appear to have much communication with the surgical team. It is with the anaesthetic person that's there that they communicate with... 

Participant 1

Again, the "go-between" role expected of nurses was outside of their own role perception.

To make it work, yeah, is for the anaesthetist to communicate with the surgeons that they are working with and not going through the nurse to do the communication for them. That is the key issue. The key issue with a lot of anaesthetists is that is when they are not happy to perform a particular surgery they will not go and communicate with the surgeon and say "I am not happy in doing it." They want you to tell them that YOU, you personally is not happy.

 Participant 6

Like the surgeons, the anaesthetists were also criticised for starting late and for not keeping nurses informed.

They're supposed to start the list, I mean some of them actually do phone and say they're going to be late and that's fair enough. That's appreciated and that's anybody but some of them, they don't care as much as you've spoken to them and said look the list is supposed to start at a certain time everybody's here and why aren't you? You know.

 Participant 2

5. What do you perceive to be the key communication skills for nurses to carry out their roles?

Responses initially focused on written rather than verbal communication and then moved to administrative issues before describing interpersonal communication. Written communication in the form of hard copy documentation and memos of policy and changes in practice.

Documentation because there are so many of us, there are so many of us it is difficult to talk to everyone, so it's documentation, it's getting a memo out, getting something in the communication book so that or putting information in the appropriate place so that everybody gets it or giving information to the key people who can cascade it down.

 Participant 4

Electronic communication was regularly used to exchange information but there are problems with the system and limited access. During long cases it was thought appropriate to read email but not all theatres have this facility.

Meetings that are uni-professional were thought valuable but were reported as often lacking in structure and there were difficulties finding dedicated "protected" time.

We had one for the first time, a structured one, on a particular subject and what came out of it was very very good because we didn't deter from that. Did you feel that? That we didn't deter from the subject so that's something that nurses aren't very good at – is using the forum for what it's been for what it's supposed to be used for or what normally happens is that you have your agenda then you go off on a tangent... 

Participant 3

There was a desire for inter-professional meetings although the content and format were not explored.

Unlike responses to other questions nurses referred to the role of nonverbal communication.

I think if you've got a good rapport with your runner (Circulating nurse), you can, you know use nonverbal communication.

 Participant 2

Definitely, yeah you can.... Definitely pick up what you want and if you have an excellent runner or an experienced runner we don't have to say anything. It's there or it's waiting.

 Participant 4

Although the need for training was recognised as crucial, nurses' experiences of surgeons did not always support such professional development.

But they don't give us the chance to teach our juniors. They are allowed to bring junior doctors there and teach them and train them and what have you and they're allowed to do that during emergency surgery and whatever at any time and they don't allow us to take a nurse to double scrub with someone to teach them or to actually let you know, they want it done, now, now, now, now (finger clicking at same time) they cannot wait.