Imagine the scenario: A nurse approaches a doctor with a question about a patient. The doctor, in a rush to get to the operating room, barks back a response. The nurse, intimidated, finds it even harder to speak up the next time around.
What happens next is a communication breakdown that benefits no one, especially the patient.
Poor communication in the workplace can happen anywhere, and healthcare facilities are no exception. But here, where communication can be the difference between life or death, studies over the past two decades have affirmed over and over again that poor nurse/physician communication is a key factor for increased morbidity and mortality.
Said Kathleen Bartholomew, MN, RN, RC, author of Speak Your Truth: Proven Strategies for Effective Nurse-Physician Communication: "When nurses and physicians don't communicate, it's the patient who loses every time. The bottom line is: negative relationships equal negative patient outcomes."
Yet, studies continue to find these negative relationships are more often the norm than not. In 2009, an American College of Physician Executives survey of 2,100 physician and nurse executives reported that 98% of respondents said they had witnessed behavioral problems between nurses and doctors within the past year. Thirty percent reported seeing it weekly - and 10% said they saw these problems every day.
The most common communication issues involved "degrading comments or insults" as well as yelling. And while nurses sometimes behaved badly, both physician and nurse respondents said physicians were a major cause of the problems.
Building Respect Through Camaraderie
Since its inception, Mount Sinai Hospital's Visiting Doctor Program - which provides care to homebound patients in the Manhattan area of New York City - has promoted camaraderie and collegiality between its doctors and nurses.
Adaga Catana, RN, a nurse clinician with the Visiting Doctors program for the past eight years, knows the program is very different from her past experience on a hospital unit, where physicians wouldn't necessarily include nurses in discussions of patient care and where nurses wouldn't even see the doctors on a daily basis.
For example, one doctor recently asked Catano for her input on a homebound patient and a certain intervention she wanted to try at home. Catano suggested it might be best to admit the patient, as the patient didn't have any family support at home. And did the physician listen? "Definitely," said Catano.
One factor? Doctors and nurses lunch together regularly, and conversation is "nothing about patient care," said Catano - a big change from other institutions where sometimes even holiday parties are segregated along nurse/physician lines.
Leadership used the same approach to build a stronger relationship with the Visiting Nurse Service of New York by encouraging get-to-know-you gatherings after work hours. For other institutions, this kind of relationship building can be a starting point to helping nurses and physicians feel as though they're on the same team and mitigate the conflict that can often arise when caring for complex patient needs.
"You feel more at ease," said Catano. "You feel more comfortable talking to the doctors, and you don't feel as intimidated."
In fact, the two services now conduct joint patient visits for complex cases and have gone on to define protocols as to how and when physicians and nurses are to be contacted - a practice studies identify as being key in improving communication.
Establishing a Shared Leadership Model
Historically, during training nurses and physicians learn about nursing and medicine, but they don't necessarily learn how to work with one another.
Although this is changing with schools such as Loyola University in Chicago now providing simulation and other activities to help build nurse/physician relationships at the student level, it can remain a challenge on the unit.
Pennsylvania Hospital in Philadelphia, part of Penn Medicine, recognized doctors and nurses in their hospital were both doing their roles - but doing them separately, not viewing their actions together and considering if they were coordinating care for the patient in the most timely and correct manner. So in 2007, they piloted a new approach - establishing unit-based clinical leadership (UBCL) on seven of the hospital's clinical care units.
UBCL partnered each unit nurse manager with a unit physician clinical leader, along with a nurse educator or specialist and a quality coordinator to collect and analyze data. The hospital worked carefully to identify the right physician leaders to partner with nurse managers, based on who the nurse managers would most like to work with, who had time to devote to the pilot and who were interested in the initiative.
Physicians and nurses shared responsibility for leading daily multidisciplinary rounds on each patient, and for working on unit-specific projects to improve documentation, compliance and issues like length of stay.
During the pilot, better communication between nurses and physicians meant misunderstandings that may have caused friction in the past were changed for the better. For example, physicians didn't realize all the issues a nurse manager has to deal with every day in coordinating care on a unit, and nurses learned the reason residents were sometimes late for a shift was because they had to see patients on five other floors.
Patient care also improved. Physicians and nurses were able to get questions answered in minutes during the daily multi-disciplinary rounds, compared to back-and-forth emails all morning. In addition, units clarified why there were sometimes delays in stat antibiotic delivery. It was a communication issue: physicians learned to consistently tell nurses when they had ordered the antibiotic stat, and nurses realized why it was so important to get the antibiotic into the patient quickly and how to better document it in the system.
Today, UBCLs are standard across all units in Penn Med's three hospitals, said Chief Nursing Officer Mary Del Guidice, RN, MSN, BS, CENP. And Pennsylvania Hospital is now working on giving patients more of a voice too by piloting multidisciplinary rounds at the bedside.
"The main thing is keeping the focus on quality outcomes and on providing the patient with the best experience possible," said Guidice. "The patient can sense when the team isn't on the same page. . It's important to create a culture where we circle the bed together. No one comes to the bed alone - it's a team led by nurses and physicians."
Promoting Tools & Training
Improving communication on their 50-bed newborn/infant ICU continues to be a priority for Children's Hospital of Philadelphia (CHOP), which serves the city and surrounding counties, southern New Jersey and Delaware.
Complex care, a large multidisciplinary staff (and an influx of new nurses), knowledge explosion and communication are all cited as unit challenges, leaders said. But much of the unit's focus has been on improving nurse/physician communication.
"We were making sure nurses had the confidence to speak up when they needed to and wanted to provide a consistent messaging system and way to give information to the physicians when calling them, so that they hear the same information," said Denise Pavan, MSN, RN, nurse manager, N/IICU. "Whether it's an experienced nurse or a new nurse, they're all speaking the same language."
First, the unit instituted a daily goals sheet, summarizing the patient's history, wound care, respiratory and neuro stats, nutrition and more to help create a clear understanding among all team members of the patient goals of the day.
Nurses also attended four-hour role-play sessions ("Finding Your Voice") that coached and helped nurses overcome established hierarchies that might deter them from speaking up. They also learned about SBAR (situation, background, assessment and recommendation), which establishes a standard framework for communication among members of the healthcare team - and standardizes expectations for information communicated each and every time.
But perhaps the most important tactic of all? Leadership buy-in. "It is absolutely pivotal," said Guidice. "Right from the start, we [the CMO and I] communicated to all our teams that this was going to be a shared partnership, and we believed in this so much, our teams were going on one organizational chart. . Right from the start, we agreed and have stuck to the fact that we would be, not only in word, but in action, partnering with each other."
And while most hospitals who put these types of practices in place experience a cultural shift where nurses feel more empowered, staff respect becomes universal, and patient safety soars, the work always has to continue.
"Beginning in January, we're doing a phase two of safety behaviors, that reinforcement to everyone that this wasn't something we just did in 2010 and we're done with it," said Theresa O'Connor, BSN, RNC, patient safety and quality improvement coordinator for CHOP's N/IICU. "We're trying to, whenever we do simulations for clinical things, to implement those safety behaviors in there, and in everything that we do, and that it's an ongoing process. It's never going to end, speaking up for safety."
Danielle Wong Moores is a freelance writer.