A recent study1 that interviewed 500 physicians in-depth has yielded some interesting results regarding communication and patient safety. While all interviewees acknowledged that failure in communication is one of the leading problems in healthcare, only 4% identified themselves as having difficulty communicating effectively. This reveals a startling lack of self-awareness surrounding the issue.
Many articles and studies address communication in healthcare in an in-depth comprehensive manner. This newsletter highlights some key recommendations to help physicians to create better communication with nurses in the interest of patient safety.
The Joint Commission has reported that nearly 60% of medical errors are a direct result of a communication breakdown. Communication breakdowns are also the most frequently identified root cause of sentinel event reports.
Consider these scenarios:
An adult daughter comes to pick up her father who is being discharged from the hospital after a four-day admission for cardiac issues. When she arrives, she learns the admitting physician is out-of-town. The nurse provides the daughter with a list of medications and advises that the hospitalist is on his way to write discharge instructions. The hospitalist’s discharge instructions include a discrepancy from the medication list provided by the nurse. When asked, the hospitalist simply says, “My list is correct.”
The nurse does not want to challenge the hospitalist in front of the patient and his daughter for fear of creating an awkward situation or receiving a verbal dressing down from the hospitalist. The patient is re-admitted approximately a week later because he did not take a certain diuretic on the nurse’s medication list.
An 86-year-old nursing home patient with brain cancer is transferred to a medical center due to a worsening in his condition. When discharged from the medical center, the treating neurologist includes a prescription for a certain dosage of a steroid to decrease swelling in the patient’s brain. When the nursing home physician sees the patient upon his return, his orders do not include the steroid. Approximately a week later, the nursing home physician orders the steroid at a lower dose.
Two weeks later, the patient passes away. Subsequently, the family files a malpractice complaint alleging that the failure to administer the steroids in accordance with the neurologist’s order caused or contributed to the patient’s premature death. The nursing home physician advises that he had never been made aware of the neurologist’s order. In fact, had he been aware, the nursing home physician likely would have called the neurologist to follow up because he did not believe that the steroids in the prescribed dosage were reasonable for a terminal patient with a short life expectancy.
The patient’s nurse at the nursing home either did not receive or notice the neurologist’s order, or she simply failed to question the nursing home physician’s orders as differing from the neurologist’s orders. If she had, the nursing home physician’s rationale would have been documented and the malpractice complaint possibly avoided.
A 68-year-old female who had been hospitalized only a couple of weeks previously for a transient ischemic attack (TIA) is brought to the emergency department in serious condition. A CT of the head confirms a stroke. Her treating physician is contacted at approximately 9:30 a.m. He gives admit orders but also recommends that the ED try to transfer the patient to a local medical center with a higher level of neurological services.
The patient is not transferred. She experiences some downward changes in her condition on the floor at approximately 3 p.m. and the nurses attempt to contact the admitting physician without success. The admitting physician goes off duty at 5 p.m. A hospitalist sees the patient at 9 p.m. and writes orders.
The next day on morning rounds, the admitting physician learns the patient has not been transferred. The patient passes away later that day.
A medical malpractice complaint is subsequently filed for an alleged failure of the medical team to address the deterioration of the patient’s condition after she had been moved from the ED to the floor in a timely manner. There was a discrepancy in testimony between the floor nurse and the office of the admitting physician as to whether a call or calls were made from the hospital to his office on the afternoon of the patient’s admission. In any event, the nurses certainly should have done more to get a physician to see the patient sooner and the admitting physician should have followed up with the ED to see if the patient had been transferred out.
Before becoming too critical of individual physicians and nurses, there must be some acknowledgment of issues unique to healthcare. One article notes “healthcare is by its very nature complicated, dynamic and unpredictable. Patient needs often arise unexpectedly.” 2 Another article states that “a continuous flow of interruptions and multiple patient handoffs affect the ability of nurses and physicians to connect effectively and establish a trusting and collegial relationship.” 3 These factors go hand-in-hand with what the healthcare industry has known since the publication of To Err Is Human almost 20 years ago–medical errors are almost always a result of “system” failures, not the failures of one or two individuals.
Many physicians are not employees of hospitals, but they are still part of the hospital team. Their actions can have dramatic legal and public relations consequences for the hospital.
Nurses should be made aware that they are increasingly being held accountable legally for failure to appropriately perform their duties as “patient advocate.” In Louisiana, it is becoming a regular allegation in most medical malpractice complaints.
Therefore, the importance of collaboration above and beyond mere “communication” cannot be over-emphasized. Because evidence suggests communication is best done face-to-face and collaboration involves problem-solving as a team, interdisciplinary rounds are an opportunity for both nurses and physicians to improve both skills. Hospitals should promote the idea of physicians, nurses and others involved in ancillary services making rounds as a team as much as possible.
Of course, as the scenarios above make clear, vital communication often becomes necessary when members of the team are not in the same location. It is important for the hospital to make clear from the top down both the protocol and tone of such communications. All hospital employees must be made aware of the appropriate chain-of-command to follow when difficulties arise in receiving an appropriate response to a situation from a team member.
An internal culture that promotes open communication is even more important. Ideally, all healthcare workers would speak up with confidence and clarity in situations where questions should be asked or suggestions made. However, that is not always the case. Many times this harmful silence is the result of fear, intimidation or a belief that superiors will not provide appropriate support if they speak up.
The great body of work that has taken place in the last 20 years on the topic of patient safety underscores that the highest-quality hospitals and most efficient healthcare units promote and exhibit clinical communication that is clear, direct, explicit and respectful. There is no question there is a significant difference in the way physicians and nurses prefer to communicate in the clinical atmosphere. Physicians like concise information that gets to the point as quickly as possible. Nurses, on the other hand, often prefer to provide more of a narrative with background information. Both sides must understand and respect these differences.
The best form of communication is always contingent upon the facts, circumstances and severity of the situation. In an emergency situation, decisions must be made quickly. In less stressful situations, there is time to delve into more background. Communication should reflect the urgency of the situation. Even in emergency situations, nurses must operate in an atmosphere that allows them to be comfortable raising concerns when, for instance, they believe that an inappropriate medication or dosage is about to be administered to a patient.
Physicians should not exhibit body language that gives the impression they are inattentive to concerns expressed by nurses or other healthcare providers. They should take the time, whenever possible, to provide the rationale for their actions when questioned instead of becoming offended or ignoring the question entirely.
A lack of mutual respect or a failure to ensure teamwork ultimately leads to finger-pointing. When that happens in a courtroom, plaintiff attorneys simply allow the defendants to make their case for them.
Finally, being aware of the downfalls of technological advances is significant when assessing communication on a unit. It is essential that nurses and physicians understand when to utilize various forms of communication depending on the situation. When in doubt, person-to-person is best. When that is not possible, voice-to-voice is the next best alternative.
This article was first published in December 2018 as an LHA Trust Funds Physicians Quarterly newsletter.
- Nurse-to-Physician Communications: Connecting for Safety
Journal of Patient Safety and Quality Healthcare, September/October 2012
- Effective Physician-Nurse Communication: A Patient Safety Essential For Labor and Delivery
American Journal of Obstetrics and Gynecology, August 2011
- Communication: A Dynamic Between Nurses and Physicians
MEDSURG Nursing, November-December 2012
If you have any questions related to this newsletter, please contact: