Nurse/physician communication through a sensemaking lens: shifting the paradigm to improve patient safety

Work-related support needs of registered nurses in a neonatal intensive care unit in the Tshwane District

Background

Registered nurses in neonatal intensive care units (NICU) are working under stressful environment caused by the need and commitment to provide care for the critically ill neonates. Therefore, there is an imperative need to know and understand the work-related support strategies that can be adapted for registered nurses working in a NICU in the Tshwane District to enable them to provide quality care for the admitted neonates.

Aim

To explore and describe the work-related support needs of registered nurses working in a specific NICU situated in the Tshwane District.

Setting

The study was conducted in a selected NICU in Tshwane District.

Method

A qualitative, exploratory, descriptive, and contextual design was used in this study. In-depth unstructured individual face-to-face interviews were conducted with nine registered nurses working at the selected NICU of an academic hospital. Thematic data analysis was conducted.

Results

Three themes, namely teamwork between registered nurses and doctors, staff development in the form of peer seminars, workshops and in-service training, and availability of adequate resources within the workplace arose.

Conclusion

This study revealed that the registered nurses working in the NICU in the Tshwane District are in need of work-related support, as it will improve their well-being.

Contribution

The contribution of this study will be used by the hospital management to plan strategies that can be adapted for the betterment of the work environment for registered nurses in the NICU and the hospital in general.

Patient’s Experiences of Violence as Perpetrator: A Qualitative Study from Patients with Schizophrenia in Indonesia

BACKGROUND: Individuals with schizophrenia are at an increased risk for violence – limited study on exploring the experience of violence in patients with schizophrenia as a perpetrator. AIM: This research aimed to investigate the perception of violence as a perpetrator in Indonesia in patients with schizophrenia. METHODS: This study used phenomenology using a purposive sampling technique. A total of 40 patients were from the psychiatric ward of significant mental hospitals in West Java, Indonesia. The inclusion criteria for patients were the following: Age over 18 years old confirmed diagnosis with schizophrenia. Focus group discussion of patients comprised four groups. Each group consisted of tens of patients. RESULTS: The patient’s experiences as a perpetrator were categorized into six subthemes: Committing physical violence to family, quarreling with family, verbal abuse to family, a perpetrator of verbal violence to neighbors, expression of anger to object, and physical violence to nurse. CONCLUSION: The patient’s experiences of violence were not linear, but rather it was a complex experience of being a perpetrator, yet at the same time as of perpetrator violence. A staff training program to reduce patient violence is needed.

Looking Back to Move Forward: Celebrating the 50th Anniversary of the Association of Leadership Science in Nursing

This article is based on an invited presentation delivered in celebration of the 50th anniversary of the Association of Leadership Science in Nursing. The article begins with framing the historical context of nursing administration/leadership. The look-back includes a glimpse at the evolution of the Council on Graduate Education for Administrative Nursing into the Association of Leadership Science in Nursing. Two present-day leadership issues are then considered-turbulence and interprofessional proficiency. Lastly, the concept of problematizing is proposed as a strategy for moving forward. Yesterday, today, and tomorrow though are not tidy packages with good boundaries. The chronology, therefore, is not always linear.

Factors Associated With Job Satisfaction in Medical Oncology Practices: Results From a Multisite Survey

OBJECTIVE

The aim of this study was to examine the factors influencing job satisfaction of nurses, physicians, and advanced practice providers in ambulatory oncology settings.

BACKGROUND

Job satisfaction is essential to clinician well-being and quality of care.

METHODS

In 2017, clinicians from 29 ambulatory medical oncology practices completed anonymous paper questionnaires that examined job satisfaction, clinician-to-clinician communication, and perceptions of patient safety. Linear regression, adjusted for clustered observations, examined the relationship between job satisfaction, clinician communication, and patient safety perceptions.

RESULTS

Of 280 respondents (response rate of 68%), 85% reported that they were satisfied or very satisfied with their current position. Patient safety and accuracy of clinician communication were positively and significantly associated with job satisfaction.

CONCLUSIONS

Although most surveyed clinicians were satisfied, 15% were dissatisfied and reported communication and safety concerns. Leadership efforts to strengthen clinician communication actions and develop positive safety cultures are promising strategies to promote clinician well-being and high-quality cancer care.

Qualitative investigation of trace-based communication: how are traces conceptualised in healthcare teamwork?

OBJECTIVES

This interview-based qualitative study aims to explore how healthcare providers conceptualise trace-based communication and considers its implications for how teams work. In the biological literature, trace-based communication refers to the non-verbal communication that is achieved by leaving 'traces' in the environment and other members sensing them and using them to drive their own behaviour. Trace-based communication is a key component of swam intelligence and has been described as a critical process that enables superorganisms to coordinate work and collectively adapt. This paper brings awareness to its existence in the context of healthcare teamwork.

DESIGN

Interview-based study using Constructivist Grounded Theory methodology.

SETTING

This study was conducted in multiple team contexts at one of Canada's largest acute-care teaching hospitals.

PARTICIPANTS

25 clinicians from across professions and disciplines. Specialties included surgery, anesthesiology, psychiatry, internal medicine, geriatrics, neonatology, paramedics, nursing, intensive care, neurology and emergency medicine.

INTERVENTION

Not relevant due to the qualitative nature of the study.

PRIMARY AND SECONDARY OUTCOME

Not relevant due to the qualitative nature of the study.

RESULTS

The dataset was analysed using the sensitising concept of 'traces' from Swarm Intelligence. This study brought to light novel and unique elements of trace-based communication in the context of healthcare teamwork including focused intentionality, successful versus failed traces and the contextually bounded nature of the responses to traces. While participants initially felt ambivalent about the idea of using traces in their daily teamwork, they provided a variety of examples. Through these examples, participants revealed the multifaceted nature of the purposes of trace-based communication, including promoting efficiency, preventing mistakes and saving face.

CONCLUSIONS

This study demonstrated that clinicians pervasively use trace-based communication despite differences in opinion as to its implications for teamwork and safety. Other disciplines have taken up traces to promote collective adaptation. This should serve as inspiration to at least start exploring this phenomenon in healthcare.

Patients' perspectives on interprofessional collaboration between health care professionals during hospitalization: a qualitative systematic review

OBJECTIVE

The objective of this review was to gain a better understanding of the interprofessional collaboration between health care professionals from the patients' point of view during hospitalisation; the influence of interprofessional collaboration on patient care, safety, and well-being; and patients' perspectives of their role in the interprofessional collaboration process.

INTRODUCTION

Interprofessional collaboration is a key factor in improving patient health care outcomes and safety through better communication between health care professionals, better teamwork, and better care coordination. However, implementing interprofessional collaboration in the clinical setting can prove complex. Patients are increasingly interested in becoming partners within the health care system. They have the potential to contribute to their own safety and to observe professionals during the care process, thus gaining a better understanding of the interprofessional collaboration process and facilitating changes in the behavior of health care professionals.

INCLUSION CRITERIA

This review considered qualitative research and mixed-method studies. Participants were hospitalized patients. Studies were included when they explored i) patients' perceptions of interprofessional collaboration, ii) the influence of interprofessional collaboration on patients' care, safety, or well-being, or iii) patients' perceptions of their own role in interprofessional collaboration. Qualitative studies focusing only on the care process or families' points of view were excluded.

METHODS

Searches of six databases including MEDLINE, CINAHL, Embase, Web of Science, PsycINFO, and Sociological Abstract, limited to English, French, and German were conducted from March 2017 to June 2018. Assessment of methodological quality of studies was performed using the JBI Qualitative Assessment and Review Instrument. Data were extracted using the standardized data extraction tool from JBI. Data synthesis following the JBI approach of meta-aggregation was performed. The level of confidence for each synthesized finding was established based on ConQual.

RESULTS

A total of 22 studies were included, which resulted in 89 findings and 24 categories. Eight synthesized findings were generated: patients' perceptions of interprofessional collaboration based on personal experiences and observations; patients' experiences with effective or ineffective interprofessional communication; patients' experience with power imbalance and paternalistic attitudes; patients' perceptions of key factors for a confident relationship with the interprofessional health care team; patients' need for comprehension of discussions between health care professionals; patients' perceptions of their role in an interprofessional health care team; patients' perceptions of opportunities for empowerment in interprofessional health care teams; and patients' need for humanizing care from interprofessional health care teams. The level of confidence of synthesized findings varied from low to moderate according to ConQual.

CONCLUSIONS

This systematic review synthesized the perspectives of hospitalized patients regarding interprofessional collaboration and their perceived role in collaborative practices. Hospitalized patients observe interprofessional collaboration, either directly or indirectly, and the way interprofessional collaboration is performed may impact both their care and their well-being. However, little evidence has been found regarding the impact of interprofessional collaboration on patient safety. Patients' perspectives on their perceived role is not unanimous; some patients want to play an active role in the collaborative process, whereas others prefer to trust the health care professionals' expertise. Health care professionals should consider patients' preferences and act accordingly regarding both the collaborative process and the inclusion of the patients in collaborative practices.

Modified Early Warning System: Quality Improvement with the Help of Healthcare Failure Modes and Effect Analysis

Introduction: Hospitals struggle to implement MEWS. This study aims to improve MEWS implementation in the studied hospital.Objective: Improve the implementation of MEWS with the help of HFMEA.Materials: HFMEA together with training is used to improve the implementation.Results: The pre-intervention RPN got reduced from 1558 to 516 in the post-implementation phase.Application: This demonstrates improvement in the implementation of MEWS with the help of HFMEA, this study design can be widely used.Conclusion: The HFMEA is an effective tool to use for the improvement of MEWS implementation by the hospital nurses.

The How Matters: How Primary Care Provider Communication With Team Relates to Patients' Disease Management

BACKGROUND

Investigating primary care provider (PCP)-team communication can provide insight into how colleagues work together to become high-functioning teams more able to address an increasingly complex set of tasks associated with chronic disease management.

OBJECTIVE

To assess how PCP communication with their care team relates to patients' health.

RESEARCH DESIGN

Longitudinal study of how 3 aspects of PCP-care team communication-participation, time spent listening, and uninterrupted speaking length-relate to disease management of patients with hypertension or diabetes, and the effect of these team communication behaviors on PCP-patient communication as a pathway by which this relationship might exist. We used multilevel regression models.

SUBJECTS

Twenty-seven PCPs and 98 team members, and 18,067 patients with hypertension and 8354 patients with diabetes affiliated with a federally qualified health center with 12 practice sites.

MEASURES

Primary data on communication collected using sociometric sensors worn by PCPs and team members, patient-PCP communication data collected with surveys, and patient health, PCP and patient characteristics extracted from electronic records.

RESULTS

PCPs participated in 75% of care team conversations, spent 56% of conversation time listening, and had an average uninterrupted speaking length of 2.42 seconds. PCP participation, listening, and length of uninterrupted speaking time were associated with significantly higher odds that their patients had controlled hypertension and diabetes and improvements in disease control over time. PCP-patient communication mediates this relationship.

CONCLUSIONS

PCP-team communication is associated with patient health management. How team members speak with one another may be as important as the content of their communication.

Using Incident Reports to Assess Communication Failures and Patient Outcomes

INTRODUCTION

Communication failures pose a significant threat to the quality of care and safety of hospitalized patients. Yet little is known about the nature of communication failures. The aims of this study were to identify and describe types of communication failures in which nurses and physicians were involved and determine how different types of communication failures might affect patient outcomes.

METHODS

Incident reports filed during fiscal year 2015-2016 at a Midwestern academic health care system (N = 16,165) were electronically filtered and manually reviewed to identify reports that described communication failures involving nurses and physicians (n = 161). Failures were categorized by type using two classification systems: contextual and conceptual. Thematic analysis was used to identify patient outcomes: actual or potential harm, patient dissatisfaction, delay in care, or no harm. Frequency of failure types and outcomes were assessed using descriptive statistics. Associations between failure type and patient outcomes were evaluated using Fisher's exact test.

RESULTS

Of the 211 identified contextual communication failures, errors of omission were the most common (27.0%). More than half of conceptual failures were transfer of information failures (58.4%), while 41.6% demonstrated a lack of shared understanding. Of the 179 identified outcomes, 38.0% were delays in care, 20.1% were physical harm, and 8.9% were dissatisfaction. There was no statistically significant association between failure type category and patient outcomes.

CONCLUSION

It was found that incident reports could identify specific types of communication failures and patient outcomes. This work provides a basis for future intervention development to prevent communication-related adverse events by tailoring interventions to specific types of failures.

Understanding mothers' perception of child's illness: Adapting the CONNECT Instrument for pediatrics

AIMS AND OBJECTIVES

To adapt the CONNECT Instrument for use in the paediatric population, to assess validity of this instrument after its adaptation and to assess concordance between mothers' perception of their child's illness and providers' understanding of mothers' perceptions.

BACKGROUND

The CONNECT Instrument (Patient Education and Counseling, 73, 2008, 232-239) was validated in an adult outpatient population to characterise both patients' perspectives and physicians' understanding of their patients' perspectives for several dimensions of the illness experience. However, this did not include the paediatric population or advanced practice providers.

DESIGN

A two-part prospective, cross-sectional, observational study to assess the validity of CONNECT for Pediatrics and to assess perception of illness.

METHODS

The CONNECT Instrument (Patient Version) was adapted from its original form and modified to CONNECT for Pediatrics to facilitate use in the inpatient paediatric population. Eighty-five participants were enrolled including mothers, advanced practice providers and physicians from 2013-2014 during a child's scheduled admission to a paediatric epilepsy monitoring unit. Principal components analysis and inter-item reliability were analysed, and differences in the six mean domain scores were assessed using repeated measures analysis of variance (RM-ANOVA). Reporting of this research adheres to the STROBE guidelines (See Appendix S1).

RESULTS

Our analysis indicated that the modifications made provided a relatively valid and reliable instrument. There were overall statistically significant differences between the mother and physician groups, specifically in the domains of meaning and preference for partnership.

CONCLUSIONS

Paediatric advanced practice providers and physicians do have an understanding of mothers' perception of illness.

RELEVANCE TO CLINICAL PRACTICE

The ability of physicians and advanced practice providers to understand mothers' perceptions of illness is increasingly important in a changing healthcare environment. CONNECT for Pediatrics facilitates the identification of mothers' perception of their child's illness and provides the opportunity for paediatric advanced practice providers and physicians to understand parents' perception of illness.

Communication skills attitude scale: a translation and validation study in asample of registered nurses in Poland

OBJECTIVES

To translate and validate the Communication Skills Attitude Scale in the Polish language (CSAS-P) and its adaptation for use among registered nurses.

DESIGN

A cross-sectional descriptive design was used in order to translate and validate the CSAS-P. The following psychometric properties of CSAS-P were evaluated: content validity (content validity index), theoretical relevance (exploratory and confirmative factor analysis), one-dimensionality of subscales (principal component analysis), internal consistency (Cronbach's α), test-retest reliability and discriminant validity.

SETTING

Participants were identified and recruited from the Centre for Postgraduate Education for Nurses and Midwives in Warsaw, Poland.

PARTICIPANTS

The validation group comprised 2014 registered nurses who were undertaking a spring specialisation exam in 2017.

RESULTS

The overall content validity index was >0.80, which was interpreted as indicating validity. The factor structure of CSAS-P differed from the original version, and removing three items from the scale better fit the data. The positive attitude subscale (11 items) and negative attitude subscale (12 items) were characterised by one-dimensionality and high internal consistency (Cronbach's α=0.901 and 0.802, respectively). Test-retest analysis confirmed the stability of the measurement for both subscales and particular items. Nurses with prior participation in communication courses scored significantly higher than those without such education (p<0.05), confirming the discriminant validity of CSAS-P.

CONCLUSIONS

The psychometric properties of CSAS-P were comparable to the English language original. Further validation of CSAS-P in other groups of healthcare professionals may increase its applicability. CSAS-P can be used to evaluate attitudes towards learning communication skills among registered nurses.

Creating Shared Meaning: Communication Between Nurses and Physicians in Nursing Homes

The current study sought to obtain pilot data from a Situation, Background, Assessment, Recommendation (SBAR) communication intervention focused on the shared meaning construct of the sensemaking model and explore shared meaning in communication between nursing home (NH) nurses and physicians. The study design was an exploratory sequential mixed method with a pre/post quasi-experiment. Grounded theory was used to collect and analyze nurse and physician interviews and medical records. The Pathway to Shared Meaning model illustrating distinct processes supported use of the sensemaking model for understanding nurse-physician communication. Quantitative changes in communication were not significant. Shared meaning and training in SBAR for communication can be used to strengthen the design and use of structured communication in NHs.

TARGETS

Nurses and physicians providing direct care in NHs.

INTERVENTION DESCRIPTION

Stories describing nurse-physician sharing of resident information using SBAR.

MECHANISM OF ACTION

Mutual understanding of one another's perspective enhances communication.

OUTCOME

Communication openness and satisfaction. [Res Gerontol Nurs. 2019; 12(3):121-132.].

Physicians' Experience of Communication with Nurses related to Patient Safety: A Phenomenological Study Using the Colaizzi Method

PURPOSE

This study attempted to understand the core experiences of physicians related to communicating with nurses in Korea.

METHODS

Ten physicians who worked at four tertiary university hospitals were interviewed. Data were analyzed using the phenomenological method developed by Colaizzi.

RESULTS

The following six categories of participants' experience of communication with nurses were extracted from the analysis: (a) "Complex situations and heavy roles that cannot afford safety," (b) "Forcing a superior position in an authoritative environment," (c) "Different perspectives on patient care and difficulties in establishing relationships," (d) "Communicating key clues and receiving feedback from each other," (e) "Apathetic agreements rather than improvements," and (f) "Gradually developing mutually complementary communication."

CONCLUSION

The present findings revealed that physicians lacked an understanding about the roles and tasks of nurses. The participants engaged in mutually complementary communication with experienced nurses, obtaining desirable patient outcomes and perceived order filtering by nurses as a safety mechanism. It is important for managers to act as proactive change agents to improve communication. Furthermore, the importance and different forms of complementary communication between physicians and nurses need to be described and taught in depth with practical cases.

Patient perspectives on interprofessional collaboration between healthcare professionals during hospitalization: a qualitative systematic review protocol

REVIEW QUESTION/OBJECTIVE

The objective of this qualitative systematic review is to examine the available evidence on interprofessional collaboration from the patients' perspectives, specifically on: i) interprofessional collaboration in adult or pediatric wards during hospitalization; ii) the influence of interprofessional collaboration on the patient's care, safety and well-being in adult or pediatric wards during hospitalization; and (iii) the patient's role in the interprofessional collaboration process in adult or pediatric wards during hospitalization.

Patient safety in nursing homes in Sweden: nurses’ views on safety and their role

Objective

Knowledge about patient safety in nursing homes is limited. The aim of this study was to describe what patient safety means to nurses working in nursing homes for the elderly and how these nurses address patient safety.

Method

Qualitative study of semi-structured interviews with 15 nurses aged 27–62 years. Qualitative content analysis was applied.

Results

Nurses describe the meaning of patient safety in terms of proper care and treatment, and a sense of security. Based on nurses’ description of patient safety, several factors were identified as prerequisites to achieve safe health care: competence; clear information transfer between health care organizations; continuity of care and appropriate environment. Barriers to patient safety were described as lack of sufficient resources; lack of communication and negative attitudes to incident reporting. To a great extent, nurses’ work for patient safety consists of efforts to compensate for defects and ensure good health care in their daily work, since work with patient safety is not a management priority.

Conclusion

Patient safety needs to be clarified and prioritized in nursing homes, and there is a need to understand nurses’ role among other care givers and the need for shared routines among care givers.

Nurses' experiences of pain management for people with advanced dementia approaching the end of life: a qualitative study

AIMS AND OBJECTIVES

To explore hospice, acute care and nursing home nurses' experiences of pain management for people with advanced dementia in the final month of life. To identify the challenges, facilitators and practice areas requiring further support.

BACKGROUND

Pain management in end-stage dementia is a fundamental aspect of end-of-life care; however, it is unclear what challenges and facilitators nurses experience in practice, whether these differ across care settings, and whether training needs to be tailored to the context of care.

DESIGN

A qualitative study using semi-structured interviews and thematic analysis to examine data.

METHODS

Twenty-four registered nurses caring for people dying with advanced dementia were recruited from 10 nursing homes, three hospices and two acute hospitals across a region of the UK. Interviews were conducted between June 2014-September 2015.

RESULTS

Three core themes were identified: challenges administering analgesia, the nurse-physician relationship, and interactive learning and practice development. Patient-related challenges to pain management were universal across care settings; nurse- and organisation-related barriers differed between settings. A need for interactive learning and practice development, particularly in pharmacology, was identified.

CONCLUSIONS

Achieving pain management in practice was highly challenging. A number of barriers were identified; however, the manner and extent to which these impacted on nurses differed across hospice, nursing home and acute care settings. Needs-based training to support and promote practice development in pain management in end-stage dementia is required.

RELEVANCE TO CLINICAL PRACTICE

Nurses considered pain management fundamental to end-of-life care provision; however, nurses working in acute care and nursing home settings may be undersupported and under-resourced to adequately manage pain in people dying with advanced dementia. Nurse-to-nurse mentoring and ongoing needs-assessed interactive case-based learning could help promote practice development in this area. Nurses require continuing professional development in pharmacology.

Exploring healthcare assistants' role and experience in pain assessment and management for people with advanced dementia towards the end of life: a qualitative study

BACKGROUND

Pain assessment and management are key aspects in the care of people with dementia approaching the end of life but become challenging when patient self-report is impaired or unavailable. Best practice recommends the use of observational pain assessments for these patients; however, difficulties have been documented with health professionals' use of these tools in the absence of additional collateral patient knowledge. No studies have explored the role, perspectives and experiences of healthcare assistants in pain assessment and management in dementia; this study provides insight into this important area.

METHODS

A qualitative approach was adopted, using key informant interviews with healthcare assistants caring for people with advanced dementia approaching the end of life in hospice, nursing home and acute care settings. Thematic analysis was the analytic approach taken to interpretation of interview data. Data were collected between June 2014 and September 2015.

RESULTS

Fourteen participants took part in the study. Participants' average length of caring experience was 15.4 years and most were female. Three key themes emerged: recognising pain, reporting pain, and upskilling. Participants were often the first to notice obvious causes of pain and to detect changes in patient norms which signified hidden causes of pain. Comprehensive knowledge of resident norms enabled participants to observe for behavioural and nonverbal indicators of pain and distinguish these from non-pain related behaviours. Pain reporting was heavily impacted by relationships with professional staff and the extent to which participants felt valued in their role. Positive relationships resulted in comprehensive pain reports; negative relationships led to perfunctory or ambiguous reporting. Participants emphasised a desire for further training and upskilling, including in the use and reporting of basic pain tools.

CONCLUSIONS

Healthcare assistants are frontline staff who have a key role in direct patient care, spending a considerable amount of time with patients in comparison to other health professionals. These staff are often first to notice changes in patients that may signify pain and to alert professional staff. However, to ensure the quality of these reports, further efforts must be made in reversing stigma attached to this role and in upskilling these members of the healthcare team.

Perceived Nurse-Physician Communication in Patient Care and Associated Factors in Public Hospitals of Jimma Zone, South West Ethiopia: Cross Sectional Study

Background

Nurse–physician communication has been shown to have a significant impact on the job satisfaction and retention of staff. In areas where it has been studied, communication failure between nurses and physicians was found to be one of the leading causes of preventable patient injuries, complications, death and medical malpractice claims.

Objective

The objective of this study is to determine perception of nurses and physicians towards nurse-physician communication in patient care and associated factors in public hospitals of Jimma zone, southwest Ethiopia.

Methods

Institution based cross-sectional survey was conducted from March 10 to April 16, 2014 among 341 nurses and 168 physicians working in public hospitals in Jimma zone. Data was collected using a pre-tested self-administered questionnaire; entered into EpiData version 3.1 and exported to Statistical Package for Social Sciences (SPSS) version 16.0 for analysis. Factor analysis was carried out. Descriptive statistics, independent sample t-test, linear regression and one way analysis of variance were used. Variables with P-value < 0.05 were considered as statistically significant.

Results

The response rate of the study was 91.55%. The mean perceived nurse-physician communication scores were 50.88±19.7% for perceived professional respect and satisfaction, and 48.52±19.7% for perceived openness and sharing of patient information on nurse-physician communication. Age, salary and organizational factors were statistically significant predictors for perceived respect and satisfaction. Whereas sex, working hospital, work attitude individual factors and organizational factors were significant predictors of perceived openness and sharing of patient information in nurse-physician communication during patient care.

Conclusion

Perceived level of nurse-physician communication mean score was low among nurses than physicians and it is attention seeking gap. Hence, the finding of our study suggests the need for developing and implementing nurse-physician communication improvement strategies to solve communication mishaps in patient care.

Trust and Reflection in Primary Care Practice Redesign

OBJECTIVE

To test a conceptual model of relationships, reflection, sensemaking, and learning in primary care practices transitioning to patient-centered medical homes (PCMH).

DATA SOURCES/STUDY SETTING

Primary data were collected as part of the American Academy of Family Physicians' National Demonstration Project of the PCMH.

STUDY DESIGN

We conducted a cross-sectional survey of clinicians and staff from 36 family medicine practices across the United States. Surveys measured seven characteristics of practice relationships (trust, diversity, mindfulness, heedful interrelation, respectful interaction, social/task relatedness, and rich and lean communication) and three organizational attributes (reflection, sensemaking, and learning) of practices.

DATA COLLECTION/EXTRACTION METHODS

We surveyed 396 clinicians and practice staff. We performed a multigroup path analysis of the data. Parameter estimates were calculated using a Bayesian estimation method.

PRINCIPAL FINDINGS

Trust and reflection were important in explaining the characteristics of practice relationships and their associations with sensemaking and learning. The strongest associations between relationships, sensemaking, and learning were found under conditions of high trust and reflection. The weakest associations were found under conditions of low trust and reflection.

CONCLUSIONS

Trust and reflection appear to play a key role in moderating relationships, sensemaking, and learning in practices undergoing practice redesign.

Assertion Practices and Beliefs Among Nurses and Physicians on an Inpatient Pediatric Medical Unit

BACKGROUND

Teamwork and communication are critical elements of safe and effective patient care. Standardized communication tools have been implemented in many health care organizations, but little is known about attitudes and perceptions of assertion, the willingness to "speak up," by nurses and physicians at an academic pediatric institution.

METHODS

We conducted 6 focus groups with nurses, residents, and attending physicians using a standardized semistructured focus group guide to promote discussion. Focus groups were recorded and transcribed, and results were analyzed by 2 independent reviewers to identify thematic content.

RESULTS

Three themes emerged: (1) interpersonal factors, (2) organizational factors, and (3) complexity of care environment. Subthemes were the roles of hierarchy, relationships, and communication and personality style; the value of using standardized communication tools such as SBAR (Situation, Background, Assessment, Recommendation), direct face-to-face communication, and geographic and technology factors; and the need for coordinated communication and agreement across care team members about the care plans. Nurses reported reliance on peers for decision-making, on when and how to assert on behalf of patient care. Nurses and residents experienced barriers to assertion from concerns of relationships and their position within professional hierarchies. Attending physicians were supportive of being asserted to by any care team provider.

CONCLUSIONS

Interpersonal relationships, power dynamics, and organizational factors impact care team providers' willingness to assert in the inpatient setting. Standardized communication tools are effective. Further development and implementation of communication models that support experience, peer reliance, and direct face-to-face communication are warranted to improve assertion communication in the inpatient setting

Interprofessional team management in pediatric critical care: some challenges and possible solutions

BACKGROUND

Aiming for and ensuring effective patient safety is a major priority in the management and culture of every health care organization. The pediatric intensive care unit (PICU) has become a workplace with a high diversity of multidisciplinary physicians and professionals. Therefore, delivery of high-quality care with optimal patient safety in a PICU is dependent on effective interprofessional team management. Nevertheless, ineffective interprofessional teamwork remains ubiquitous.

METHODS

We based our review on the framework for interprofessional teamwork recently published in association with the UK Centre for Advancement of Interprofessional Education. Articles were selected to achieve better understanding and to include and translate new ideas and concepts.

FINDINGS

The barrier between autonomous nurses and doctors in the PICU within their silos of specialization, the failure of shared mental models, a culture of disrespect, and the lack of empowering parents as team members preclude interprofessional team management and patient safety. A mindset of individual responsibility and accountability embedded in a network of equivalent partners, including the patient and their family members, is required to achieve optimal interprofessional care. Second, working competently as an interprofessional team is a learning process. Working declared as a learning process, psychological safety, and speaking up are pivotal factors to learning in daily practice. Finally, changes in small steps at the level of the microlevel unit are the bases to improve interprofessional team management and patient safety. Once small things with potential impact can be changed in one's own unit, engagement of health care professionals occurs and projects become accepted.

CONCLUSION

Bottom-up patient safety initiatives encouraging participation of every single care provider by learning effective interprofessional team management within daily practice may be an effective way of fostering patient safety.

The Effect of Health Information Technology on Health Care Provider Communication: A Mixed-Method Protocol

Background

Communication failures between physicians and nurses are one of the most common causes of adverse events for hospitalized patients, as well as a major root cause of all sentinel events. Communication technology (ie, the electronic medical record, computerized provider order entry, email, and pagers), which is a component of health information technology (HIT), may help reduce some communication failures but increase others because of an inadequate understanding of how communication technology is used. Increasing use of health information and communication technologies is likely to affect communication between nurses and physicians.

Objective

The purpose of this study is to describe, in detail, how health information and communication technologies facilitate or hinder communication between nurses and physicians with the ultimate goal of identifying how we can optimize the use of these technologies to support effective communication. Effective communication is the process of developing shared understanding between communicators by establishing, testing, and maintaining relationships. Our theoretical model, based in communication and sociology theories, describes how health information and communication technologies affect communication through communication practices (ie, use of rich media; the location and availability of computers) and work relationships (ie, hierarchies and team stability). Therefore we seek to (1) identify the range of health information and communication technologies used in a national sample of medical-surgical acute care units, (2) describe communication practices and work relationships that may be influenced by health information and communication technologies in these same settings, and (3) explore how differences in health information and communication technologies, communication practices, and work relationships between physicians and nurses influence communication.

Methods

This 4-year study uses a sequential mixed-methods design, beginning with a quantitative survey followed by a two-part qualitative phase. Survey results from aim 1 will provide a detailed assessment of health information and communication technologies in use and help identify sites with variation in health information and communication technologies for the qualitative phase of the study. In aim 2, we will conduct telephone interviews with hospital personnel in up to 8 hospitals to gather in-depth information about communication practices and work relationships on medical-surgical units. In aim 3, we will collect data in 4 hospitals (selected from telephone interview results) via observation, shadowing, focus groups, and artifacts to learn how health information and communication technologies, communication practices, and work relationships affect communication.

Results

Results from aim 1 will be published in 2016. Results from aims 2 and 3 will be published in subsequent years.

Conclusions

As the majority of US hospitals do not yet have HIT fully implemented, results from our study will inform future development and implementation of health information and communication technologies to support effective communication between nurses and physicians.

The need for predictability in coordination of ventilator treatment of newborn infants--a qualitative study

OBJECTIVE

New strategies for interprofessional collaboration are needed to achieve best practice in the care of ventilated newborns. This study explores what physicians and nurses believe to be important to improve collaboration during ventilator treatment.

METHODS

Qualitative data collected from one focus group were analysed using Gittell's theory of relational coordination.

RESULTS

To optimise communication about and coordination of ventilator treatment, six strategies were needed: (1) a pathway toward the goal for each newborn, (2) regular meetings, (3) accurate communication following an established pattern in the rounds conference, (4) collaboration to improve interprofessional level of knowledge, (5) courage to communicate one's own point of view, and (6) flexible responsibility in extubation situations.

CONCLUSION

By identifying weak areas in collaboration, nurses and physicians were inspired to suggest and discuss concrete improvements of work practices in the neonatal intensive care unit. Nurses and physicians can coordinate ventilator treatment by using a pathway and at the same time enhance nurses' involvement and responsibility in order to increase the flexibility of job boundaries, allowing the professions to cover for each other's work.

Effective followership: A standardized algorithm to resolve clinical conflicts and improve teamwork

In healthcare, the sustained presence of hierarchy between team members has been cited as a common contributor to communication breakdowns. Hierarchy serves to accentuate either actual or perceived chains of command, which may result in team members failing to challenge decisions made by leaders, despite concerns about adverse patient outcomes. While other tools suggest improved communication, none focus specifically on communication skills for team followers, nor do they provide techniques to immediately challenge authority and escalate assertiveness at a given moment in real time. This article presents data that show one such strategy, called the Effective Followership Algorithm, offering statistically significant improvements in team communication across the professional continuum from students and residents to experienced clinicians.

Shift change handovers and subsequent interruptions: potential impacts on quality of care

OBJECTIVES

Two statistical surveys in France revealed both widespread dissatisfaction about shift change handovers and the feeling of being frequently disturbed by interruptions. Shift change handovers (SCHs) are being reduced or eliminated in France to reduce staff costs. The objective of our study is to clarify the consequences of short SCHs on efficiency, team function, and quality of care.

METHODS

Real-time task ergonomic analysis of 29 state-registered nurses (RNs), 18 nursing aides (NAs), and 14 full-time physicians was conducted in various departments of general and university hospitals.

RESULTS

The average time available to RNs for sharing information during SCHs was 15 minutes at the beginning of the work session and 13 minutes at the end. There were, on average, 50 interruptions of activity, and these interruptions occupied 16% of the working time. Consequently, less time was available for direct care, although the number of such acts was increased. Periods for preparation of care, writing, seeking information, or equipment were very numerous. The mean number of changes of activity was very large: 260 per work session. For NAs, SCHs were similar to those for RNs at the beginning of the work session (mean = 18 minutes) but shorter at the end (10 minutes). The mean number of interruptions was 30 and caused 10.3% of the working time to be lost with 164 changes of activity. For physicians, SCHs were even shorter and, in many cases, nonexistent. The mean number of interruptions was 30 (11.4% of their working time, 153 changes of activity). Shift change handovers were mostly conducted separately for RNs, NAs, and physicians.

DISCUSSION

A better sharing of knowledge between the different health-care workers, and especially at the beginning of the work session, could reduce interruptions and potentially improve quality of care.

Perceived quality of interprofessional interactions between physicians and nurses in oncology outpatient clinics

PURPOSE

To evaluate the perceived quality of interactions between nurses and physicians in oncology outpatient clinics.

METHODS

A cross-sectional, observational survey involving 250 physicians and nurses was conducted at oncology outpatient clinics at two regional cancer centres in the province of Ontario, Canada. Eligible participants were identified by administrators and invited to complete a one-time survey questionnaire. Quality of interactions was assessed using a seven-item survey of relational coordination, which measures two factors of interaction: supportive relationships and quality communication. Descriptive analyses and multivariate analyses of variance (MANOVA) were conducted to assess potential differences between the two study sites and the two professional groups.

RESULTS

Overall, nurses and physicians at both study sites rated their interactions highly (mean = 4.32 and 4.51 out of 5 for supportive relationships and quality communication, respectively). No difference in either factor was reported between physicians and nurses at either study site, but the two study sites differed significantly in both factors [F(2, 245) = 7.54, p < 0.001].

CONCLUSIONS

Overall, oncology nurses and oncologists at outpatient clinics rated their levels of interprofessional interaction highly. Contextual factors may have contributed to the high interaction scores and different ratings between the two cancer centres. The finding that nurses and physicians reported similar levels of perceived interactions suggests that relationships in these outpatient cancer clinics are highly collaborative and collegial.

Interdisciplinary Rounds and Structured Communication Reduce Re-Admissions and Improve Some Patient Outcomes

Hospital communication is more than access to information. Among staff, it is about achieving situation awareness-an understanding of a patient's current condition and likely trajectory. In the multidisciplinary context of providing care, structure, consistency, and repeatability of communication will enable a shared understanding of the patient and plan, leading to improved patient satisfaction and outcomes. This was tested using the Situation-Background-Assessment-Recommendation (SBAR) protocol, a re-admissions risk assessment and daily interdisciplinary rounds (IDR) in the medical/surgical units of a hospital. The impact of these interventions on patient satisfaction, Foley catheter removal compliance, and patient re-admission rates was assessed. Over the 3 year period, Foley compliance improved from 78% to 94%, and re-admissions decreased from 14.5% to 2.1%, both significant. Patient satisfaction trended positively, but was not significant. These results support the value of SBAR and IDR, and are advocated to improve situation awareness and maintain focus on key patient data.

Errors in after-hours phone consultations: a simulation study

BACKGROUND

After-hours out-of-hospital phone consultations require physicians to make decisions based on information provided by a nurse over the phone.

METHODS

We conducted a simulation study to evaluate physicians' actions following communication of key information. 22 nurses were asked to call physicians with six cases based on the six most common reasons for after-hours phone calls. We evaluated physicians' actions following the communication of key clinical information: A situation cue described a patient's problem (eg, confusion). A background cue described a specific clinical finding regarding the cause of the problem (eg, patient's sodium is low). For each cue we defined a list of indicators, based on the medical literature, to ascertain whether physicians acted upon the provided information (which was defined as addressing at least one of the indicators).

RESULTS

A total of 108 phone consultations (containing 88 situation and 93 background cues) were analysed. Situation cues were communicated in 90% (79/88) of the calls and background cues in 33% (31/93). Physician acted upon the provided information in 57% (45/79) and 48% (15/31) of the communicated situation and background cues, respectively. When the background cues were not communicated, physicians asked questions expected to elicit the cue in 12% of the cases. Responding to the situation cue was associated with longer conversations and active inquiry by the physician.

CONCLUSIONS

After-hours phone calls are error prone. Both nurse communication and physician decision-making are problematic. Efforts to improve patient safety in this setting must address both communication and decision-making.

An academic hospitalist model to improve healthcare worker communication and learner education: results from a quasi-experimental study at a Veterans Affairs medical center

BACKGROUND

Although hospitalists may improve efficiency and quality of inpatient care, their effect on healthcare-worker communication and education has been less well-studied.

OBJECTIVE

To test various approaches to improving healthcare-worker communication and learner education within the context of a newly designed academic hospital medicine program.

DESIGN

Before-and-after design with concurrent control group.

SETTING

A Midwestern Veterans Affairs medical center.

INTERVENTION

Multimodal systems redesign of 1 of 4 medical teams (Gold team) that included clinical modifications (change in rounding structure, with inclusion of nurses, a Clinical Care Coordinator, and a pharmacist) and educational interventions (providing explicit expectations of learners and providing a reading list for both learners and attending physicians).

MEASUREMENTS

Number of admissions, length of stay, readmissions, house officer and medical student ratings of attendings' teaching, medical student internal medicine National Board of Medical Examiners Subject Examination ("shelf" exam) scores, and clinical staff surveys.

RESULTS

Length of stay was reduced by about 0.3 days on all teams after the initiative began (P = 0.004), with no significant differences between Gold and non-Gold teams. The majority of physicians (83%) and nurses (68%) felt that including nurses during rounds improved healthcare-worker communication; significantly more nurses were satisfied with communication with the Gold team than with the other teams (71% vs 53%; P = 0.02). Gold attendings generally received higher teaching scores compared with non-Gold attendings, and third-year medical students on the Gold team scored significantly higher on the shelf exam compared with non-Gold team students (84 vs 82; P = 0.006).

CONCLUSIONS

Academic hospitalists working within a systems redesign intervention were able to improve healthcare-worker communication and enhance learner education without increasing patient length of stay or readmission rates.

Reframing communication with physicians as sensemaking: moving the conversation along

Poor communication between physicians and nurses is one of the most common causes of adverse events for hospitalized patients and a major root cause of sentinel events. Physician and nurse perspectives on what constitutes good communication differ. This article describes sensemaking as a cognitive process that builds consensus by getting nurses and physicians to answer these questions: What is happening here? What should we do about it? Sensemaking goes beyond communication, requiring that diverse opinions are brought to bear on a situation framed by salient cues.

Current medical staff governance and physician sensemaking: a formula for resistance to high reliability

PURPOSE

To offer a theoretical explanation for observed physician resistance and rejection of high reliability patient safety initiatives.

DESIGN/METHODOLOGY/APPROACH

A grounded theoretical qualitative approach, utilizing the organizational theory of sensemaking, provided the foundation for inductive and deductive reasoning employed to analyze medical staff rejection of two successfully performing high reliability programs at separate hospitals.

FINDINGS

Physician behaviors resistant to patient-centric high reliability processes were traced to provider-centric physician sensemaking.

RESEARCH LIMITATIONS/IMPLICATIONS

Research, conducted with the advantage that prospective studies have over the limitations of this retrospective investigation, is needed to evaluate the potential for overcoming physician resistance to innovation implementation, employing strategies based upon these findings and sensemaking theory in general.

PRACTICAL IMPLICATIONS

If hospitals are to emulate high reliability industries that do successfully manage environments of extreme hazard, physicians must be fully integrated into the complex teams required to accomplish this goal.

SOCIAL IMPLICATIONS

Reforming health care, through high reliability organizing, with its attendant continuous focus on patient-centric processes, offers a distinct alternative to efforts directed primarily at reforming health care insurance. It is by changing how health care is provided that true cost efficiencies can be achieved. Technology and the insights of organizational science present the opportunity of replacing the current emphasis on privileged information with collective tools capable of providing quality and safety in health care.

ORIGINALITY/VALUE

The fictions that have sustained a provider-centric health care system have been challenged. The benefits of patient-centric care should be obtainable.

Nurse-physician relationships in ambulatory oncology settings

PURPOSE

The purpose of this study was to explore nurses' perceptions of nurse-physician relationships in ambulatory oncology settings, which are linked to patient safety.

DESIGN

This cross-sectional, descriptive study analyzed survey data collected in 2010 from oncology nurses employed in ambulatory settings. The sampling frame was the nurse licensure database in one state in the Southeastern United States. Nurses completed the Practice Environment Scale of the Nursing Work Index (PES-NWI), reported on the quality of care in their setting, and commented on factors that promoted or inhibited high-quality care delivery.

METHODS

Data analysis used three study variables: empirically derived values from the PES-NWI, a scale of nurse-reported quality of care in their setting, and open-text comments about features in their workplace that promoted or hindered high-quality care. After categorizing open-text comments, analysis of variance was used to evaluate differences in PES-NWI subscales by comment category. Chi-square test statistics were calculated to examine differences in overall practice environment and quality of care by comment category.

RESULTS

Nurses reported their relationships with physicians as generally favorable. Qualitative findings suggest two themes that influence how nurses characterize their working relationships with physicians: (a) physician behaviors and (b) structural factors. Both PES-NWI scores and quality of care were rated significantly higher by nurses who wrote favorably about physicians.

CONCLUSIONS

Favorable nurse-physician relationships in ambulatory settings may reflect positive workplaces and promote high-quality care.

CLINICAL RELEVANCE

Consistent with findings from inpatient units, nurse-physician relationships are important to the quality of ambulatory oncology care. Systematic measurement and attention to reported deficits in these relationships may promote higher quality care.

Using a clinical postconference to introduce baccalaureate nursing students to a quality framework

Novice nurses are expected to contribute to an organization's quality initiatives and strategic goals. Therefore, it is imperative for nursing students to learn how a quality framework is woven within an organization. A figure was created that introduced baccalaureate nursing students to key quality concepts linking regulations, the organization, the quality department, and quality improvement (QI) methods. One important goal was to provide a visual framework that could facilitate clinical postconference discussions regarding the interrelationship of these concepts. Fifty-three undergraduate nursing students participated in a pilot over three semesters. Student response was heavily influenced based on their levels of training, which allowed for programmatic revisions each semester. Evaluation yielded improved QI knowledge and attitudes among advanced students (those in a senior transition course ready to graduate); it also served as a useful method to begin meeting the Quality and Safety Education for Nurses' QI competency.