Communication Among Healthcare Providers

1. Communication Among Healthcare Providers

2. Purpose • To review the importance of excellent communication among health care providers in promoting career satisfaction and patient safety

3. Objectives • At the completion of this exercise, you should: • Understand the contribution of good communication to safe patient care • Be able to concisely summarize a concern about a patient • Actively listen to information communicated by the physician or other healthcare providers • Assertively yet professionally communicate concerns you have about a patient that are not being adequately addressed

4. Effective Communication Requires: • Structured communication-SBAR • Assertion/Critical Language-key words, the ability to speak up and stop the show • Psychological safety-an environment of respect • Effective leadership-flat hierarchy, continuously inviting team members into the conversation

5. Nurse-Physician Communications • Frequent occurrence • Communication across a hierarchy can be intimidating • Gender or cultural issues may complicate further • Often named as cause of nurse job dissatisfaction • Critical for patient safety

6. MD – RN : Different Communication Styles • Nurses are trained to be narrative and descriptive – “you don’t make diagnoses” • Physicians are trained to be problem solvers “what do you want me to do” – “just give me the headlines” • Complicating factors: gender, national culture, the pecking order, prior relationship • Perceptions of teamwork depend on you point of view

7. Communication and Safe Care • 60 % of medication errors are caused by mistakes in interpersonal communication1 • Poor coordination of care is the most common cause of adverse events triggering root cause analyses1 1Joint Commission Data

8. Steps to Excellent Healthcare Communication 4 Assert concerns if needed 3 Actively listen to response 2 Concisely describe the problem 1 Clarify the problem & gather data

9. SBAR-Situational Briefing Model Used in the nuclear submarine service for concise and accurate communication S – situation – what is the situation? B – background – how did we get here? what is the context? A – assessment – what do I think the problem is? R – recommendation – what are we going to to fix it?

10. Situational Briefing Model S-B-A-R • Situation • Background • Assessment • Recommendation

11. SBAR • Enhances predictability – how we’re going to talk to each other • Crisp – to the point • Promotes critical thinking • Similar in structure to the SOAP model that is taught in medical school

12. Recommendation Recommend what you think you be helpful or needs to be done: • Medications, lab test, ABG, X-Ray, EKG, CT, MRI etc • Transfer to critical care or another level of care • Physician or Consultation Evaluation

13. Communication is a big theme in the JCAHO Patient Safety Goals • Structured communication for hand-offs • Read-backs on verbal orders – “tell me what I said” • Identify patient from 2 sources – sadly mistakes still occur • Verification of correct patient, correct site, correct procedure – Time Out • Briefing before procedures, operations, SBAR

14. SBAR Situation – the punch line, give it in 5-10 seconds Background – the context, objective data, the numbers, how did we get here Assessment – what is the problem Recommendation – what do we need to do and when?

15. SBAR in OB – 5:00 AM S – Dr. Droga, I’m worried about Ms. Klein, I think she is going to rupture her uterus B – She is a VBAC; she has a dense epidural, but she is having persistent breakthrough abdominal pain; she is complete and ready to push A – I’m concerned – something is wrong – I don’t want her to push R – I think we need to think about a C-Section. I think you need to come in and see her now.

16. Assertion – What is it? “Individuals speak up, and state their information with appropriate persistence until there is a clear resolution.”

17. Why is Assertion / Critical Language Important? • Because we know that 25-40% of nurses tell us on the Safety Attitude Questionnaire they would be hesitant to speak up if they saw an MD make a mistake • Often people don’t speak up or do so quite indirectly • Knowing the plan – using SBAR – makes it much easier to speak up

18. The Difficult Conversation – How to Achieve Agreement • Focus on the common goal – high quality, safe care • 3rd person – depersonalize the conversation – it’s not about you and me • Avoid judgment; who’s right, who’s wrong is a loser • What needs to happen for us to do the right thing here?

19. SBAR Situation: Dr. Jones, I’m Paul, the RT. Mr. Jakus in 403 is really having trouble breathing. Background: He has severe COPD, has been going downhill and is now acutely worse. RR 40, O2 sat 74% on oxygen Assessment: His breath sounds are way down on the right side…I think he has a pneumothorax Recommendation: I really need your help now…this guy is in real trouble – he needs a chest tube before he stops breathing.

20. Prior to calling the Physician • Assess the patient • Review the chart for the appropriate physician to call • Know the admitting diagnosis • Read the most recent physician and nursing notes • Have the chart in hand and be ready to report current vital signs, allergies, medications, IV fluids, test results • Every SBAR is different. Focus on the problem. Be concise. Not everything in the outline below needs to be reported – Just what is needed for the situation

21. Situation • State your name and unit • Patient Name and room number • Diagnosis/reason for admission • Brief history of patient • Patient problem/complaint or event/pain level • If serious problem, patient’s code status

22. Background • Synopsis of treatment/procedures and date • Current vital signs, pulse ox, O2 amt, heart rhythm and other pertinent hemodynamic data • Relate the physical assessment pertinent to the problem especially any changes related to mental status

23. Assessment • Give your conclusions about the present situation • Give signs/symptoms, abnormal labs, severity of problem

24. Communication with Other Healthcare Workers • Step 1 - Gather and clarify all of the information you need to provide to the physician: • Nature of the problem • Supporting information or data • Clarify in your mind what you would like for the patient to do

25. Case Presentation • You are assigned to care for a 68 year old lady for the evening shift. She is two days post-op following hip fracture surgery. No problems were noted at nursing sign-out other than c/o pain, for which she was receiving pain medication. • When you perform your initial assessment on this patient, you find her to be confused.

26. Case Presentation • What additional information do you need to gather prior to contacting the physician?

27. Case Presentation • Additional information you might gather: • Vital signs and pulse oximetry • Name, dose and timing of pain medication previously given • Any additional observations that you feel would be helpful

28. Case Presentation • Vital signs and pulse oximetry • T 37.5, P 108, R 24, O2 sat 82% (RA) • Name, dose and timing of pain medication previously given • Morphine sulfate 2 mg IV two hours ago • Any additional observations that you feel would be helpful • Patient’s respirations seem somewhat labored

29. Communication withOther Healthcare Workers • Step 2 – State concisely to the physician the problems that the patient is experiencing. • Nature of the problem • Supporting information or data • Question or issue on which you need his/her input

30. Role Play • When you call the resident physician on duty, how would you state your concerns and question? • Give a brief summary (no more than 60 sec) to the person sitting next to you. • Have that person give you feedback on: • What was effective about your communication? • What could have been clearer?

31. Communication withOther Healthcare Workers • Step 3 – Actively listen to information communicated by the physician/healthcare worker • Listen to the plan of care • Clarify areas which are unclear by asking appropriate questions

32. Case Presentation • The resident physician asks that you obtain the following tests: • CXR • ABG • EKG • Routine blood work (CBC, BMP) • Is there any additional information you need to know at this time?

33. Case Presentation • The resident physician asks that you obtain the following tests: • CXR • ABG • EKG • Routine blood work (CBC, BMP) • Is there any additional information you need to know at this time? • Since her respirations are somewhat labored, should patient be placed on O2?

34. Case Presentation • The CXR suggests pneumonia, and the resident orders an IV antibiotic. • Two hours later, as you start the antibiotic, you note that the patient is more short of breath. You request that the resident re-evaluate the patient. • Let’s do another SBAR with the person sitting next to you, same feedback please!

35. Case Presentation…Later on… • The patient’s O2 sat is now 88% on 50% face mask, and her respiratory rate is 30/minute. • You feel she needs almost 1:1 nursing, and are worried about how you will care for your other three patients. • You ask if the resident if the patient should be moved to the ICU, but he states he wants to first see how she responds to the antibiotic. What now?

36. Communication withOther Healthcare Workers • Step 4 – Know how to tactfully use assertive communication when necessary • State your concern • State information that supports your concerns • Suggest a course of action • Recap why you feel this action is best option Practice SBAR with the resident or as you escalate

37. Role Play • Practice assertive communication to the person sitting next to you: • State your concern • State information that supports your concerns • Suggest a course of action • Recap why you feel this action is best option

38. Assertive Communication in Patient Care • Is not: • Yelling or bullying • Accusatory • Being disrespectful of authority • Is: • Focused on patient • Noting your perceptions • Persistently raising concerns, intended to move toward desired action

39. Case Presentation • If your effort at assertive communication does not have the desired effect, what other options are available to you?

40. When Assertiveness Doesn’t Work • Restate your concerns in another way • Engage another healthcare worker (i.e. Respiratory Therapy) • Engage your supervisor • Engage another physician on the team

41. Effective Communication • Essential for real teamwork • Essential for long term career satisfaction • Essential for patient safety and quality care

42. Read Back Orders to Physician Document After Signature Document read back on chart after order written: -Hang normal saline @ 100ml/hour -Aspirin 325 mg po every day T.O. Dr. Donald Duck/ Minnie Mouse RN/ RB times 1

43. Be sure to ask for necessary follow-up Clarify when physician would like to be called back

44. Critical Lab Values When notified about a critical lab value • RN must read back the lab value to lab personnel • Write down lab value • Document in physician progress notes that the critical value was called to MD with the date and time