July 2019, Volume XXXIII, No 4
The nurses’ perspective
ecognizing that effective communications and coordination benefit all parties, doctors at Johns Hopkins Hospital years ago designed a system to reduce medical errors through improved teamwork and communication. It involved a patient safety checklist and one golden rule: listen to nurses and other frontline staff when safety rules aren’t followed. Initially, the system was so successful at lowering mortality that other hospitals adopted it to reduce medical errors.
But more recently, Johns Hopkins failed to follow its own system, the Tampa Bay Times has found. The result? Allegations of preventable, egregious adverse events. According to the report, in at least nine recent cases, basic safety rules were not followed, even though nurses and other frontline staff brought the safety lapses to the attention of hospital executives, and those problems continued long after. At least eight employees warned supervisors about issues with two heart surgeons at Johns Hopkins All Children’s Hospital. The complaints fell on deaf ears. By the time the hospital responded, the mortality rate in its Heart Institute had tripled, and at least 11 children had died.
Johns Hopkins Hospital responded, “The Tampa Bay Times has identified occasions where it is apparent that as an organization we failed to act quickly enough, we failed to listen closely enough and, in some instances, we failed to deliver the care our patients and their families deserve.” It’s clear that breakdowns in health care team communications create dangerous gaps in care.
Health care teams include not only nurses and physicians, but others involved in care delivery. These professionals work cooperatively and share responsibilities to provide quality and effective care through trust and mutual respect. Effective teams that trust each other, respect each other, and collaborate to work through challenges ensure the best outcomes.
Interdisciplinary teamwork promotes effective communication and cohesiveness during patient handoffs among caregivers with different levels of education, skills, and patient care goals. Over the course of a five-day hospital admission, a patient may interact with more than 50 hospital staff. Interactions among health care teams are far more frequent.
Under the strains of a fast-paced, stressful, high-liability setting, critical information must be communicated accurately and effectively. Also, positive communication between nurses and physicians can improve job satisfaction, improve patient outcomes, and result in fewer medical errors.
Effective communication promotes teamwork and information flow; clarity of purpose; quality patient care, safety, satisfaction, and decreased lengths of stay; the prevention of delays in patient care; reduced medical and treatment errors; heightened staff morale, satisfaction and retention; and reduced costs to insurers, government, and patients.
Teams that don’t know what the others are doing are ineffective and put patients at risk. And it’s not just patients. Breakdowns in communication take a toll on physicians and nurses as well. Physician and nurse suicides are on the rise. One nurse cited poor communications between health care team members as a likely cause during a recent podcast on physician suicide.
A 2015 Malpractice Risks in Communications report shows that communication breakdown was a key factor in 30% of all malpractice claims and 37% of all high-severity injury cases (including death) filed between 2009 and 2013. The study of 7,149 cases examined facts, figures, or findings that were miscommunicated between persons who had the information and those who needed it.
Improving individual communication skills is not the answer. Health care team members already have good communication skills. Critical medical mistakes arise when vital information is unrecorded, misdirected, never received, never retrieved, unclear, overlooked (such as changes in a patient’s status), or simply ignored.
Critical information must be communicated accurately and effectively.
Modes of communication
Webster’s Dictionary defines communication as “the imparting or interchange of thoughts, opinions, or information by speech, writing, or signs.” However, 93% of communication involves body language, attitude, and tone. While spoken and/or written words contain critical information, it’s only 7% of the communication. When caregivers rely on written communication and don’t talk to each other at all, nuances in body language, attitude, and tone are missed.
Structured communication techniques streamline the process and decrease miscommunications. An environment where frontline caregivers can express concerns in the best interest of patient care—without fear of retaliation—reduces medical mistakes and improves overall effectiveness. Health care facilities that tolerate ineffective interpersonal working relationships among health care staff or that do not support educational efforts to improve behaviors perpetuate unacceptable conditions that put patients at risk.
The nurses’ perspective
An effective care team can provide quality, improved patient care through collaboration. For example, an Advance Practice Registered Nurse (APRN) depends on the pharmacist to provide alternative formularies that might be cheaper but equally effective as brand-name medications. A good best practice for an APRN is to always discuss difficult cases with other nurse practitioners and doctors on the care team to identify better treatment options. Good health care team communication and collaboration is just as important for patients who need community services. APRNs collaborate with social workers to assist patients and their families find available community resources, providing quality care while utilizing the expertise and skills of team members.
Attributes of successful care teams include open communication, nonpunitive environments, clear direction, clearly defined roles and tasks, respect, shared responsibility, an appropriate balance of member participation, acknowledgment and processing of conflict, clear specifications regarding authority and accountability, clear and known decision-making procedures, regular and routine communication and information sharing, an enabling environment with access to needed resources, and mechanisms to evaluate outcomes and adjust accordingly.
Many people believe that individuals—not organizations—should be held liable for serious medical mistakes through lawsuits, fines, and suspensions or other encumbrances on a professional’s license. The human tendency to blame bad outcomes on an individual’s personal inadequacies, rather than on situational factors beyond the individual’s control, is a serious barrier to preventing or mitigating inevitable errors that occur in all complex organizations, not just health care.
Ninety-three percent of communication involves body language, attitude, and tone.