Communication%20Among%20Healthcare%20Providers

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Communication Among Healthcare Providers
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Purpose

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

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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

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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

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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

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MD RN Different Communication Styles

• Nurses are trained to be narrative and
  descriptive you dont 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

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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
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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
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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?

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Situational Briefing Model

• S-B-A-R
• Situation
• Background
• Assessment
• Recommendation

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SBAR

• Enhances predictability how were 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

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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

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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

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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?

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SBAR in OB 500 AM

• S Dr. Droga, Im 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 Im concerned something is wrong I dont
  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.

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Assertion What is it?

• Individuals speak up, and state their
  information with appropriate persistence until
  there is a clear resolution.

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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 dont speak up or do so quite
  indirectly
• Knowing the plan using SBAR makes it much
  easier to speak up

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The Difficult Conversation How to Achieve
Agreement

• Focus on the common goal high quality, safe
  care
• 3rd person depersonalize the conversation
  its not about you and me
• Avoid judgment whos right, whos wrong is a
  loser
• What needs to happen for us to do the right thing
  here?

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SBAR

• Situation Dr. Jones, Im 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 sideI think he has a pneumothorax
• Recommendation I really need your help nowthis
  guy is in real trouble he needs a chest tube
  before he stops breathing.

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Prior to calling the Physician

1. Assess the patient
2. Review the chart for the appropriate physician to
   call
3. Know the admitting diagnosis
4. Read the most recent physician and nursing notes
5. Have the chart in hand and be ready to report
   current vital signs, allergies, medications, IV
   fluids, test results
6. 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

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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, patients code status

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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

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Assessment

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

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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

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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.

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Case Presentation

• What additional information do you need to gather
  prior to contacting the physician?

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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

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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
• Patients respirations seem somewhat labored

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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

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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?

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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

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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?

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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?

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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.
• Lets do another SBAR with the person sitting
  next to you, same feedback please!

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Case PresentationLater on

• The patients O2 sat is now 88 on 50 face mask,
  and her respiratory rate is 30/minute.
• You feel she needs almost 11 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?

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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

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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

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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

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Case Presentation

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

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When Assertiveness Doesnt Work

• Restate your concerns in another way
• Engage another healthcare worker (i.e.
  Respiratory Therapy)
• Engage your supervisor
• Engage another physician on the team

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Effective Communication

• Essential for real teamwork
• Essential for long term career satisfaction
• Essential for patient safety and quality care

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Read Back Orders to Physician Document After
Signature

• Document read back on chart after order written
• -Hang normal saline _at_ 100ml/hour
• -Aspirin 325 mg po every day
• T.O. Dr. Donald Duck/ Minnie Mouse RN/ RB times 1

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Be sure to ask for necessary follow-up

• Clarify when physician would like to be called
  back

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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