Communication Among Healthcare Providers. Purpose To review the importance of excellent communication among health care providers in promoting career

Communication Among Communication Among Healthcare ProvidersHealthcare Providers

PurposePurpose

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

ObjectivesObjectives• At the completion of this exercise, you At the completion of this exercise, you

should:should:– Understand the contribution of good Understand the contribution of good

communication to safe patient care communication to safe patient care – Be able to concisely summarize a concern Be able to concisely summarize a concern

about a patientabout a patient– Actively listen to information communicated Actively listen to information communicated

by the physician or other healthcare by the physician or other healthcare providersproviders

– Assertively yet professionally communicate Assertively yet professionally communicate concerns you have about a patient that are concerns you have about a patient that are not being adequately addressednot being adequately addressed

Effective Communication Effective Communication Requires:Requires:

• Structured communication-SBARStructured communication-SBAR• Assertion/Critical Language-key Assertion/Critical Language-key

words, the ability to speak up and words, the ability to speak up and stop the showstop the show

• Psychological safety-an environment Psychological safety-an environment of respectof respect

• Effective leadership-flat hierarchy, Effective leadership-flat hierarchy, continuously inviting team members continuously inviting team members into the conversationinto the conversation

Nurse-Physician Nurse-Physician CommunicationsCommunications

• Frequent occurrenceFrequent occurrence• Communication across a Communication across a

hierarchy can be hierarchy can be intimidatingintimidating

• Gender or cultural Gender or cultural issues may complicate issues may complicate furtherfurther

• Often named as cause of Often named as cause of nurse job dissatisfactionnurse job dissatisfaction

• Critical for patient Critical for patient safetysafety

MD – RN : Different MD – RN : Different Communication StylesCommunication Styles

• Nurses are trained to be narrative and Nurses are trained to be narrative and descriptive – “you don’t make diagnoses”descriptive – “you don’t make diagnoses”

• Physicians are trained to be problem Physicians are trained to be problem solvers “what do you want me to do” – solvers “what do you want me to do” – “just give me the headlines”“just give me the headlines”

• Complicating factors: gender, national Complicating factors: gender, national culture, the pecking order, prior culture, the pecking order, prior relationshiprelationship

• Perceptions of teamwork depend on you Perceptions of teamwork depend on you point of viewpoint of view

Communication and Safe Communication and Safe CareCare

• 60 % of medication errors 60 % of medication errors are caused by mistakes in are caused by mistakes in interpersonal interpersonal communicationcommunication11

• Poor coordination of care is Poor coordination of care is the most common cause of the most common cause of adverse events triggering adverse events triggering root cause analysesroot cause analyses11

1Joint Commission Data

Steps to Excellent Steps to Excellent Healthcare CommunicationHealthcare Communication

1 Clarify the problem & gather data

2 Concisely describe the problem

3 Actively listen to response

4 Assert concerns if needed

SBAR-Situational Briefing SBAR-Situational Briefing ModelModel

Used in the nuclear submarine service Used in the nuclear submarine service for concise and accurate communicationfor concise and accurate communication

S – situation – what is the situation?S – situation – what is the situation?

B – background – how did we get here?B – background – how did we get here?

what is the context?what is the context?

A – assessment – what do I think the A – assessment – what do I think the

problem is?problem is?

R – recommendation – what are we going to R – recommendation – what are we going to

to fix it?to fix it?

Situational Briefing Situational Briefing ModelModel

S-B-A-RS-B-A-R

1.1. SituationSituation

2.2. BackgroundBackground

3.3. AssessmentAssessment

4.4. RecommendationRecommendation

SBARSBAR

• Enhances predictability – how we’re Enhances predictability – how we’re going to talk to each othergoing to talk to each other

• Crisp – to the pointCrisp – to the point• Promotes critical thinkingPromotes critical thinking• Similar in structure to the SOAP Similar in structure to the SOAP

model that is taught in medical model that is taught in medical schoolschool

RecommendationRecommendation

Recommend what you think you be Recommend what you think you be helpful or needs to be done:helpful or needs to be done:

1.1. Medications, lab test, ABG, X-Ray, Medications, lab test, ABG, X-Ray, EKG, CT, MRI etcEKG, CT, MRI etc

2.2. Transfer to critical care or another Transfer to critical care or another level of carelevel of care

3.3. Physician or Consultation EvaluationPhysician or Consultation Evaluation

Communication is a big Communication is a big theme in the JCAHO Patient theme in the JCAHO Patient

Safety GoalsSafety Goals• Structured communication for hand-Structured communication for hand-

offsoffs• Read-backs on verbal orders – “tell me Read-backs on verbal orders – “tell me

what I said”what I said”• Identify patient from 2 sources – sadly Identify patient from 2 sources – sadly

mistakes still occurmistakes still occur• Verification of correct patient, correct Verification of correct patient, correct

site, correct procedure – site, correct procedure – Time OutTime Out• Briefing before procedures, operations, Briefing before procedures, operations,

SBARSBAR

SBARSBAR

Situation – Situation – the punch line, give it in 5-the punch line, give it in 5-10 seconds 10 seconds

BackgroundBackground – the context, objective – the context, objective data, the numbers, how did we get data, the numbers, how did we get herehere

AssessmentAssessment – what is the problem – what is the problem

RecommendationRecommendation – what do we need – what do we need to do and when?to do and when?

SBAR in OB – 5:00 AMSBAR in OB – 5:00 AM

S – Dr. Droga, I’m worried about Ms. Klein, I S – Dr. Droga, I’m worried about Ms. Klein, I think she is going to rupture her uterusthink she is going to rupture her uterus

B – She is a VBAC; she has a dense epidural, B – She is a VBAC; she has a dense epidural, but she is having persistent breakthrough but she is having persistent breakthrough abdominal pain; she is complete and ready abdominal pain; she is complete and ready to pushto push

A – I’m concerned – something is wrong – I A – I’m concerned – something is wrong – I don’t want her to pushdon’t want her to push

R – I think we need to think about a C-Section. R – I think we need to think about a C-Section. I think you need to come in and see her now.I think you need to come in and see her now.

Assertion – What is it?Assertion – What is it?

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

Why is Assertion / Critical Why is Assertion / Critical Language Important?Language Important?

• Because we know that 25-40% of Because we know that 25-40% of nurses tell us on the Safety Attitude nurses tell us on the Safety Attitude QuestionnaireQuestionnaire

they would be hesitant to speak up if they would be hesitant to speak up if they saw an MD make a mistakethey saw an MD make a mistake

• Often people don’t speak up or do so Often people don’t speak up or do so quite indirectlyquite indirectly

• Knowing the plan – using SBAR – Knowing the plan – using SBAR – makes it much easier to speak upmakes it much easier to speak up

The Difficult Conversation – The Difficult Conversation – How to Achieve AgreementHow to Achieve Agreement

• Focus on the common goal – high Focus on the common goal – high quality, safe carequality, safe care

• 33rdrd person – depersonalize the person – depersonalize the conversation – it’s not about you and conversation – it’s not about you and meme

• Avoid judgment; who’s right, who’s Avoid judgment; who’s right, who’s wrong is a loserwrong is a loser

• What needs to happen for us to do the What needs to happen for us to do the right thing here?right thing here?

SBARSBAR

Situation: Situation: Dr. Jones, I’m Paul, the RT. Mr. Dr. Jones, I’m Paul, the RT. Mr. Jakus in 403 is really having trouble Jakus in 403 is really having trouble breathing.breathing.

Background: Background: He has severe COPD, has been He has severe COPD, has been going downhill and is now acutely worse. RR going downhill and is now acutely worse. RR 40, O2 sat 74% on oxygen40, O2 sat 74% on oxygen

Assessment:Assessment: His breath sounds are way down His breath sounds are way down on the right side…I think he has a on the right side…I think he has a pneumothoraxpneumothorax

Recommendation: Recommendation: I really need your help now…I really need your help now…this guy is in real trouble – he needs a chest this guy is in real trouble – he needs a chest tube before he stops breathing.tube before he stops breathing.

Prior to calling the Prior to calling the PhysicianPhysician

1.1. Assess the patientAssess the patient2.2. Review the chart for the appropriate physician to Review the chart for the appropriate physician to

call call 3.3. Know the admitting diagnosisKnow the admitting diagnosis4.4. Read the most recent physician and nursing Read the most recent physician and nursing

notesnotes5.5. Have the chart in hand and be ready to report Have the chart in hand and be ready to report

current vital signs, allergies, medications, IV current vital signs, allergies, medications, IV fluids, test resultsfluids, test results

6.6. Every SBAR is different. Focus on the problem. Every SBAR is different. Focus on the problem. Be concise. Not everything in the outline below Be concise. Not everything in the outline below needs to be reported – Just what is needed for needs to be reported – Just what is needed for the situationthe situation

SituationSituation

• State your name and unitState your name and unit• Patient Name and room numberPatient Name and room number• Diagnosis/reason for admissionDiagnosis/reason for admission• Brief history of patientBrief history of patient• Patient problem/complaint or Patient problem/complaint or

event/pain levelevent/pain level• If serious problem, patient’s code If serious problem, patient’s code

statusstatus

BackgroundBackground

• Synopsis of treatment/procedures and dateSynopsis of treatment/procedures and date

• Current vital signs, pulse ox, O2 amt, heart Current vital signs, pulse ox, O2 amt, heart rhythm and other pertinent hemodynamic rhythm and other pertinent hemodynamic datadata

• Relate the physical assessment pertinent to Relate the physical assessment pertinent to the problem especially any changes related the problem especially any changes related to mental statusto mental status

AssessmentAssessment

• Give your conclusions about the Give your conclusions about the present situationpresent situation

• Give signs/symptoms, abnormal labs, Give signs/symptoms, abnormal labs, severity of problemseverity of problem

Communication with Communication with Other Healthcare WorkersOther Healthcare Workers

• Step 1 - Gather and clarify all of the Step 1 - Gather and clarify all of the information you need to provide to information you need to provide to the physician:the physician:– Nature of the problemNature of the problem– Supporting information or dataSupporting information or data– Clarify in your mind what you Clarify in your mind what you

would like for the patient to dowould like for the patient to do

Case PresentationCase Presentation

• You are assigned to care for a 68 year You are assigned to care for a 68 year old lady for the evening shift. She is two old lady for the evening shift. She is two days post-op following hip fracture days post-op following hip fracture surgery. No problems were noted at surgery. No problems were noted at nursing sign-out other than c/o pain, for nursing sign-out other than c/o pain, for which she was receiving pain which she was receiving pain medication. medication.

• When you perform your initial When you perform your initial assessment on this patient, you find her assessment on this patient, you find her to be confused.to be confused.


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


• Additional information you might Additional information you might gather:gather:– Vital signs and pulse oximetryVital signs and pulse oximetry– Name, dose and timing of pain Name, dose and timing of pain

medication previously givenmedication previously given– Any additional observations that you Any additional observations that you

feel would be helpfulfeel would be helpful


• Vital signs and pulse oximetryVital signs and pulse oximetry– T 37.5, P 108, R 24, O2 sat 82% (RA)T 37.5, P 108, R 24, O2 sat 82% (RA)

• Name, dose and timing of pain Name, dose and timing of pain medication previously givenmedication previously given– Morphine sulfate 2 mg IV two hours Morphine sulfate 2 mg IV two hours

agoago

• Any additional observations that Any additional observations that you feel would be helpfulyou feel would be helpful– Patient’s respirations seem somewhat Patient’s respirations seem somewhat

laboredlabored

Communication withCommunication withOther Healthcare WorkersOther Healthcare Workers

• Step 2 – State concisely to the Step 2 – State concisely to the physician the problems that the physician the problems that the patient is experiencing.patient is experiencing.– Nature of the problemNature of the problem– Supporting information or dataSupporting information or data– Question or issue on which you Question or issue on which you

need his/her inputneed his/her input

Role PlayRole Play• When you call the resident physician on When you call the resident physician on

duty, how would you state your duty, how would you state your concerns and question?concerns and question?

• Give a brief summary (no more than 60 Give a brief summary (no more than 60 sec) to the person sitting next to you.sec) to the person sitting next to you.

• Have that person give you feedback on:Have that person give you feedback on:– What was effective about your What was effective about your

communication?communication?– What could have been clearer?What could have been clearer?


• Step 3 – Actively listen to Step 3 – Actively listen to information communicated by the information communicated by the physician/healthcare worker physician/healthcare worker – Listen to the plan of careListen to the plan of care– Clarify areas which are unclear by Clarify areas which are unclear by

asking appropriate questionsasking appropriate questions

Case PresentationCase Presentation• The resident physician asks that The resident physician asks that

you obtain the following tests:you obtain the following tests:– CXRCXR– ABGABG– EKGEKG– Routine blood work (CBC, BMP)Routine blood work (CBC, BMP)

• Is there any additional information Is there any additional information you need to know at this time? you need to know at this time?

Case PresentationCase Presentation• The resident physician asks that The resident physician asks that

you obtain the following tests:you obtain the following tests:– CXRCXR– ABGABG– EKGEKG– Routine blood work (CBC, BMP)Routine blood work (CBC, BMP)

• Is there any additional information Is there any additional information you need to know at this time? you need to know at this time? – Since her respirations are somewhat Since her respirations are somewhat

labored, should patient be placed on labored, should patient be placed on O2?O2?

Case PresentationCase Presentation• The CXR suggests pneumonia, and The CXR suggests pneumonia, and

the resident orders an IV antibiotic.the resident orders an IV antibiotic.• Two hours later, as you start the Two hours later, as you start the

antibiotic, you note that the patient antibiotic, you note that the patient is more short of breath. You request is more short of breath. You request that the resident re-evaluate the that the resident re-evaluate the patient.patient.

• Let’s do another SBAR with the Let’s do another SBAR with the person sitting next to you, same person sitting next to you, same feedback please!feedback please!

Case Presentation…Later Case Presentation…Later on…on…

• The patient’s O2 sat is now 88% on The patient’s O2 sat is now 88% on 50% face mask, and her respiratory 50% face mask, and her respiratory rate is 30/minute.rate is 30/minute.

• You feel she needs almost 1:1 You feel she needs almost 1:1 nursing, and are worried about how nursing, and are worried about how you will care for your other three you will care for your other three patients.patients.

• You ask if the resident if the patient You ask if the resident if the patient should be moved to the ICU, but he should be moved to the ICU, but he states he wants to first see how she states he wants to first see how she responds to the antibiotic. What responds to the antibiotic. What now?now?


• Step 4 – Know how to tactfully use assertive Step 4 – Know how to tactfully use assertive communication when necessarycommunication when necessary– State your concernState your concern– State information that supports your State information that supports your

concernsconcerns– Suggest a course of actionSuggest a course of action– Recap why you feel this action is best Recap why you feel this action is best

optionoption

Practice SBAR with the resident or as you Practice SBAR with the resident or as you escalateescalate

Role PlayRole Play

• Practice assertive communication to Practice assertive communication to the person sitting next to you:the person sitting next to you:– State your concernState your concern– State information that supports State information that supports

your concernsyour concerns– Suggest a course of actionSuggest a course of action– Recap why you feel this action is Recap why you feel this action is

best optionbest option

Assertive Communication Assertive Communication in Patient Carein Patient Care

• Is not:Is not:– Yelling or bullyingYelling or bullying– AccusatoryAccusatory– Being disrespectful of authorityBeing disrespectful of authority

• Is:Is:– Focused on patient Focused on patient – Noting your perceptionsNoting your perceptions– Persistently raising concerns, intended Persistently raising concerns, intended

to move toward desired action to move toward desired action

Case PresentationCase Presentation• If your effort at assertive If your effort at assertive

communication does not have the communication does not have the desired effect, what other options desired effect, what other options are available to you?are available to you?

When Assertiveness Doesn’t When Assertiveness Doesn’t WorkWork

• Restate your concerns in another Restate your concerns in another wayway

• Engage another healthcare worker Engage another healthcare worker (i.e. Respiratory Therapy)(i.e. Respiratory Therapy)

• Engage your supervisorEngage your supervisor• Engage another physician on the Engage another physician on the

teamteam

Effective CommunicationEffective Communication

• Essential for real teamworkEssential for real teamwork• Essential for long term career Essential for long term career

satisfactionsatisfaction• Essential for patient safety and Essential for patient safety and

quality carequality care

Read Back Orders to Read Back Orders to Physician Document After Physician Document After

SignatureSignatureDocument read back on chart after Document read back on chart after

order written:order written:

-Hang normal saline @ 100ml/hour-Hang normal saline @ 100ml/hour

-Aspirin 325 mg po every day-Aspirin 325 mg po every day

T.O. Dr. Donald Duck/ Minnie Mouse T.O. Dr. Donald Duck/ Minnie Mouse RN/ RB times 1RN/ RB times 1

Be sure to ask for Be sure to ask for necessary follow-upnecessary follow-up

Clarify when physician would Clarify when physician would like to be called backlike to be called back

Critical Lab ValuesCritical Lab Values

When notified about a critical lab valueWhen notified about a critical lab value

1.1. RN must read back the lab value to RN must read back the lab value to lab personnellab personnel

2.2. Write down lab valueWrite down lab value

3.3. Document in physician progress Document in physician progress notes that the critical value was notes that the critical value was called to MD with the date and timecalled to MD with the date and time

Documents

Communication Among Healthcare Providers. Purpose To review the importance of excellent communication among health care providers in promoting career