Medicolegal Issues

The Constant and Familiar Face


 

Editors’ note: “Alliances” is a series written about the relationships that hospitalists have with members of the clinical care team, from the team members’ points of view. It’s our hope that each installment of “Alliances” will provide valuable, revealing feedback that hospitalists can use to continually improve their intrateam relationships and, ultimately, patient care.

Nancy Perovic, RN, BSN, quality improvement and innovations coordinator with the hospitalist program at the University of Chicago Medical Center, says this quote from In Our Hands: How Hospital Leaders Can Build a Thriving Workforce is a statement she refers to often in her work and teaching: “Mutual respect between nurses and physicians for each other’s knowledge and competence, coupled with a mutual concern that quality patient care will be provided, are key organizational elements of work environments that attract and retain nurses.”1

In hospitals around the United States, in efforts to improve patient safety and in other initiatives including nurse recruitment and retention, one consistent element is optimizing communication among providers.2-4 Barbara Blakeney, MS, RN, president of the American Nurses Association, interviewed for the publication Web Morbidity and Mortality by its editor, hospitalist Robert Wachter, MD, says that when nurses are not properly supported in the work environment by other staff, and when there are not enough nurses, “it becomes a catch-22—the fewer nurses you have, the more difficult is the working environment, which leads to fewer nurses.”5

Blakeney recommends mutual training for physicians and nurses to improve patient care and safety focus on a number of key areas:

  1. Understanding and appreciating each other’s skill sets and knowledge base;
  2. Properly handing off patients and information; and
  3. Nurturing “a culture in which safety is considered a problem-solving situation and not a punishment situation.”6

“Nurses comprise the surveillance system in hospitals for errors and adverse occurrences,” emphasizes Blakeney, and “the effectiveness of nurse surveillance is influenced by factors that include the quality of the work environment.”5

As essential members of hospital teams, hospitalists play a big role in nurses’ work environments, and mutual support between hospitalists and nurses affects patient care and outcomes, and physician and nurse job satisfaction.6,7 In general, nurses give hospitalists high marks for communication, nurse support, and teamwork.

“From a communication perspective, working with hospitalists makes patient care a lot safer because you don’t have to think of everything that you need to tell attending physicians when they are making their daily rounds,” says Scarlett Blue, RNC, MSN, administrative director, Hospitalist Services for FirstHealth of the Carolinas, Pinehurst, N.C. “With hospitalists you know you can do real-time communication, real-time information. That’s not saying you can’t do that with other physicians who are not in the hospital, but it certainly does make it a lot easier when they’re right here.”

Nurses report that compared with other physicians hospitalists are more accessible, more approachable, and more appreciative of the value of the nurse’s role.

Make Contact

One way that hospitalists support their nurse colleagues is by their ready availability to answer questions about patient care. Julie Koppel, RN, BSN, patient care manager on the General Medicine floor at the University of California at San Francisco Medical Center, has worked exclusively with the hospitalist model in her five years of nursing. She is complimentary about hospitalists’ communication skills and refers to them as “the constant and familiar face.” Koppel relates an instance where the attending hospitalist was already off service and yet she still paged him. “He got back to me promptly and still addressed the issues even though he wasn’t on service anymore and it was about something that had happened a month ago. I still feel hospitalists are available when they’re not even here.”

Many nurses don’t have a second thought about calling a hospitalist about a patient care issue, but may still be afraid of “bothering” the hospitalist when he or she is busy. Blue says her colleagues have worked with their nursing staff to overcome that reluctance. “Call them because if they’re talking with a family or if they’re in the middle of a physical exam or if it’s something where they can’t talk, they’re going to put the hold button on,” she tells her staff. “So when you hear the Muzak, the elevator music, then you know that you need to call them back. And it’s worked.”

It’s especially important, Blue says, that nurses surmount any reluctance they feel to initiate a call so that they will do so easily in urgent situations such as alerting rapid response teams and reporting medical errors.4 Blue believes the following anecdote illustrates the perspective of most hospitalists about this issue.

“We just started rapid response teams here,” she says, “And I heard one of the hospitalists say, ‘We’ve had five rapid response team calls so far and we were looking at whether or not the calls met the criteria and were appropriate.’ And one of the other hospitalists said, ‘You know, this really wasn’t a rapid response team call, but I want the nurses to feel free to call and I think that when we’re first starting out, we just want them to call. And then we can work on fine tuning it later. I don’t want to stifle them so they feel they cannot call.”

Mark Williams, MD
Heedful interrelating is based on true mutual respect, which is almost more important over agreement. And in heedless interrelating, only one view of the situation is considered correct. It represents your classic arrogant physician.

—Mark Williams, MD

Clear and to the Point

What are the best means to improve communication between hospitalists and nurses? Three major areas for attention include developing relationships, defining communication strategies, and packaging information for clarity.7

Blue often advises nurses to speak with clarity. “Probably the best thing from a hospitalist’s perspective is to be real clear about what you are asking or what it is that you need,” she says. “The clearer that you can be in your requests, the better off you’re going to be in the long run.”

But, Blue says “hospitalists have to understand that one of the greatest benefits from a nurse’s perspective about the hospitalist program is access, immediate access, and dealing with a nurse who does not communicate well might sometimes come along with it.”

The mismatched communication styles of most physicians and nurses are well recognized by a committee at the University of Chicago in which Nancy Perovic is involved. Vineet Arora, MD, MA, a hospitalist and associate program director for the Internal Medicine Residency Program at the University of Chicago, is one of the three hospitalist members on a committee working to improve nurse-physician communication.

“We know that nurses and physicians communicate differently,” says Dr. Arora. “Physicians communicate in more of a task-oriented way and nurses are trained to communicate in a descriptive way. And that’s part of the problem, because nurses might report that physicians don’t respond to them when they need to be responded to; they might not prioritize a patient that the nurse believes is very sick. And a physician might say, ‘I didn’t know that patient was really sick’ because he was given a description such as, ‘They’re not doing OK.’”

Also, Dr. Arora says, “part of the problem that nurses and physicians may have in communicating with each other can be traced to a difference in how they were trained. Physicians are trained to interact with other physicians and nurses are trained by other nurses.”

The committee at Chicago has adopted what is referred to as the Situation-Background-Assessment-Recommendation (SBAR) technique, a tool that the U.S. Navy has used to improve communication on aircraft carriers.8 Developed by Michael Leonard, MD, physician coordinator of clinical informatics, and others at Kaiser Permanente of Colorado, the SBAR technique has been implemented widely at health systems to provide a standard framework for members of the healthcare team when communicating about a patient’s condition.

“What nurses are not very good at is being assertive,” says Perovic. “We’re getting better as we’re getting more modern, but sometimes nurses talk in a more holistic, narrative fashion and doctors just want: what’s the problem, pinpoint it, let me know what it is.”

Chicago’s Perovic and her colleagues plan to educate nurses to use the SBAR technique so they can “talk in the way that doctors are trained to accept information and respond,” she says. “For example, this might sound like, ‘This is this patient with this diagnosis and these vital signs; this is what’s happening: they’re going down, their blood pressure’s dropped, I’m really concerned, this is a different change, I suggest that we do this and that, and I need you here in 10 minutes.’”

Perovic says nurses are then instructed to “make a recommendation; so the hospitalist can prioritize from all the other patients he has to see, to answer the questions: What does this patient need right now? When do I need to see this patient? and What can the nurse do until I get there?”

Literature on the SBAR technique and the tool itself are available online at www.ihi.org/IHI/Topics/PatientSafety/SafetyGeneral/Tools/SBARTechniqueforCommunicationASituationalBriefingModel.htm.8

The best ways to improve communication between hospitalists and nurses involve three major areas: Developing relationships, defining communication strategies, and packaging information for clarity

Heedful Versus Heedless Interrelating

Exactly how hospitalists affect outcomes and influence system issues is being addressed in research led by Mark V. Williams, MD, and Tracy Scott, PhD, at Emory University Medical Center, Atlanta. Dr. Williams, who is the director of the medicine unit at Emory Hospital, the editor-in-chief of the Journal of Hospital Medicine, and a past president of SHM, spoke to The Hospitalist about the exploratory research his team is doing to assess the impact hospitalists have in nurse-physician relationships in two hospitals in Atlanta, and to particularly examine how these relationships affect patient safety.

High Reliability Organization theory, which elucidates causal pathways between work relationships and reduced error, may provide a framework for how hospitalists affect hospital functioning. “Heedful interrelating,” the theory postulates, creates an organization “mind” and through facilitating teamwork is more alert to and capable of dealing with unexpected occurrences. In fact, says Dr. Williams, data from operating rooms, emergency departments, and ICUs suggest that a lack of teamwork adversely affects patient care and increases medical errors. Research along this vein has been absent on general medical floors.

The research design explores the degree of “heedful interrelating” as opposed to “heedless interrelating” between physicians and nurses and whether hospitalists have different relationships with nurses than do other physicians.

“In heedful interrelating,” explains Dr. Williams, “the physician heeds what the nurse is saying and doing and, likewise, the nurse heeds what the physician is saying and doing.” To date, the investigators have interviewed 45 nurses (half in a university hospital setting and half in a community hospital) and 24 physicians of whom half are hospitalists.

The study examines multiple components, but an example is that “heedful interrelating is based on true mutual respect, which is almost more important over agreement,” says Dr. Williams. “And in heedless interrelating, only one view of the situation is considered correct. It represents your classic arrogant physician.”

Another example of heedful interrelating is that “it advances the goals of the whole team; in heedless interrelating, you think only of your own role,” he says. Nurses in the study reported that compared with other physicians hospitalists are more accessible, more approachable, and more appreciative of the value of the nurse’s role.

The investigators conclude that hospitalists improve the nurse-physician relationship through heedful interrelating and thereby may improve patient safety. In addition, “the nurses emphasized the need for more collaboration and perceived that physicians were not proactive in asking them about their knowledge of the patient, and lacked a holistic view of the patient’s needs. Most importantly, about half the nurses mentioned specific instances where problems in their communication with physicians led directly to problems in patient care.

Dr. Williams believes that the ideal system for communication between hospitalists and nurses would include a means for them to do their patient rounds together. Nurses want hospitalists to develop a system to deliver the patient care plans quickly and reliably, include them in formal and informal educational efforts, and acknowledge them.

Timely Distribution of Care Plans

Blue says that hospitalists at her institution, FirstHealth Moore Regional Hospital (Pinehurst, N.C.), a 385-bed acute care, nonprofit hospital that serves as the referral center for a 15-county region in the mid-Carolinas, work often and closely with the nurses on issues of outcomes. “And outcomes here are like discharge planning utilization review,” she says. “We have a report every morning and there’s a representative from that department who’s online sending out the plans for the patients for the day to the other outcomes managers. That’s already in the works, and we’re not waiting for the hospitalist to get up to the floor to see the patient.”

Overall, however, nurses in other (e.g., larger) settings may not have as good a system in place to distribute care plans. Perovic says that in focus groups she facilitates, she often hears frustration from nurses because “doctors in general—although hospitalists are better at it—do not give nurses the plan of the day or the plan of care in a timely, organized fashion so they can do their care appropriately and prepare themselves and the patient.”

Some of the problem is due to the systems of an academic medical center, Perovic says, where “doctors make rounds at various times of the day and sometimes one team can make four rounds a day. What happens is that the plan for patient care changes each time new rounds are completed because you either get new information or discover you didn’t do something.” But although the team doctors are good at communicating plan modifications among themselves, she says, “what they fail to do is always communicate that well to the nurses.”

Perovic says there is an ideal and then a real solution. “Ideally, it would be great if patient rounds were at a certain time of the day every day so that the nurse can pass her meds and then be available for rounding,” she says. “You could say to nurses, ‘Rounds are between 10 and 11; take care of your patients’ needs and then be on call and ready to go to your rounds when possible.’ Or another solution is what we do in the pediatric hospital: We have a charge nurse who has no patients and she is able to round with all the teams and all the doctors and then give the individual nurse that plan for her patients.”

Hiring a charge nurse in this vein is a human resource issue, Perovic says, and an individual hospital has to decide that it wants to pay a nurse to not have patients. In that case, she says, it is an expensive but good fix. However, accommodating nurses to accompany hospitalists on rounds is logistically almost impossible. “Because if a nurse on the general medicine ward has five patients,” Perovic says, “she might have five different teams of doctors. But depending on the diagnosis of each patient, it won’t be the same team of doctors rounding on them. She might not catch A, B, and C at the same time that D and E are making their rounds. And she could be doing a blood draw on patient D when D team comes, or giving a bath to patient A when team E comes.”

Perovic and her coworkers have tried the call light method, where the doctor comes into the room, the attending presses the call light, and the nurse knows rounds are happening and to join them at that room. But that, as well as other avenues they tried, failed because neither the nurse nor the team can necessarily count on their times of availability coinciding. Still, Dr. Arora says, “we learned a lot about trying to work together and how to understand each other. And we used some of that information to continue thinking about how to best improve physician-nurse communication.”

The team at Chicago is now considering how to design and evaluate “an intervention for more of an interdisciplinary educational process where physicians and nurses would be trained on how to communicate with each other using this standard language,” says Dr. Arora. “Nurses would understand that they could potentially use the SBAR tool to communicate with physicians, and physicians would understand that the nurses need to be included in the plan for the day and would make time to incorporate nurse suggestions and input for the plan.”

Acknowledgment

In some hospital settings what has been described as a two-class system can exist for providers.9 A culture that encourages patient safety is threatened by the nature of the hierarchy or the segregation that is established, even subtly, where nurses are treated as unequals.6,9 In the hospital culture, the “invisibility of nursing” has historically been perpetuated by a number of factors, not the least of which are differences in gender and income.6 In this atmosphere, nurses are not as likely to share from their skills and knowledge. Their lack of assertiveness with hospitalists or other physicians may take its toll in many ways, including increased risks to patient outcomes and to provider morale and satisfaction.7

Linda Aiken, PhD, FAAN, FRCN, RN, the Claire M. Fagin Leadership Professor of Nursing and director of the Center for Health Outcomes and Policy Research at the University of Pennsylvania (Philadelphia), has extensively investigated the dynamics between nurses and their co-workers. “Nurse-physician relationships are one of the most important drivers of the work environment,”9 she writes. There are also data that demonstrate the association of nurse-doctor relationships on cost, lower morbidity and mortality, retention of nurses, higher quality of care, and improved hospital reimbursement and/or market share.9

In other words, “healthy nurse-physician relationships are not just a nice thing to have,” writes Dr. Aiken. “They are a competitive advantage.”

Given the association of these relationships to so many outcomes, it is unfortunate that many nurses crave greater acknowledgment for what they bring to their work. One benefit for nursing is that because hospitalists are around the hospital more than an average attending, they know the nurses better.

“As a nurse, what I need from hospitalists is for them to recognize and teach their residents and interns that the nurse is a constant player at the bedside in the hospital, with many more years of experience,” says Perovic. “Even though she doesn’t have as much medical training as a doctor or resident, she has enough clinical-nursing hospital experience. Doctors need to appreciate that nurses are experts at hospital care and bedside care, and [doctors] need to show that respect when we’re teaching our residents because we can learn a lot from the nurses, and the nurses can actually make the doctors’ lives easier.”

In a study of a multidisciplinary intervention tested on an acute inpatient medical unit, the effect of the intervention—to improve communication and collaboration—was strongest among house staff, who reported significant increases in collaborative efforts with nurses.10 This finding underlines the importance for hospitalists to serve as models to students, interns, and residents because the most effective time to learn collaborative practice is during early training when experienced nurses can assist inexperienced interns.10 Hospitalists can also consciously reject the traditional “doctor-nurse game,” whereby patterns of behavior suggest that doctors are the dominant players and nurses must defer to them.

“Ask nurses for their opinion,” advises Blue. “Treat them like an equal, which is another one of the beauties of this program, because hospitalists certainly do that. When it comes down to it, people want to be appreciated, respected, and acknowledged for their contribution.”

Blue and her team also encourage hospitalists to share with the nurses if they happen to hear news of their patients’ progress. “If we have follow-up on somebody from the primary care provider after that patient has left the hospital, for example, we try to share that with the nursing staff because they’re our patients. They’re not just my patients and they’re not your patients; they’re our patients.”

Conclusion

The quality of the nurse-hospitalist relationship is central to patient care. The methods, means, and styles of individual and team communication all influence the effectiveness of a hospital team. Retraining providers to traverse the gap of different communication styles is a way to approach the issues that exist. Mutual training for physicians and nurses, as well as training nurses to communicate in ways that more approximate how physicians communicate, will better serve patient and provider needs.

Hospitalists can encourage nurses to overcome hesitancies to initiate calls, clarify their preferences for how nurses should contact them, and work with nurses to seek workable ways to perform patient rounds in concert. Most of all, nurses need timely care plan distribution and acknowledgment for their contributions to teamwork and patient care. TH

Writer Andrea Sattinger will write about occupational therapists’ experiences with hospitalists in the January issue.

References

  1. ANA Commission on Workforce for Hospitals and Health Systems. In our hands: how hospital leaders can build a thriving workforce. American Hospital Association; Chicago; 2002;55:30-31.
  2. Aiken LH. The unfinished patient safety agenda. In: Wachter R, ed. Morbidity and Mortality Rounds on the Web: Agency for Healthcare Research and Quality; 2005. Accessed August. 29, 2005 at http://webmm.ahrq.gov/perspective.aspx?perspectiveID=7&searchStr=The+unfinished+patient+safety+agenda
  3. Aiken LH, Clarke SP, Sloane DM. International Hospital Outcomes Research Consortium. Hospital staffing, organization, and quality of care: cross-national findings. Int J Qual Health Care. 2002;14:5-13.
  4. Friesen MA, Farquhar MB, Hughes R. The nurse’s role in promoting a culture of safety: American Nurses Association Continuing Education, Center for American Nurses; 2005.
  5. Wachter R. In conversation with … Barbara A. Blakeney, MS, RN. In: Wachter R, ed. Morbidity and Mortality Rounds on the Web. Agency for Healthcare Research and Quality; 2005. Accessed Aug. 29, 2005 at http://webmm.ahrq.gov/perspective.aspx?perspectiveID=8&searchStr=Blakeney
  6. Lindeke LL, Sieckert AM. Nurse-physician workplace collaboration. Online J Issues Nurs. 2005;10:5.
  7. Burke M, Boal J, Mitchell R. Communicating for better care: improving nurse-physician communication. Am J Nurs. 2004;104:40-47
  8. SBAR initiative to improve staff communication. Healthcare Benchmarks Qual Improv. 2005;12:40-41.
  9. Smith AP. Partners at the bedside: the importance of nurse-physician relationships. Nurs Econ. 2004;22:161-164.
  10. Vazirani S, Hays RD, Shapiro MF, et al. Effect of a multidisciplinary intervention on communication and collaboration among physicians and nurses. Am J Crit Care. 2005;14:71-77.

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