Transcript Communication Among Healthcare Providers

Communication Among
Healthcare Providers
Purpose
• To review the importance of excellent
communication among health care
providers in promoting career
satisfaction and patient safety
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
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
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
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
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
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
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?
Situational Briefing Model
S-B-A-R
1.
2.
3.
4.
Situation
Background
Assessment
Recommendation
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
Recommendation
Recommend what you think you be helpful or
needs to be done:
1. Medications, lab test, ABG, X-Ray, EKG, CT,
MRI etc
2. Transfer to critical care or another level of care
3. Physician or Consultation Evaluation
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
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?
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.
Assertion – What is it?
“Individuals speak up, and state their information
with appropriate persistence until there is a clear
resolution.”
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
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?
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.
Prior to calling the Physician
1.
2.
3.
4.
5.
6.
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
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
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
Assessment
• Give your conclusions about the present
situation
• Give signs/symptoms, abnormal labs, severity
of problem
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
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.
Case Presentation
• What additional information do you need to
gather prior to contacting the physician?
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
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
Communication with
Other 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
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?
Communication with
Other 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
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?
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?
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 reevaluate the patient.
• Let’s do another SBAR with the person sitting
next to you, same feedback please!
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?
Communication with
Other 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
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
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
Case Presentation
• If your effort at assertive communication does
not have the desired effect, what other options
are available to you?
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
Effective Communication
• Essential for real teamwork
• Essential for long term career satisfaction
• Essential for patient safety and quality care
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
Be sure to ask for necessary
follow-up
Clarify when physician would like to be
called back
Critical Lab Values
When notified about a critical lab value
1. RN must read back the lab value to lab
personnel
2. Write down lab value
3. Document in physician progress notes that the
critical value was called to MD with the date
and time