Improving verbal communication in clinical care
Suzanne C. Beyea
Most health care organizations have developed guidelines or policies and procedures to address certain forms of written communication, such as which parts of the clinical record or forms should be completed during an episode of care. Typically, admission assessment forms specify which data should be collected and recorded when a patient is admitted to a health care facility. Certain forms are completed before ambulatory surgery, whereas others are completed before inpatient surgery. Most clinical records consist of specifically designed forms that help ensure the type and consistency of information about a patient’s care.
Structured clinical documents and written procedures do not always ensure the completeness or accuracy of clinical forms or records. Clinicians encounter situations in which a patient cannot answer questions or provide accurate information. Occasionally, clinicians may record information in an illegible manner or fail to complete a form. Despite this, the clinical record provides the most consistent source for patient-specific health care data. The patient’s record serves as the source from which numerous clinicians can access pertinent information about a patient’s diagnosis, allergies, laboratory results, history, physical examination findings, and other data. Most clinicians expect a patient’s chart to contain reliable and valid information and understand that it serves as the legal record of the patient’s care.
VERBAL COMMUNICATION PROBLEMS
Verbal communication between clinicians generally is much less structured and consistent than written communication. In health care facilities, verbal communication is a primary way in which vital information about a patient’s status and care is transmitted. Nurses and physicians give each other verbal reports with few guidelines to ensure completeness and accuracy, however. When information is transferred verbally, valuable data can be lost or misinterpreted. Problems with verbal communication in health care emerge in part from the fact that clinicians receive little education on how to communicate effectively with each other.
Other factors contributing to problems with verbal communication include a lack of structured policies and procedures about its content, timing, or defined purposes. Furthermore, most clinicians lack a shared mental model or framework for verbal health care communication. Rules exist for written documentation, but none exist for the frequent verbal transmissions of information that occur face-to-face or on the telephone.
Most health care professionals receive education that focuses on communicating with patients. These same programs otter little or no education about communicating with other clinicians or how to communicate effectively in urgent or emergent situations. Most recent graduate nurses have limited experience calling a physician on the telephone to give a status report or giving report when transferring a patient to another unit.
Each nurse also has specific ideas or beliefs about what information should be communicated during a verbal report. Valuable information may not be provided or may be forgotten. Writing information down may help a clinician recall data later, but if there is no consistent format for recording the information, it may be lost regardless. Interruptions, distractions, and the frequency of communications also may negatively affect the communication process and contribute to a clinician forgetting to share pertinent information.
The rate of communication in an OR adds to the complexity of keeping track of information in an accurate manner. A recently published study examined communication patterns in four OR suites. From 17 nonconsecutive days of observations in four-hour to six-hour blocks, researchers found that charge nurses experienced 32 to 74 communication episodes per hour. Within an hour, charge nurses communicated with at least five members of the health care team. The modes of communication included face-to-face, telephone, and intercom and lasted a mean of 40 seconds each. (1)
Communication problems have been associated with medical errors and adverse events in a number of studies. (2,3) Errors related to communication problems may result from the lack of guidelines for clinician-to-clinician communication and the lack of a shared framework and approach to communication. A number of experts have begun to explore and identify approaches to improve clinician-to-clinician communication. Their goal is to enhance patient safety by preventing the loss of crucial clinical data and promoting sharing of pertinent information at the right time in the most effective manner.
Michael Leonard, MD, director of patient safety for the Colorado Permanente Medical Group, Denver, and physician director of patient safety for Kaiser Permanente, Oakland, Calif, describes distinct differences between nurse and physician communication. He characterizes nurses’ communications as narrative and descriptive, whereas physicians’ communications are more focused on an exact problem or need. Dr Leonard suggests using the situational briefing model or SBAR (ie, situation, background, assessment, recommendation) model as one approach to addressing these differences in communication style and approach. The SBAR model provides a consistent and shared framework for nurse/physician communication. (4) This model proposes that a nurse communicating with a physician should provide
* information about the patient’s current situation;
* a context (ie, background) for the patient’s current clinical situation;
* an assessment of the current problem; and
* a recommendation that addresses the patient’s needs.
For example, a nurse might tell a physician, “Mrs L’s blood pressure is 90 over 40, and her pulse is 120” (ie, situation). “She underwent a laparoscopic appendectomy this morning” (ie, background). “I think she may be actively bleeding” (ie, assessment), “and I would like you to come and see her now” (ie, recommendation). (4)
Safety experts purport that assertive communication is crucial to patient safety. Two experts suggest that characteristics of assertive communication include
* being organized in thought;
* possessing technical and social competence; and
* seeking common understanding, ownership, and value from all members of the team. (5)
They suggest starting assertive communications with the phrase, “I am concerned.” Using this structured framework and specific phrase provides a shared approach to getting each other’s attention and alerting others to the need for help.
Assertive communication contributes to situational awareness and a shared understanding of what is happening. (6) Situational awareness helps clinicians understand and recognize clinical situations and act in an effective manner. It is not only a result of improved communication but also requires team training, ongoing briefings, and information verification in a regular, systematic manner. Imagine an OR in which members of the team never talk to each other. The circulating nurse would never know when the surgeon decides to convert to an open procedure instead of continuing with a laparoscopic approach. The required instruments would not be available when needed. Situational awareness in any clinical environment requires ongoing, effective, active communication.
Communication that promotes safety includes both active communication and listening. Clinicians may not listen to their colleagues or their own intuition. Within clinical environments there often are distractions and interruptions that make it difficult for clinicians to listen carefully. Often, there is so much information and there are so many communications that it is difficult, if not impossible, to determine which communications are the most critical. Having a shared mental model and approach and using words that signal the need for help and attention can promote effective communication and patient safety.
Effective communication in health care requires a team approach and training to ensure competency. Predetermining approaches to verbal communication and, thus, enhancing team members’ situational awareness helps create an environment in which members of the multidisciplinary team can reduce the risk of adverse events. Clinicians must work together to prevent injuries that result from ineffective or incomplete communication and develop strategies to ascertain that verbal transmissions of information are effective and timely.
(1.) J Moss, Y Xiao, “Improving operating room coordination: Communication pattern assessment,” Journal of Nursing Administration 34 (February 2004) 93-100.
(2.) L Leape et al, “Systems analysis of adverse drug events,” JAMA 274 (July 5, 19951 35-43.
(3.) R M Wilsor et al, The Quality in Australian Health Ca re Study,” The Medical Journal of Australia 163 (Nov 6, 1995) 458-471.
(4.) H Groff, T Augello, “From theory to practice: An interview with Dr Michael Leonard,” Forum 23 (July 20(13) 10-13.
(5.) K R Simpson, G E Knox, “Adverse perinatal outcomes. Recognizing, understanding, and preventing common accidents,” AWHONN Lifelines 7 (June/July 2003) 224-235.
(6.) N A Stanton, P R Chambers, J Piggott, “Situational awareness and safety,” Safety Science 39 no 3 (2001) 189-204.
SUZANNE C. BEYEA RN, PHD, FAAN DIRECTOR OF NURSING RESEARCH DARTMOUTH-HITCHCOCK MEDICAL CENTER LEBANON, NH
COPYRIGHT 2004 Association of Operating Room Nurses, Inc.
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