1. Communication Among Healthcare Providers

2. Purpose To review the importance of excellent communication among health care providers in promoting career satisfaction and patient safetyTo review the importance of excellent communication among health care providers in promoting career satisfaction and patient safety

3. Objectives At the completion of this exercise, you should: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

4. Effective Communication Requires: Structured communication-SBARStructured communication-SBAR Assertion/Critical Language-key words, the ability to speak up and stop the showAssertion/Critical Language-key words, the ability to speak up and stop the show Psychological safety-an environment of respectPsychological safety-an environment of respect Effective leadership-flat hierarchy, continuously inviting team members into the conversationEffective leadership-flat hierarchy, continuously inviting team members into the conversation

5. Nurse-Physician Communications Frequent occurrenceFrequent occurrence Communication across a hierarchy can be intimidatingCommunication across a hierarchy can be intimidating Gender or cultural issues may complicate furtherGender or cultural issues may complicate further Often named as cause of nurse job dissatisfactionOften named as cause of nurse job dissatisfaction Critical for patient safetyCritical for patient safety

6. MD – RN : Different Communication Styles Nurses are trained to be narrative and descriptive – “you don’t make diagnoses”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”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 relationshipComplicating factors: gender, national culture, the pecking order, prior relationship Perceptions of teamwork depend on you point of viewPerceptions of teamwork depend on you point of view

7. Communication and Safe Care 60 % of medication errors are caused by mistakes in interpersonal communication 160 % of medication errors are caused by mistakes in interpersonal communication 1 Poor coordination of care is the most common cause of adverse events triggering root cause analyses 1Poor coordination of care is the most common cause of adverse events triggering root cause analyses 1 1 Joint Commission Data

8. Steps to Excellent Healthcare Communication 1 Clarify the problem & gather data 2 Concisely describe the problem 3 Actively listen to response 4 Assert concerns if needed

9. SBAR-Situational Briefing Model Used in the nuclear submarine service for concise and accurate communication 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? what is the context? A – assessment – what do I think the problem is? problem is? R – recommendation – what are we going to to fix it? to fix it?

10. Situational Briefing Model S-B-A-R S-B-A-R 1.Situation 2.Background 3.Assessment 4.Recommendation

11. SBAR Enhances predictability – how we’re going to talk to each otherEnhances predictability – how we’re going to talk to each other Crisp – to the pointCrisp – to the point Promotes critical thinkingPromotes critical thinking Similar in structure to the SOAP model that is taught in medical schoolSimilar in structure to the SOAP model that is taught in medical school

12. Recommendation Recommend what you think you be helpful or needs to be done: 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

13. Communication is a big theme in the JCAHO Patient Safety Goals Structured communication for hand-offsStructured communication for hand-offs Read-backs on verbal orders – “tell me what I said”Read-backs on verbal orders – “tell me what I said” Identify patient from 2 sources – sadly mistakes still occurIdentify patient from 2 sources – sadly mistakes still occur Verification of correct patient, correct site, correct procedure – Time OutVerification of correct patient, correct site, correct procedure – Time Out Briefing before procedures, operations, SBARBriefing before procedures, operations, SBAR

14. 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?

15. 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.

16. Assertion – What is it? “Individuals speak up, and state their information with appropriate persistence until there is a clear resolution.”

17. Why is Assertion / Critical Language Important? Because we know that 25-40% of nurses tell us on the Safety Attitude QuestionnaireBecause 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 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 indirectlyOften people don’t speak up or do so quite indirectly Knowing the plan – using SBAR – makes it much easier to speak upKnowing the plan – using SBAR – makes it much easier to speak up

18. The Difficult Conversation – How to Achieve Agreement Focus on the common goal – high quality, safe careFocus on the common goal – high quality, safe care 3 rd person – depersonalize the conversation – it’s not about you and me3 rd person – depersonalize the conversation – it’s not about you and me Avoid judgment; who’s right, who’s wrong is a loserAvoid judgment; who’s right, who’s wrong is a loser What needs to happen for us to do the right thing here?What needs to happen for us to do the right thing here?

19. 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.

20. 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

21. Situation 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 event/pain levelPatient problem/complaint or event/pain level If serious problem, patient’s code statusIf serious problem, patient’s code status

22. Background Synopsis of treatment/procedures and dateSynopsis of treatment/procedures and date Current vital signs, pulse ox, O2 amt, heart rhythm and other pertinent hemodynamic dataCurrent 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 statusRelate the physical assessment pertinent to the problem especially any changes related to mental status

23. Assessment Give your conclusions about the present situationGive your conclusions about the present situation Give signs/symptoms, abnormal labs, severity of problemGive signs/symptoms, abnormal labs, severity of problem

24. Communication with Other Healthcare Workers Step 1 - Gather and clarify all of the information you need to provide to the physician: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

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

26. Case Presentation What additional information do you need to gather prior to contacting the physician?What additional information do you need to gather prior to contacting the physician?

27. Case Presentation Additional information you might gather: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

28. Case Presentation Vital signs and pulse oximetryVital signs and pulse oximetry –T 37.5, P 108, R 24, O2 sat 82% (RA) Name, dose and timing of pain medication previously givenName, dose and timing of pain medication previously given –Morphine sulfate 2 mg IV two hours ago Any additional observations that you feel would be helpfulAny additional observations that you feel would be helpful –Patient’s respirations seem somewhat labored

29. Communication with Other Healthcare Workers Step 2 – State concisely to the physician the problems that the patient is experiencing.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

30. Role Play When you call the resident physician on duty, how would you state your concerns and question?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.Give a brief summary (no more than 60 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 communication? –What could have been clearer?

31. Communication with Other Healthcare Workers Step 3 – Actively listen to information communicated by the physician/healthcare workerStep 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

32. Case Presentation The resident physician asks that you obtain the following tests: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?Is there any additional information you need to know at this time?

33. Case Presentation The resident physician asks that you obtain the following tests: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?Is there any additional information you need to know at this time? –Since her respirations are somewhat labored, should patient be placed on O2?

34. Case Presentation The CXR suggests pneumonia, and the resident orders an IV antibiotic.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.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. Let’s do another SBAR with the person sitting next to you, same feedback please!Let’s do another SBAR with the person sitting next to you, same feedback please!

35. Case Presentation…Later on… The patient’s O2 sat is now 88% on 50% face mask, and her respiratory rate is 30/minute.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 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?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?

36. Communication with Other Healthcare Workers Step 4 – Know how to tactfully use assertive communication when necessaryStep 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

37. Role Play Practice assertive communication to the person sitting next to you: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

38. Assertive Communication in Patient Care Is not:Is not: –Yelling or bullying –Accusatory –Being disrespectful of authority Is:Is: –Focused on patient –Noting your perceptions –Persistently raising concerns, intended to move toward desired action

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

40. When Assertiveness Doesn’t Work Restate your concerns in another wayRestate your concerns in another way Engage another healthcare worker (i.e. Respiratory Therapy)Engage another healthcare worker (i.e. Respiratory Therapy) Engage your supervisorEngage your supervisor Engage another physician on the teamEngage another physician on the team

41. Effective Communication Essential for real teamworkEssential for real teamwork Essential for long term career satisfactionEssential for long term career satisfaction Essential for patient safety and quality careEssential for patient safety and quality care

42. 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

43. Be sure to ask for necessary follow-up Clarify when physician would like to be called back

44. 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