To provide the most effective patient care possible, nurses must collaborate with other health care professionals, including physicians (Boyle & Kochinda, 2004). Providing the best patient care possible must begin with clear and appropriate communication, and without communication, true collaboration among professionals is impossible (Arford, 2005). Research shows that nurse-physician communication remains problematic (Manojlovich & Antonakos, 2008). In one study, when productive communication occurred between health care professionals, improvements were observed in the resolution of patient and family problems (Dixon, Larison, & Zabari, 2006). This same study, and a similar one several years later, showed that positive communication between nurses and physicians was associated with improved job satisfaction among nursing staff, improved patient outcomes, and fewer medical errors (Dougherty & Larson, 2005; Manojlovich & Antonakos, 2008). Components of positive, productive communication include being honest, remaining open both as a communicator and as a listener, listening with interest, being concise, keeping emotions out of the conversation, and being aware of the audience (Apler, Propp, Ford, & Hofmeister 2006).
Communication and collaborative work between professionals is so important to patient care and nursing job satisfaction that it is one of the features measured to determine whether hospitals achieve Magnet status (American Nurses Credentialing Center, 2003). Work environments that tolerate ineffective interpersonal relationships among health care workers or that do not support educational efforts to change behaviors perpetuate unacceptable conditions and put patients at risk (American Association of Colleges of Nursing, 2007).
Researchers interviewed physicians and nurses caring for 437 hospitalized patients as to their priorities for the patient (Evanoff, Potter, Wolf, Dunagen, & Boxerman, 2006). There was full agreement on patient priorities between the physician and the nurse in 17% of cases, partial agreement in 53% of cases, and no agreement in 30% of cases. Findings from the current study show that the priorities for patient care often differed between members of the health care team, and verbal communication between team members was inconsistent.
Collaboration has been defined as the process of joint decision-making among independent parties, involving joint ownership of decisions and collective responsibility for outcomes (Boyle & Kochinda, 2004). There is evidence that interprofessional collaboration among physicians, medical residents, and nurses is important to ensure quality clinical outcomes (Hojat et al., 2001; Sterchi, 2007; Thomson, 2007).
Numerous research studies show the complex nature of nurse-physician relationships and collaboration in the practice environment. Dougherty and Larson (2005) and Sterchi (2007) used the Jefferson Nurse-Physician Relationship Scale to survey 72 physicians and 65 nurses in the perioperative area. Seventy percent of the nurse respondents were female, whereas 88% of the physicians were male. Findings from the current study showed that physicians and nurses differed significantly in the need for collaboration, with physicians having significantly lower scores on questions concerning the importance of collaboration (t = 7.99, p = .01). The researchers speculated that these differences might be based on gender differences (because nursing is still a primarily female profession and medicine is primarily a male profession) and role misunderstandings. Using interviews, these researchers found that a lack of understanding and support between nurses and physicians led to medical errors and negatively affected patient outcomes.
A study by Hojat et al. (2001) compared U.S., Israeli, Italian, and Mexican nurse and physician responses to questions regarding attitudes toward nurse-physician collaboration. The findings showed that, overall, nurses desired collaborative nurse-physician relationships more than physicians did, regardless of cultural background and independent of gender and age. These researchers concluded that there is a great deal of role ambiguity between nurses and physicians in complementary practice environments.
Effective communication is a cornerstone of successful collaboration for patient care (McKay, Davis, & Fanning, 1995). Skilled communication focuses on critical communication proficiencies, including self-awareness, inquiry and dialogue, conflict management, negotiation, advocacy, and listening. The Joint Commission has recognized the importance of communication for patient safety by setting a national patient safety goal for 2007 to improve the effectiveness of communication among caregivers (Joint Commission, 2006).
Before effective communication can take place, the basic components of communication must be understood. Manojlovich and Antonakos (2008) found that nurses and physicians differ in their ideas about what constitutes effective communication. In the current study, 462 nurses and 78 physicians were surveyed and asked to describe openness, understanding, and accuracy as components of effective communication. Generally, the findings showed that most nurses did not believe that the communication styles they experienced at work were effective, especially for communication between nurses and physicians. Physicians described the need to spend little time on communication; the ability of the nurse to anticipate the physician’s needs and take orders correctly was important to them. Physicians did not identify information obtained from nurses as particularly useful or important, and often described it as bothersome.
Researchers found that little attention is given to professional communication skills in nursing and medical education programs or during physicians’ residency years, which may contribute to the communication problems between health care providers. In several other studies, nurses identified using goal worksheets and patient conferences as effective ways to communicate patient care issues, whereas physicians identified abbreviated discussions pertaining only to medical issues as effective communication (Baggs, Schmitt, Mushlin, Eldredge, Oakes, & Hutson, 1999; Rao, Anderson, Inui, & Frankel, 2005). In a study by Apler et al. (2006) of the critical role that communication plays in professional nursing care, four categories of important communication skills were identified (Sidebar 1).
Four Categories of Communication Skills
Collaboration: Organizing, engaging in dialogue, and working to identify solutions.
Credibility: Avoiding jargon and vague terminology and interacting assertively, yet respectfully.
Compassion: Caring for patients, families, and team members; advocating for team members’ needs; and showing respect.
Coordination: Assigning responsibilities and organizing the team, providing mentorship, and encouraging and valuing input from team members.
Data from McKay, M., Davis, M., & Fanning, P. (1995). Messages: The communication skills book (2nd ed.). Oakland, CA: New Harbinger.
The researchers theorized that a wide range of actual communication skills is necessary for nurses to communicate effectively with the entire health care team. Also, nurses should be educated to communicate in ways that enhance patient outcomes.
Dixon et al. (2006) described professional communication as a complex process and identified components of skilled communication as education, teamwork, commitment, evaluation, and ongoing vigilance. Each of these qualities is essential when caring for patients, especially in a new environment with the addition of medical residents. McKay et al. (1995) studied communication skills and found that these skills can and should be learned as the basis for any professional endeavor.
The SBAR (situation, background, assessment, recommendation) tool has been tested as a possible mechanism that could be taught to nursing students to improve the content and clarity of nurse-physician communications. Although this method provides a means for communicating basic factual information, it is not sufficient for communicating the nuances of nursing assessment and plans of care. In one study (Hamilton, Gemeinhardt, Mancuso, Sahlin, & Ivy, 2006), the SBAR tool reduced physician dissatisfaction with nurse communication, but did little to improve patient care or nursing satisfaction with communication.
The goal of the current study was to develop, implement, and evaluate an educational and experiential program for communication and collaboration skills. The American Association of Colleges of Nursing standards for developing and sustaining health care work environments were used as the basis for this program (American Association of Colleges of Nursing, 2007) (Sidebar 2).
Essentials of a Healthy Work Environment
Skilled communication: Nurses must be as proficient in communication skills as they are in clinical skills.
True collaboration: Nurses must be relentless in pursuing and fostering true collaboration.
Effective decision-making: Nurses must be valued and committed partners in making policy, directing and evaluating clinical care, and leading organizational operations.
Appropriate staffing: Staffing must ensure the effective match between patient needs and nurse competencies.
Meaningful recognition: Nurses must be recognized and must recognize others for the value each person brings to the work of the organization.
Authentic leadership: Nurse leaders must fully embrace the imperative of a healthy work environment, authentically live it, and engage others in its achievement.
Data from Association of Critical Care Nurses. (2007). Healthy workplace environment initiative. Retrieved from http://classic.aacn.org/aacn/pubpolcy.nsf/vwdoc/workenv.
Goals of the Program
The goals of the educational and experiential program were to:
Inform nurses, attending physicians, and medical residents about the importance of communication and collaboration to promote positive patient outcomes.
Evaluate current nurses’ feelings about the new residency program, especially related to communication and collaboration on the unit and within the hospital.
Educate staff about positive communication and collaboration skills. Develop a booklet for medical residents to enable them to learn the same communication techniques and ideas concerning the benefits of collaboration as nursing staff.
Practice positive communication and collaboration skills in role-playing exercises and weekly dialogues.
Complete follow-up focus groups and compare themes from the first focus groups with those from the final focus groups to see how attitudes about communication and collaboration changed.
The educational program was developed for this particular hospital because it was instituting a medical residency program that would be unique. In this residency program, patients who were admitted through the emergency room without a primary care physician would be admitted to the residents’ unit, and the medical residents and attending physician instructors would be the only primary care or internal medicine physicians on the unit. This provided a “closed” environment where residents, attending physicians, and nurses worked very closely on a daily basis. Institutional review board approval was obtained for both the nurses and the medical residents on the unit, and each participant signed informed consent to take part in the project.
Medical residents did not have a formal class because the Accreditation Council for Graduate Medical Education, which regulates objectives for this group, did not approve the class before the setting of objectives. Medical residents did receive a self-learning packet with questions that they returned to the researchers during the first week of the residency period. The average age of the medical residents was 29.8 years, and there were 38 men and 12 women in the group.
All of the nurses on the unit attended a 2-hour class 1 month before the arrival of the residents in July. The class included a discussion of the new residency program, information about working with medical residents and their attending physician instructors, positive and effective communication techniques, and the need for collaboration among professionals.
The unit where the medical residents would practice had 65 nurses who worked 12-hour shifts. All 65 nurses agreed to participate in the program. Thirty-five of the nurses on the unit (54%) were prepared at the associate’s degree level; 15 (23%) were bachelor’s-prepared; 3 (5%) had completed hospital-based diploma programs; 10 (15%) were educated in Caribbean Island nursing programs at various levels; and 2 (3%) were licensed practical nurses. Twenty-three of the nurses with associate’s degrees were enrolled in bachelor’s degree programs, and four of the bachelor’s-prepared nurses were enrolled in master’s degree programs. The average age of the nurses in the study was 41.5 years (SD = 5.8); 61 nurses were female and 4 were male. The mean number of years working as a nurse was 14.2 (SD = 2.4), and the mean number of years working at the study hospital was 6.3 (SD = 1.9).
Each nurse on the unit was assigned to 1 of 10 classes during which the 2-hour educational portion of the program took place. The unit was staffed so that other nurses could care for the patients of the nurses who were in class. Lunch or dinner was provided to the staff attending the session as well.
After the new program was discussed with the medical residents and attending physicians, a presentation was made regarding communication and collaboration skills. The same presentation in written form was given to the residents when they arrived. Contents of the course were designed and approved by the chief nursing officer, residency director, nurse manager, and director of education for the hospital.
Collaboration was presented as including mutual respect and trust, personal integrity, competence, caring, and decision-making. Interestingly, nurses were most interested in the aspects of mutual respect and trust and personal integrity. They spoke about having self-confidence in their decision-making as being a positive step toward collaboration and mutual respect between health care providers.
Communication skills presented included improving listening skills, using self-disclosure, expressing a clear message, understanding the significance of body language, dealing with culture and gender issues, using assertive versus aggressive communication styles, and using negotiation and conflict resolution with coworkers and other health care professionals. Effective listening skills presented included listening actively, listening with empathy, listening with awareness, and listening with openness. Scenarios and practice situations in which each of these types of listening could be used were included in the class. Self-disclosure issues included self-awareness, identifying one’s own agenda, and putting more energy into communication. After this presentation, an exercise was completed to demonstrate sending clear, straight, and supportive messages.
Body language is an important part of communication and accounts for approximately 67% of the actual message received by the listener (Dixon, Larison, & Zabari, 2006). Nurses in the class did not always recognize the body language that they used when communicating; however, after some role-playing, it became evident that body language played an important role in their current communication with other health care providers and that they could improve this aspect of communication and appear more confident and assertive without appearing aggressive.
Cultural differences in communication styles and response to authority were discussed in each group. Many of the nurses on the unit were not born in the United States or were first-generation Americans. Nurses came from Caribbean countries, such as Haiti, Cuba, and the Dominican Republic, as well as from South America, the Philippines, and Europe. A general discussion took place in each group about the role of culture in communication and collaboration. Many foreign-born or first-generation nurses found it difficult to communicate and collaborate with those they considered authority figures. These nurses stated that they tended to avoid confrontation or even discussion with those in positions of power. Some participants stated that they simply did not engage in substantive dialogue or discussion with physicians or even with nurse managers or other nursing leaders in the hospital.
Nurses came to the classes with hesitancy, wondering whether they would learn anything new or useful. By the end of each class, nurses stated that the information provided was indeed new to them and was very interesting, and they found the role-playing very enlightening. There were several male nurses on the unit on both day and night shifts. Their participation in the course prompted a wider discussion about gender differences in communication. Female nurses were surprised to learn that male nurses experienced some of the same frustrations in communicating with a primarily female nursing staff as did the physicians. The male nurses wanted communication to be short and to the point, with facts presented clearly, whereas female nurses found that discussion about the patient, group dialogue about decision-making, and gaining an understanding of other nurses’ personal style were important when communicating patient needs
Focus Group Follow-Up
Focus group meetings were used to collect data on changes in communication and collaboration styles and the effect of those changes. Meetings with nursing staff and residents were held every other week during a 6-month period, during both day and night shifts. The meetings were held in the room where meal breaks were taken during the most common lunch and dinner break times. Each meeting was led by two members of the team. One member interacted with and directed the focus group, and one member took notes from the discussion and recorded nonverbal cues and body language. During these meetings, nurses and residents were asked to discuss examples of positive and negative communication and collaboration. In total, 26 meetings were held, 13 on day shift and 13 on night shift. Attendance at the meetings varied; however, at least seven nurses and four residents attended each meeting. All 65 nurses and 50 residents attended at least three meetings, with many attending more often. Six new nursing staff were hired or transferred to the unit during the 6-month study period. Each one met with a researcher who presented the class during orientation.
Outcomes of the Educational Program
The research team analyzed the focus group data by reading and discussing the notes. Members of the research team were on the unit daily and added information about events on the unit that were influenced by the work on positive communication and collaboration styles among nurses and residents. The data were compiled into a table of anecdotes and discussion topics. These were presented to the staff at a final meeting held away from the unit and attended by 28 residents and 19 nurses. At that time, both residents and nurses confirmed the validity of the data presented.
Because this was a new residency program and the residents and attending physicians were new to the hospital, positive communications were needed to help all participants understand the others’ role and the physical workings of the unit. Both nurses and residents stated that, at the beginning, they felt tension in relationships, but as they came to know each other as colleagues and used positive communication skills, the groups became united in their ability to meet patient and family needs. All of the participants were able to identify specific instances when they used the skills learned in the class or from the self-learning packet.
An example of positive communication and collaboration provided by both nurses and residents during one of the unit meetings was a joint effort to avoid excessive ordering of stat laboratory tests, which take the phlebotomist away from real emergencies. In their first few weeks, many of the residents forgot to order important laboratory tests that they would need to share with the attending physicians during afternoon rounds. When this happened, the residents would order laboratory tests “stat” to have the results by afternoon rounds. The nurses worked with the residents to help them prioritize and order appropriate laboratory tests on time, thereby avoiding “stat” orders. Some of the positive skills nurses used when working with residents included (1) thoroughly explaining issues and points of view, (2) sharing thoughts and solutions, (3) compromising, (4) acknowledging general respect for everyone’s position, and (5) discussing agreed-on solutions with all involved. Many of the nurses were especially proud of this effort at collaboration and stated that they thought it gave the residents an idea of just what nurses could do and how they could be partners in care. The residents also felt good about the resolution because they had a mechanism to assist with getting appropriate laboratory tests drawn at appropriate times.
Nurses and residents worked collaboratively to meet hospital core measures aimed at improving patient outcomes. The nurses and physicians worked together to develop an orientation to core measure protocols and create information sheets to remind health care providers of core measures on the unit. Nurses and residents both stated that this provided a sense of working together toward a common goal to benefit patient outcomes. Expression of a common goal, open discussion, and acceptance of everyone’s ideas were the positive communication and collaboration ideals expressed by the group when discussing this project.
Other areas in which nurses and residents worked collaboratively to overcome problems and improve patient care included improvement in timely discharge orders, including discharge prescriptions and medication reconciliation. A collaborative effort was made to develop bridge orders so that nurses could reduce the time patients had to wait for meals and pain medications. Again, participating in open communication, listening to everyone’s ideas, and valuing everyone’s input were positive styles of communication and collaboration used.
Finally, the most important demonstration of collaboration and effective communication achieved through this program occurred when residents were able to work with a multidisciplinary team to better identify patients who were in need of immediate care or whose condition was deteriorating quickly. This team approach was initiated by nursing staff as they recognized the need for quick action in their patients. Based on the model of collaboration, using clear and precise communication, listening with the intent to understand, and valuing everyone’s input provided increased efficiency to enable patients to receive the care they required and improve patient outcomes on the unit.
Another outcome of the improved communication and collaboration between nurses and residents was an increase in patient satisfaction scores. Starting 1 month after the completion of the educational program and continuing for 6 months, the hospital unit where the nurses and residents worked had the highest patient satisfaction scores for the entire hospital.
Implications for nursing and nursing education were evident in the outcomes of this educational program. Nurses should use assertive, clear, and effective communication skills to work as part of a multidisciplinary team. Staff development offerings regarding communication and collaboration should be provided to nurses frequently and should be part of annual skills evaluation. The ability to communicate clearly and effectively may reduce medical errors and will certainly improve the efficiency and effectiveness of the unit. Improvements in communication and collaboration may also increase nurses’ job satisfaction.
Implications for residency programs were also evident in the study. The Association for Continuing Graduate Medical Education should consider implementing communication and collaboration skills as part of residency programs. Providing communication and collaboration education would enable residents to begin their professional careers with a better understanding of the need for collaboration and the ability to communicate effectively with other health care professionals.
Research has shown the need for clear and effective communication among physicians, residents, nurses, and other hospital staff. An educational program was implemented for nursing staff and new medical residents. The elements of positive communication and collaboration were the focus of the educational program. After the formal educational program, meetings were held several times a month for 6 months. The hospital began a new internal medicine residency program, and all incoming residents received a self-learning packet and attended meetings during the 6-month study period. The educational program proved to be successful in improving collaboration and communication between nurses and medical residents, which in turn improved patient care.
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