Research in Gerontological Nursing

Empirical Research 

Creating Shared Meaning: Communication Between Nurses and Physicians in Nursing Homes

Donna C. Owen, PhD, RN; Alyce S. Ashcraft, PhD, RN, CNE, FNGNA, ANEF

Abstract

The current study sought to obtain pilot data from a Situation, Background, Assessment, Recommendation (SBAR) communication intervention focused on the shared meaning construct of the sensemaking model and explore shared meaning in communication between nursing home (NH) nurses and physicians. The study design was an exploratory sequential mixed method with a pre/post quasi-experiment. Grounded theory was used to collect and analyze nurse and physician interviews and medical records. The Pathway to Shared Meaning model illustrating distinct processes supported use of the sensemaking model for understanding nurse–physician communication. Quantitative changes in communication were not significant. Shared meaning and training in SBAR for communication can be used to strengthen the design and use of structured communication in NHs.

Targets:

Nurses and physicians providing direct care in NHs.

Intervention Description:

Stories describing nurse–physician sharing of resident information using SBAR.

Mechanism of Action:

Mutual understanding of one another's perspective enhances communication.

Outcome:

Communication openness and satisfaction.

[Res Gerontol Nurs. 2019; 12(3):121–132.]

Abstract

The current study sought to obtain pilot data from a Situation, Background, Assessment, Recommendation (SBAR) communication intervention focused on the shared meaning construct of the sensemaking model and explore shared meaning in communication between nursing home (NH) nurses and physicians. The study design was an exploratory sequential mixed method with a pre/post quasi-experiment. Grounded theory was used to collect and analyze nurse and physician interviews and medical records. The Pathway to Shared Meaning model illustrating distinct processes supported use of the sensemaking model for understanding nurse–physician communication. Quantitative changes in communication were not significant. Shared meaning and training in SBAR for communication can be used to strengthen the design and use of structured communication in NHs.

Targets:

Nurses and physicians providing direct care in NHs.

Intervention Description:

Stories describing nurse–physician sharing of resident information using SBAR.

Mechanism of Action:

Mutual understanding of one another's perspective enhances communication.

Outcome:

Communication openness and satisfaction.

[Res Gerontol Nurs. 2019; 12(3):121–132.]

Preventing avoidable hospitalization is a key metric of quality of care in nursing homes (NHs) (Maslow & Ouslander, 2012). Avoidable hospitalization of NH residents could be prevented if NH staff were better able to assess, communicate, and initiate available care strategies (Trahan, Spiers, & Cummings, 2016). Avoidable hospitalization is defined as 19 resident conditions that, if treated in the NH, could prevent hospitalization (Walsh et al., 2010). Licensed vocational or practical nurses (LVNs/LPNs) are most often the predominant NH staff members in direct communication with physicians when there is a change in resident condition. Technical training programs for LVNs/LPNs are short (typically 1 year) and have little to no curriculum focused on communication. In the United States, NHs are only required to have one RN with the necessary professional expertise on duty for 8 consecutive hours of a 24-hour period. Most of these hours are covered by the presence of the RN Director of Nursing or RN weekend supervisor (Elder Law Answers, 2017). The NH organizational and operational structure presents challenges to preventing avoidable hospitalizations. Focusing on the communication skills of LVNs/LPNs is one approach for optimizing the quality of care for NH residents.

One of the best examples of trying to enhance communication in the NH is the Interventions to Reduce Acute Care Transfers (INTERACT) quality improvement system. This system requires buy-in by stakeholders (i.e., administrators, physicians, and nurses), resources to initiate and sustain its multiple components, and persistence and constant monitoring to ensure change (Ouslander et al., 2011). System-wide approaches to structured communication, such as the INTERACT tools (Ouslander, Bonner, Herndon, & Schutes, 2014), have the greatest potential to work well when specifically adapted to the environment (Mochel et al., 2018). Although INTERACT tools were not significantly better in preventing avoidable hospitalizations than the control condition in one study (Kane et al., 2017), the negative impact of the highly changeable and complex NH environment was underscored. The motivation for staff to implement a change is also as complex as the change itself (Mochel et al., 2018). It is therefore important to understand structured communication from the NH staff perspective.

Structured communication (e.g., Situation, Background, Assessment, Recommendation [SBAR]), defined as an agreed upon standardized approach for health care clinicians to talk with one another, relies on communication of clear, concise data about a change in condition of a NH resident. High level communication skills are needed for LVNs/LPNs to adequately convey information physicians need to make data-informed decisions that could appropriately treat resident conditions in the NH (Renz, Boltz, Wagner, Capezuti, & Lawrence, 2013). NH LVNs/LPNs are challenged by the requirement for immediate collection of resident data and communication of symptoms. Physicians are equally challenged to respond in a timely manner. Failure of nurses to recognize presenting and co-occurring symptoms and their significance to the overall health of a resident or the failure of physicians to use NH resources to address these symptoms plays a role in preventing avoidable hospitalization of residents (Ashcraft & Owen, 2014). Ensuring that nurses and physicians are on the same page about changes in resident conditions is essential for optimal care of NH residents, and structured communication has been shown to facilitate the handoff of information. However, the impact of structured communication must be better understood to improve communication between nurses and physicians using these communication strategies.

Sensemaking has been used as a conceptual model to better understand communication between nurses and physicians in the acute care setting (Manojlovich, 2010; Weick, 1995). The sensemaking process directed the current authors' examination of communication between nurses and physicians to observe opportunities for shared meaning about resident events. Sensemaking is an activity or process that occurs when individuals turn experiences into words and categories that they can understand, which are then used as a basis for action (Blatt, Christianson, Sutcliffe, & Rosenthal, 2006).

Sensemaking is an iterative process arising from dialogue when two or more people share their unique perspectives. Sensemaking has the potential to overcome many of the weaknesses in the current approach to the study of nurse/physician communication because it encourages the sharing of differing viewpoints and provides a roadmap for actions arising from the communication exchange.

Sharing the meaning underlying occurrence, treatment, and resolution of a resident event is one way to see agreement on outcomes and mutual understanding of one another's perspective. Although this model has been used to understand communication processes, only limited examination of the core constructs has been reported (Manojlovich, 2010). The current pilot study was conducted to determine the feasibility of a communication intervention and examine shared meaning as a component of communication between nurses and physicians caring for NH residents.

Method

Design, Sample, and Recruitment

An explanatory sequential mixed methods design (Creswell & Clark, 2018), with a pre/post quasi-experiment, was used to obtain pilot data from a SBAR communication intervention and qualitatively explore an underlying construct of the sensemaking conceptual model (Weick, 1995). Communication openness, communication satisfaction, and SBAR training satisfaction were quantitatively examined before and after the intervention. Communication events between nurses and physicians regarding changes in resident status were identified by NH nurses and examined over 4 months using ethnographic debriefing interviews, provider logs, medical record nurse/physician notes, and SBAR forms.

The study was implemented on six skilled units in one NH with an average census of 120. The consented sample included 20 physicians (i.e., family medicine residents and one faculty member who provided off-duty coverage) in a geriatric clinical rotation at the NH and 24 nurses working >24 hours per week. A small effect size, based on a study using a communication scale (DeMeester, Verspuy, Monsieurs, & Van Bogaert, 2013), supported an estimated sample of 20 individuals taking part in the intervention. Eight nurses and eight physicians who recorded having communicated about a change in status of a resident participated in qualitative interviews, including one faculty physician whose responses were similar to other participant responses.

In total, 33 communication events were documented through 16 interviews, 17 nurses' notes, 22 physician orders, and 16 physician notes. Texas Tech University Health Sciences Center gave Institutional Review Board approval, which included a HIPAA waiver. Participants received gift cards for completing the SBAR training, surveys, and interviews.

Procedure

SBAR Training Intervention. SBAR training was based on the following three principles of sensemaking: (a) problem identification—prespecified rules and conventions; (b) information gathering—shared meaning and eliciting information; and (c) information integration—agreement and consensus (Manojlovich, 2010). Using scenarios or stories to convey challenges and opportunities for communication is central to a sensemaking approach (Anderson et al., 2005; Weick, 1995) and forms the main approach for conveying information. In separate training sessions for nurses and physicians conducted by one author (A.S.A.), scenarios were used to describe resident change in status using the SBAR format and included practice. The 1-hour sessions used two scenarios to illustrate clinical application. The first SBAR scenario was about a resident with right-sided hip pain after falling, and the second SBAR scenario was about a resident with high blood pressure. Nurses completed an SBAR form based on a resident's story and physicians listened to the SBAR report to determine missing information and decide a course of action. Nurses were also instructed how to complete a tracking log for linking SBAR communications with physicians, physician notes, physician orders, and nurses' notes. The SBAR training was delivered face-to-face (20 physicians/21 nurses) or by video (two physicians/one nurse) for those not able to attend the educational session.

Fidelity of the communication intervention was addressed by tracking specific aspects of the intervention, including observation, attendance, delivery, and receipt (Sidani & Braden, 2011). The study authors were also mindful of introducing an intervention into the clinical practice of two participant groups who had expressed concerns about time constraints within their jobs. Observation fidelity was addressed by recording time spent on training sessions and comparing between sessions for physicians and nurses, and between video and face-to-face sessions. All nurses and physicians enrolled in the study attended the educational sessions for the full length of time. Delivery of the content occurred for nurses and physicians in separate 1-hour sessions. Each session lasted 1 hour. Receipt of content was verified through question/answer and participation in the practice SBAR scenarios. Choosing not to directly observe how and when nurses and physicians used the SBAR format when communicating posed a challenge to tracking intervention fidelity. Therefore, these communication opportunities were monitored within nurse and physician notes and orders. Participants were asked for feedback about the SBAR intervention related to content, format, length, and overall satisfaction with the training. At the end of the study, participants were asked about their satisfaction with use of SBAR during the study.

Outcome Measures. Quantitative data collection comprised pre- and postintervention administration of scales modified for the NH setting. Communication openness examined quality of communication; communication satisfaction in the clinical setting referred to SBAR use in the NH after the intervention, and SBAR training satisfaction assessed the training session (i.e., content, format, length, and overall satisfaction with the training) pre- and postintervention. Satisfaction with the intervention was examined because of reports that NH nurses did not frequently use SBAR, even when required by work rule (Ashcraft & Owen, 2017).

Communication openness was defined as an open, free exchange of information between nurses and physicians, characterized by positive or affirming words and the initiation of conversational turns by both participants (Shortell, Rousseau, Gillies, Devers, & Simons, 1991). The Communication Openness Scale was originally created for use in a larger communication questionnaire focused on the organizational climate with a reported Cronbach's alpha of 0.80 in the intensive care unit (ICU) and 0.81 in long-term care (LTC) (Anderson, Corazzini, & McDaniel, 2004). This 5-item scale has scores ranging from 1 (very dissatisfied) to 5 (very satisfied).

Communication satisfaction in the clinical setting (post SBAR intervention) was measured by a single item examining nurse–physician communication after the SBAR training intervention. A score of 1 indicated low satisfaction and a score of 5 indicated high satisfaction.

SBAR training satisfaction was measured postintervention using a 5-item scale related to the study's format, content, length, and overall satisfaction. A score of 1 indicated low satisfaction and a score of 5 indicated high satisfaction. A total score was calculated by summing the mean score for each item and dividing by the number of items.

Qualitative Data Collection. Data sources were provider logs as well as nurse and physician notes or orders related to resident change of status for 33 communication events. To extract cues, nurse/physician provider logs, nurse/physician notes, and physician orders were examined by asking “What was happening here?” and “What was done about it?” using a Medical Record Data Abstraction form. A semi-structured interview guide (Table A, available in the online version of this article) was used with an intensive qualitative interviewing approach (Mason, 2002). Participants were asked to describe their conversation with the relevant nurse or physician about the change in resident status. Interview questions focused on the content and use of SBAR and aspects of the sensemaking model to help examine potential processes about how shared meaning might occur. Interviews were transcribed verbatim and transcripts verified for accuracy and completeness prior to analysis. Both investigators conducted interviews and created field notes of their observations and thoughts following each interview.

Improving Nurse–Physician Communication in the Nursing Home Semi-Structured Interview Guide (NS-mod)

Table A:

Improving Nurse–Physician Communication in the Nursing Home Semi-Structured Interview Guide (NS-mod)

Data Analysis

Quantitative data for this pilot study were managed using SPSS version 23. NVivo 11.0 was used as a data management system for qualitative data. Descriptive statistics were used to examine nurse/physician characteristics (Table 1). Communication openness between nurses and physicians before and after the SBAR training intervention (Table 2), communication satisfaction in the clinical setting, and post SBAR training satisfaction were rated by participants (Table 3).

Participant Demographic Variables (N = 44a)

Table 1:

Participant Demographic Variables (N = 44)

Communication Openness Pre/Post SBAR Training

Table 2:

Communication Openness Pre/Post SBAR Training

Post SBAR Training Satisfaction

Table 3:

Post SBAR Training Satisfaction

Using grounded theory (Charmaz, 2006), words, phrases, and concepts relevant to how shared meaning might be derived were highlighted in transcripts and coded according to a growing understanding of the role of shared meaning and communication in preventing an avoidable hospitalization. Investigator discussions and use of analytic memos led to the formation and refinement of categories (Saldana, 2013). To better understand potential relationships among categories, transcripts were reexamined as new ideas in the analysis arose to facilitate grounding of the developing theory in the data.

Analysis of data was instituted with the interviews of the first participants. As additional participants completed interviews, they were examined for new concepts, lines of thinking, and concepts from interviews with earlier participants to better understand emerging categories and the relationship between categories (Charmaz, 2006). Diversity of individual experiences with communication in the NH setting emerged but was tempered by the limited range of time that individuals had been nurses or physicians. For physicians, infrequently communicating about changes in residents and time participating in the 3-year family medicine residency program contributed to a relatively uniform set of responses in their interviews. In the final three interviews analyzed, no new insights into the theoretical meaning of categories and the building of the model appeared.

Trustworthiness was addressed by using strategies to enhance the credibility of the study, including collecting data through interviews that occurred over the course of 4 months, triangulation of interview data with medical records, and using sensemaking to guide interpreting codes and develop understanding of the model (Anney, 2014; Lincoln & Guba, 1985). Fit between participant and researcher view was addressed by using a constant comparative approach and asking probing questions during interviews of subsequent participants about ideas elicited during earlier interviews. This probing enabled participants to provide additional perspective on ideas held by peers. Early stage communication models were presented to nurse and physician groups to obtain feedback about the model and their own views of communication. To address transferability, participants were asked to provide examples to support their comments about communication and the processes used to communicate about resident events. They generated descriptions that were well developed and expansive. To address dependability and confirmability, the process of data collection and analysis was tracked through memos to create an audit trail of the decisions made and to chronicle the development of the emerging model. Reflexivity was addressed through the creation of field notes following participant interviews and inclusion of these notes in the analysis.

Results

Communication With SBAR Training

The size of the sample completing communication measures before and after the intervention was low (six physicians, seven nurses) compared to initial participant enrollment (N = 44). The results of the four Communication Openness Scale statements in terms of increasing or decreasing satisfaction are descriptively presented in Table 2. Participants did not clearly perceive the SBAR training as increasing communication openness. Communication satisfaction between nurse and physician after the SBAR training found nurses to be more satisfied (satisfied, n = 4; very satisfied, n = 2) than physicians (dissatisfied, n = 1; neither dissatisfied/satisfied, n = 1; satisfied, n = 2; very satisfied, n = 2).

Physicians and nurses were asked about their past SBAR training. As shown in Table 1, most physicians had no experience with SBAR, which was significantly lower than the percentage of nurses without SBAR experiences (p < 0.001). The SBAR training intervention was found to be satisfactory (Table 3). Open-ended responses included having short refresher sessions and SBAR not working well in emergency situations. Nurses expressed the SBAR training intervention helped them communicate better with physicians by using a standardized way to organize information before calling the physician and stated that the SBAR format required just enough content to give the physician the right amount of information. Nurses also valued this format as a useful teaching tool for new nurses.

Pathways to Shared Meaning: Can You Hear Me?

Exploration of Communication Events. Six distinct aspects of the communication process were identified: (a) Nursing Knowledge and Information Presentation; (b) Focused Communication; (c) Sustaining Conversation; (d) Shared Meaning; (e) Event Resolution; and (f) Documentation. Table 4 defines each of these aspects and includes definitions and examples from qualitative interviews, investigator analytic memos, and medical record abstraction.

Communication EventsCommunication Events

Table 4:

Communication Events

Emerging Model.Figure 1 presents the communication model that emerged through exploration of shared meaning in the context of nurse–physician communication about change in status of NH residents. For nurses, engaging and sustaining a conversation with physicians facilitated creation of shared meaning. When an event occurred, focused communication facilitated sustained conversation by using individualized communication routes (e.g., cell phone, pager, contact lists). Physicians described that nurses' availability during physician visits to the NH facilitated their coming to know the nurses and their capabilities. At times, contrasting views about the same event were described by nurses and physicians. Nurses described the importance of telling physicians about symptoms and asking for order or transfer requests. In contrast, physicians noted the importance of having nurses present resident information for decision making (Table 4). Shared meaning encompassed information presentation consistent with expected order of information by the listener (i.e., using the SBAR format).

Pathways to Shared Meaning.

Figure 1.

Pathways to Shared Meaning.

Shared meaning was best achieved by nurses and physicians hearing about the resident from their distinct disciplinary perspective. Using what they heard to engage with one another in a series of conversations resulted in resolution or non-resolution of the resident event (Figure 1). The pathways demonstrate the choice of nurses and physicians to communicate with and without shared meaning and potential outcomes. Being able to hear one another was critical to being able to engage in and sustain conversation, and it was difficult for nurses and physicians to hear the conversation from outside their disciplinary point of view.

In the model, nurses are the first to know resident status has changed. These events trigger nursing assessment and exploration of resident and family wishes. This assessment is supported by the nurse's level of knowledge of health and illness and knowledge of NH resources. The nurse's ability to engage the physician in focused communication depends on the ability to communicate the most relevant aspects of the event. Ideally, focused communication allows the physician to make sense of the event in a way that aligns with his/her understanding of disease and illness. This understanding leads to addressing the resident need with the most appropriate resources. Despite shared meaning, there is still potential for the event to not be resolved if needed resources are not available or used in a timely manner. Failure of the nurse and physician to engage in focused communication results in no or little continuing conversation and can result in failure of event resolution and poor outcomes. There is, however, the potential for the event to be resolved if the nurse can garner resources to resolve the event or at least push it “down the road” for later intervention. In the current study of nurse–physician communication about changes in resident health status, preventing an avoidable hospitalization was the critical outcome. Failure at several points in the pathways of the model has the potential to negatively impact the resident and not prevent an avoidable hospitalization or not address the resident issue in a timely manner.

Discussion

Communication Quality

One of the main contributions of the current study was the inclusion of measures to better examine communication outcomes relevant to clinicians in the NH setting. Several issues that hampered previous studies (Tan, Zhou, & Kelly, 2017) have been addressed in the current study, including engaging greater numbers of physicians and broadening the understanding of the quality of communication by measuring communication openness and communication satisfaction. Few studies have evaluated communication between nurses and physicians in the NH, and most include only nurses' points of view. O'Leary et al. (2011) found that although intensive care unit physicians rated communication with nurses very high, the same nurses rated it very low, despite an intervention targeting improvement of nurse– physician interaction. The current study included nurse and physician ratings of communication. Improving communication measurement is needed in future studies.

Pilot testing of the sensemaking-based educational intervention using SBAR scenarios supported the feasibility of LVNs/LPNs and physicians learning about structured communication in the context of the NH. Literature frequently considers communication as a skill and has not sufficiently focused on communication as an outcome (Robinson, Gorman, Slimmer, & Yudkowsky, 2010: Tan et al., 2017). In their integrative review, Foronda, MacWilliams, and McArthur (2016) focused on improving and measuring the use of specific types of communication skills and did not report outcomes of communication. The current study adds to the literature by including a measure of communication openness in the NH setting that addressed trust, respect, and collaborative attitudes.

Development of the Intervention

Initiating SBAR in the NH goes past implementation and support for the process and requires particular focus on the NH environment. This focus includes quality of the nursing and medical staff, resident complexity, and the desire by administration to reduce potentially avoidable hospitalizations (Kane et al., 2017). INTERACT tools (inclusive of SBAR forms) were developed to assist with identifying relevant resident data related to acute changes in condition for sharing with other clinicians (Ouslander et al., 2014). All too frequently in the clinical setting, the SBAR form is used as a means of documentation versus communication of resident data. Using sensemaking theory, the current study sought to understand a communication approach to SBAR training to help physicians and nurses communicate beyond SBAR documentation. Using structured formats such as SBAR for communication and not documentation alone is important because disease-specific protocols and assessment tools may not be the best way to manage acute changes in condition in the NH (Ouslander et al., 2018).

Contribution of the Pathways to Shared Meaning: Do You Hear Me? Model

The importance of the model Pathways to Shared Meaning: Do You Hear Me? lies in how shared meaning is arrived at through sensemaking. The current study supports findings of Tan et al. (2017) that sharing and clarifying information between nurses and physicians is a critical aspect of communication to ensure what they term as common understanding. Common understanding appears to be similar in definition to shared meaning (Wieck, 1995). At the center of the current authors' model is the ability of nurses and physicians to willingly engage in a sustained conversation that allows the possibility of creating a shared perspective on the resident event. Sustained conversation requires skill and effort from the nurse and physician that should facilitate the pathway leading to an optimal outcome. The model provides insight into where emphasis in the communication process needs to be placed (i.e., engagement in conversation and sustaining conversation) to ensure decisions can be more easily made to avoid hospitalization. Other studies support the idea that targeting select components of the communication process can improve clinical outcomes (Tan et al., 2017). Tschannen et al. (2011) found using a collaboration intervention helped nurses and physicians increase agreement about plans for patient treatment.

What drives nurses to initiate nurse–physician communication is a change in resident condition. How well and to what extent nurses understand resident presentation of symptoms and concerns plays directly into the content of communication with physicians. Although nurses attempted to make sense of assessment data, they did not express confidence in their ability to communicate with physicians. Lack of confidence has been identified as a communication barrier (Kirsebom, Hedstrom, Wadensten, & Poder, 2014; Laging, Ford, Bauer, & Nay, 2015), but may also reflect the impact of the interprofessional hierarchy (Rice et al., 2010). Not only was there hesitancy to initiate communication, nurses were unsure of what to present to physicians. Nurses often placed an emphasis on asking for a specific outcome, such as a new medication, and not on presentation of assessment data even though they had completed a thorough assessment. Focusing on recommendations rather than assessment data often leads to omission of key data the physician needs to better understand the resident's condition (Joffe et al., 2013).

The Pathways to Shared Meaning model focuses on the communication surrounding a specific change in condition. This communication is most often iterative in nature and may persist across many encounters and conversations of what to do to arrive at an optimal resolution. Other studies have focused only on structuring initial handoff information but have not sufficiently looked at the cumulative impact on positive nurse–physician interaction and resident outcomes (Trahan et al., 2016). Engaging in shared meaning has the potential to reinforce the participation of nurses and physicians in future positive communication.

Limitations

An important limitation is that the intervention, stories describing nurse–physician sharing of resident information using the SBAR format with practice, was delivered only once with the expectation that it would be used from that point forward by nurses when communicating with physicians. Monitoring did not occur to ensure adherence to the intervention. The findings should be considered in relation to the sample because physicians in a family medicine training program (including one supervising faculty member physician) and NH LVNs were primary participants in interviews. Physicians had a targeted geriatric focus and were engaged in long-term care and supervision from a single program. Communication with other groups of physicians and nurses (e.g., RNs, advanced practice RNs [APRNs]) may vary, particularly in light of formal education and experiences. Communication between LPNs/LVNs and APRNs is recognized as a common occurrence in many NHs; however, communication between LPNs/LVNs and APRNs was not examined in this study. Examining one component of the sensemaking model, shared meaning, without the full context of the model may have placed unintended constraints on understanding a change in resident condition. Looking at shared meaning in isolation from other constructs in the model may have given a skewed understanding of nurse–physician communication and shared meaning. The quantitative aspects of the study were designed to focus on the feasibility of the intervention. Not every individual who consented to participate in the study took part in all aspects of the study. Although this made the analysis from a feasibility standpoint more challenging, more was learned about the acceptability of various components of the study.

Conclusion

Facilitating nurse–physician engagement in a systematic way and understanding how each discipline contributes to the conversation around the care of NH residents presents a unique view of the communication process. Sensemaking provides perspective about the roles played by nurses and physicians in creating shared meaning for optimal communication. Shared meaning and training in SBAR use as a means of communication (versus documentation) has the potential to provide for the development of stronger interventions with structured communication. The perspective of physicians in how one communicates in the NH setting is essential to establishing future models of care delivery in the NH. This setting is emerging as a major focus, and the care of older adults, many of whom will spend time near the end of their life in a NH, needs to be improved. Improving communication between nurses and physicians provides an important entry point for changing the quality of life for older adults in NHs. The Pathway to Shared Meaning model holds promise for use across disciplines in NHs. This model was supported by nurses and physicians placing high value on understanding each other to provide the best care. Shared meaning, as a central component of sensemaking, shows the importance of sharing disciplinary perspectives between nurses and physicians to better communicate about and understand the needs of NH residents.

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Participant Demographic Variables (N = 44a)

DemographicPhysiciansNurses
Age (years) (mean [SD]) (median [range])b31.79 (8.58) 30 (24 to 61)47.16 (13.99) 51 (22 to 68)
Gender (n = 42)
  Female1221
  Male72
Ethnicity (n = 43)
  White1113
  Hispanic49
  Asian4
  Black2
Highest educational level
  MD19
  DO1
  Some college21
  Bachelor's degree1
  Master's degree2
Licensing (n = 43)
  MD20
  LVN21
  RN2
Years in practice (mean [SD]) (median [range])c3.84 (8.36) 1.5 (1 to 35)13.78 (12.37) 10 (0 to 40)
Years in the NH or geriatrics (mean [SD]) (median [range])d3.78 (8.37) 1.5 (1 to 35)7.68 (6.21) 5.5 (0 to 20)
How often do you talk with physician/nurse caring for a NH resident?
  More than once per week116
  Once per week13
  Once per month174
  Twice per year01
Previous SBAR tr aining experiencese
  Readings or lectures were required in school3 (15)14 (58)
  Readings or lectures were required as an intern or resident3 (15)9 (38)
  Formal classes in using SBAR for acute care06 (25)
  Formal classes in using SBAR for long-term care010 (42)
  Uses SBAR every day in caring for residents3 (15)8 (33)
  Never17 (85)6 (25)

Communication Openness Pre/Post SBAR Training

Statementn
Decreased SatisfactionNo Change in SatisfactionIncreased Satisfaction
PhysiciansNursesPhysiciansNursesPhysiciansNurses
1. It is easy for me to talk openly with the nurses/physicians providing care for NH residents.13621
2. Communication is very open between nurses and physicians providing care for NH residents.112432
3. I find it enjoyable to talk with nurses/physicians providing care for NH residents.211531
4. It is easy to ask advice from nurses providing care for NH residents.12532

Post SBAR Training Satisfaction

Statementn
DissatisfiedNeither Dissatisfied or SatisfiedSatisfiedVery Satisfied
PhysiciansNursesPhysiciansNursesPhysiciansNursesPhysiciansNurses
Format13422
Content113322
Length124311
Overall satisfaction14412

Communication Events

Data SummaryExample Quotes
Aspect 1. Nursing Knowledge and Information Presentation Definition: Process used to identify and engage with key stakeholders in resident care
Nurses initiated communication after resident event. Nurses described underlying knowledge of the history of disease/illness, resident and family preferences, and assessment data. Nurses tailored information to what they knew about the physician and his/her communication preferences. Nurses attempted to avoid contact with physicians by trying other resident treatment options within nursing's scope of practice.I knew he was busy, but he responded. I was terrified because I'd never talked to this doctor. I've always been the one that will pick up the phone and call and talk. I was not sure if I had the right information.… It made me anxious. Is he going to bite my head off? How will you learn if you can never make a mistake? (LVN) Have your ducks in a row. Have it all laid out there…. [The doctor is thinking]: “You're calling me urgently about somebody and you don't know what you're talking about.” [Of course, the Dr. is going to think]:“Well, what do you want me to do?” (LVN)
Aspect 2. Focused Communication Definition: Process the nurse or physician used to exchange information about a shared nursing home (NH) resident
Nurses were seeking orders or relaying test results. They were also trying to convey the significance of the resident event to the physician to have the physician accept future calls related to the resident. Physicians were attempting to obtain information to make a decision. They allowed nurses time to present information and asked questions to seek specific information. Seeking information was emotionally charged because of trust and time issues and wanting to return to activities disrupted by a telephone call.I think I had one call about a fall and the resident was fine, and I don't think we needed to order any x-rays or anything like that. It was more just reporting the incident and what had happened and what they had done. And I think another time maybe someone was constipated, and the nurse was calling in just asking for a laxative or something like that. (MD)
Aspect 3. Sustaining Conversation Definition: Technical or practical approach for sharing resident information (e.g., via telephone, fax, text, in-person, notes on the chart) and demonstrating trust in one another
Many routes of communication were used by nurses and physicians. It was important for nurses to determine the fastest/easiest way to contact each physician. The two main routes for sustaining a conversation were through telephone calls and texting. Getting a physician to agree to text (not regarding resident information, but as a signal that they needed to talk) was important. Interrupting a physician during clinic or not being available to take a return telephone call was of concern to nurses and physicians.I like texting if you can get all the information that you need. It's probably more useful in the hospital...because if it's just some quick information then you can get in the chart and fill in the gaps. At the NH, we don't have online access to anything, so a phone call is probably more appropriate. (MD)
Aspect 4. Shared Meaning Definition: Agreement about the rationale underlying the occurrence, treatment, and resolution of a resident event
Nurses and physicians were thinking about resident events from their unique vantage points. Back and forth conversation was used to achieve shared meaning. At times, the conversation shaped how the nurse and/or physician came to understand the other's point of view.I'm sure the nurse appreciated me calling the family. My calling the family occurred after my exam of the patient and the results of the mental status exam that I performed. And there were two different tracks of treatment options—one was expensive, but less invasive; the other much cheaper, but potentially more hazardous. So, it was a question for the family to decide what resources they wanted to put forth and that their option was always “do nothing” and let disease progress. The family needed to have some time to think about what the next step was. (MD) I had been talking with the daughter about changes they saw in her mother. It was hard for her to believe the disease getting worse. It helped. (LVN)
Aspect 5. Event Resolution Definition: Decisions impacting resident health following communication and care related to a specific event
Resident events could be directed toward solutions through nurse and physician decisions that had either an optimal or less than optimal impact on the resident. Although there were many decision points along the pathway to event resolution, the most visible juncture was during Focused Communication. The decisions and the information used or desired to make decisions were seen from first assessment of the event through orders, conversations, and a decision to transfer a resident or have the resident remain in the NH.If it is something I know I can't resolve on my own and I have to send them to the ER [emergency room] or I need an order or something, I will call. For example, when I walked into the room and [the resident] was grey. I know I panicked a little bit and I called. “Can I send him to the ER?” “What do you want to send him to the ER for?” (MD) So, I told him. “Umm. I don't think his family wants to send him to the ER. Give him oxygen. Give him this…give him that.” (MD) I said, “I've already given all of those.” [The doctor] said, “No, don't send him to the ER. Just watch him and see.” Well, he came around. (LVN)
Aspect 6. Documentation Definition: Written information recording care for a single resident event
Documents including SBAR were filled out when transfer was likely and not as a way of organizing thinking before conversations. Completing the documentation to present a final summary of what had taken place was emphasized. This summary included events or decisions leading up to transfer and even follow up to events, treatments, or new medications occurring during a hospital stay for those residents returning quickly to the NH.Basically, those SBARs when you first start off as a nurse, they come in quite handy. I remember them being quite a help because it helps you remember what to say…because once you've been through it a couple times, you kinda know what you're doing.... Then, again, it's kinda hard for me to use them now because on my floor alone…it's kinda hard to find time to sit there and write it out, especially if I kinda know what I'm going to go about talking. To me, I feel like I'm writing this down and I already know it. (LVN)

Improving Nurse–Physician Communication in the Nursing Home Semi-Structured Interview Guide (NS-mod)

We are interested in hearing about what it was like to talk with your physician colleagues about a change in health status of a resident.

Please tell us about a recent event for a resident and what you remember most talking with the physician.

What did you want the physician to understand about the resident's change in status?

What information was important for you to tell/learn about the actual change in resident status? (Situation)

What information was important for you to tell/learn about the history and life of the resident before his/her change in health status? (Background)

What information was important for you to tell/learn about assessment of the resident with a change in health status? (Assessment)

What information was important for you to tell/learn about recommendations of what to do about the resident's change in health status? (Recommendation)

Describe what you and the physician were in agreement about with the change in resident status.

Can you give an example of conversations with physicians that were easy to have?

Can you give an example of conversations with physicians that were difficult to have?

Is there anything else you want to tell us that we have not asked?

Authors

Dr. Owen is Professor, and Dr. Ashcraft is Professor, Texas Tech University Health Sciences Center, Lubbock, Texas.

The authors have disclosed no potential conflicts of interest, financial or otherwise. This work was supported by a Sigma Theta Tau International/National Gerontological Nursing Association Research Award.

The authors acknowledge Huaxin Song, PhD, for statistical support; and John Culberson, MD, and Kitten Linton, MD, for clinical and medical education discussions.

Address correspondence to Donna C. Owen, PhD, RN, Professor, Texas Tech University Health Sciences Center, 3601 4th Street, Lubbock, TX 79430; e-mail: donna.owen@ttuhsc.edu.

Received: August 27, 2018
Accepted: February 13, 2019
Posted Online: March 25, 2019

10.3928/19404921-20190315-01

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