Calling The Doctor Should Not Be This Hard

Nurses and physicians are the two largest groups in the healthcare field that work closely together to save lives and ensure positive patient outcomes. However, the hierarchical nature of the healthcare system and the stark differences in their training can sometimes make communication between these two groups perilous. A 2016 study within U.S. hospitals found that up to 30% of all malpractice cases (resulting in 1,744 deaths and $1.7 billion in costs) were due to communication failures (The Joint Commission, 2017).

This article will summarize the foundational studies that led to the study of communication between nurses and physicians and how it affects patient care. Please note that for the purpose of this article, we will refer to most “physicians” as the providers, not as an attempt to overemphasize the role of physicians in today’s medical environment but rather as an attempt to accurately quote the original papers which examined this relationship. Furthermore, the relationship between nurses and physicians is intrinsically different from the one between nurses and nurse practitioners or physician assistants, mostly due to their backgrounds and differences in training.

While the studies and research in this course discuss nurse-to-physician communication, all healthcare professionals can benefit from applicable techniques to improve communication.

The Joint Commission is an independent, nonprofit organization that is responsible for evaluating, accrediting, and certifying hospitals and healthcare organizations in the United States (The Joint Commission, 2017). It works to establish safety goals for hospitals with the aim of improving patient safety in hospitals and other healthcare organizations. The Joint Commission identified “improving staff communication” as its second patient safety goal, only preceded by “identifying patients correctly” (The Joint Commission, 2021). This underscores the importance of improving communication between physicians and nurses, which are two groups of healthcare professionals who need to communicate often and with clarity in demanding situations.

The Joint Commission’s sentinel event program demonstrated that the most common root cause of serious medical errors was communication problems (Agency for Healthcare Research and Quality [AHRQ]). Telephone and electronic communication now play a significant role in the care of patients. Physician preference as to type of communication can also play a role in responsiveness.4 This form of communication is even more evident in patients who are outside of the hospital setting. Inefficient communication can negatively affect patient outcomes. Well-working teams employ effective strategies to optimize communication between healthcare professionals.

Foundational studies of the interaction between workforce and patient outcomes are based on nursing pioneering research that established this concept (Aiken et al., 2002; Buerhaus, 2009). Many of these studies demonstrated that medical errors increase with higher patient-to-nurse ratios. Aiken demonstrated that surgical patients had a 31% chance of dying in a hospital when a nurse cared for more than seven patients (Buerhaus, 2009).

In addition to identifying the issues with staffing shortages in the nursing field, these studies also pointed out the problematic relationship between nurses and their physician colleagues. A large 6-year study including 3000 hospitals showed that poor communication among care team members and with patients, family members, and post-acute care facilities could result in confusion around follow-up care and medications (Patient Safety & Quality Healthcare [PSQH], 2017; Manojlovich et al., 2021). This can lead to unnecessary readmissions and preventable malpractice litigation. This study demonstrated that communication between caregivers and patients has the largest impact on reducing readmissions (PSQH, 2017). These studies demonstrate the need to establish effective communication strategies between physicians and nurses. In addition, these studies catapulted the drive to establish and enforce behavioral standards for all healthcare professionals.

The first step to fostering good relationships is to lessen authority gradients between nurses and physicians. This can be done by the leader introducing themselves to the rest of the team and then proceeding to introduce all the members of a team at the beginning of the shift or the start of a specific activity such as a procedure. It is important to have the leader admit their own limitations to the group and then invite and welcome input from all the members of the team. These techniques are often applied to surgical or critical care settings, but they can be incorporated into healthcare professionals’ relationships in different settings.

For example, critical care attending may introduce themselves at the beginning of the shift and then have all the team members do the same. She may tell the team, “I know that at some point, I will overlook or miss something, and I want you to feel comfortable enough to speak up if you see anything that you are uncomfortable with.” The leader should reiterate the idea that the team is safer together than any of them can be individually. In addition, debriefing sessions after a sentinel event or procedure should be conducted in a blame-free environment.

Giving others the power to speak up is commendable, but it is important to provide them with the tools to do so effectively and in a productive manner. Some nurses have reported trying to raise concerns regarding physicians only to be reprimanded. Consequently, some nurses choose not to speak up even when they feel the patient is at risk. Strong communication among healthcare workers has been shown to improve work conditions and job satisfaction (PSQH, 2017). Good communication can improve outcomes and increase patient satisfaction, which can increase payments to hospitals (Burgener, 2017). To improve communication within a system fraught with hierarchy, there are several techniques that have been shown to be effective. The two techniques that will be examined in this course are the SBAR and the CUS word techniques.

The SBAR tool is a communication tool that was developed with the goal of facilitating and fostering communication between members of the healthcare team to improve patient care and ultimately patient outcomes.

SBAR stands for:

• Situation
• Background
• Assessment
• Recommendations

This tool focuses on structuring of communication with physicians in a way that captures the physician’s attention and thereby generates the appropriate action. The thought behind SBAR originates from the idea that nurses are trained and socialized to report findings within the context of the patient’s story, whereas physicians are trained to think and process information based on problems which need to be solved. Also, physicians tend to present and best receive the information as facts.

CUS words are another technique used to improve communication between physicians and nurses. CUS words are used to convey escalating levels of concern on the part of a nurse or really anybody who is lower on a hierarchy who needs to get the attention of someone higher up in the hierarchy.

CUS words begin with the phrase:

• “I’m Concerned about... next...
• “I’m Uncomfortable about” … and finally,
• “This is a Safety issue!”.

It is critical to teach those who may be receiving these CUS messages (who are usually physicians) to appreciate their meaning and respond accordingly. Likewise, it is important to teach those using the CUS words technique to avoid overusing thereby ensuring that it has its intended impact over time.

No matter what form of communication is used, it is important that all team members receive communication skills training. The providers should be aware of the type of communication that is being used and understand it so that they can respond appropriately. If every nurse uses SBAR communication, but a provider does not listen or cuts off the nurse, the communication is still not going to be effective. It is important to receive training and for leadership and management to also participate in and encourage good communication skills.

A nurse, Tina Cole, who is working on a medical-surgical floor calls the doctor and reports:

“Hi doctor, I am calling about Mr. Abe. he started having chest pain five mins ago. He was eating lunch and started having chest pain. He did receive all his medication this morning including his blood pressure medication. He seems a little sweaty but does not have a fever. He just had surgery yesterday and was supposed to go home tomorrow. I am not sure what is going on. Do you have any orders?”

After SBAR training, an appropriate response from the nurse would be:

• Situation: Hello Dr. X, my name is Tina Cole, and I am taking care of your patient Mr. Jeremy Abe on 3 SW. He started complaining of chest pain about ten mins ago which he qualifies as 10/10 pain. The pain is constant, is associated with shortness of breath and chest palpitations.
• Background: He is a 58-year-old male who is now on postoperative day two from a laparoscopic appendectomy. He has been ambulatory since the day of surgery and his pain has been well controlled up to this point.
• Assessment: I obtained a 12-lead electrocardiogram (ECG) which is ready for your review. He already received one dose of nitroglycerin which helped alleviate the pain. He is currently on 2L of oxygen. His vitals are BP 105/70, HR 52, T 98.0, RR 26, with an oxygen saturation of 98%. I am concerned about a pulmonary embolism versus a myocardial infarction.
• Recommendation: Can I please have a physician come now to evaluate the patient?

Using the SBAR technique, you can walk the physician through your thinking process and your assessment. Whether your assessment is correct is not critical. What matters is the fact that you can convey your concerns in an organized and efficient manner thereby laying a foundation for the physician’s subsequent evaluation.

Nurses work in stressful environments. To thrive and perform high-quality work in such environments, it is important for nurses to maintain situational awareness. Situational awareness refers to the degree to which one’s perception of a situation matches reality. Inability to maintain situational awareness during a crisis will inevitably lead to a breakdown in communication which can, in turn, create more problems, which worsen the crises.

The most effective healthcare teams should cultivate a culture of safety where team members feel comfortable drawing attention to potential or actual hazards, without fear of retaliation. The key to creating a culture of safety is communication. Nurses and physicians are the two largest workforces in the healthcare field and any plans to improve patient outcomes hinges on their ability to communicate appropriately. Effective teams depend on its members to work in a cohesive manner both as individuals and as a group in responding to crises appropriately.

• The Joint Commission. (2017). Sentinel event alert: Inadequate hand-off communication. Visit Source.
• The Joint Commission. (2021). National Patient Safety Goals® Effective January 2021 for the Hospital Program. Visit Source.
• Agency for Healthcare Research and Quality. (AHRQ). (2019). Communication between clinicians. Visit Source.
• Manojlovich, M., Harrod, M., Hofer, T., Lafferty, M., McBratnie, M., & Krein, S. (2021). Factors influencing physician responsiveness to nurse-initiated communication: A qualitative study. BMJ Quality & Safety. 30:747-754. Visit Source.
• Aiken, L., Clarke, S., Sloane, D., Sochalski, J., & Silber, J. (2002). Hospital nurse staffing and patient mortality, nurse burnout, and job dissatisfaction. Journal of the American Medical Association (JAMA). (288):1987-1993. Visit Source.
• Buerhaus, P., Auerbach, D., & Staiger, D. (2009). The recent surge in nurse employment: Causes and implications. Health Aff (Milwood). (28):w657-w688. Visit Source.
• Patient Safety & Quality Healthcare (PSQH). (2017). Communication: A critical healthcare competency. Patient Safety & Quality Healthcare. Visit Source.
• Burgener, A. (2017). Enhancing communication to improve patient safety and to increase patient satisfaction. The Health Care Manager: 36(3): 238-243. Visit Source.