Improving Nurse-Physician Communication

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. Studies have shown communication errors resulting in as many as 49% of malpractice cases (Humphrey et al., 2022).

This course 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 this course, 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 that examined this relationship. Furthermore, the relationship between nurses and physicians is intrinsically different from the one between nurses and nurse practitioners or physician assistants, primarily due to their differing backgrounds and training.

While the studies and research in this course focus on nurse-to-physician communication, all healthcare professionals can benefit from applying applicable techniques to enhance their 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, n.d.a). It aims to establish safety goals for hospitals, with the goal 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, n.d.b). This highlights the importance of enhancing communication between physicians and nurses, two key groups of healthcare professionals who often require clear and concise communication in high-pressure situations.

The Joint Commission’s sentinel event program demonstrated that the most common root cause of serious medical errors was communication problems (UC Davis PSNet Editorial Team, 2025). Telephone and electronic communication now play a crucial role in patient care. Physician preference regarding the type of communication can also influence responsiveness. This form of communication is even more evident in patients outside the hospital setting. Inefficient communication can have a negative impact on patient outcomes. Effective teams employ strategies to optimize communication among healthcare professionals.

Foundational studies of the interaction between the workforce and patient outcomes are based on pioneering nursing research that established this concept (Aiken et al., 2002; Buerhaus et al., 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 et al., 2009).

In addition to identifying issues with staffing shortages in the nursing field, these studies also highlighted the problematic relationship between nurses and their physician colleagues. A large 6-year study involving 3,000 hospitals found that poor communication among care team members and with patients, family members, and post-acute care facilities could lead to confusion regarding follow-up care and medications (Merlino, 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 (Merlino, 2017). These studies highlight the importance of establishing effective communication strategies between physicians and nurses. In addition, these studies catapulted the drive to establish and enforce behavioral standards for all healthcare professionals.

There are many possible causes for communication breakdown, including incompatible personalities and hierarchical structures within an organization. There is a culture in every institution that can affect communication, both positively and negatively. A patient safety culture is one where communication is perceived as important. Hospitals that lack a patient safety culture may experience issues with communication if the culture hinders open communication. Different training backgrounds between nurses and providers are also thought to play a role (Clancy & Wehbe, 2022).

Communication failure can occur at any time during patient care, but is especially common during handoff, when something may be missed, including the plan of care for the patient and the severity of the illness (Humphrey et al., 2022).

There is a communication breakdown where the person sending the message does not send acceptable, understandable information, or when the person receiving the message doesn’t accept or understand the message (Wieke et al., 2021).

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 team members at the beginning of the shift or the start of a specific activity, such as a procedure. The leader needs to acknowledge their own limitations and then invite and welcome input from all team members. These techniques are often applied in surgical or critical care settings, but they can also be incorporated into the relationships between healthcare professionals in various settings.

For example, a 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. Additionally, debriefing sessions following a sentinel event or procedure should be conducted in a blame-free environment.

It is important to note that Registered Nurses are not assistants to doctors and practice within their own scope of practice (American Nurses Association (ANA), n.d.). Nurses have the responsibility to protect, promote, and optimize the health of their patients. Therefore, the information that they communicate to providers is important and should be respected.

Interdisciplinary teams can improve patient-centered care and outcomes (McLaney et al., 2022). Core competencies of this team include communication, interprofessional conflict resolution, shared decision-making, reflection, role clarification, and values and ethics. When utilizing an interdisciplinary team approach, communication is key. Providing information in a language common to all team members, as well as practicing active listening, are essential components of effective communication. The team should also work together to resolve anticipated or current conflicts by maintaining an open mind and finding mutually agreed-upon solutions. Shared decision-making is the goal of the interdisciplinary team. Collaboration within the team ensures that all patients’ needs are met. Reflection is an opportunity to examine past experiences and learn from them – what went right and what could be improved. The team should set aside time to meet and reflect on the care they are giving. Role clarification should be reviewed at the beginning of the patient’s care. Each team member should know what the other’s role is and utilize them to the highest level of that member’s scope of practice, without being redundant, and avoid having two people in the same role. Finally, this team should value each of its members’ input and perspective. Team members should only speak positively about other roles and teams within the organization. A well-run interdisciplinary team can have a significant positive impact on a patient’s outcomes.

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 (Merlino, 2017). Effective communication can improve outcomes and increase patient satisfaction, ultimately leading to higher payments to hospitals (Burgener, 2017). To improve communication within a system characterized by hierarchy, several techniques have been proven effective. Two techniques that will be examined in this course are the SBAR and the CUS word. TeamSTEPPS will also be reviewed.

The SBAR tool is a communication tool designed to facilitate and foster effective communication among healthcare team members, thereby improving patient care and ultimately enhancing patient outcomes.

SBAR stands for:

• Situation
• Background
• Assessment
• Recommendations

Some people add an I before SBAR to represent an introduction. The nurse calling the physician would introduce themselves and then explain the exact patient situation, including the seriousness of the illness or the reason for the call. Then, the nurse would provide background information on the patient related to the situation. The nurse would then give their assessment of the patient and finally make a recommendation of what the patient needs (American Society for Quality [ASQ], n.d.).

The SBAR tool focuses on structuring 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. In contrast, physicians are trained to think and process information based on problems that 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 in the 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 crucial to educate those who may receive these CUS messages (typically physicians) to understand their meaning and respond accordingly. Likewise, it is important to teach those using the CUS words technique to avoid overusing them, thereby ensuring that it has its intended impact over time.

TeamSTEPPS is an evidence-based program that hospitals can use to optimize the performance of healthcare teams(Agency for Healthcare Research and Quality [AHRQ], 2023). The TeamSTEPPS curriculum focuses on five areas, including (AHRQ, 2023):

• Patient Focus
• Integrated TeamSTEPPS platform
• Modular course design
• Active learning strategies
• Emerging team challenges and opportunities

In-person training is available through various organizations, or the course can be completed online. There is also a train-the-trainer education program, which allows some members of an organization to become trainers and bring the program to their own organization. The training should include all members of the healthcare team. TeamSTEPPS modules focus on four areas. The first module is communication, which includes models of communication, communication tools, and handoff. The second module is team leadership, which focuses on teams, team leadership, and team activities. The third module is situation monitoring, which focuses on situation monitoring tools, including the I’m Safe checklist, cross-monitoring, and STAR (stop, think, act, review). The fourth model is mutual support, which focuses on model support tools, the two-challenge rule, and CUS. The program is designed to raise safety awareness, reduce harm, and improve team communication.

It is essential to identify effective strategies to enhance communication. These include (Clancy & Wehbe, 2022):

• Bedside rounding 
• Use inclusivity 
• Role model respect 
• Practice mindfulness 
• Empathy training 
• Stress management 
• Huddles 

Bedside rounding with an interdisciplinary team (as discussed above) is an opportunity for patients to be at the center of the team and included in the plan of care. In the past, rounds were often conducted in the hallway or at the nurse’s station without the patient's involvement. Well-informed patients can express their concerns, discuss treatment options, and participate in a shared decision-making approach, which contributes to patient empowerment and satisfaction. Bedside rounding has also been shown to reduce adverse effects and, in some studies, decrease length of stay (Heip et al., 2022). Families should also be included when available, which can help them and patients make informed decisions about placement options sooner. Bedside rounding has also been shown to improve communication among the interdisciplinary team and should encourage input from everyone involved (Heip et al., 2022).

Barriers to bedside rounding include challenges in coordinating team availability and time constraints (Heip et al., 2022). However, using a structured checklist can help the team run the rounds efficiently and reduce the time required for all involved in patient care. Inconsistency in attendance is another barrier to bedside rounding. Team members must be present, but also ensure that rounds are not scheduled during busy periods, such as medication administration. To prevent hierarchical barriers, all team members should have valued input in bedside rounds. Patients may experience stress or confusion during rounds, especially if the language used is unfamiliar to them, so the team must use language that is patient-appropriate.

Inclusivity can help promote teamwork. It is essential to always use the patient’s pronoun preferences. However, when referring to a doctor, a nurse should say “our patient” instead of “your patient” or “my patient.” This helps to show accountability by both parties.

Role model respect refers to knowing team members’ preferred names and using them. It is ok to ask a person’s name if you don’t remember, but then that name should be used. It is essential to never speak negatively about team members. Constructive criticism is preferred over negative comments behind their back.

Mindfulness is a useful tool for all healthcare workers. Being aware of what you are feeling without judgment can improve the wellness of the person practicing it. This can lead to improved listening skills, social skills, emotional skills, and job satisfaction (Clancy & Wehbe, 2022). Mindfulness can help individuals become more engaged in their environment.

Empathy training for team members can deepen their understanding. It is a skill that can be learned and can improve communication. Empathy utilizes emotional intelligence, as well as nonverbal actions, to demonstrate respect and compassion to patients and to one another.

Stress management has become a topic of discussion in all areas of healthcare. With increased demands at work, increased patient complexity, and even increased personal stress, almost everyone can benefit from stress management. Various techniques, such as yoga, exercise, meditation, fitness, and nutrition, as well as employee assistance programs, can all help healthcare workers reduce their stress, leading to improved performance and, consequently, enhanced communication at work.

Team huddles and briefings can improve communication about patients. These huddles can occur outside of bedside rounding and can be used to assess patient priorities and review team roles for the day. Huddles can be conducted with or without the patient's involvement. Huddles have been shown to minimize hierarchical barriers within a team, improve staff satisfaction, and improve outcomes (Pimentel et al., 2021). These huddles can also enhance efficiency and communication, as well as improve situational awareness. Huddles have various definitions and can be used in various settings, but should be interdisciplinary and collaborative.

The use of technology can improve communication. Whiteboards can share useful patient information with nurses and physicians.  Best practice advisories (in the electronic health record (EHR) can alert the nurse and provider about changes in the patient's status or evidence-based treatment guidelines. Secure chat messages are another technique that can improve communication. Sometimes, it is easier for the nurse or provider to communicate through a secure chat. However, when technology is used for communication, the nurse and provider must understand how that communication is being conducted and the rules governing it (Borawski et al., 2025).

Any form of bullying within a healthcare setting should not be tolerated. A connection exists between workplace safety and patient care (The Joint Commission, 2016). Physician-to-nurse bullying has had a long history. Some of this may be due to the assumption that doctors are primary decision-makers because of their extensive training, as well as the notion that nurses are inferior and have a lower social status (Mawuena et al., 2024). Doctors’ authority, status, and disrespect for nurses can decrease teamwork and impact how nurses are perceived and heard. Physicians who bully nurses may not listen to suggestions and ignore nurses’ concerns, leading to bad outcomes, including death. Nurses may tend to remain silent when they are being bullied.

All team members should be held accountable that bullying is never tolerated. Nurse managers may have an impact on the bullying that occurs in their units. Nurses, as well as all healthcare professionals, should know how to follow their chain of command and report bullying without fear of retaliation.  The chain of command is a structure within a healthcare organization that directs staff members, including nurses, to present issues up the line of authority until a resolution is reached (Pennsylvania Patient Safety Authority, 2010). Nurses must be protected from bullying. The use of the chain of command should never lead to retaliation against the nurse. The chain of command may vary from institution to institution, but it should always adhere to basic principles. These include (Pennsylvania Patient Safety Authority, 2010):

• There should be a chain of command that is presented to all staff
• Code of conduct should exist and be brought up the chain of command if not followed
• The organization should have a policy about the transparency of adverse events
• There should be zero tolerance policies for bullying and disruptive behaviors
• Ensure that people involved in adverse events are treated fairly
• Use nonconfrontational interventions when dealing with events
• Encourage interdisciplinary dialogues to address conflict

How an organization tolerates or prevents bullying can significantly impact its entire culture.

Regardless of the form of communication used, all team members must receive training in effective communication skills. Providers should be aware of the type of communication being used and understand it, so they can respond appropriately. If every nurse uses SBAR communication, but a provider does not listen or interrupts the nurse, the communication is still unlikely to be effective. It is essential to receive training, and for leadership and management to participate in and encourage the development of 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 minutes 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 minutes ago, which he qualifies as 10/10 pain. The pain is constant and is associated with shortness of breath, perspiration, 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. He took his lisinopril and furosemide this morning. He has no allergies, and he last took ketorolac 10mg about 60 minutes ago. He reports his surgical pain as 1/10.
• Assessment: I obtained a 12-lead electrocardiogram (ECG), which is ready for your review. He already received one PRN 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: I would like you to evaluate him at the bedside as soon as possible.

Using the SBAR technique, you can guide the physician through your thought process and assessment. The nurse can’t make a diagnosis, but can provide the physician with information that may help them to decide on a plan. It is essential to convey your concerns in a clear and organized manner, thereby laying a solid foundation for the physician’s subsequent evaluation.

Nurses work in stressful environments. To thrive and perform high-quality work in such environments, nurses need to maintain situational awareness. Situational awareness refers to the degree to which one’s perception of a situation matches reality. The inability to maintain situational awareness during a crisis will inevitably lead to a breakdown in communication, which can, in turn, create additional problems that exacerbate the crisis.

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 hinge on their ability to communicate appropriately. Effective teams depend on their members to work cohesively both as individuals and as a group in responding to crises appropriately.

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