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Calling The Doctor Should Not Be This Hard

1.00 Contact Hour
A score of 80% correct answers on a test is required to successfully complete any course and attain a certificate of completion.
Author:    Berthina Coleman (MD, BSN,RN)

Outcomes

The purpose of this course is to enable healthcare professionals with applicable strategies to improve communication between nurses and physicians.

Objectives

After completing his course, the learner will be able to meet the following objectives

  1. Discuss the root causes of sentinel events
  2. Discuss how healthcare professionals’ communication effects patient outcomes
  3. List two communication techniques used to enhance nurse-physician communication
  4. Apply SBAR in the clinic setting
  5. Apply CUS in the clinical setting

Introduction

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. The idea for this course was born from my own frustration as I went through my training as a critical care nurse over a decade ago. I found that the process of calling the doctor can be both onerous and extremely unpredictable. In my experience, nurses were forced to adjust their approach and delivery to cater to the physician’s preferences. I was told, “Dr. X did not like suggestions from the nurses, but Dr. Y preferred to hear suggestions from the nurses since he loved teaching.” After a few weeks, I sighed in utter frustration, “calling the doctor should not be this hard.” I thought “there must be a science to this process.”

A few years later, I was delighted to find that this was a growing field of research. In this article, I will summarize the foundational studies that led to the studying 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 background 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.

Communication As A Matter Of Patient Safety

The Joint Commission is an independent, nonprofit organization which is responsible for evaluating, accrediting, and certifying hospitals and healthcare organizations in the United States. 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.1” Thereby, underscoring the importance of improving communication between physicians and nurses, which are two groups which 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.1 Telephone and electronic communication now play a significant role in the care of patients. 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.

Lessons Learned From The Interaction Between Workforce And Patient Outcomes

Foundational studies of the interaction between workforce and patient outcomes are based on nursing pioneering research which established this concept.2-3 Much 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.

In addition to identifying the issues with staffing shortages in the field of nursing, these studies also pointed out the problematic relationship between nurses and their physician colleagues. In a survey of more than 700 nurses, 96% reported that they had witnessed or personally experienced disruptive behaviors by physicians. When asked why these acts were not reported to superiors, almost 50% of nurses reported the fear of retaliation as the primary reason. 30% of nurses reported that they knew at least one nurse who had resigned due to disruptive physician behavior.4-5 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.

Principles of Effective Communication In The Workplace

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 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 his or her own limitations to the group and then invite and welcome the 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, a critical care attending may introduce himself or herself at the beginning of the shift and then have all the members of the team 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 give them 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. One study reported that up to 12% of nurses would not speak up even when they felt that the patient was at risk.6 To improve communication within a system fraught with hierarchy, there are several techniques which 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 Communication Tool

The SBAR tool is a communication tool which 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, and Recommendations. It is training which focuses on nurses to structure their communication with physicians in a way that captures the physician’s attention and thereby generate 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.6

CUS Words

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.8
CUS words begin with the phrase,

  1. I’m concerned about...next...
  2. “I’m uncomfortable” … and finally,
  3. “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.

Case Study

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?

Discussion

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 58 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 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 Oxygen saturation 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.

Conclusion

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 effect 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.9

References

  1. The Joint Commission. About The Joint Commission. Joint Commission. https://www.jointcommission.org/about_us/about_the_joint_commission_main.aspx. Published 2017. Accessed September 16, 2017.
  2. Aiken LH, Clarke SP, Sloane DM, Sochalski J, Silber JH. Hospital nurse staffing and patient mortality, nurse burnout, and job dissatisfaction. JAMA . 2002;(288):1987-1993.
  3. Buerhaus PI, Auerbach DI, Staiger DO. The recent surge in nurse employment: causes and implications. Health Aff. 2009;(28):w657-w688.
  4. Rosenstein AH, O'Daniel M. Disruptive behavior and clinical outcomes: perceptions of nurses and physicians. American Journal of Nursing . 2005;1(105):54-64.
  5. Walrath JM, Dang D, Nyberg D. Hospital RNs' experiences with disruptive behavior: a qualitative study. J Nurs Care Qual . 2010;(25):105-116.
  6. Kurtzman ET, Buerhaus PI. New Medicare Payment Rules: Danger or Opportunity for Nursing? The American Journal of Nursing.2008;108(6):30-35.
  7. Needleman J, Kurtzman ET, Kizer KW. Performance measurement of nursing care: state of the science and the current consensus. Med Care Res Rev 10S–43S. 2007;2 suppl(64):10S-43.
  8. Wachter RM. Teamwork and Communication Errors. In: Understanding Patient Safety. 2nd ed. New York, NY: McGraw-Hill; 2012.
  9. Devita MA, Bellomo R, Hillman K, et al. Findings of the first consensus conference on medical emergency teams . Crit Care Med. 2006;34:2463-2478.

Other Resources

  1. Rosenstein AH, O'Daniel M. Impact and implications of disruptive behavior in the perioperative arena. Journal American Coll Surg . 2006;203:96-105.
  2. Hugonnet S, Chevrolet JC, Pittet D. The effect of workload on infection risk in critically ill patients. Crit Care Med . 2007;(35):76-81.
  3. Needleman J, Buerhaus P, Pankratz VS, Leibson CL, Stevens SR, Harris M. Nurse staffing and inpatient hospital mortality. N Engl J Med 2011;364:1037–1045.
  4. Rogers AE, Hwang WT, Scott LD, Aiken LH, Dinges DF. The working hours of hospital staff nurses and patient safety. Health Aff (Millwood) . 2004;23:202-212.
  5. Aiken  LH, Clarke SP, Cheung RB, Sloane DM, Silber JH. Educational levels of hospital nurses and surgical patient mortality. JAMA . 2003;(290):1617-1623.

This course is applicable for the following professions:

Advanced Registered Nurse Practitioner (ARNP), Certified Registered Nurse Anesthetist (CRNA), Clinical Nurse Specialist (CNS), Licensed Practical Nurse (LPN), Licensed Vocational Nurses (LVN), Midwife (MW), Registered Nurse (RN)

Topics:

CPD: Practice Effectively, CPD: Promote Professionalism and Trust, Medical Surgical


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