Poor communication between physicians and nurses is consistently ranked as one of the top causes of adverse patient outcomes in health care settings. It’s to blame for hundreds of deaths each year and a third of malpractice cases, according to a recent Comparative Benchmarking Report from CRICO Strategies, an insurance company that serves the health care community.
Examples of communication failures pepper the report, such as a mother requesting a tubal ligation after her cesarean section. The on-duty obstetrician was unaware of the request and the mother sued the hospital when she became pregnant again. In another example, a nurse did not communicate a notable change in discharge vital signs resulting in the patient’s return a few hours later with acute sepsis.
“Poor communication between nurses and physicians can have the most serious consequences for a patient,” said Milisa Manojlovich, PhD, RN, CCRN, a University of Michigan School of Nursing associate professor and actively-practicing nurse. “Communication mistakes affecting patients are well-documented, but the health care industry really hasn’t been able to address the problem adequately yet.”
While examining communication issues in health care, Manojlovich theorized that communication strategies taught to physicians and nurses were severely flawed because they have been uni-dimensional.
“Years ago, health care adopted aviation industry strategies, namely the ‘sender to receiver’ approach,” said Manojlovich. “It means I’ll send you a message, you acknowledge receipt of the message, and carry out what was asked of you.”
Based on her research and her personal nursing experience, Manojlovich has found significant challenges when using that strategy alone in a hospital environment.
“Patients are not airplanes,” said Manojlovich. “A pilot flying a specific model of plane knows that wingspan will not vary from plane to plane. It doesn’t work that way for patients. There’s a lot of complexity and the same diagnosis for two patients can have very different trajectories. An exclusive focus on a sender-receiver type of communication cannot capture all of the variability and uncertainty of human beings, because there is little opportunity to consider the problem from the receiver’s perspective.”
The Shared Understanding Approach
Instead of a sender-to-receiver approach, Manojlovich is focusing on a type of communication which depends on the development of shared understanding between members of health care teams. The process includes using the unique knowledge base and experience of each team member to build a collective picture of what is happening with a patient. That base is then used to make the best decisions for the patient’s care.
“It’s not just about nurses and doctors,” said Manojlovich. “It also means including pharmacists, nutritionists, social workers, and the patients themselves to make the best decisions. We each have important information but we don’t always look at things the same way because we’ve been trained in separate disciplines. Once you understand the other person’s perspective, it’s easier to incorporate that perspective into the plan of care, and ultimately enhance what is done for the patient.”
Manojlovich is working on a series of communication-focused research projects to better understand how shared understanding can improve patient outcomes.
Videotaping doctors and nurses in real-world clinical settings is one strategy Manojlovich is using to get answers. In addition to gathering data about how communication is happening, Manojlovich has the clinicians who were recorded review the exchanges to address where they believe shared understanding did or did not occur. Manojlovich is using that information to identify themes in communication failures and to find solutions for the future.
Understanding how technology can help, or in some cases hurt, the communication process is another significant aspect of Manojlovich’s work. She explains that many clinicians have the right intentions but don’t see where communication gaps are happening.
“The doctor goes to one computer terminal to enter information about the patient, and the nurse goes to another terminal and does the same thing” she said. “The problem is, they aren’t talking to each other. The back and forth dialogue that needs to happen for shared understanding is not there.”
Changing Communication Practices
Manojlovich believes building shared understanding means many nurses may need to learn how to identify and discuss their nursing knowledge with others, making a case for why nursing knowledge is crucial to patient outcomes. When making patient rounds, some physicians may not seek out nurses because they don’t believe the nurses have information that they need.
“Nurses need to be able to speak up and say, ‘from a nursing perspective, here is important information that you need to consider in the care of this patient,’ and we’re not that good at that on the nursing side unfortunately,” she said.
The Next Steps
Manojlovich’s research, while still in the early stages, is already finding promising results. “We’re finding that doctors who work in one specific area or unit of a hospital, instead of caring for patients on multiple hospital units, develop better relationships with the nurses and as a result have better communication,” she said. “We’re looking at how that lesson can be used in the bigger picture.”
Manojlovich expects that changing technology and communication practices in a hospital will take extensive work and time, but the end goal of improving patient outcomes will be worth the effort.
“An emphasis on developing shared understanding needs to happen because the single focus on receiver-sender communication doesn’t work by itself,” she said. “Having more than one view of communication is critical for developing effective strategies to reduce patient harm. It’s important to do all we can to improve patient safety.”