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Abstract
Background Interdisciplinary communication is critically important to provide safe and effective care, yet it has been inadequately studied for hospitalised medical patients. Our objective was to characterise nurse–physician communication and their agreement on patients' plan of care.
Methods During a one-month period, randomly selected hospitalised patients, their nurses and their physicians were interviewed. Nurses and physicians were asked to identify one another, whether communication had occurred, and about six aspects of the plan of care. Two internists rated nurse–physician agreement on aspects of the plan of care as none, partial or complete agreement. Measures included the percentage of nurses and physicians able to identify one another and reporting communication and the percentage of nurse–physician pairs in agreement on aspects of the plan of care.
Results 310 (91%) and 301 (88%) of 342 eligible nurses and physicians completed interviews. Nurses correctly identified patients' physicians 71% of the time and reported communicating with them 50% of the time. Physicians correctly identified the patients' nurses 36% of the time and reported communicating with them 62% of the time. Physicians and nurses showed no agreement on aspects of the plan of care ranging from 11% for planned procedures to 42% for medication changes.
Conclusions Nurses and physicians did not reliably communicate with one another and were often not in agreement on the plan of care for hospitalised medical patients.
- medical error
- communication
- teamwork
- Interdisciplinary communication
- Medical error
- Teamwork
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Communication between nurses and physicians is critically important to provide safe and effective care, as poor communication represents a major aetiology of preventable adverse events in hospitals. A Joint Commission study of 3548 sentinel events reported from 1995 to 2005 indicated communication failures were the root cause for two-thirds of them.1 Another study found that communication failures of one kind or another contributed to 91% of the medical mishaps reported by residents.2 Without effective communication, nurses and physicians may operate under divergent mental models regarding the goals of care. Effective teams work with a shared mental model—an organising knowledge structure of the relationship between the tasks facing the team and how the team members will interact.3
Although patterns of communication and barriers to effective communication have been well studied in operating rooms and intensive care units,4–6 relatively little research has been conducted in the general medical inpatient setting. This is concerning in light of studies demonstrating that hospital-based physicians dedicate nearly a quarter of their time to communication and coordination of care in general medical inpatient settings.7 8 We conducted this study to characterise patterns of nurse–physician communication, assess the frequency of nurse–physician agreement on the plan of care and explore the association between communication and agreement on the plan of care for hospitalised general medical patients.
Methods
Design
Interviews of a cross-sectional sample of patients, their nurses and their physicians took place during a four-week period in June 2007. Each day during the study period, approximately 20 randomly selected patients admitted to general medical services and their nurses and physicians were interviewed in the afternoon of the patients' second hospital day.
Setting and participants
The study was conducted at a 753-bed academic hospital in Chicago, Illinois. The study was approved by the Institutional Review Board of Northwestern University. General medical patients were admitted to either a teaching service or a non-housestaff hospitalist service. Admissions were distributed to these services in sequence, with approximately two-thirds of the patients assigned to the teaching service and one to the hospitalist service. Teaching service teams consisted of one attending physician, one resident physician, one or two interns and one or two third-year medical students. Hospitalists cared for patients independently without the assistance of housestaff physicians or mid-level providers.
Interviews of patients, nurses and physicians
We created a structured interview instrument designed to characterise nurse–physician communication and assess understanding of patients' plan of care. We first conducted pilot interviews and made modifications to the structured interview based on feedback from participants. Standardised interviews of patients, nurses and physicians were then conducted by one of two research assistants (KH and JJ) (see appendix). Patients with cognitive impairment or who were unable to speak and/or understand English were excluded. Nurses and physicians of excluded patients remained eligible for participation in the study. Patient interviews assessed their expectations with regard to nurse–physician communication and complemented demographic data from administrative databases.
Interviewers asked nurses whether they knew the name of the physician primarily responsible for the care of the patient and whether they had discussed the plan of care with the physician on that day. Nurses were given credit if they correctly identified any physician on the primary physician team. Similarly, discussion of the plan of care with any physician on the primary physician team was assessed as reflecting presence of communication. If discussion had taken place, nurses were asked whether communication had taken place face-to-face, via telephone or via text-page. Nurses were then asked specific questions about six aspects of the plan of care for the patient that day, including the main diagnosis, planned tests, procedures, medication changes, which physician consulting services were expected to see the patient, and the expected length of stay. Nurses' responses to questions about the plan of care were recorded verbatim by the research assistants.
For physician interviews, we interviewed interns for patients admitted to the teaching service and hospitalists for patients admitted to the hospitalist service. The rationale was that these were the physicians primarily responsible for nurse–physician communication. Interviewers asked physicians whether they knew the name of the nurse taking care of the patient and whether they had discussed the plan of care with the nurse. The form of communication and specific questions regarding the plan of care were assessed in the same fashion as for the nurses.
In order to minimise confounding due to evolving plans of care and various levels of physician training, all interviews were conducted during the afternoon of the patients' second hospital day. This ensured that housestaff physicians were interviewed after their supervising attending physician had rounded with the team and discussed the plan of care for patients admitted the previous day. Conducting interviews in the afternoon also allowed sufficient time for communication between nurses and physicians to occur, if it was to occur.
Physician review for agreement on the plan of care
Two board-certified internists (MPL and NK) reviewed nurse and physician responses and rated nurse–physician agreement on each aspect of the plan of care as none, partial or complete agreement. For example, if the nurse responded that a patient's main diagnosis was fainting and the physician responded that it was syncope, complete agreement was given for that aspect of care (primary diagnosis). If the nurse responded that the patient's planned testing for the day included only a lower extremity venous duplex study and the physician responded that the patient was planned for a lower extremity venous duplex study and a computed tomographic scan of the chest, partial agreement was given. For anticipated length of stay, we defined complete agreement as an exact match between the nurse and physician, partial agreement as a difference of 1 day and no agreement as a difference of >1 day. We calculated a nurse–physician summary agreement score by assigning 0, 1 or 2 points for none, partial and complete agreement, respectively, to each of the six aspects of the plan of care. To assess inter-rater reliability, approximately 30% of participant responses underwent duplicate review.
Data analysis
Demographic data on patients, nurses and physicians were obtained from administrative databases and complemented with information from interviews. We report the number and per cent of nurses and physicians reporting that communication had occurred, the form of communication, and whether healthcare professionals knew each others' names. We report the number and per cent of nurse–physician pairs who agreed on specific aspects of the plan of care. We assessed inter-rater reliability on the plan of care using the weighted κ statistic. We compared the nurse–physician summary agreement scores of the nurse–physician pairs in which neither reported communication and the pairs in which both reported communication using the Student t test. All analyses were conducted using Stata version 9.0.
Results
Three hundred and forty-two patients were identified to participate in the study. Twenty-three patients were discharged before we approached them for interview. Forty-two patients were ineligible to participate because of cognitive impairment or inability to speak English. Thirty patients were unavailable for interview because they were undergoing testing or procedures. Of the 247 eligible patients, 229 (93%) agreed to be interviewed. Of 342 patient's nurses, 310 (91%) completed the interview. Nurse interviews represented 140 different nurses because individual nurses may have been interviewed more than once about separate patients in the study. The range of interviews individual nurses completed was 1–8 (median=2, IQR=1–3). Three hundred and one of 342 (88%) patients' physicians completed the interview. Physician interviews represented 42 different physicians. The range of interviews individual physicians completed was 1–27 (median=7, IQR=3–11).
Participant characteristics
Participant characteristics are summarised in table 1. The majority (84%) of the patients were admitted via the emergency department, and half (51%) were admitted at night. Approximately two-thirds (64%) of the patients were admitted to the teaching service and one-third (36%) to the hospitalist service.
Characteristics of patients, nurses and physicians
Communication between nurses and physicians
Two hundred of 224 patients (89%; n<229 due to five missing responses for this item) stated that they expected their nurse and their physician to discuss their care on a daily basis. The reported frequency and types of communication between nurses and physicians are summarised in table 2. Nurses correctly identified patients' physicians 71% of the time and reported communicating with physicians 50% of the time. When communication did occur, nurses reported that it was performed in person (face-to-face) 65%, over the telephone 28% and with the use of text-page alone 7% of the time.
Nurses' and physicians' patterns of communication and ability to identify each other on day of interview
Physicians correctly identified patients' nurses 36% of the time and reported communicating with nurses 62% of the time. When communication did occur, physicians reported that it was performed in person 69%, over the phone 29% and with the use of text page alone 2% of the time.
Agreement between nurses and physicians on the plan of care
Agreement between nurses and physicians on aspects of the plan of care is summarised in table 3. Inter-rater reliability between the internists in their rating of nurse–physician agreement on aspects of the plan of care was excellent (weighted κ range 0.90–0.98). For each aspect of care, nurses and physicians lacked complete agreement on the plan of care in a large number of instances. There was no agreement between nurses and physicians on planned tests or procedures for the day in 26% and 11% of instances, respectively. There was no agreement between nurses and physicians on planned medication changes for the day in 42% of instances. Examples of nurse–physician responses rated as having no agreement are listed in table 4.
Agreement between nurse and physician on aspects of the plan of care
Examples of nurse–physician responses rated as no agreement
The Nurse–Physician Summary Agreement Score was not significantly different when comparing nurse–physician pairs in which neither the nurse nor the physician reported communication with pairs in which both reported communication had occurred (mean score 7.63 vs 7.78, p=0.67).
Discussion
The vast majority of patients in our study expected their nurse and their physician to discuss their care on a daily basis. In spite of this and a body of literature linking communication failures with medical error, we found that nurses and physicians did not communicate 40% to 50% of the time on hospitalised general medical patients. When communication did occur, it was often performed using telephone or text page (face-to-face 65% to 69%, telephone 28% to 29% and text page alone 2% to 7% of the time).
There are several potential explanations why communication between nurses and physicians did not occur more often. Studies in operating rooms and intensive care units suggest that steep hierarchies and discrepant perceptions regarding collaboration serve as barriers to teamwork.5 6 Physicians often overestimate their collaboration with non-physician team members.5 6 Another possible explanation why communication did not occur more often may have been that providers relied on the medical record for information about the plan of care for their patients rather than discussion with other team members. Physicians may have felt that placing the order for medication changes was sufficient communication to the nurses caring for their patients. Because physicians may not read nursing notes routinely and physician notes are often written late in the day, the medical record (in its current format) is not an effective communication tool.
Nurses and physicians in our study often did not agree on important aspects of the plan of care. This is particularly concerning for certain high-risk aspects of care such as planned procedures and medication changes. Without a shared understanding of the plan of care, team members are unable to engage in mutual performance monitoring and backup behaviour (anticipating and reacting to the needs of other team members), two critical skills that allow teams to prevent errors from causing harm.9 10
We had expected to find that nurse–physician agreement would be higher when nurses and physicians had communicated with one another. In fact, there was no difference in the Nurse–Physician Summary Agreement Score based on whether or not nurses and physicians had communicated. The explanation for this finding may relate to the quality and content of communication between nurses and physicians, which we did not assess in our study. Incomplete exchange of information between team members appears to be common in healthcare settings, often becoming the norm as a ‘culture of low expectations’ with regard to communication practices.11
The lack of association between nurse–physician communication and agreement on the plan of care in our study should not undermine the importance of interdisciplinary communication. Instead, the lack of agreement on the plan of care should prompt investigation into what methods may be devised to ensure complete, meaningful communication between nurses and physicians caring for hospitalised general medical patients. Significant barriers to collaboration exist in the general medical inpatient setting. Unlike an operating room, physicians and nurses care for multiple patients simultaneously. Although nurses typically care for patients on a single unit, physicians often care for patients on multiple units, making it difficult for physicians and nurses to discuss the care of their patients in person. Teamwork training has been used in emergency medicine and labour and delivery units with variable success.12 13 Teamwork training may prove to be beneficial in the general medical setting, but successful interventions will need to include steps to overcome the geographic dispersion of team members. Intensive care units have successfully used worksheets focused on daily goals of care to clarify and communicate care plans.14 15 The daily goals worksheet provides structure to the discussion among team members and ensures that critical elements of the plan of care are communicated. Finally, interdisciplinary rounds have been studied as a means to bring providers together in the general medical setting and to allow collaboration on the plan of care.16–18 Studies show improved perceptions of collaboration among providers, but understanding of the plan of care has not been assessed.17 18
Our study has several limitations. Our findings reflect the experience at one hospital. However, we believe inadequate communication between nurses and physicians on the plan of care is likely to exist in general medical units in other hospitals. Our findings highlight that communication is often suboptimal even when it occurs, which is valuable for healthcare workers to consider in a variety of settings. Future studies should evaluate the connection between the quality of nurse–physician communication and actual preventable adverse events.
We believe the results of this study reveal a critical deficit in communication and understanding of the plan of care between providers caring for hospitalised general medical patients. We have recently localised our physicians to specific hospital units and now plan to investigate the potential benefit of daily interdisciplinary rounds incorporating structured discussion elements similar to those used in daily goals of care interventions. The intervention holds promise in creating a shared understanding of the plan of care and potentially reducing the risk for preventable adverse events.
References
Footnotes
Funding Funding support was received from the Northwestern University Department of Medicine.
Competing interests None.
Patient consent Obtained.
Ethics approval This study was conducted with the approval of the Institutional Review Board of Northwestern University.
Provenance and peer review Not commissioned; externally peer reviewed.
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