Theresa Brown, BSN/RN/OCN, is a floor nurse in Pittsburgh and author of “Critical Care: A New Nurse Faces Death, Life and Everything in Between.” SmartBrief editor Kathryn Doherty recently spoke with her about the challenges of communication — with physicians, patients and other hospital departments — facing nurses today and how these challenges affect patient safety. A condensed version of that conversation follows.
How does the nature of the nurse-physician relationship affect communication between these professionals? Does it affect patient safety?
The hierarchical nature of the nurse-physician relationship often impedes good communication. Nurses are looking out for physicians to be arrogant and dismissive, and physicians can be unfairly impatient with nurses. These kinds of interactions are more likely when people are under stress — and almost everyone working in a hospital is under stress.
The problem begins with our training. In nursing school, I received no training in how to work with physicians, and my sense is that physicians get no training in how to communicate with nurses. Yet, each group completely depends on the other to take care of patients. A half-day or daylong workshop, where nurses and physicians work together to learn how to communicate better, could do wonders.
Safety issues are what make the communication between nurses and physicians so important. A physician who dismisses a nurse’s concern for a patient may be ignoring an important sign that the patient is in crisis. A nurse who fails to bring an important detail to the attention of a physician because talking to MDs makes her uncomfortable is also not giving her patient the best care possible. Simple medication errors could be avoided if the nurse’s question was heard not as a criticism of the doctor’s skill, but as a striving for clarification.
Bedside nurses are considered the closest link to patients. How does this proximity affect nurse-patient communication and overall patient safety in a hospital?
Nurses are the “canaries in the coal mine.” The nurse sees the patient for the entire day or night, and will often be the one who first notices when the patient is having a serious problem. Whatever is affecting the patient that day — physically or emotionally — will be impossible to hide from the nurse.
That proximity can also create friction, if the patient treats the nurse as waitress, maid, counselor or punching bag. Patients who make unreasonable demands on nurses (and we’ve all had these patients) may not realize that they’re distracting their nurse from paying attention to their health.
What changes in hospital culture could be made to improve patient safety?
A lot of the problems in hospitals would solve themselves if people had time to listen to each other, and then do what needed to be done. My feeling at work is that everyone has a little more to do than can be done in the time available — and sometimes a lot more. If we could slow down, we could keep patients safer.
And one thing that would help nurses slow down would be staffing ratios and well-stocked float pools that could fill gaps when nurses were unable to come to work. “Working short” benefits neither nurses nor doctors, and certainly not patients.
Hospital departments can be very separated, physically and ideologically. How could that situation be improved?
An “Us versus Them” mentality has become endemic in many hospitals, and it makes communication very difficult. Medical people don’t like surgical staff, ICUs don’t like floor nurses, certain nurses don’t like certain physicians, etc.
What I find myself saying over and over again is, “We all have the same goal.” Most people who work in hospitals have a deep commitment to being helpful, or at least started their careers with that feeling. If we could reawaken that feeling in people, make them remember why they got into this crazy work environment in the first place, it might help.
The goal of everyone in the hospital should be to give all patients the best care possible. and institutions need to really commit to that goal, rather than giving it lip service while really focusing on profits. Staff who don’t appreciate that goal may need retraining or reassignment. The nurses and physicians I like the most and respect the most all share the same professional mantra: “It’s all about the patient.”
Twitter
Facebook
Linkedin
RSS
Such interesting insight into the challenges nurses face day in and day out. Good for ANY person to read – since all of us will probably visit a hospital for one reason or another at some point! Great interview!
This is so true! Respectful listening to patients and each other will contribute to safer care and more rewarding careers. Tough to quantify and connect with reimbursement, but critical for patient care.
Thanks for this great article!
Beth Boynton, RN, MS
Author, Confident Voices: The Nurse's Guide to Improving Communication & Creating Positive Workplaces
I agree that problem begins with training. As a recent graduate of a adult nursing BSN program, I cannot believe how unprepared I felt for the realities of such a complex environment. Students should have much more contact with doctors as well as experienced nurses in their workplace throughout their nursing education so they can begin to understand how essential good communication is to positive patient outcomes.
Confidence can go a long way in helping nurses communicate better with doctors. Nursing schools must "clean" their curricula of superfluous material and add more pathophysiology to their programs so that new nurses can ask thoughtful, informed questions. For example, I had to take a two credit course entitled "Into. to Nursing" which was focused primarily on the history of nursing. Wouldn't that time have been better spent on an in-depth focus on diabetes, which affects a large proportion of the population?
The nursing education I received does not make me feel like a professional, so I might be less likely to communicate like one.
Good thoughts, Linda. I hope you will take action on your views and write to your BSN program- tell them what you are experiencing and offer your suggestions- perhaps get others to do so too! "Be the change"!
Thanks for your 'real life' practice thougthts, Linda.
Kathy G
Beth, why must everything a nurse does be quantified? There's something that nurses gain through their experiences and that is called wisdom. Try as an educator may, you can't put everything into a neat little theory and package it for a student nurse to save them the time and headaches of gaining experience as a staff nurse. For myself, the way nurse educators and researchers attempt to dissect the process of nursing just creates distance from myself to them. Whenever advanced degree nurses try to solve problems of nursing practice, it's really comes down to adding more work for the staff nurse.
Remember, when nurse educators were trying to increase enrollment in nursing programs, I heard over and over again how they couldn't do it without more nurse educators. Funny, when staff nurses are told to take more patients (or other duties) in our assignments, we are told there's no money and that we just need to be more efficient.
This is my humble opinion as an Associate Degreed nurse, with a BA in Liberal Arts.
I really did enjoy this short interview. Well done, Ms. Brown
Hi Marie, What you may be missing is when nurse leaders go to institution leadership to increase funding for increased staffing numbers at the bedside, they have to provide data as to why this is necessary. Just saying "for patient safety" will not convince most institutional leadership that the increases are necessary. So to quantify those crucial communications that protect patients from harm would go a LONG way to convincing the leadership that increased bedside staffing would indeed improve patient safety. Ms Brown is absolutely correct that we need more time to communicate and to think but change in health care is coming at us more rapidly than ever so her descriptions of the reality of nursing go a long way to increase understanding of the profession with not only lay people but other health care professionals.
[...] This post was mentioned on Twitter by Danny Wahlquist, Ken Potalivo. Ken Potalivo said: Oncology nurse Theresa Brown, on promoting a patient-centered culture http://ow.ly/1afwrd [...]
A lot of contact made to doctors to clarify orders that are illegible or not complete could be decreased if not eliminated with a computerize order form. How about it. Maybe something that would come up with standing orders according to diagnosis and treatment plan off the progress note? Let's not make them take even more time to do all the documentation required.
[...] nurse communications, Nursing, Patient, Patient Safety, Theresa Brown RN Here is a blog post from SmartBlogs.com by Theresa Brown. I love to read her thoughts about nursing, so I felt you might enjoy this post, [...]
*What Theresa Brown wrote about communication is so true. In the hospital where I work the communication between doctors and nurses is very poor, but the communication between administration and nurses is almost total dysfunctional. When administration is making changes regarding patients, they do not involve the nurses, the nurses has no say. It seems as if the nursing director is working against the nurses.
An excellent article on the importance of communication to provide the best care to all of our patients every day. I am a tenured RN of 37 years. We did not have education on communication in our BSN program. Experienced has provided me with the confidence to speak up and to be the patient advocate to physicians and administration. I also try to attend a continuing education on leadership annually. I believe Bob Hess and others who promote shared governance is an excellent avenue to bring everyone (nurses, physicians, administration) together to determine the best care. thank you for the article
I would be interested to hear how others experience with Computer Order Entry by the physicians is impacting the communication between nurses and physicians. I am very concerned that with CPOM, we are losing a very important communication point between physicians and nurses. Many times now, orders just "show up" on the computer without the physician being there or communicating with the nurse about the orders. There is no corresponding progress note to refer to and no physician on the phone or in person to ask about the orders. We are "catching" orders entered on the wrong patient but it is much more difficult than with the previous process. What are others experience with this process change and how are you addressing it?
This article offers great insight about promoting a better environment for nurses. However, I would like to add how doctors rarely receive training or methods on dealing with nursing conflicts, it's like they are trained to only be right… but I don't want to point any fingers. I just would like to see more of a GROUP effort for improving the communication. The more nurses and doctors work together as a team, the more effective patient care can become.
I certainly agree that communication is a skill that must be stressed during the training process for nurses but even the most highly-skilled communicators can fail when staffing levels aren't adequate to allow enough time for effective communication to take place. All too often, I've seen information important to patient care fail to be passed between nurses and physicians as a result of necessity rather than conflict.
I really agree that communication has an important thing in caring critical patient. Interdiciplinary should be involved to increase quality of care. So that communication has to be good among them. Poor communication makes everything impossible.
But many nurses, such as in Indonesia still have lack of communication skill. So that between nurses and doctors are so different while giving services to the patients..
Effective communication could improve quality of care become high