Penn Nursing JOSNR 2014

Communication Barriers and Solutions in Health Care

josnr

Journal of Student Nursing Research Vol 7 Iss 1 2013-2014

Table of Contents Introduction from the President VANESSA DIMARIA --------------------------------------------------------- 1 Deaf Culture in the Medical Setting SARAH A. VOISINE ------------------------------------------------------ 2 - 5 Barriers to Nurse-Physician Communication and Patients’ Outcomes MARY BLACKWELL --------------------------------------------------- 7 - 12 The Nurse-Physician Relationship: Problems and Solutions CAROLINE BOURASSA ---------------------------------------------- 14 - 16 Communication: The Human Connection ALAINA M. STOCHAJ -------------------------------------------------18 - 19 The Effectiveness of Current Communication Training on End of Life for Nurses in Oncology and Critical Care Settings VANESSA DIMARIA -------------------------------------------------- 21 - 25

Introduction from the President Dear Readers,

Welcome to the 7th volume of The Journal of Student Nursing Research (JOSNR). JOSNR is a student-run research journal published annually based at the University of Pennsylvania School of Nursing. It serves as an opportunity for students to voice their ideas about nursing and health care practice. Created by the Organization of Student Nursing Research (OSNR) in 2007, it supports research among both undergraduate and graduate nursing students, promotes greater awareness of nursing research, encourages student participation in research, and provides a forum for students to voice their views on current nursing-related topics.

The journal’s theme was inspired from the overarching focus for academic year 2013-2014 of the University of Pennsylvania, The Year of Sound. Thinking about sound and its relation to health care, the journal aimed to encompass an untapped area of research: Communication Barriers and Solutions in Health Care. Under this umbrella theme, three sub-categories of research developed: (1) barriers which impact nurse-patient communication, (2) communication with patients hard of hearing or part of the Deaf community, and (3) the communication between health care professionals.

We thank all of the contributing authors for submitting their work to JOSNR. We hope that you as the reader enjoy our journal, but more importantly, hope to inspire you to begin research of your own to improve patient-centered care and overall health care practice.

Vanessa DiMaria President of OSNR

Vol 7, Iss 1, 2013-2014

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Deaf Culture in the Medical Setting Sarah A. Voisine

Many people today understand the word “deaf” in a literal sense, meaning “unable to hear”. However, behind the diagnosis of “deaf” exists a rich culture and communication system. Deaf individuals have a strong sense of belonging within their Deaf community and embrace deafness as part of their identity (Stebnicki & Coeling, 1999). Outside of this small community, Deafness is not well understood by the majority of Americans. In the medical world, Deaf patients face unique challenges when working with their health care team. Physicians and nurses alike tend to experience discomfort and apprehension when working with Deaf clients because of a lack of understanding of this linguistic minority (Fileccia, 2011). The health care disparity experienced by Deaf individuals is unacceptable in today’s medical system. A focused effort to understand and listen to the needs of the Deaf community must be incorporated into nursing practice in order to improve health care access and quality for these patients.

Deaf Culture: An Overview

Currently, there are over 36 million Americans living with some form of hearing loss (Centers for Disease Control and Prevention [CDC], 2008). While many of these individuals can improve their hearing with the use of hearing aids or other medical devices, there are some who are completely deaf. These people may acclimate to a Deaf community where they are accepted by others who have similar hearing difficulties. The “d” in “Deaf” is capitalized when referring to the Deaf community in order to separate the culture from the purely medical diagnosis of deafness (Fileccia, 2011). American Sign Language (ASL) is the primary form of communication used, although there are many other social and behavioral norms involved in the culture. One important thing to note is that English and American Sign Language are not just the same language expressed in different ways. Deaf individuals cannot always read written English materials and may not understand certain elements of English such as the verb “to be” or conjunctions (Fileccia, 2011). This is especially important in health care when considering how to obtain written consent or provide educational Vol 7, Iss 1, 2013-2014

materials to Deaf patients. Lastly, one key element of Deaf culture which must be understood by physicians and nurses is the emphasis on social interaction. It is important to Deaf people that they are welcomed and included in a community. Information is shared openly with everyone in the community and secrets are rare (Richardson, 2014). When considering the cultural system of Deaf individuals, it becomes clear why effective communication and interaction with others is so important to these patients.

Barriers within the Health Care System Deaf individuals frequently experience difficulty navigating the health care world— a setting where there is little consideration or understanding of the experience of a Deaf person. Historically, Deaf patients have been called offensive terms such as “deaf and dumb” or “deaf mute” by health care professionals (Fileccia, 2011). Although these labels are not as common in today’s language, they emphasize the lack of cultural education and respect for this patient population. In terms of face-to-face communication with nurses and physicians, Deaf people often feel misunderstood and frustrated (Iezzoni, O’Day, Killeen, & Harker, 2004). Most health care professionals do not have much knowledge about American Sign Language or other social norms used in conversation, and mutual anxiety develops over the potential misunderstanding or misinterpretation of important medical information.

Lip-reading is one potential solution that many practitioners and Deaf patients are willing to try. However, research shows that even the best lip-readers can only understand what the speaker is saying 35-45% of the time (Scheier, 2009). Therefore, there is still great potential for crucial medical information to become lost in translation.

Other barriers related to Deaf culture that often are seen in medical settings include a lack of financial resources to pay for interpreters and other adjustments to communication systems and social stigma.

Among Deaf individuals, there is a higher incidence of sexually transmitted infections (STIs), alcohol abuse, and substance abuse (Scheier, 2009). Additionally, evidence is emerging to suggest that Deaf people are

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more likely to have a co-morbidity of mental illness (Fellinger, Holzinger & Pollard, 2012). In a country where it can be very difficult to access comprehensive mental health care, Deaf patients are at an even greater disadvantage as they try to navigate a complicated system.

Current Communication Methods Presently, health care professionals have made efforts to connect with their patients from Deaf communities with limited success. The American Disabilities Act outlines the rights of hearing impaired individuals by stating, “Hospitals must provide effective means of communication for patients, family members, and hospital visitors who are deaf or hard of hearing” (U.S. Department of Justice, 2005). The law goes on to suggest the use of oral interpreters to aid in lip-reading, ASL interpreters, and computer assisted transcription as options for effective communication with Deaf patients. However, each of these approaches has its disadvantages. ASL interpreters are the gold standard but can be expensive for small hospitals and clinics where Deaf patients are not commonly seen.

Deaf patients may fear being judged by an interpreter, especially when mental health issues are present, or may want to keep their health information private from others (Glickman & Gulati, 2003). Family interpreters are typically not an appropriate option because of the potential for family members to influence the conversation with their own opinions. Also, patients sometimes prefer to keep aspects of their health care private from their families, in which case a family interpreter would not be useful (Glickman & Gulati, 2003).

As mentioned previously, medical use of lip reading may result in the misinterpretation of important information. Computer-assisted transcription (CART) is a service that helps translate real-time speech into words on a screen for Deaf patients to read. This system requires a person familiar with the CART system to operate the system while the physician or nurse is speaking (Larson, 2014). While this appears to be an exciting option for Deaf patients, use of CART is costly and not considered practical for one-on-one conversations. Rather, examples of effective uses of CART would be in a community health lecture attended by many Deaf patients, or a prenatal class for Deaf mothers.

Strategies to Improve Communication It is not practical to expect every physician, nurse practitioner, and nurse in the nation to learn Vol 7, Iss 1, 2013-2014

American Sign Language or understand every aspect and idiosyncrasy of Deaf culture. However, changes that can be made during medical appointments and hospitalizations to help Deaf people feel more included, accepted, and understood in the medical setting.

In terms of hospital design, it is important to install a visual alarm system, such as flashing lights, to alert Deaf patients to emergencies or fire drills. Televisions should be equipped with closed captioning and telephones should have teletypewriting (TTY) capabilities so Deaf patients have the same access to entertainment and communication as other hospital patients (Fileccia, 2011). Medical settings, including exam rooms, hallways, cafeterias, and waiting rooms should be well-lit and have extra space available for an interpreter. Vibrating pagers are one example of a system that could be used to alert patients that it is their turn to be seen by the physician or nurse practitioner (Fileccia, 2011).

Communication is the largest area of improvement for practitioners working with Deaf patients. The most important question a nurse can ask a Deaf patient is, “How would you prefer to communicate during this visit?” This gives control of the situation to the patient and increases their feelings of acceptance and trust.

Hospitals are required by the American Disabilities Act to attempt to provide an ASL interpreter whenever possible (U.S. Department of Justice, 2005). In cases where an ASL interpreter is not readily available, pictorial and written aids may be helpful when explaining a procedure or diagnosis. As stated before, not all Deaf individuals are proficient in reading or writing English. Written material should be adjusted to a second-grade reading level in order to maximize comprehension (Richardson, 2014). If a patient chooses to lip-read, there are several things a nurse or physician can do to help their patient understand as much as possible. Bright lighting, eye contact, and slightly exaggerated enunciation of words can improve the amount of information a Deaf patient is able to understand from lip-reading. It is also helpful if practitioners remove facial hair and masks before beginning the conversation (Richardson, 2014). Finally, the use of slang or complicated words should be avoided.

Reliance on technology is not always preferred because Deaf culture is an interactive culture where personal communication is highly valued. In addition to the CART system previously discussed, pre-recorded video with closed captioning can aid in patient education. Additionally, health care professionals can

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provide a list of reputable Internet sources for Deaf patients to use (Richardson, 2014). Before endorsing such a list, providers should screen the websites to ensure that the reading level is appropriate for their patients.

It is always important to consider the body language of both the patient and the provider. Nurses should avoid placing an IV in the patient’s signing hand, as this will significantly interfere with that patient’s ability to communicate (Richardson, 2014).

Facial expressions are a significant part of communication in Deaf culture, so health care providers should take care to keep their body language, facial expressions, and speech congruent. For example, serious news should be matched with a serious face, while a humorous comment can be expressed with a smile or laugh and a slight tilt of the head. When an interpreter is present, the health care practitioner should face the Deaf patient and maintain eye contact with the patient (Lieu, Sadler, Fullerton, & Stohlmann, 2007). There are clearly quite a few considerations to keep in mind when working with Deaf patients in the medical setting. While many of these changes in behavior and environment are small, when implemented together they can drastically improve a Deaf patient’s experience with the health care system.

Conclusion

The ability to provide every patient with the same high level of care regardless of race, socioeconomic status, or disability is a health care goal for every practitioner. Deaf patients should feel welcome and comfortable in medical environments, but instead often find themselves confused, marginalized, and frustrated. Cultural competence in this patient population is possible, but practitioners must embrace a level of communication that is particularly attuned to body language and attitudes. Subtle changes to the environment and a conscious effort to communicate on the part of the provider are two key ways in which the health care community can work towards becoming more accepting of Deaf patients and their needs.

Education on Deaf culture and basic ASL signs is another important tool hospitals can provide to their staff to improve cultural competence. The process to evaluate and improve communication should be an ongoing movement within each health care organization in order to constantly ensure that the best care is being offered to Deaf patients. As former president of Gallaudet University I. King Jordan, Ph.D. once said, “Most people don’t realize that deafness or disability Vol 7, Iss 1, 2013-2014

isn’t the primary barrier to success; the real barrier is social attitudes” (Jordan, 2006). It is time to reevaluate social attitudes in health care organizations around the country and begin to make health care more accessible and successful for Deaf patients.

References Center for Disease Control and Prevention. (2008).

Healthy People 2010: Progress Review Focus Area 28—Vision and Hearing Presentation.

Retrieved April 17, 2014, from http://www.cdc. gov/nchs/ppt/hp2010/focus_areas/fa28_2_ppt/ fa28_vision2_ppt.htm Fellinger, J., Holzinger, D., & Pollard, R. (2012).

Mental health of deaf people. The Lancet, 379(9820), 1037-1044.

Fileccia, J. (2011). Sensitive care for the deaf: a cultural challenge. Creative nursing, 17(4), 174-179.

Glickman, N. S., & Gulati, S. (Eds.). (2003). Mental health care of deaf people: A culturally affirmative approach. Routledge.

Iezzoni, L. I., O’Day, B. L., Killeen, M., & Harker, H. (2004). Communicating about health care: observations from persons who are deaf or hard of hearing. Annals of Internal Medicine, 140(5), 356-362.

Jordan, I. K. (2006). Deaf president now (DPN): The protest heard around the world in 1988 continues to change the world. Retrieved April 20, 2014, from http://www. gallaudet.edu/documents/president/ikj/ikj_ presentation_9may2006.pdf Larson, J. (2014). Communication access realtime translation. Retrieved from http://www. necc.mass.edu/academics/support-services/ learning-accommodations/deaf-and-hard-ofhearing-services/student-resources/accommodations-tipsheets/communication-access-realtime-translation/ Lieu, C. C. H., Sadler, G. R., Fullerton, J. T., & Stohlmann, P. D. (2007). Communication strategies for nurses interacting with deaf patients. Medsurg Nursing, 16(4).

Richardson, K. J. (2014). Deaf culture: Competencies

and best practices. The Nurse Practitioner.

Scheier, D. B. (2009). Barriers to health care for people with hearing loss: A review of the literature. Journal of the New York State Nurses

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Association, 40(1), 4.

Stebnicki, J. A. M., & Coeling, H. V. (1999). The culture of the deaf. Journal of Transcultural Nursing, 10(4), 350-357.

U.S. Department of Justice. (2005). ADA business brief: Communicating with people who are deaf or hard of hearing in hospital settings.

Washington, DC: US Government Printing Office.

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Sarah Voisine is a BSN candidate in the Class of 2015 at the University of Pennsylvania School of Nursing. Her interests include pediatrics and health care within minority populations.

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“...effective communication is defined as a ‘two way process sending the right message that is also being correctly received and understood by the other 1 person.’”

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Tay, L., Ang, E., & Hegney, D. (2012). Nurses’ perceptions of the barriers in effective communication with

inpatient cancer adults in Singapore. Journal of Clinical Nursing, 21(17), 2647-2658. doi:10.1111/j.1365 2702.2011.03977.x Vol 7, Iss 1, 2013-2014

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Barriers to Nurse-Physician Communication and Patients’ Outcomes Mary Blackwell Abstract

This inquiry seeks to answer the question: what factors impair nurse-physician communication, and how does this issue affect patient outcomes? A review of the literature yielded eleven peer-reviewed articles concerning the subject. The majority of the articles cited in this inquiry were obtained through a search of the Medline electronic database. The purpose of this literature review is to explore the state of the evidence, and make recommendations for practice, policy, and future research specific to the field of nursing. The literature indicated that numerous educational, systematic, cultural, and demographic factors prevent effective nurse-physician communication. Poor interdisciplinary communication negatively impacts the quality and safety of patient care.

Based upon these findings, key recommendations include reforming the educational system of both disciplines, promoting research of nurse-physician communication, and changing policies and work culture of health care settings.

Barriers to Nurse-Physician Communication and Patients’ Outcomes

Communication between nurses and physicians is too often infrequent and ineffective. Nurses and physicians comprise the largest portion of health care providers and both professionals have integral roles in patient care (Manojlovich & DeCicco, 2007).

There are many common factors spanning health care settings that impede nurse-physician communication, which may in turn lead to poor patient outcomes. Issues of patient quality and safety are in the forefront of health care advancement today. It is widely accepted that an interdisciplinary approach is integral to widespread improvement (Xyrichis & Lowton, 2008). The term interdisciplinary is best defined as the collaboration between professionals from different disciplines, such as nursing and medicine (Nancarrow, Booth, Ariss, Smith, Enderby, & Roots, 2013).

The Institute of Medicine’s often cited report, “To Err is Human,” estimated that as many as 98,000 people in hospitals in the United States die annually as the result of preventable medical error (Kohn, Corrigan, & Donaldson, 2000). The report identifies “failure of communication” as one of the types of error leading to preventable patient death (Kohn et al., 2000). In 2006, the Joint Commission on the Accreditation of Health care Organizations identified communication between caregivers as their second National Patient Safety Goal (Haig, Sutton, & Whittington, 2006). The Joint Commission reports that communication is a Vol 7, Iss 1, 2013-2014

factor associated with 65% of sentinel events across the nation (Haig et al., 2006). Additionally, communication breakdown is a factor in nearly 60% of medical errors (Filcek, 2012). Poor communication results in substandard medical care.

There are many challenges in health care today that require an interdisciplinary approach. “The Institute of Medicine in the United States recommends that contemporary health care teams should be ‘using all the expertise and knowledge of team members to meet patients’ needs’” (Zwarenstein, Rice, Gotlib-Conn, Kenaszchuk, & Reeves, 2013). In the United States we are facing the challenge of an aging population with complex medical issues and chronic disease, increasing specialization of health care providers causing fragmentation of care, and an emphasis on continuity of care and quality improvement (Nancarrow et al., 2013). These complex issues require an interdisciplinary approach relying on good communication as no one health care provider can care for all the needs of a medically complex individual and in a complex health care system (Nancarrow et al., 2013). Nancarrow et al.

(2013) identified both formal and informal communication as one of the ten characteristics of good interdisciplinary team work. Coupled with the increased opportunity for and financial advantage of specialization in medicine, interprofessional collaboration, especially between nurses and physicians, is necessary meet the health demands of the public (Xyrichis & Lowton, 2008).

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Method A literature review was conducted to address the barriers to nurse-physician communication and its effect on patient outcomes. A Medline (PubMed) search was conducted using the search terms “nurse physician communication,” “interprofessional communication,” and “interdisciplinary communication.” These searches were aimed at exploring poor nurse-physician communication. In order to find evidence for the relationship between communication and patient outcomes, search items “nurse physician communication outcomes” and “communication patient safety” were used. I constrained my initial searches to human research articles that were available in English and published within the past 10 years.

These restricted searches resulted in hundreds of articles, and I narrowed my results based upon relevancy to my topic. I excluded articles that focused on communication interventions such as employee training or use of technology. I omitted many articles that targeted intervention through educational simulation as this topic was not the focus of my inquiry. I excluded articles with low credibility and those that did not focus on nurse-physician communication specifically. Once an applicable article was found, using search term “related citations in PubMed” aided in locating similar articles. Two articles were included to the body of evidence due to previous exposure to the topic through academic coursework.

Empirical Evidence

This inquiry is divided into two categories: factors that impair nurse-physician communication and how poor nurse-physician communication affects patients’ outcomes. The literature relevant to this topic often provides insight into both categories.

Barriers to Communication

Difficulty in nurse-physician communication starts with differences in education. The significant contrast between nursing school and medical education leads to the variation in the way nurses and physicians are taught to communicate. Haig et al.

(2006) states that nurses are trained to communicate in a descriptive and detailed manner while physicians routinely communicate in concise, summarizing statements. Filcek (2012) conducted a qualitative literature review, and the article references the author’s clinical experience as a registered nurse on a medical unit in a large teaching hospital. The author found that pre-licensure training for both nurses and physicians emphasizes their profession’s individual role in patient Vol 7, Iss 1, 2013-2014

care (Filcek, 2012). Therefore, nursing students learn what the nurse’s role is in the clinical setting while medical students learn what the physician role is in the clinical setting (Filcek, 2012). In one study referenced, physicians described nurses’ communication as disorganized and illogical, expressing frustration with lack of preparation and inclusion of irrelevant, distracting information when communicating with physicians (Filcek, 2012). Clearly differences in communication style lead to dissatisfaction and disconnect.

A qualitative study conducted on a general medicine unit in Canada found that interprofessional communication is a rarity. In 155 hours of observation, only one incidence of discussion based communication, defined as a two-way conversation with multiple exchanges, between a physician and non-physician members of the health care team was noted (Zwarenstein et al., 2013). The majority of nurse-physician communication occurred during daily rounds. However most of the communication was from physicians to nurses and nurses rarely spoke up unless prompted to do so (Zwarenstein et al., 2013). When nurses did participate, often their attempts at initiation of conversation or direct questions were ignored (Zwarenstein et al., 2013). This study suggests that barriers to nursephysician communication include lack of support for nurses and lack of opportunity apart from daily rounds. During structured opportunities for communication, the suggestions and opinions of the nursing staff were often ignored and considered less important than physician contributions (Zwarenstein et al., 2013). Communication from nurse to nurse was far more frequent and more likely to be a two-way conversation when compared to communication between nurses and physicians, which was both rare and “terse in nature” (Zwarenstein et al., 2013). The information gathered in this study suggests that the culture of a unit can prevent positive interdisciplinary communication and teamwork. Generalizing the findings, the study suggests that in order to improve nurse-physician communication, there must first be a cultural change where all members of the interdisciplinary health care team are treated as equals.

The isolation in education may result in lack of understanding of the other professional’s role in the interdisciplinary team. Nancarrow et al. (2013) sought to describe elements of good interdisciplinary team work through a systematic review of literature and interviews with 253 health care staff in rehabilitation and immediate care settings in the UK. The study

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identified role clarity as an element of good interdisciplinary teamwork (Nancarrow et al., 2013). Research shows that nurses believe physicians don’t understand the nurse’s value, role, and scope of practice (Filcek, 2012). Physicians may lack respect for nursing input because they are unaware of nurses’ scope of practice and knowledge base (Zwarenstein et al., 2013).

Other factors preventing a lack of mutual understanding include sex, ethnic background, and hierarchy (Haig et al., 2006). Nursing is a predominantly female profession and while females typically prefer discussion-based communication, males often prefer quick fact based communication (Filcek, 2012).

Interruptions, change of shift, lack of time, and patient handoffs also prevent effective nurse-physician communication (Filcek, 2012). Understaffed work environments, high patient acuity, and the use of technology rather than face-to-face communication, are all barriers to effective communication (Filcek, 2012). Separation in geographical location, for example if staff gives care on different units or different clinics, also hinders teamwork and interdisciplinary communication (Xyrichis & Lowton, 2008).

The hierarchy of nurse-physician relationships is detrimental to open communication. However, the ability to speak up in a team setting and encouraging two-way communication is integral to positive team communication (Nancarrow et al., 2013). Therefore, the perceived lack of equality between nurses and physicians, which invalidates the contribution of the nurse, hinders positive teamwork and communication.

Effect on Patient Outcomes

Nurse-physician communication affects patient safety and quality. Research shows that highquality communication leads to good interdisciplinary teamwork, which is correlated with improved clinical performance in the inpatient setting (Filcek & Manojlovich, 2012). Though studies are specific to the medical setting in which they are conducted, conclusions supporting nurse-physician communication as a means to improving patient outcomes are similar.

Physician dismissal of nursing input may result in poor patient management. Zwarenstein et al. (2013) found that patient safety and individualized care was compromised when physicians ignored interdisciplinary input. While physicians concentrated heavily on patient medical issues, they ignored other complications that could prevent timely discharge or cause adverse patient events (Zwarenstein et al., 2013). Interdisciplinary input is essential to a holistic approach Vol 7, Iss 1, 2013-2014

(Xyrichis & Lowton, 2008).

In the past few decades there has been a push to standardize the way nurses and physicians communicate-the SBAR (Situation, Background, Assessment, and Recommendation) method is one widely accepted approach. Haig et al. (2006) describe the changes in patient outcomes recorded at the Order of St. Francis St. Joseph Medical Center in Bloomington, Illinois after an initiative to standardize nurse-physician communication using the SBAR method. After the implementation of SBAR communication between nurses and physicians, the facility recorded a decrease in the rate of adverse events, from a baseline of 89.9 incidents in 1,000 days of patient care to 39.96 incidents per 1,000 days of patient care (Haig et al., 2006). The incidence of adverse drug events decreased, and the frequency of medication reconciliation significantly increased in the facility after widespread implementation of the SBAR model (Haig et al., 2006). These findings suggest that standardized communication between physicians and nurses improved communication between staff. The article proposes that improved communication improved patient outcomes measured by the rate of adverse events, incidence of adverse drug events, and frequency of medication reconciliation (Haig et al., 2006).

Filcek & Manojlovich (2012) conducted a cross-sectional, descriptive study to explore the relationship between nurse-physician relationship and nurse-reported perceived quality of care and practice environment in the ambulatory oncology setting. A survey of nurses employed in this setting indicated that good nurse-physician communication led to positive nurse-physician relationships (Filcek & Manojlovich, 2012). A high proportion, or 73.3%, of nurses who reported positive nurse-physician working relationship also reported favorable practice environments (Filcek & Manojlovich, 2012). Similarly 79.1% of nurses who reported positive nurse-physician working relationship also reported that their facility provided excellent care (Filcek & Manojlovich, 2012). The researchers used the Practice Environment Scale of the Nursing Work Index (PES-NWI) scale to measure nurse-reported quality of care in the workplace. Previous research demonstrates that PES-NWI scale measured reports of positive practice environments (based upon individual perception) are associated with data supported positive patient outcomes (Filcek & Manojlovich, 2012). This article concludes that good communication is one aspect of good working relationships with physicians. Improving

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nurse-physician relationships improves patient quality and safety in this setting (Filcek & Manojlovich, 2012).

Manojlovich and DeCicco (2007) explored the relationship between nurse-physician communication, perceptions of work environments, and patients’ outcomes in the intensive care unit (ICU) setting in a sample of 462 nurses in 25 different ICUs. The authors used the Conditions for Work Effectiveness Questionaire II, Practice Environment Scale of the Nursing Work Index, and ICU Nurse-Physician Questionaire to measure nurse perceptions in the ICU setting. Patient outcomes were based upon nurse reported medication errors, ventilator-associated pneumonia (VAP), and catheter-associated sepsis over a three month period.

As cited in Manojlovich and DeCicco (2007) in one classic study, nurse-physician communication was the factor most significantly associated with excess hospital mortality in the intensive care unit (Knaus, Draper, Wagner, & Zimmerman, 1986). A more current study found nurse-physician verbal miscommunication responsible for 37% of errors (Donchin et al., 1995).

In the ICU setting, positive workplace empowerment and practice environment were significantly associated with positive nurse-physician communication (Manojlovich & DeCicco, 2007). Practice environment and workplace empowerment scales were inversely related to medication errors (Manojlovich & DeCicco, 2007).

These findings suggest that workplace empowerment, positive practice environment, and increased communication between nurses and physicians decrease nurse medication errors. The authors found that enhancing practice environment likely improves nurse-physician communication (Manojlovich & DeCicco, 2007).

In a similar study of ICU nurses in the state of Michigan, authors explored the relationship between nurse-physician communication, practice environment, and patient outcomes as indicated by VAP, catheter associated bloodstream infection, and pressure ulcers (Manojlovich, Antonakos, & Ronis, 2009).

Nurse-physician communication was not significantly related to patient outcomes, but findings indicate “as the timeliness of communication increased, the prevalence of pressure ulcers decreased” (Manojlovich et al., 2009, p. 25).

Manojlovich (2005) surveyed 332 randomly selected hospital nurses using the PES-NWI, Index of Work Satisfaction, and Conditions for Work Effectivness Questionnaire II. The study found nursephysician communication to be a significant predictor of nursing job satisfaction. Nurses’ job dissatisfaction Vol 7, Iss 1, 2013-2014

is associated with lower patient satisfaction levels (McHugh, Kutney-Lee, Cimiotti, Sloane & Aiken, 2011). It stands to reason that increased job satisfaction may lead to higher patient satisfaction levels.

Improving nurse-physician communication contributes to better nursing job satisfaction and workplace environment, leading to improved quality of care.

Appraisal of the Literature

The quality of evidence in this body of literature is relatively low. On the Johns Hopkins Nursing Evidence-Based Practice Rating Scale, which rates articles on a scale from I-V, I being the highest, the highest score given to articles in this inquiry was level III. This is largely because this topic does not lend itself to the type of studies with the highest strength of evidence. The evidence that exists is convincing but makes no definitive statements because non-experimental research cannot determine causality. It is not possible to use a randomized controlled trail to test the relationship between nurse-physician communication and patient outcomes. The question of what factors impair nurse-physician communication lends itself to the form of a qualitative study.

Another issue is a lack of research on the subject. “There is a lack of data identifying the processes of interdisciplinary team work and linking these with outcomes” (Nancarrow et al., 2013, p. 3). I was only able to find four articles directly connecting nursephysician communication with patient outcomes, and three were articles written by the same author. In the small body of research that does link nurse-physician communication with patient outcomes, each study is focused on one inpatient specialization such as intensive care or labor and delivery (Filcek & Manojlovich, 2012). Additionally studies are often limited to a geographical region of the country. This makes it difficult to generalize findings to other areas of medicine or other clinical settings. There is not enough research to limit the scope of this inquiry to one country or health care system. Therefore, the information compares nurse-physician communication in various systems of health care in various countries. The studies in this review of literature are consistent with previous research.

Recommendations

There remains much room for growth in the area of nurse-physician communication research.

Based upon the existing body of evidence, it would not be possible to recommend definitive changes to clinical practice. The evidence indicates that there must be a cultural change in the health care setting in order to

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improve interdisciplinary communication and thereby improve patient safety and quality.

Implications for Practice

One of the primary roles of nurses is to advocate for their patients. Nursing’s contribution to care may improve patient safety and patient and family centered care (Zwarenstein et al., 2013). However, too often nursing suggestions are minimized in physician led creation of the patient care plan. Nurses may not feel comfortable speaking up to physicians because of the established hierarchy of power. These barriers limit optimal patient care. Therefore nurses should be treated as equals with physicians, which requires a cultural change that must come from changes in medical and nursing education and training.

Nurses and physicians should have structured opportunities to engaged in two-way discussions of patient care. Lack of time for interdisciplinary communication limits opportunity for building positive personal and professional relationships between nurses and physicians (Zwarenstein et al., 2013). Nurses should also be comfortable with, and physicians receptive to, nurse initiated discussion of patient cases. Hospitals should establish standardized, evidence-based practices for nurse-physician communication, such as use of the SBAR model.

Implications for Policy

Policies should promote patient quality and safety. Therefore, health care management teams should promote healthy, positive, supportive workplaces that encourage interdisciplinary communication. In order to decrease health care costs, complications, and avoidable error, nurse-physician communication must be prioritized and further developed. “Evidence indicates that a substantial degree of equality is required for interprofessional collaboration” (Zwarenstein et al., 2013, p. 6). Health care policies should promote equality in the health care team and break down hierarchal structures. Policy should standardize interprofessional communication.

One solution to promote interdisciplinary communication supported by the literature is pairing a resident with a nurse in the clinical setting. The nursephysician partnership allows the physician and nurse to come to a mutual role understanding and to create a relationship (Filcek, 2012). This provides the nurse with more comfort when communicating with physicians (Filcek, 2012).

Implications for Education

Pre-licensure clinical training should promote Vol 7, Iss 1, 2013-2014

interdisciplinary role understanding (Filcek, 2012).

Nursing school should educate students about the role of the nurse and physician while medical school should educate students about the role of the physician and the nurse. Additionally, education should not take place in isolation. Nursing and medical students should be trained together using simulation, lecture, and clinical to promote teamwork and communication. Understanding of effective nurse-physician communication should begin in the classroom. Standardized communication techniques such as SBAR should be taught and practiced in nursing and medical education (Haig et al., 2006). Interdisciplinary education and training will promote equality and mutual understanding in physicians and nurses.

Implications for Research

There are incredible opportunities for research in the area of enabling effective nurse-physician communication and linking that communication to patient outcomes. It is widely accepted that good teamwork leads to positive patient outcomes, but more research is needed specific to nurse-physician relationships in various settings such as ambulatory care settings (Filcek & Manojlovich, 2012). Research should focus on creating communication interventions that reduce conflict and improve efficiency of communication through standardized methods (Zwarenstein et al., 2013). These standardized methods must be considered practical and useful to both nurses and physicians. These methods should be validated and supported by research evidence, showing improvements in patient outcomes, interdisciplinary communication, and health care provider satisfaction. Filcek & Manojlovich (2012) state, “Addressing the root causes of unfavorable nurse-physician relationships is a key strategy to improve practice environments and potentially minimize adverse patient events” (p. 263). Research identifying the cause of poor relationships and poor communication will reveal areas for targeted improvement.

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References Donchin Y., Gopher D., Olin M., Badihi Y., Biesky M.,

Biesky M., Sprung C.L., Pizov R., & Cotev S.

(1995). A look into the nature and causes of

human errors in the intensive care unit. Critical

Care Medicine, 23(2): 294-300.

Filcek, C. L. (2012). Communication: A dynamic

between nurses and physicians. Medsurg Nurs

ing : Official Journal of the Academy of Medi

cal-Surgical Nurses, 21(6), 385-386, 387.

Friese, C. R., & Manojlovich, M. (2012). Nurse physician relationships in ambulatory oncology

settings. Journal of Nursing Scholarship : An

Official Publication of Sigma Theta Tau Inter national Honor Society of Nursing / Sigma

Theta Tau, 44(3), 258-265. doi:10.1111/j.1547 5069.2012.01458.x; 10.1111/j.1547- 5069.2012.01458.x Haig, K. M., Sutton, S., & Whittington, J. (2006).

SBAR: A shared mental model for improving

communication between clinicians. Joint Com

mission on Accreditation of Health care Orga

nizations, 32(3), 167-175.

Knaus W.A., Draper E.A., Wagner D.P., Zimmerman J.

E. (1986). An evaluation of outcome from

intensive care in major medical centers. Annals

of Internal Medicine, 104:410-418.

Kohn, L. T., Corrigan, J., & Donaldson, M. S. (2000).

To err is human: Building a safer health system.

Washington, D.C: National Academy Press.

Manojlovich, M. (2005). Linking the practice environ

ment to nurses’ job satisfaction through nurse physician communication. Journal of Nursing

Scholarship : An Official Publication of Sigma

Theta Tau International Honor Society of Nurs ing / Sigma Theta Tau, 37(4), 367-373.

Manojlovich, M., Antonakos, C. L., & Ronis, D. L.

(2009). Intensive care units, communica tion between nurses and physicians, and

patients’ outcomes. American Journal of Criti cal Care : An Official Publication, American

Association of Critical-Care Nurses, 18(1), 21 30. doi:10.4037/ajcc2009353; 10.4037/ ajcc2009353 Manojlovich, M., & DeCicco, B. (2007). Healthy work

environments, nurse-physician communica tion, and patients’ outcomes. American Journal

of Critical Care : An Official Publication,

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16(6), 536-543.

McHugh, M. D., Kutney-Lee, A., Cimiotti, J. P., Sloane,

D. M., & Aiken, L. H. (2011). Nurses’ wide spread job dissatisfaction, burnout, and frustra tion with health benefits signal problems

for patient care. Health Affairs, 30(2), 202-210.

doi: 10.1377/hlthaff.2010.0100 Nancarrow, S. A., Booth, A., Ariss, S., Smith, T., Ender by, P., & Roots, A. (2013). Ten principles of

good interdisciplinary team work. Hu-

man Resources for Health, 11(1), 19-4491-11 19. doi:10.1186/1478-4491-11-19; 10.1186/1478-4491-11-19 Xyrichis, A., & Lowton, K. (2008). What fosters or

prevents interprofessional teamworking in

primary and community care? A literature

review. International Journal of Nursing Stud ies, 45(1), 140-153. doi:10.1016/j. ijnurstu.2007.01.015 Zwarenstein, M., Rice, K., Gotlib-Conn, L., Kenasz chuk, C., & Reeves, S. (2013). Disengaged: A

qualitative study of communication and collab oration between physicians and other profes sions on general internal medicine wards. BMC

Health Services Research

Journal of Student Nursing Research

Mary Blackwell is a member of the graduating Class of 2014 at the University of Pennsylvania School of Nursing. She plans on starting her nursing career in New York City.

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“High-quality communication is a key determinant and facilitator of patient2 centered care.�

2 Slatore, C., G., Hansen, L., Ganzini, L., Press, N., Osborne, M., L., Chesnutt, M., S., & Mularski, R., A. (2012).

Communication by nurses in the intensive care unit: Qualitative analysis of domains of patient-centered care. American Journal of Critical Care, 21(6), 410-418. doi:10.4037/ajcc2012124 Vol 7, Iss 1, 2013-2014

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The Nurse-Physician Relationship: Problems and Solutions Caroline Bourassa

The nurse-physician relationship is a prominent issue that continues to grow in our health care settings. These two different professionals work side by side in many areas, and it is critical for their communication, collaboration, and interactions to be up to par. There are studies that have shown that the nurse— physician relationship has a direct correlation with job satisfaction and, more importantly, patient outcomes (Alaniz, Baum, & Savett, 2004). The problem is that many hospitals are unaware of how crucial the bond between the nurse and physician really is. It is critical that hospitals respect and acknowledge the nurse— physician relationship and grasp how to foster these connections.

Differences Between Nurses and Physicians

The health care field consists of a wide range of occupations. From dentists, to pharmacists, to nurses, to physicians, each profession has specific goals and ideals; however, the common thread between all these professionals is that everyone wants to work in a place that they are valued (Alaniz, Baum, & Savett, 2004). No matter what position they hold, everyone wants to feel important and respected. Relationships are important, especially because there is a wide range of occupations and each profession has their own goals and values.

Regardless, everyone wants to work in place that they are valued.

The purpose of this paper is to explore the differences between nurses and physicians; especially because they often work independently (Mannahan, 2010, p.72). It is true that both nurses and physicians each play a unique role and the problem is the lack of understanding between them (Alaniz, Baum, & Savett, 2004). What must happen is that each side needs to have a clear basis of the other party in order to work together successfully. One nurse stated, “Part of the problem with nursing is that, because we have various levels of education and practice, it’s not clear to the public what we do,”(Alaniz, Baum, & Savett, 2004, p.10). This lack of understanding of the other’s profession ultimately creates a barrier to develop a strong professional relationship. While it is quite simple to say that doctors and nurses need to acknowledge ones differences and professional outlooks, it is much more difficult to implement it.

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Components of a Nurse-Physician Relationship

While most components to a relationship come naturally, those between a nurse and physician need more attention. According to the Critical Care Nurse 2009 issue, after 20,000 nurses were interviewed, there were five specific nurse-physician relationships through nurse interviews; collegial, collaborate, student-teacher, friendly stranger, and hostile-adversarial (AM J NURS, 2009). Collegial is understood as the collective responsibility shared by each of a group of colleagues, with minimal supervision from above. Physicians and nurses need to collectively work together as a unit, automatically taking on different duties without the need of a hierarchy. Hostile-adversarial is also a key component to avoid in a nurse—physician relationship. The relationship needs to be made up of teammates, not enemies, who respect each other’s professional opinions (American Journal of Nursing, 2009).

What is imperative to remember is that, “…every sector in every workplace benefits from the essentials of collaborative efforts.

There is no more important an area than health care where the need for collaboration of those involved in the day-to-day care of patients is evident,” (Rodts, 2010, p.1).

Collaboration, communication, and teamwork are the essential components to the nurse—physician relationship.

Communication

Nurses and physicians must work together towards improving their relationships and it ultimately starts with communication.

“Components of positive productive communication include being honest, remaining open both as a communicator and as a listener, listening with interest, being concise, keeping emotions out of the conversation, and being aware of the audience,” (McCaffrey et al., 2010).

It is imperative to build a cooperative relationship because that is what creates a better work environment.

The key is to have effective communication. Effective communication is the cornerstone of successful collaboration for patient care. It focuses on critical communication proficiencies, including self-awareness, in-

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quiry and dialogue, conflict management, negotiation, advocacy and listening (McCaffrey et al., 2010). Even before effective communication can exist, components such as openness, understanding, and accuracy need to occur. Research has shown that nurses did not believe that the communication style they experienced at work were effective, especially for communication between nurses and physicians (McCaffrey et al., 2010). This gap in communication between physicians and nurses is what creates the blockage for a strong relationship.

Four key areas that are essential for good communication are: 1.collaboration, 2.credibility, 3.compassion, and 4.coordination (McCaffrey et al., 2010). Collaboration consists of being organized, working to identify solutions, and engaging in positive dialogue. Credibility is trying to avoid jargon and vague terminology and interacting assertively—though maintaining respect (McCaffrey et al., 2010). Among both nurses and doctors, a level of compassion for patients, families, and team member’s help creates mutual respect. Providing mentorship and encouraging and valuing input from team members helps enhance coordination (McCaffrey et al., 2010). While these components of communication seem rather basic, it is hard to maintain due to outside forces, such as stress from work.

Good communication also starts out with the confidence level of the nurses. Nurses need to feel empowered and secure in their knowledge and clinical expertise (Peters, 2009, p.11).

“By staying up-to-date with advances in their specialty, nurse scan take pride in their expertise. Continuing education, specialty certification, and participation in professional organizations, clinical research and conferences are good way to stay in touch with developments in [the] field…participating on interdisciplinary.”

(Peters, 2009, p.11) With this empowerment, communication with physicians progresses easily because nurses feel more confident in approaching physicians. Nurses also assume more responsibility for the quality of relationship with physicians.

“The professional empowerment that they feel helps nurses stay focused on approaching all physicians in collegial, respectful, and problemsolving-based manner, no matter how badly an individual may behave,” (Peters, 2009, p.11).

This confidence issue is something that needs to be focused on, because in one study there was still data that indicated nurses still lack confidence to ask doctors questions (Churchmann & Doherty, 2010). It Vol 7, Iss 1, 2013-2014

is not just all up to the nurses to maintain this strong level of communication. The most basic communication behavior used in any interpersonal context that physicians should do is make an appropriate introduction. Health care personnel can reduce anxiety during initial interaction by introducing themselves to both patients and coworkers (Wanzer & Wojtaszczyk,2009).

Better communication among nurses and physicians have additional beneficial outcomes. For example, there are fewer complications and miscommunications for both the nurses and physicians (Manahan, 2010). Physicians function with short parcels of time, so they value concise and relevant information when they are focused on a specific patient. Effective communication during rounds can really reduce the need for nurse to contact physicians at other times, which is ultimately helps for a smoother work day. (Manahan, 2010). It is important to remember that this cannot exist without the confidence of nurses, proper communication, and respect between the two professionals.

The Impact of a Positive Nurse—Physician Relationship

The nurse and physician relationship can affect patient outcomes. “There is no more important an area than health care where the need for collaboration of those involved in the day-to-day care of patients is evident,” (Rodts, 2010, p.1). Collaborative efforts are extremely necessary to achieve the best patient outcomes, because without collaboration, chaos occurs and chaos cannot occur when dealing with patients (Rodts, 2010). Other investigators have linked poor nurse-physician communication with physician and nurse job dissatisfaction and increases in nursing job stress (Manahan, 2010). The nurse—physician relationship has been shown to have an impact on patient outcomes (McCaffrey et al., 2010). The lack of communication and collaboration between nurses and physicians has been cited as a reason for poor patient outcomes (Rodts, 2010, p.1). It has even been noted in the UK and Ireland that a significant relationship between the presence of excellent communication and nurse—physician relationship corresponded to lower patient mortality in intensive care units (Tschannen & Kalisch, 2009, p.797). It is believed that when nurses and physicians collaboratively develop and implement treatment plans, patients may receive a higher quality of care (Tschannen & Kalisch, 2009). The idea that the nurse—physician relationship not only benefit’s nurse and physicians, but also patients ultimately places its importance at a much higher level.

Solutions and Programs

Nurse—physician relationships are truly looked

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at as a cornerstone for safe, quality patient care (Colombo, 2009). There are many summits and programs that hospitals put their employees through to help create stronger bonds: “At Sharp Mary Birch Hospital for Women & Newborns in San Diego, a team of frontline nursing staff, administrators and physicians challenged themselves to address nurse-physician communication and collaboration in a unique fashion,” (Colombo, 2009, p.511). With the help of administration, an open nurse—physician summit was designed to directly help improve the nurse—physician relationship among the staff. The summit turned out very successful and in the end, the participants had created ‘commitments’ to specific nursing or physician areas in their hospital.

(Colombo, 2009) This summit proved that there are direct and fairly simple ways that a nurse—physician relationship can be built and enhanced. A nurse— physician summit can be another tool in a hospital’s toolbox to foster nurse—physician collaboration (Colombo, 2009).

Models have been created to help develop the nurse—physician relationship. The CampinhaBacote’s model is one that has been empirically tested and applied in a variety of settings (Manahan, 2010, p.73). The model’s goal is to acknowledge the complexity of internalized culture and provide a structure for examining the worlds of nursing and medicine from a cultural perspective (Manahan, 2010, p.73). This model creates an excellent starting point for nursing leaders to design strategies to bridge differences between nurses and physicians. The model focuses on awareness, knowledge, cultural skills, encounters, and desires (Manahan, 2010).

Ideal collaborative relationships are not impossible nor far out of reach if matters are taken seriously and programs are created. Every hospital can truly develop better nurse—physician relationships.

Conclusion Work-related relationships are important, and the nurse—physician relationship is no exception.

More importantly, the nurse—physician relationship is extremely critical to the success of the institution.

There are a growing number of summits and models that hospitals can follow to aid in improving the relationships between nurses and physicians. Ultimately, a cohesive nurse—physician relationship is key for everyone, because it helps improve patient outcomes and establishes a better work environment.

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References Alaniz, K., Baum, K., & Savett, L. A. (2004). Enhancing and enriching the nurse-physician relationship.

Creative Nursing, 10(3), 9-13.

Churchman, J. J., & Doherty, C. (2010). Nurses’ views on challenging doctors’ practice in an acute hospital. Nursing Standard, 24(40), 42-47.

Colombo, C. (2009). Nurse-physician summit: Fostering communication, collaboration, and commitment. Nursing for Women’s Health, 13(6), 511-514. doi:10.1111/j.1751-486X.2009.01487.x Mannahan, C. A. (2010). Different worlds: A cultural perspective on nurse-physician communication.

Nursing Clinics of North America, 45(1), 71-79.

NewsCAPS. Nurse-physician relationships fall into five types--collegial, collaborative, student-teacher, friendly stranger, and hostile-adversarial. (2009).

American Journal of Nursing, 109(7), 18-18.

McCaffrey, R. G., Hayes, R., Stuart, W., Cassell, A., Farrell, C., Miller-Reyes, C., & Donaldson, A. (2010). A program to improve communication and collaboration between nurses and medical residents. Journal of Continuing Education in Nursing, 41(4), 172-178. doi:10.3928/0022012420100326-04 Peters, D. (2009). Nurse/physician relationships: Are we making any progress? Georgia Nursing, 69(1), 11-11.

Rodts, M. F. (2010). From the editor. collaboration... not just a catch phrase. Orthopaedic Nursing, 29(4), 224-225.

Tschannen, D., & Kalisch, B. J. (2009). The impact of nurse/physician collaboration on patient length of stay. Journal of Nursing Management, 17(7), 796-803.

Wanzer, M. B., Wojtaszczyk, A. M., & Kelly, J. (2009).

Nurses’ perceptions of physicians’ communication: The relationship among communication practices, satisfaction, and collaboration.

Health Communication, 24(8), 683-691. doi:10.1080/10410230903263990

Journal of Student Nursing Research

Caroline Bourassa will be graduating May 2014 with her BSN and a minor in nutrition from the University of Pennsylvania School of Nursing. She hopes to work in pediatrics in the future.

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“Increased collaboration and communication can result in more appropriate care and increased physician, nurse, patient, and family satisfaction.� 3

3Puntillo, K. A., & McAdam, J. L. (2006). Communication between physicians and nurses as a target for improv ing end-of-life care in the intensive care unit: Challenges and opportunities for moving forward. Critical

Care Medicine, 34(11), S332-40.

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Stochaj, A.

Communication: The Human Connection Alaina M. Stochaj Imagine visiting a primary care physician or nurse practitioner and being unable to understand what he was telling you. Imagine being rushed to the emergency department and being incapable of having effective communication between you and the health care provider. Unfortunately, this is the case for many individuals seeking medical attention in the United States. One of the most interesting populations that experiences communication issues within health care is the Deaf who use American Sign Language.

As of 2002, approximately one million Deaf individuals used American Sign Language as a primary language (Steinberbg, Wiggins, Barmada, & Sullivan, 2002). Contrary to popular belief, American Sign Language does not directly translate to English. There is a different grammar structure, and many signs do not exist in the written or spoken English language. Only a small percentage of spoken English can be lip-read.

There are over 450,000 Deaf individuals in Pennsylvania (Harrington, 2010). The hospitals in the city of Philadelphia should take the initiative and break down both communication and culture barriers between the Deaf and their health care providers.

A solution that may come to mind is the implementation of medical interpreters. However, interpreters have only been available 50 percent of the time (Zazove, 2003). Also, medical interpreters do not typically have a health care science education.

The hospitals in Philadelphia should pay for registered nurses to learn American Sign Language. As an example, I will use the University of Pennsylvania’s sign language course of study. In order to learn a great deal about American Sign Language and Deaf culture, Penn requires a minimum of four levels of sign language.

The focus point of the first level is basic signing. The second level concentrates on basic grammar. The third level focuses on advanced grammar and the expansion of signing vocabulary. The fourth level is all about communicating in depth topics and becoming proficient in both grammar and vocabulary. For the average student, completing four levels of sign language would take four semesters. If registered nurses were able to learn American Sign Language, this would cut out the middleman (the interpreter) as well as improve patient

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and health care provider communication.

If a health care provider was not able to use American Sign Language with the Deaf patient, a system of written materials corresponding to the patient’s reading level should be implemented. This would be extremely helpful when it came to certain tasks such as discharge from an inpatient setting. Discharge teaching is usually verbal with and comes from the registered nurse. Paper instructions are given pertaining to certain aspects of discharge. With a Deaf patient it would be extremely helpful to give a written packet for discharge. It would cover all aspects of discharge.

It would be important to have these packets be written at a level no higher than a fifth grade reading level, as this is the average reading level of a Deaf American (Zazove, 2003).

Registered nurses using American Sign Language and using written materials would improve the communication between the health care provider and Deaf patient. It is important to go directly to the patient. In all specialties, from surgery to dialysis, Deaf patients should be asked what they believe could help to improve care and communication. When working with different populations, the best way to understand the culture and barriers is to ask members of that population. This could be done in a few ways. There could be surveys and questionnaires at offices and on hospital floors. Also, it might be beneficial to go into the Deaf community and run a focus group. For example, the Philadelphia American Sign Language Social Group has meetings at the Starbucks on 4th and South several times per week. The individuals who attend would be helpful in providing insight. Also, the Pennsylvania School for the Deaf (PSD) would be a great place to contact to start a focus group.

Communication is so important in all aspects of life- especially health care. The hospitals in Philadelphia have the ability to improve communication and access local American Sign Language programs. If successful, this model could be applied on a national level.

Sending registered nurses to American Sign Language programs, providing written materials, and going into the Deaf community for suggestions could change how the Deaf community experiences health care.

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References Harrington, T. (2010). Local and regional deaf populations. Gallaudet University Library, http://libguides.gallaudet.edu/content. php?pid=119476&sid=1029190.

Steinberg, A., Wiggins, E., Barmada C., & Sullivan, V. (2002). Deaf women: Experiences and perceptions of health care system access. Journal of Women’s Health, 11, 729-740.

Zazove, P. (2003). The health status and health care utilization of deaf and hard-of-hearing persons.

Arch Family Medicine, 2, 745-752.

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Journal of Student Nursing Research

Alaina Stochaj is a Class of 2014 BSN candidate at the University of Pennsylvania School of Nursing. Her interests include women’s health and American Sign Language.

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“An increase in shared decision-making can result from a better understanding and respect for the perspectives and burdens felt by other caregivers.� 4

4Puntillo, K. A., & McAdam, J. L. (2006). Communication between physicians and nurses as a target for improv-

ing end-of-life care in the intensive care unit: Challenges and opportunities for moving forward. Critical Care Medicine, 34(11), S332-40.

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DiMaria, V.

The Effectiveness of Current Communication Training on End of Life for Nurses in Oncology and Critical Care Settings Vanessa DiMaria Abstract OBJECTIVE: To explore the current literature addressing communication training for oncology and critical care nurses and how effective it is in enhancing their ability to communicate, especially when discussing end-of-life decisions.

DESIGN: A systematic literature search with review of six studies that use nursing interventions.

SETTING: CINAHL, Scopus, and PubMed/MEDLINE databases.

PARTICIPANTS: Clinical trials with randomized control trials, non-randomized control trials, longitudinal studies, multi-level interventional studies, and quasi-experimental studies.

MEASUREMENTS: Data analyzed from included studies graded on quality and overall strength of the evidence.

RESULTS: The studies as a whole provide data to support that current communication skills training programs using didactic education are not as effective as role-play simulations, which allow participants to practice newly taught communication tools in the clinical setting.

CONCLUSION: Interventions improve nurses’ confidence in end-of-life patient discussions and the importance of implementing education on this topic outside of nursing education and in the hospital setting. These training programs need to be tested on a large scale, with a focus on end-of-life discussion in critical care and oncology settings.

The Effectiveness of Current Communication Training on End of Life for Nurses in Oncology and Critical Care Settings

Nurses spend more time with patients and their families than other health care professionals, tending to the patient and family’s needs while explaining their plans of care. Nurses converse with patients every day, but what happens when the topic of conversation becomes difficult? Nurses often have discussions with patients about dying without knowing how to carry out the conversation. Rather, nurses report that they learn these communication skills through trial and error or by observing others (Radtke, 2012). It is essential for patients and families to know not only the risks and benefits of treatments, but also to evaluate them in relation to their goals of care and values to make medical decisions. Nurses deserve preparation and guidance to be ready for these questions. Previous studies show that many nurses do not feel comfortable with the topic and do not feel equipped or able to address these issues properly (Aslakson, 2014). This discomfort is notable because “high-quality communication is a key determinant and facilitator of patient-centered care” (Slatore, 2012, p. 410). To address the key determinant, this systematic review investigates how effective current communication-training methods are for nurses facing end-of-life discussions in critical care and oncology settings, where end-of-life discussions are Vol 7, Iss 1, 2013-2014

common.

Background

Current literature identifies that communication is necessary in providing quality care; therefore, it is a problem when clinicians are not skilled in communication. Training programs implemented with the purpose of enhancing nurses’ communication skills show limited improvements over the years (Langewitz et al., 2010). Several studies show that nurses lack the confidence, knowledge, and skills necessary to effectively communicate with patients. Nurses also see themselves as a translator between the physician and the family, filling in the pieces of disconnect when the physician may not address or explain in detail when at the bedside. This task is very difficult and challenging for nurses who are unaware of the proper way to handle the situation or topic since nurses are not trained with the necessary communication skills (Slatore, 2012). The conversation becomes exponentially more difficult for nurses when the patient has a negative prognosis (Aslakson, 2012).

Nurses also identified a lack consistency and effective communication between nurses and physicians.

Physicians wrongly assume nurses understand the numerous medical interventions and procedures, leading to inadequate and strained communication that increases their lack of trust in each other (WittenbergLyles, 2013). Trust is the foundation of successful inter-

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disciplinary communication and results in improved patient care (Aslakson, 2012). Nurses and physicians need to collaborate and share opinions on what each considers “end of life” for a patient and when to address the topic (Asklakson, 2012).

A language or cultural barrier is the final problem identified that inhibits patient communication because “patients are … less receptive to nurses who they do not share a common language or culture” (Haddad, 2002). It behooves nurses not only to be culturally competent, but also fully aware of the patient’s goals and expectations for their end-of-life care prior to it being too late: “…effective communication is defined as a ‘two way process- sending the right message that is also being correctly received and understood by the other person’” (Tay, 2012, p.2655) While nurses are not expected to be bilingual or competent with all religions and traditions, education should be provided to know who to ask for help or assistance, like translators, when caring for a specific patient to ensure a successful discussion.

These five barriers to effective end-of-life communication cannot be ignored in communication training programs. For example, training should include an interdisciplinary approach to address nurses who feel like a “middle man” and avoid strained nursephysician communication by offering tools or strategies to utilize. Educational classes and simulations would give nurses more confidence in their knowledge and skills on end-of-life discussions and the chance to practice the skills. Medical language classes or a cultural competence course should be offered by hospitals to enhance nurses’ awareness and comfort when caring for an international or foreign-speaking patient at the end of their life. This foundation of knowledge helps to better evaluate the current communication-training interventions. After investigating these qualitative and non-experimental studies, active interventions that tested nurse communication-training programs were researched and the results were analyzed to determine their effectiveness.

Methods Assisted by an experienced librarian with a back-

ground in bedside nursing, CINHAL, PubMed/MED-

LINE, and Scopus literature databases were used to search for studies from the past ten years. Searches incorporated nursing subheadings, keywords, and text words. The following search terms were used in various combinations with each other to find studies: communication skills training, end of life, critical care nurse, oncology nurse, education, and intervention. Reference lists of selected studies were hand searched for addiVol 7, Iss 1, 2013-2014

tional clinical trials and literature.

Eligibility for analysis was defined before the search began. All literature had to be focused on nursing communication, not physician communication.

Many results were excluded due to this limitation, and therefore found a small number of search results solely focused on nursing communication-training programs and their effectiveness. Initially analyzing both experimental and non-experimental studies, it was soon modified to investigate literature on experimental and interventional studies. It was important to use literature aimed toward evaluating critical care and oncology nurses. Searching end-of-life communication skills training interventions for unspecified nurses was too broad. To be noted, palliative care and hospice nurses were included in certain studies.

Six studies constitute the final participants in the review that use interventional experiments, specifically nursing interventions, and include an effective analysis. These studies tested the following interventions: interactive role-play, training, didactic and educational lectures, simulation scenarios with fake patients, collaborative communication training including learning activities, small group skill practice and problem solving, feedback and reinforcement of new skills, and planning assignments (Boyle, 2004). The studies used randomized control trials, non-randomized control trials, longitudinal studies, multi-level interventional analysis, and quasi-experimental as methods of conducting their investigations. While some studies are focused on critical care or oncology nursing communication not specified to end-of-life discussions, it is known that patients with severe diseases or medical conditions are often treated in critical care and oncology units; these diagnoses are the leading causes death (Friedenberg, 2012; Tay, 2012).

State of the Science

Six of the studies were identified as eligible for review and are listed in Table 1. The literature included in this analysis can be separated into three categories for evaluation: educational training interventions, interactive role-play interventions, and interventions for improved nurse-physician communication. Some of the studies implement hybrid interventions using already-established programs or tools along with new approaches or resources; others created and applied a completely new intervention. There is at least one longitudinal study in each category.

There are three studies that evaluate the effectiveness of educational communication-training interventions. The first study of this analysis measures the impact of three varying levels of education on

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communication frequency, quality, success, and ease between nurses and intensive care unit patients (Happ et al., 2013). The first level includes no intervention, the second implements basic communication training skills with classes and provides a communication cart of “low tech” supplies (communication boards and writing supplies) on their unit, and the third level of training incorporates teaching from a speech-language pathologist with plan-of-care practice. To test its effectiveness, Happ and colleagues (2013) evaluated nurses’ communication improvement by videoing their interactions with patients during a shift and applying a numerical coding system based on body language, word choice, and the participant’s actions or reactions (Happ, 2013). The study found that these interventions are effective, but only resulted in a small improvement.

Researchers acknowledged the need for growth and future changes in this intervention.

Two other studies implemented new tools to assess the effectiveness of educational interventions.

The first used a randomized control trial design to determine effects of a training intervention focused on existential issues, nurses’ confidence in communication, and their attitude toward dying patients (Henoch, 2013). Assessing nurses in oncology, hospice, and palliative care settings, the trial group received training in existential issues supplemented with group reflection for a better understanding. These groups discussed both theoretical and practical communication practices based on training material read outside of the training time in order to discuss and apply their knowledge to earlier or ongoing experiences with severely ill patients. Using three different evaluation instruments, Henoch et al. (2013) examined if participants felt more confident and comfortable in caring for dying patients and answering patients who question their reason to live. The newly tested intervention was evaluated at baseline, immediately after the intervention, and five to six months later. The results suggest the intervention was effective by significantly increasing nurses’ confidence when caring for patients dying from cancer (Henoch, 2013).

The second new interventional tool aimed to improve concerns about communication and support for patients and families. Based off a pre-existing tool, Methods of Researching End-of-Life Care (MORECare), Higginson and colleagues (2013) created the Psychosocial Assessment and Communication Evaluation (PACE) to assist nurses in providing individualized assessments on communication, information status, and patient concerns among other clinical aspects. It required nurses to take a one-week training program Vol 7, Iss 1, 2013-2014

prior to the tool’s use. This study “led to much discussion about decision-making, communication, and endof-life issues” (Higginson, 2013, p.18). The intervention was evaluated by a post-implementation survey in addition to a qualitative interview with the patient and family. Findings indicate that the intervention improves communication and information provision based on the family survey results (Higginson, 2013).

This is the first study to evaluate both the clinicians and the patient/family receiving care from nurses who participated in the intervention.

The next group of studies evaluated effective communication skills through interactive role-play exercises. In 2010, Langewitz et al. implemented improvements on an already-established program used for communication skills training and applied it to oncology nurses who were the participants. The techniques were altered to address how nurses should approach oncology patients and how to have these patients express their feelings, attitudes, and expectations. In addition, the investigators offered participants the option to call trainers for support and conducted a booster seminar six months later (Langewitz, 2010).

The researchers evaluated the participants’ skills by assessing them during simulated patient-scenarios.

Investigators found that nurses demonstrated more empathetic responses and a more patient-centered communication style after the training program (Langewitz, 2010).

The following year, Krimshtein et al. (2011) addressed nurse-physician communication and developed a new intervention to evaluate an interactive approach. Critical care nurses participated in a sixhour communication-training session led by specialized experts (physicians, oncology nurse specialists, and doctorate nurses). Nurses were taught skills to optimize effective communication with role-play using scenarios that included common communication challenges nurses face on critical care units (Krimshtein, 2011). Pre- and post-test evaluations showed that using role-play to teach communication skills enhanced the nurses’ interdisciplinary communication and holds promise as a strategy to develop ICU nurses’ communication expertise (Krimshtein, 2011, p.1330).

Boyle and Kochinda (2004) also addressed nurses’ concerns about communicating with physicians. Using an intervention previously designed to improve communication between physicians and nurses (“The Collaborative Communication Intervention”), critical care nurses were taught core communication and relationship-building skills that addressed important key principles like esteem, empathy, involve-

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ment, sharing, and support (Boyle & Kochinda, 2004, p.63). Nurses were evaluated on these skills through a simulation vignette test along with a pre and post-tests at baseline, immediately after the intervention, and six months later. The findings provide evidence that the intervention not only improved nurse-physician communication and collaboration, but also increased satisfaction and confidence in the participants’ own communication skills (Boyle & Kochinda, 2004).

Discussion The studies bring attention to the fact that effective communication skills training programs exist; the problem is the lack of prevalence and use of the programs and interventions. It is important to appreciate the effective aspects of educational training programs for effective communication at the end of life. The interventions in the studies increased nurses’ confidence in leading an end-of-life discussion with patients; however, the studies suggest that using realistic role-play to practice the skills taught in the educational programs is the most effective intervention.

Furthermore, all of the included studies validate Boyle and Kochinda’s (2004) finding that communication skills training programs are feasible and possible to incorporate into the hospital setting without taking time from nurses’ every day duties. The studies suggest that effective communication training will improve successful communication and patient-centered care, but there is a lack of implementation and evaluation of these communication-training programs at hospitals (Higginson, 2013). The studies prove that communication skills are both teachable and learnable with the right intervention (Krimshtein, 2011).

Limitations While each of these studies has their own limitations, an overarching theme is the small sample sizes and limited settings where the studies were performed.

Varying in hospital locations around the United States and globally would strengthen the results. Another limitation was the lack of strong methods of study, with only one randomized control trial and no metaanalyses. In addition, all of the studies but one evaluated their intervention through a nurse’s self-evaluation; it is important to assess the patient and family’s satisfaction after a nurse received communication skills training. All of the studies failed to address the many variables and complications associated with end of life care (ethical, social, or medical concerns) that vary from patient to patient. Further, none of the studies investigated the language or cultural barrier. There is great potential for growth in this area of research. Addressing these limitations would be a productive step Vol 7, Iss 1, 2013-2014

towards improved and evidence-based communication skills training programs.

Clinical Implications

Effective communication training programs affect nurses, patients, and the whole interdisciplinary team in the clinical setting. When implemented, nurses feel they gain practical and professional benefits, like lower personal stress and better patient-centered care (Radtke, 2012). Aside from nurses, leaders are needed to implement these training programs and actively strive for collaborative communication between nurses and physicians. This can directly lower the risk of negative patient outcomes (Boyle, 2004). These interventions could be implemented in general hospital settings during patient admission rather than solely for critically ill patients (Higginson et al., 2013). Overall, the findings from these studies imply that hospitals would benefit from communication skills training studies to make substantial improvements in patient-centered communication (Langewitz et al., 2010). In relation to future policy changes, institutions need to implement a standardized mandatory program for all oncology or critical care nurses to partake in during orientations.

For academic nursing programs, at least one communication class should be a mandatory part of students’ curriculum; the class could address end-of-life conversations in addition to parent communication for pediatric nurses and mother-baby communication for labor and delivery nurses. The goal is a standardized requirement to teach future nurses communication skills that can be applied in various situations for non-specialized undergraduate nurses before entering the workforce.

Future Research The future for communication skills training programs is promising, especially for end-of-life communication. Research on these programs and their effectiveness will need to address the ever-evolving technology for life support. One option for future research is investigating the prevalence of communication skill training programs, both geographically and specific clinical units of an institution. This can help identify where there is a lack of end-of-life communication support. Further, it is important for future research to evaluate the effectiveness of training from the patient and family’s perspective. Investigators need to assess and analyze the effectiveness of follow-up education and benefits from refresher courses offered after a training program is implemented as well.

Conclusion Several communication skills training programs, along with education on end-of-life discussions, have been around for years; however, it is only

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becoming apparent now that nurses lack confidence in these discussions. This systematic literature review offers examples of effective communication-training techniques, like using role-play scenarios to practice end-of-life discussions or educational classes with reflective discussion about end-of-life situations.

Nurse-physician collaboration is also a key component to successful end-of-life communication with a patient.

Improving nurses-patient communication on end of life, especially in critical care or oncology, can lead to improved patient outcomes, patient-centered care, and overall increase patient satisfaction when facing the hardest thing one may face—the end of life.

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Happ, M. B., Garrett, K. L., Tate, J. A., DiVirgilio, D., Houze, M. P., Demirci, J. R., George, E., & Sereika, S. M. (2014). Effect of a multi-level intervention on nurse-patient communication in the intensive care unit: Results of the SPEACS trial. Heart and Lung 43(2), 89-98. Retrieved from www.scopus.com Henoch, I., Danielson, E., Strang, S., Browall, M., & Melin-Johansson, C. (2013). Training intervention for health care staff in the provision of existential support to patients with cancer: A randomized, controlled study. Journal of Pain and Symptom Management, 46(6), 785-794. Retrieved from www.scopus.com Higginson, I. J., Koffman, J., Hopkins, P., Prentice, W., Burman, R., Leonard, S., ... Shipman, C. (2013).

Development and evaluation of the feasibility and effects on staff, patients, and families of a new tool, Vol 7, Iss 1, 2013-2014

the psychosocial assessment and communication evaluation (PACE), to improve communication and palliative care in intensive care and during clinical uncertainty.BMC Medicine, 11(1) Retrieved from www.scopus.com Krimshtein, N., S., Luhrs, C., A., Puntillo, K., A., Cortez, T., B., Livote, E., E., Penrod, J., D., & Nelson, J., E. (2011). Training nurses for interdisciplinary communication with families in the intensive care unit: An intervention. Journal of Palliative Medicine, 14(12), 1325-1332. doi:10.1089/ jpm.2011.0225 Langewitz, W., Heydrich, L., Nübling, M., Szirt, L., Weber, H., & Grossman, P. (2010). Swiss cancer league communication skills training programme for oncology nurses: An evaluation. Journal of Advanced Nursing, 66(10), 2266-2277. Retrieved from www. scopus.com Radtke, J. V., Tate, J. A., & Happ, M. B. (2012). Nurses’ perceptions of communication training in the ICU. Intensive and Critical Care Nursing, 28(1), 16-25. Retrieved from www.scopus.com Slatore, C., G., Hansen, L., Ganzini, L., Press, N., Osborne, M., L., Chesnutt, M., S., & Mularski, R., A. (2012).

Communication by nurses in the intensive care unit: Qualitative analysis of domains of patientcentered care. American Journal of Critical Care, 21(6), 410-418. doi:10.4037/ajcc2012124 Tay, L., Hui, Ang, E., & Hegney, D. (2012). Nurses’ perceptions of the barriers in effective communication with inpatient cancer adults in singapore. Journal of Clinical Nursing, 21(17), 2647-2658.

doi:10.1111/j.1365-2702.2011.03977.x Wittenberg-Lyles, E., Goldsmith, J., & Ferrell, B. (2013). Oncology nurse communication barriers to patient-centered care. Clinical Journal of Oncology Nursing,17(2), 152158. doi:10.1188/13.CJON.152-158

Journal of Student Nursing Research

Vanessa DiMaria is a BSN candidate in the Class of 2014 at the University of Pennsylvania School of Nursing. Her interests are adult and geriatric intensive care with a passion for palliative care and communication.

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JOSNR Editorial Board Vanessa DiMaria President diva@nursing. upenn.edu

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JOSNR is a publication of The Organization of Student Nursing Research. Copyright Š 2014 OSNR. The contents of this journal should not be reproduced or reprinted without the permission of The Journal of Student Nursing Research or its authors. All rights reserved.

Special Thanks to: Faculty Advisor Kathleen McCauley, PhD, RN, ACNS- BC, FAAN, FAHA Class of 1965 25th Reunion Term Professor of Cardiovascular Nursing Associate Dean for Academic Programs University of Pennsylvania School of Nursing Members of the JOSNR Faculty Editorial Board Cynthia A. Connolly, PhD, RN, PNP, FAAN Kirsten Hickerson, RN, MS, CEN Eun-Ok Im, PhD, MPH, RN, CNS, FAAN Anita Iyengar, MSN, BSN Editing Assistance Mary Blackwell Penn Nursing Community

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