Questions
to think about before reading:
·
Is nurse really
professional enough to share a physician’s work
·
What are the essential
elements in improving collaboration to further reduce malpractice
·
Why is it so uneasy to
achieve patient safety by different professional backgrounds working together?
As
discussed in the group blog, improving patient outcome lies upon successful
inter-professional collaboration between physician and nurse (and other people
such as patient, their family and other caregivers) in today’s highly
complicated health care delivery model.
Improving
patient outcome means
·
Reducing healthcare cost
·
Reducing
malpractice to reducing patient errors
·
Optimizing the well beings of
patients and their family
·
Improving communication among
healthcare providers
·
Enhancing the overall state of
healthcare organization
The
ability of physicians and nurses to
work together plays a crucial role in determining whether the above can be
achieved. Among all these goals,
reducing malpractice and patient errors seem to be the most concerned. After reading number of medical cases, many
patient errors, regardless of nurse, physician, or nurse with physician
together, are due to miscommunication such as,
·
Conditions of patient are not written
clearly when transferring from one discipline to another
·
Assumption rather than evidence-based
even when the EBP system is in place.
·
Verbal treatment and medication
instruction was not written down in black and white, no proof for point of
responsibility when the instruction was found wrong later. Both physician and nurse were accusing each
other.
The
very key to IPC to reduce patient errors seem to be effective communication. In the following, we will discuss about how Trust, Team works, and Conflict
affect and contribute to effective communication.
Trust –
Open communication require certain level of trust. The level of trust affects the communication
effectiveness. Pathos affects Logos. [i]You
have to know you audience before you can effectively persuade them. [ii]Higher
level of communication generate more trust.
How much you know and trust about your audience affects the amount and
quality of your communication. In
general one would be able to speak up with someone you trust or someone you are
familiar with. Advanced communication and
record technology has greatly improved the efficiency of caregivers. Rather than the traditional face to face in
exchanging patient information, and giving orders, everything is now in
electronic record. Instead of consulting
the doctor face to face, the nurse will now depend on the information from the
computer to decide the nursing plan.
Simultaneously, the physician will have to depend on the same computer
for patient information to aid their planning and decision making. Undoubtedly, advanced technology has changed
the day to day caregivers’ interactions.
The less you interact, the less trust can be built mutually.
Growing
shortage of primary caregivers, both physician and nurse has given great
challenge in trust building. As it is
uneasy to fill the permanent nurse vacancy due to the limited graduates, new
positions are created such as the patient care technicians and nurse extenders
to fill the gap by temporary and contract staff. People come and go, new faces all the time. Contract ends before the working relationship
can really be developed. The same
happens on the physician side as well.
Trust therefore can’t really be built with someone you don’t know for
long. Technical advancement improved the
traditional communication process.
Dynamic workforce filled the staff shortage temporarily. However, at the same time they have both
diminishing the interaction between caregivers which subsequently weakened the
trust.
Nurse’s
work in the past was simply a skill and task job but now it involves more
critical thinking and analysis in order to perform the shared doctor’s
work. Well educated people wouldn’t
become a nurse in the past. However,
after several economic fluctuation, nurse work becomes more attractive in terms
of job security. People entering the
industry are now with higher education. [iii]The
higher competence the nurse has, the better trust physician placed upon them in
building high performance team.
Team work (partnership
rather than hierarchical) – From the above statement made by Steele in 1986,
maximizing interactions between physician and nurses seem to be essential for
high performance team collaboration in order to achieve the mutual goal of
physician and nurse – ‘providing quality patient care’. The physician-nurse work was once very
hierarchical in the past (exp. Superior-worker relationship). Straightly following orders didn’t require much
trust, respect, communication, and interaction.
However, the raise of population, healthcare demand, more complicated
medication and treatment developed, it is impossible for the doctor to do all
the critical thinking by themselves.
Nurses are sharing some doctor’s ground work such as preliminary
diagnosis, research, and is capable in giving opinion and advices to
doctor. Nurse’s work in the past was simply
a skill and task job but now it involves more critical thinking and analysis in
order to perform the shared doctor’s work.
The working relationship has transformed to a more of a partnership. Doctor today will seek nurse’s opinion and
advice. A culture of willingness to
confront each other for important care issues was fostered. Nurse has begun taking part in leadership in
the institutional level at their clinical discipline, acting as an effective counterpart
of the physicians. In many organization
today the CNO (Chief Nursing Officer) and CMO (Chief Medical Officer) have
equal level of authority and responsibility to jointly facilitate quality health
care.
It
is unlikely that nowadays you see a physician or a nurse alone in bedside
diagnosing patients. There could be a
physician, his or her assistant, residents in training, nurse, critical care
intensivist, the hospitalist, and so on.
However, there are so many titles and specialist nowadays and you would
be easily confused on whom to listen to, who is in charge. Nevertheless, the most valuable form of
communication is face to face[v]. Seeing each other in person is the strongest
way in building a team by better quality interaction, true interaction.
As
you can see from the below survey[vi]
done by nurse every year in terms of 8 organizational characteristics:
autonomy, clinician-physician relations, control over practice, communication,
teamwork and leadership, conflict management, internal work motivation, and
cultural sensitivity, the perception of nurse-physician relationship is
improving every year.
Team building in Operation Room (Shapiro) [vii]- to
tackle this dynamic workforce issue, Dr. Shapiro, Chief, Division of
Otolaryngology at Boston’s Brigham and Women’s Hospital has developed a
successful operating room briefing technique to enhance communication and team
spirit before an operation. The briefing
starts by gathering all the personnel around the patient after he/she is
intubated. This is to get everyone’s
full attention by literally seeing the patient in the center. Then Shapiro will get everyone to speak out
their full name and their role in this case.
Even though the faces look familiar to you, you might not know 100%
about who they are, what they do, and how they could help in this
operation. So by getting to know
everyone’s name and role, a sense of teamwork is raising/building. Then they will confirm the patient’s name and
the procedure, who at what time to do what.
The entire plan will be given at this point. This sort of helps members (both physician
and nurse) to build a shared mental model of what is going to happen and allow
people to have an idea of what instrument will be needed by when. This also could avoid all those ad hoc
running around for things scene and resulted in more efficient and lower
risk. And then people will start
discussing the difference of this particular case in compare to other usual
case. For example, does this patient
carry anything in his/her body that we should pay attention to and avoid doing
certain treatment. The ‘OR equivalent of
read backs’ will be adopted, ie. verbally repeat what is requested to avoid
delay and error due to misunderstood of the request. Shapiro will then emphasize that they are a
team now so everybody’s input is equally important and valuable. He invites people to speak up their concern
during the operation, lower the hierarchy temporarily to allow information to
flow freely. Those receivers should also
treat the information given seriously.
Doesn’t matter if it is a concern raised by the nurse to some senior
physician, it should be respected and handled seriously. Of course, there are always concerns from
physician about blurring the hierarchy might result in ambiguous
responsibility. But as mentioned by
Shapiro, final decisions are still made by the physician but information from
other team members should not be disrespected or ignored. Otherwise teamwork is over.
According
to article ‘The New Science of Building Great Teams’, 3 key elements of
communication are identified teams with higher performance – energy,
engagement, and exploration[viii]. People gather around to talk face to face
helped to spread the energy to exchange.
Temporarily lowering the hierarchy allows members in the team to
participate equal, and to insert the equal amount of energy across team
members, the engagement will be strong.
Exploration in my opinion is rather personal. Exploring outside the team with information
that ultimately benefit the team is absolutely good. But what is more important is creating the
atmosphere/culture to encourage team members to share their knowledge.
Conflict
arises when there are different, priorities, incentives, and ways of doing
things[ix]
in the healthcare practice. There are
task conflict as well as relationship conflicts between physician and
nurse. They have different perspective
and expectation toward each other. For
example, [x]in
the middle of a night (2:00am) the condition of a patient changed suddenly and
the nurse will have to judge whether to call up the physician or not. And whether the physician will come in person
or give instruction by phone will depend on how good the nurse describe about
the patient’s condition, how well the physician know about the nurse and the
level of trust placed upon the nurse. On
the other hand, the physician received the call will be expecting a professional
assessment and description from the nurse about the patient’s condition. Luckily if the physician knew about the nurse
very well and trusted her so much then the decision wouldn’t be difficult to
make. However, due to the dynamic
workforce mentioned earlier, this wouldn’t always happen. And when the physician comes in and finds out
that he/she isn’t necessary to come, conflict arise.
In
addition to the traditional curing tasks, physicians nowadays has to take care
many other administration work on their own such as financial concern, business
management, office technology, research, and coding which has taken them away
from patients and nurses. There are more
for physicians to concern other than direct medication work. It takes many years of study and training to
become a doctor. Great deal of
accountability associated in everyday work.
Pressure cannot be easily understood unless you are really into the
practice. Nurse’s job, on the other hand
is also exhausting, both physically and mentally, with round the clock works
under great stress. It is
challenging. Much clinical knowledge,
skills and education, patience, and especially great deal of compassion is a
must in order to continue the job. [xi]In
broad terms, physicians tend to focus on measurable and factual understanding
of the patient’s disease or condition, while nurses are trained to focus on the
narrative – the patient’s experience and response to treatment.
Resources
is indeed another root cause of conflict.
Nursing is at greater portion in patient care. Therefore, nurses are involved in most
malpractice cases. However, the
statistic from CRICO told us that in most malpractice case that require legal
action, physicians are normally the named defendant rather than nurses.
l
41% of the 364 cases in
1888-2007 involved high-severity injuries (89 death)
l
One of more physicians are
also named defendants in about 1/2 of the nursing cases
Whenever
a malpractice found, patients and their family suffer. Roles and responsibility of physician and
nurse blur. It is uneasy to define whose
error is in some cases. Conflicts arise
when roles and responsibility are not clear.
Fights between nurse and physician are always about whose job is
it. For example, frequently heard
arguments are, ‘Isn’t this your job?’, ‘Shouldn’t this be noted and told
earlier?’, ‘I thought you knew it!’. There
are too many assumption when roles and responsibilities are not clear. When tasks are not communicated in written
form, physician might assume the nurse will do it and vice versa. Malpractice cases, fines are normally shared
by the involved caregivers. So people
might think, why would I need to pay for the mistake that isn’t made by
me. Unclear roles and responsibilities
induced conflict of interest.
In
case 1[xii]
below, physician completed the evaluation form without reading all required
information, nurse noticed the missing piece of information but assumed the
relevant caregivers know about it and called for medication. Patient eventually died because of this
malpractice. In this particular case, I
am thinking effective health care definitely involves not only the physician
and nurse, but also the patients and their family as well. If the ulcer was communicated by the patient
or his/her earlier, it might have another outcome.
Below case 2[xiii]
is another malpractice from miscommunication that made the patient suffer. Number of gauze used was not recorded down
twice. This case is rather simple,
should the surgeon follow the rules to record down the number of gauze used, or
the nurse in the repacking was able to speak up about it, or if she would have
record down in her repacking, the case would not happen or the repacking nurse
will not be found liable for the malpractice.
In conclusion,
advanced technology improved communication as well as in a way distanced
people. Physician Nurse Collaboration
absolutely require more face to face communication, supporting and role
modeling mutual respect from the organization level and top management,
inter-professional education for teamwork and communication. Conflicts can be managed by ‘Talk it Out’ and
‘Sharing responsibility’ (instead of denying it). Patient errors can therefore be further
reduced and outcome optimized.
[iv] Jeanette Ives Erickson, RN, MS, FAAN, and Joyce C. Clifford, RN,
PhD, FAAN, Physician-Nurse Collaboration and Patient Safety, Building a
Foundation for Nurse-Physician Collaboration https://www.rmf.harvard.edu/~/media/Files/_Global/KC/Forums/2008/forumMay2008.pdf
[v] Alex “Sandy” Pentland, The New Science of Building Great Teams, The
chemistry of high-performing groups is no longer mystery, Harvard Business
Review, April 2012
[vi] Jeanette Ives Erickson, RN, MS, FAAN, and Joyce C. Clifford, RN,
PhD, FAAN, Physician-Nurse Collaboration and Patient Safety, Building a
Foundation for Nurse-Physician Collaboration https://www.rmf.harvard.edu/~/media/Files/_Global/KC/Forums/2008/forumMay2008.pdf
[vii] Jo Shapiro, MD , Physician-Nurse Collaboration and Patient Safety,
How to Encourage Collaboration in the OR https://www.rmf.harvard.edu/~/media/Files/_Global/KC/Forums/2008/forumMay2008.pdf
[viii] Alex “Sandy” Pentland, The New Science of Building Great Teams, The
chemistry of high-performing groups is no longer mystery, Harvard Business
Review, April 2012
[x] Patricia Folcarelli, RN, PhD, and Michael Howell, MD, MPH,
Physician-Nurse Collaboration and Patient Safety, Triggers: Rapid Response at
Beth Israel Deaconess Medial Center https://www.rmf.harvard.edu/~/media/Files/_Global/KC/Forums/2008/forumMay2008.pdf
[xi] Alexander R. Carbo, MD and Patricia Folcarelli, RN, PhD, Physician-Nurse
Collaboration and Patient Safety, Let’s Talk: building Better Physician-Nurse
Collaboration https://www.rmf.harvard.edu/~/media/Files/_Global/KC/Forums/2008/forumMay2008.pdf
[xii] Claudia A, Hunter, Esq., Physician-Nurse Collaboration and Patient
Safety, Lessons from Settled Malpractice Cases Involving Failed Physician-Nurse
Communication https://www.rmf.harvard.edu/~/media/Files/_Global/KC/Forums/2008/forumMay2008.pdf
[xiii] Claudia A, Hunter, Esq., Physician-Nurse Collaboration and Patient
Safety, Lessons from Settled Malpractice Cases Involving Failed Physician-Nurse
Communication https://www.rmf.harvard.edu/~/media/Files/_Global/KC/Forums/2008/forumMay2008.pdf
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