How to talk to doctors – a guide for effective communication
Kate Curtis, Trauma Service, St George Hospital, Gray St, Kogarah, NSW, 2217, Australia; Tel: +612 9113 2686; Fax: +612 9113 3974; E-mail: email@example.com.
Curtis K., Tzannes A. & Rudge T. (2011) How to talk to doctors – a guide for effective communication. International Nursing Review58, 13–20
Background: Nurses and doctors undertake segregated and distinct preparation for clinical practice, yet are expected to communicate effectively with each other in the workplace. Most healthcare facilities have policies relating to written communication, but guidelines for verbal communication, which is used most in times of uncertainty and urgency, are generally less regulated. Poor communication and communication overload are shown to have a direct correlation with patient outcomes, adverse events and stressors among healthcare professionals. We suggest a guide for more effective verbal communication between nurses and doctors.
Methods: We perform an integrated review of the extensive literature that identifies specific problems that contribute to ineffective communication between a doctor and nurse. We discuss these in five themes in the modern clinical context including intensification of workload, workforce mobility, differing perceptions, language use and heuristics. To combat these, we provide a four point practical guide to arm the nurse clinician with effective tools to ensure a satisfactory exchange of information in the context of patient advocacy.
Conclusions: The guide assists in overcoming the discussed barriers by creating a premise for fostering communication, understanding each clinician's information needs in a mutually respectful manner, especially in the context of uncertainty. We recommend that a shared mental model regarding communication in health be adopted at tertiary institutions offering pre-registration nursing and medical training and techniques and be woven into respective curriculum design.
Working with others effectively in healthcare is a challenge. Sound communication and effective relationships with all those involved in the patient's care has an impact on nursing practice, patient care and how nurses feel about themselves (Sweet & Norman 1995). As such, nurse and doctor colleagues are together responsible in providing high quality, safe care. As a component of this, throughout the care processes, it is essential to ensure communication occurs on several levels; nurse to patient and family/carers, nurse to nurse and nurse to medical staff. Harmonious relationships with patients, between healthcare providers/team members, the organization, and the community are known to be dependent on effective communication (Kelly 2005). On this score, public surveys, practitioner accounts, emerging policy and practice-based research are unanimous: communication determines clinical quality, patients' safety, clinicians' well-being and public satisfaction (Iedema 2009).
Universally, no one medical or nursing specialty or practice environment is immune from error if poor communication exists (Hindle et al. 2005), and together as a group of collaborative clinicians, it is essential that nurses and doctors are able to exchange information in a coherent, comprehensive way. While doctors and nurses have individual, essential and specific roles within health systems, much recent work on patient safety and effective care points to a growing interdependence between these groups of professionals Garling (2008). Iedema (2009) goes as far as stating that communication is constitutive of healthcare, without communication, healthcare would not happen. It is our contention that central to the issues around communication is preparation for clinical practice where, for most part and in most countries, student doctors and nurses undertake largely segregated, distinct and varied training and preparation for clinical practice (Suter et al. 2009, National Health Service 2008, Garling 2008). Such a situation continues to ensure that inter-professional relations and communication are not part of early professional preparation and make effective communications in the employment situation unfamiliar to both groups (Suter et al. 2009; Wilhelmsson et al. 2009).
Healthcare facilities are often busy, crowded and seemingly chaotic. Attempts at communication in this environment are frequently interrupted, and occur along multiple channels between multiple individuals simultaneously (Woloshynowych et al. 2007). Poor communication and communication overload has a direct correlation with patient outcomes (Hindle et al. 2005), adverse events (Wilson et al. 1995), transfer delays (White et al. 2004) and length of stay (Sprivulis et al. 2006). Effective communication plays a central role in the development and maintenance of collaborative relationships between healthcare workers and their patients, and between members of the healthcare team (Kelly 2005). Poor communication is also one of the most common elements of stress among healthcare professionals (Perry 1997). Research among nurses in critical care workplaces has found significant correlation between communication with peers and supervisors and job satisfaction (Blegen 1993; Sengin 2003). In particular, an attentive communication style and avoidance of authoritarian communication styles were shown to significantly affect nurses' perceptions of nurse–doctor collaboration and nurse satisfaction (Coeling & Cukr 2000). In addition, the way in which communication is conducted is closely related to patient satisfaction (Saunders 2005), in particular relating to interpersonal skills and staff attitudes (Taylor & Benger 2004). A Nigerian study found that the doctor–nurse relationship was impacted on negatively by each profession's inimical union activity, nurses delaying giving important information about patient deterioration, doctors not notifying nurses about patients with infectious diseases and doctors having disregard for nurses' work (Ogbimi & Adebamowo 2006). This view is supported by Champion, Austin & Tzeng (1990), who found that in those countries with more expenditure for community and public health, community attitudes towards nurses were more positive.
We performed an integrative literature search in databases including Medline, CINAHL, SCIRUS and Pubmed using the search term doctor–nurse communication. A multitude of barriers to effective communication in healthcare and causes of poor nurse to doctor relationships were reported. We selected five predominant themes on which to focus, highlighting the historical and current contexts for ineffective communication: traditional hierarchical relationships; increasing workload; mobile workforce; differing perceptions and language; prior experience. We discuss these themes and the resultant impact in the modern clinical context, considering cognitive science and shared mental models (an organized system or philosophy to blend different ideas about and solve a problem) to include differing perceptions, language use and heuristics. Based on the findings in our search, and clinical experience, we suggest a guide for more effective communication which includes ISBAR, an acronym coming from the first letters of five elements of communication that ensure thorough and effective communication. These elements are introduction, situation, background, assessment, recommendation (Jansky & Zafi 2007) and graded assertiveness. The guide assists in overcoming the previously discussed barriers by creating a premise for fostering communication, understanding each clinician's information needs in a mutually respectful manner, especially in the context of uncertainty.
Barriers to effective nurse–doctor communication
Traditional hierarchical relationships
There is extensive literature identifying several specific problems that contribute to ineffective communication between the doctor and nurse (Fagin & Garelick 2004; Porter 1991; Sweet & Norman 1995), summarized in Supporting Information Table S1. Historically, many aspects of the doctor–nurse relationship stem from the traditional associations quoted below.
No matter how gifted she may be, she will never become a reliable nurse until she can obey without question. The first and most helpful criticism I ever received from a doctor was when he told me I was supposed to be simply an intelligent machine for the purpose of carrying out his orders. (Dock 1917)
Since these thoughts were penned, the traditional nurse–doctor relationship has and continues to undergo major change (Nancarrow & Borthwick 2005). In many countries, with the support of extensive university training, the expansion of skills and changes in societal, institutional and professional norms, nurses have made considerable advances in their professional standing (Fagin & Garelick 2004). In fact, in many contexts, nurses provide the vast majority of healthcare and have responsibility for whole communities. The level of education attained by practising nurses directly influences their perceived assertiveness, an attribute believed to be linked to nursing advocacy competencies (Kubsch et al., 2003). One could also argue that the independent practice of nurses in remote areas and developing nations out of necessity contributes to confidence and assertiveness. Further, participant observation studies report that nurses feel less subservient to doctors and experience much greater participation in informal decision-making (Farrell 2001; McKay 1993; Porter 1991).
Despite these changes, research specific to doctor to nurse communication in the context of healthcare in developed nations report that nurses have difficulties in voicing their concerns or opinions directly, particularly if it involves contradiction or criticism of doctors or of other senior figures within the team (Fagin & Garelick 2004). Since Stein (1967) outlined the elements of the doctor–nurse game, there are still times when this game plays out where there are inter-generational conflicts on either the doctor or nurse's side of the game. This game was one constructed in order to avoid direct contradiction or conflict – recommendations were made without acknowledgement and led to the taking up of advice without direct communication. This game was highly gendered and could often go awry. Moreover, as Stein et al. noted in 1990, this game is little seen except in cases of older physicians who retain their earlier views on professional relationships. The pace of change may lead to intergenerational conflict, with older members of staff adhering to traditional hierarchies, and more recent graduates challenging these role delineations.
Although it is important to understand the historical factors that have determined each profession's roles and responsibilities, as well as areas of conflict and disagreement, it is the mutual recognition of interdependence of nurses and doctors that will lead the way to truly collaborative clinical work (Fagin & Garelick 2004; Miller et al. 2008).
Modern healthcare facilities are seeing more patients each year with proportionately fewer resources. The acuity and complexity of presenting conditions is also increasing due to an aging population, and pressures from administrators to process each patient in the least possible time. Diagnostic technology and therapeutic modalities are increasing in complexity, efficacy and potential for adverse effects. A British study examined the communication load for a head nurse in an emergency department and documented over 1000 separate communication events over a ten-hour shift. Fourteen per cent of these were simultaneous, that is, in addition to any other concurrently active tasks that did not involve communication of any form. Furthermore, 30% of communications were interruptions to a task already at hand (Woloshynowych et al. 2007) in which a person interrupted an ongoing communication event. An error rate of only 1% could potentially lead to ten errors relating to patient management over the course of a typical shift. On medical and surgical wards in Australia over the past 5 years, patient acuity has risen and the number of different diagnostic related groups (DRG) or illness types cared for has increased. There is considerable movement of patients on and off nursing wards, defined as ‘churn’ which increases the work burden for nurses. Moreover, as hospital length of stay drops, it concentrates the need for nursing into shorter and shorter time periods (Duffield et al. 2007). Increased workload results in less time, motivation and energy for communication with medical staff and patients (Carayon & Gurses 2008).
The modern developed nations' healthcare team is increasingly fragmented into sub-specialties, with multiple individuals involved in facets of an individual patient's care. Shift times overlap to varying degrees, and team members (particularly medical) rotate through teams and wards as part of their training programme. Rotating interns, residents and registrars are not fully aware of the hospital internal system and resources (Ursic et al. 2009) and developing relationships with individual nursing staff in relation to their knowledge, capabilities and skill levels is difficult. The same could be said of any healthcare in any environment. In addition, an increasing reliance in many institutions on a casual labour pool expands the number of individuals who must learn to communicate and work effectively as a team.
Differing perceptions and language
Modern medicine is rooted in the scientific method, which favours objective data over subjective opinion, and an evidence base gathered collectively rather than from individual anecdote. Against this, many nurses have difficulty articulating their concerns and opinions and have difficulty being assertive (Canam 2008; Skei 2008). One cited cause of this is the specialized language employed by healthcare workers, with the frequent use of highly technical terminology reflecting an objectified, evidence-based approach to medical care (Canam 2008). Other causes may be the culture of the work environment, or the expectations of the community in that country.
Nursing had its historical roots conversely in religious institutions and places of convalescence (Nelson 2001). Since that time, the education of nurses has focused more on the physical and psychological needs of the individual patient. Empathy and nurturing are strong features of a nurse's traditional role characteristics (Griffin & Griffin 1973). Typically, a nurse will spend more time at the bedside (or in closer, more sustained clinical relations) with a patient and their relatives than will an individual doctor, and rightfully defends his role as the patient's advocate (Miller et al. 2008). As mentioned previously, there is an increasing overlap in the focus and content of medical and nursing training, but these slightly differing perspectives and communication techniques set the two professions up for potential conflict and miscommunication (Woodhall et al. 2008). Although on the same team, with the same overall aim of patient care, the priorities perceived by each healthcare worker may be quite different. Many levels of difference are evident in research that explores inter-professional communications and identifies that there are new spaces and places where the doctor–nurse game plays out, such as in corridors and fights over access to ward computers for nursing or medical work (Miller et al. 2008). It is clear that some aspects of difference are sustained but are played out differently away from the ‘front of house’ places such as the patient's bedside or in multi-disciplinary case meetings (Miller et al. 2008).
An individual's prior experience also determines their emotional state when interacting with others. For example, if a nurse had previously been bullied or felt defensive communicating with other healthcare workers, it is likely this will affect her attitude to future collaboration. Similarly, if a bad patient outcome has previously left a doctor feeling somehow to blame they may be overly cautious or overly aggressive when faced with a similar clinical scenario. Studies have shown nurses use past experiences in their decision-making process by comparing the current situation to previously experienced situations held in their memory. This type of thinking, that is, learning from previous experience, is termed ‘heuristics’ and can yield powerful clues as to an individual's approach to their work relationships (Cioffi 2001). Moreover, there is strong evidence of how the emotional labour of nurses comes to constitute the communication process as one where open communications are hidden behind emotion work (Bolton 2000).
Furthermore, thoughts or emotions left unexpressed have a tendency to surface in other counterproductive ways, such as passive aggressive behaviour, open hostility to other staff or patients, and absenteeism. All of these erode the healthcare team's ability to function in the best interests of the patient. Less commonly reported but just as insidious are cases of verbal abuse redirected by nursing staff at more junior doctors (Marsden 1990), or indeed other members of the healthcare team deemed lower down in the hierarchy (for example, orderlies and cleaners) (Table 1).
Table 1. Practical points to consider when speaking with a doctor about a patient
|Recognize your own emotional state and take stock|
|Attempt to understand and acknowledge the receivers perspective|
|Questioning of your information is not personal but fact gathering|
|Decide what you want to achieve from the call|
|How urgent is the matter?|
|Prepare your case|
|Contact the right person the first time|
|Anticipate– what information will the doctor need to make a decision?|
|Have a structure: ISBAR|
|Be your patient's advocate and use assertiveness appropriately|
|Don't accept bullying!|
Discussion and recommendations
In light of these various barriers, it is useful to consider methods to improve the quality of nurse–doctor communication both at an organizational and personal level. There is an extensive body of work on cognitive science and ideology in the context of an organization which support the statement that the organization has a responsibility to implement and support clinicians with a shared mental model in relation to fostering communication especially in the context of uncertainty (Denzau & North 2000, p. 107). Until more time and space is made in educational programmes for interprofessional learning (see Wilhelmsson et al. 2009, Areskog 2009), it is clear that there remain constraints on how interprofessional collaboration can be obtained. The World Health Organisation in 1984 indicated that interprofessional education was central in primary health teams and in prevention programmes (Areskog 2009). At the level of policy and accreditation of medical programmes and in standards for practice in nursing, in Australia the Australian Medical Council requires that there be evidence of interprofessional learning in medical curricula (Australian Medical Council Inc 2009). Most organizations will have policies relating to written communication, but verbal communication, most used in times of uncertainty and urgency is generally less structured, consistent and supported by guidelines (Beyea 2004), which is the focus of this paper.
Until medical and nursing education systems meet more often both in the clinic and classroom in structured learning processes, the following guide is offered for effective communication. It presents four main themes: personal considerations, preparation, structure, and graded assertiveness. Each section contains practical suggestions and considerations to ensure successful communication using the premise of a nurse calling a doctor to report concern regarding patient status and collaborate on appropriate intervention. The points are summarized in Table 1.
Effective communication guide
Learn to recognize your own emotional state: are you tired, angry, time pressured? How does this affect your style of communication and tolerance for others? In turn, how does this affect the people you are communicating with? How can you modulate your own stressors? These may be work related or external but will regardless impact on the interaction.
Likewise, attempt to understand the other person's perspective: are they tired, angry, time pressured? This may help you control the direction and tone of a conversation with the ultimate aim of advancing the patient's care and avoiding unnecessary conflict. It may be useful to acknowledge the other person's stressors as a means of defusing the situation. Remind yourself and the other person that you are all on the same team
Importantly, learn to control your anxiety or other response to interrogation by a doctor or other team member. They are most likely testing various hypotheses and checking facts to help make a decision. Although intellectually confronting, it is not likely intended as a personal challenge.
Prior to contacting the doctor, it is important to be mentally prepared. A few moments of preparation aids delivery of your message, both in terms of structure and content. It builds professional respect and is ultimately empowering for the nurse. Gather notes, gather your thoughts, and address the following points.
- 1Determine what it is that you want to achieve from your call. Are you notifying the doctor of a change in condition, or are you seeking clarification regarding a drug order? How urgent is the matter: does your patient need urgent review or can it wait until the next scheduled round? By triaging the urgency of the situation, you aim to get a timely response to emergencies, without ‘crying wolf’ about non-urgent situations. This is a skill that develops with experience, and if in doubt, it is always prudent to seek another opinion.
- 2Who is the person you need to speak to? It is frustrating and time wasting to present a case only to be informed that the person on the end of the line is not the right doctor to help you out. Some institutions persist with limiting nurses' calls to junior members of the medical team; but research suggests that nurses are more satisfied with responses from more senior doctors, who may be able to make rapid trustworthy decisions.
- 3Learn to anticipate the needs of the other person, who in turn will be more able to give you what you need. If it is likely that a doctor will require certain information (e.g. latest observations, ECG) to help make a decision, then having that information at hand when you make the call facilitates communication.
A structured approach to communication has important advantages. In addition to providing a framework for preparation as noted above, it ensures important details are not missed, and from the outset minimizes the risk of communication error. If adopted as an expected norm by all members of a healthcare team, it may facilitate the reception and processing of information and enables the person receiving the call to make an informed clinical contribution.
The use of ISBAR, a communication tool is an excellent way to achieve these goals (Table 2). ISBAR, an acronym for Introduction, Situation, Background, Assessment, Recommendation is a framework for structured communication (Table 2). Originating as SBAR (Haig et al. 2006; Manning 2006) and enhanced by Jansky & Zafi (2007), the tool can be useful for nurses as a means of communicating with physicians about the change in a patient's status (Pope et al. 2008) and prompts the initiator to introduce themselves, state the current situation, give relevant background, state assessment findings and recommendations in any situation. It has recently been validated in Australia as an effective way to improve the clarity and content of clinically based communication (Marshall et al. 2009).
Table 2. ISBAR, Introduction, Situation, background, assessment, recommendation (Adapted from: Australian Commission on Safety and Quality in Health Care 2009)
|I – Introduction|
|Identify yourself (your name, role and location) and the person you are calling.|
|Don't allow familiarity to erode your professionalism.|
|S – Situation|
|Give the patient's name, age and gender, and the main reason for your call.|
|State the perceived urgency of the problem. This will focus the listeners mind.|
|B – Background|
|Provide a succinct clinical history to contextualize the current problem.|
|A – Assessment|
|Pertinent examination findings, latest vital signs.|
|Results of relevant investigations as required.|
|Put it all together (their current condition, risks and needs).|
|What is your assessment of the situation? What is the doctor's assessment?|
|R – Recommendation|
|Be clear about what you are requesting, and what the listener requests in turn.|
|When should it happen? Agree to a time frame for review.|
|Repeat any orders to avoid misinterpretation.|
Graded assertiveness is a concept that originated from the airline industry's investigations into factors contributing to crashes. Analysts seeking to understand why adverse incidents happened in the airline industry found that there were staff who were afraid to be assertive in communicating with pilots and other senior staff even though they were aware that something was not right. This is not dissimilar in the healthcare environment (Attree 2007; Chiarella & McInnes 2008). The technique aims to assist the staff member to escalate their concern through a stepped process. It is important to use assertive communication tactfully, but prioritize the patient's safety over the healthcare provider's ego (Hunt et al. 2007). Although this may seem an intimidating task, remember your central role as your patient's advocate. Ultimately, you need to do what is right for them.
Assertiveness is not the same as aggression. One is about self-respect and expressing your validly held opinions, the latter is about disrespecting the other person and denying them their opportunity to express their opinions. Graded assertiveness is useful when team members have divergent thoughts about the situation or plan. The use of gentle cues initially may be all that is required to effectively communicate our misgivings about a patient's condition or the doctor's proposed course of action. The doctor may act in light of this new perspective, or alternatively be able to provide their reassuring perspective. Should the situation warrant it, and the context enables it, further statements as suggested in Table 3 can be offered in a non-threatening fashion, gradually escalated until each team member is satisfied that their concerns have been addressed.
Table 3. Levels of graded assertiveness and examples
|Level one: express initial concern with an ‘I’ statement|
|I am concerned about . . . |
|Level two: make an enquiry or offer a solution|
|Would you like me to . . . |
|Level three: ask for an explanation|
|It would help me to understand . . . |
|Level four: a definitive challenge demanding a response|
|For the safety of the patient you must listen to me|
All of the above techniques for obtaining effective verbal communication are offered in order to facilitate safe and high quality patient care. In addition, the quality of the communication environment and nurses' or doctors' experiences with this are directly related to levels of staff satisfaction. While nurses and doctors continue to receive distinct and segregated training, yet are required to be effective in their communication with each other there is the potential for communications, which do sink to the doctor–nurse game. Instead, using knowledge about what are productive ways to communicate in a chaotic environment will ensure nurse and doctor colleagues are able to maintain open communications. We have provided some insight for nursing staff into communicating with doctors, and a guide to facilitate mutually beneficial exchanges of information with the focus on patient-centred care and safety at their centre. We recommend that the capacity to develop shared mental models concerning communication in health be adopted at tertiary institutions offering pre-registration nursing and medical training and techniques and be woven into respective curriculum design. It is clear that policy directions have moved towards such a situation, and have been part of the international agenda at least since 1984. Standards for practice and curricula and also reports into the quality of healthcare professionals all tend in this direction. Until these policy directions find their way into inter-professional learning and education, techniques such as those offered above may afford nurses in practice with forms of productive communication with their medical colleagues.
Dr Alexandra Sasha Campbell, bsc (Medical), mbbs, fanzcp, Perinatal Psychiatrist, for her assistance in reviewing the manuscript.
Authors had equal contribution in the preparation of the manuscript.