The importance of effective communication between doctors and nurses and its impact on patient careCritical Analysis of a Clinical Incident.

by sih10unibrightonacuk (student)

University Degree Subjects allied to Medicine

The importance of effective communication between doctors and nurses and its impact on patient care; Inter-professional learning from a student nurse’s perspective

Critical Analysis of a Clinical Incident

As student nurses, throughout this nursing course, we have continuously been reminded of the numerous issues in healthcare; some ongoing and some more current. Members of the multidisciplinary team are encouraged and expected to work together and overcome these issues so they can provide patients with the care they need. Therefore, the need for Inter-professional learning (IPL) is ongoing.
Considering the limited word count allowed for this assignment, I will be reflecting on a clinical incident (see Appendix I) that took place on a cardiology ward where I worked as a third year student nurse. Although this clinical incident arises various problems that could be classed as current issues in healthcare, for the purpose of this assignment I have decided to focus on the issue of communication between nurses and doctors in the clinical setting and its’ impact on patient’s care. This assignment offers definitions on effective communication and inter-professional learning as well as it outlines certain barriers that can prevent effective communication. Gibbs’ reflective cycle (1988) is used throughout the assignment to encourage a natural flow of events and to aid a comprehensive reflection (Gibbs, 1988).

‘Information is fundamental to choice and making informed decisions. Without information, there is no choice. Information helps knowledge and understanding. It gives patients the power and confidence to engage as partners with their health service.’
(Department of Health, 2004, p.2 as cited in Berry, 2007)

Communication is the way in which information is shared with others. Northouse and Northouse (1998) define communication as the transfer of information between a source and one or more receivers using a set of common rules (Berry, 2007). Berry (2007), states that communication can be verbal and non-verbal; therefore we as human beings communicate with each other even when we are not saying anything. Mc Hugh Schuster (2010) claims that: ‘communication is the use of words and behaviours to construct, send and interpret messages’. Ellis et al. (2003) state that communication is a basic human need and according to them, lack of communication can have adverse consequences on one's psychological, social and physical health (Ellis et al, 2003). Inter-professional learning (IPL) can be described as the process where two or more professionals who share a common subject, work together whilst understanding and respecting each other’s roles (Cullen et al., 2003).

As a student nurse, I consider ward round to be an excellent inter-professional learning opportunity. In my experience, this is one of the rare occasions when the medical and the nursing team, physiotherapists, pharmacists, nursing and medical student are confined to one area and expected to collaborate jointly. Zwarenstein and Bryant (2000) define collaboration as nurses and doctors working together and sharing patients’ care responsibility. They claim that for collaboration to be successful, decision making has to be joint (Zwarenstein and Bryant, 2000). However, Barnsteiner et al. (2007) claim that collaboration is much more complex than that and requires mutual commitment and mutual respect among collaborators, including face to face encounters as well as telephone and e-mail communication. Furthermore, they present evidence that doctors and nurses may define teamwork and collaboration differently; whilst nurses often describe collaboration as including shared decision making, some doctors describe it as having their directions followed and their needs anticipated (Barnsteiner et al., 2007). The nursing and midwifery code of conduct (2008) state that nurses should work co-operatively with others while respecting their knowledge, experience and contribution (Nursing and Midwifery Code of Conduct, 2008).

Reflecting back on the clinical incident (Appendix I), it was obvious that communication between the medical team, the nursing team and the patient had not been effective; the doctor had ignored the concerns raised by the nursing team on the previous day and had not read the notes properly, nor briefed his team beforehand as he had agreed to.

‘Listening is as important as what we say and do and essential for "no decision about me without me". Communication is the key to a good workplace with benefits for those in our care and staff alike.

(Department of Health, 2013)

This quote was coined by the Department of Health in the aftermath of the Mid-Staffordshire report (Francis, 2013). Communication is one of the 6Cs, alongside care, compassion, competence, courage and commitment, which the government has used to reinforce the values and beliefs that should underpin all nursing care (Department of Health, 2013).

Despite the excellent nursing care Patient X had received on the ward, the doctor’s oversight had left the whole team appear unprofessional in front of the patient. As she later pointed out to her nurse, she had begun to doubt the doctors’ expertise because they had missed out such vital informations about her on two consecutive occasions.
Nurses are in a unique position within a healthcare environment, and are often the first point of contact for patients (Sheldon et al., 2006). Nurses spend a large amount of time communicating with patients, often not only conveying information but also conveying emotion, and transmitting a reaction to a patient that shows them that their feelings are being recognised (McCabe, 2006). For example, by showing empathy towards a patient, a nurse is demonstrating an understanding of their feelings. The nurse looking after Patient X that day spent prolonged periods of time reassuring her patient that she will receive the best care possible during the procedure and after, which seemed to help the patient.

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As McCabe's (2006) study shows, communication in nursing care is an area that is largely overlooked, often because nurses within a hospital setting will tend to focus on practical tasks involving a patient, and on occasion may feel unable to communicate with patients due to lack of time. However, if the care a patient receives in hospital is to be a positive experience then the care must be more patient-centered. Peplau’s (1988) findings would also appear to support the theory that nursing, is in essence, an interpersonal process. This suggests that nurses need to be able to communicate on a variety of levels with patients, relatives, and members of the multidisciplinary team and thus be active in developing their communication skills (Ellis et al., 2003). This forms the idea that how nurses communicate with patients can have a major influence on their health and wellbeing and it can help to explain why communication is so important within nursing. Poor communication can affect a patient's health and wellbeing in a number of ways. On this specific occasion the nurse tried to communicate with Doctor A but he was not willing to engage in an effective communication process with her or the patient. The patient tried to ask questions at ward round but my feeling was that the doctor’s ignorance had shocked her so she could not say much at the time. The nurse attempted talking to the doctor after the ward round but he was not willing to answer questions and walked away without talking to either of them. Despite the nurse’s best effort to act as her patient’s advocate, she was left feeling angry and disappointed because the doctor had not acknowledged her concerns.

Communication failures between medical professionals can occur for a variety of reasons. Bach and Grant (2012) argue that communication between groups of professionals working within the same team can be a challenging process. Firstly, it has been theorised that the way in which nurses and doctors are trained to communicate is different (Leonard et al., 2004). It could be argued that nurses are trained to be descriptive of a patient's concerns and conditions whereas doctors are trained to be concise and to the point. This can lead to medical colleagues misinterpreting information which in extreme circumstances can lead to patient harm. The way in which the doctor had trained could be one of the possible explanations why he was focusing only on the procedure that Patient X had to undergo and failed to treat her holistically as a person. Another possible reason for his behaviour could have been that he was undermining the nurse’s role. Furthermore, Fagin and Garelick (2004) believed that doctors were supposed to control nurses by identifying tasks for them to carry out. Although, this traditional view is now considered being old fashioned and untrue, some doctors are still practicing with this attitude. Finally, another rationalisation for the doctor’s arrogance could be explained by Garmarnikow’s theory (1978) of Doctor’s masculinity over the nurse’s feminine nature (Allen, 2001). According to this theory, doctors are strong willed and nurses are much more placid. However, with the changes in the NHS and the development of the specialist nurse this attitude that nursing is feminine is slowly changing. Nowadays, specialist nurses work alongside senior doctors so their expertise is highly valued (Reed, 1994). These stereotypical views are not as common within the NHS as they used to be due to the fact that inter-professional learning and practice is much more common than in the past; different health professionals are aware of each other’s roles and work together with mutual respect for their professions. However, the perception that nursing is for girls is still widely shared within the general public. Lord (1997), suggests that stereotyping can be reduced by influencing the media. Media plays a very important role in raising awareness and by portraying the modernisation of nursing it can educate the general public of development in the nursing profession.

Stereotyping of a particular profession can occur if individuals are not open minded towards other professions they are to learn and work with (Borkowski, 2011). Although, this had never been an issue on this particular ward in the time of me being there, on this particular occasion the nurse felt that she was unable to get through to the doctor so she let him walk away. Occasionally it can be that there is a hierarchy between medical professionals which can make nurses feel unable to voice concerns about a patient or even challenge information. Barrett et al. (2005) suggest that communication is essential to inter-professional learning and working and that any problems or differences should be dealt with to achieve a positive outcome. This could be overcome with a more standardised approach to communication within the hospital care environment, for example by creating a standardised communication method in training both nurses and doctors (Leonard et al., 2004). In clinical settings, successful teamwork often results in communication that is more effective. When this is done at a basic level, by embedding effective communication skills within the training of medical professionals, it can mean better patient outcomes and a minimised risk to patient's health (Leonard et al., 2004).

Later on that morning, after the cardiac team had finished their ward round, Doctor A was back on the ward and catching up with his patient; the nurse saw this as an opportunity to approach him and discuss her patient. She explained that her patient was left anxious and very doubtful of the medical care she was receiving on the ward. The fact that the doctor appeared to have missed some vital information about her condition had left frightened and skeptical that her angiogram would go without complications. On this occasion, the doctor was ready to engage in a conversation with the nurse and could see what effect his behaviour had had on the patient’s emotional state. He explained to the nurse that he was coming to the end of his 24 hours shift and had not had much time to rest; at the same time, he was feeling the pressure of presenting all his patients to the consultant and had done the ward round in a hurry. After being made aware of his unacceptable behaviour, he was very willing to discuss the matter with the nurse and the patient. Doctor A offered his apologies to both of them and reassured the patient that her case would be looked into much more details before she goes for her angiogram. Furthermore, she will be awake for the procedure and will have a say in what happens during and after it. This left the patient reassured and satisfied that she will be in safe hands. Although, the nurse could not get through to the doctor earlier that day, she was much more successful when there was less pressure on the doctor from the rest of the team and he had time to reflect on his behaviour. However, these personal issues that the doctor was experienced should not have affected his professional relationship with the nurse or the patient and he should have been more self-aware of his behaviour and unprofessional practice.

Inter-professional learning is now a required part of the education of all working within heath care today and aims to ensure effective collaborative working across a multidisciplinary workforce (Uys and Gwele, 2005). There has been recent evidence to suggest that inter-professional learning should be started as early as possible within an undergraduate curriculum (Barr et al., 2005)

Communication between medical professionals is not the only area where there can be issues and barriers to successful communication. Often patients can experience communication barriers that can affect the care and services they receive. One study has highlighted the need for more generalised language to be used when medical professionals communicate with patients, an area that would appear to be relatively unexplored. Patients can be generally unfamiliar with medical terminology; as a result can feel confused by the vocabulary used by doctors and nurses (Ong et al., 1995). This claim would support the theory that for more quality patient interaction to occur there is a need for better communication training to take place. There is also evidence to suggest that although doctors and nurses view communication as a vital and important tool within nursing, it is often overlooked due to 'lack of time'. However, communication need not be for prolonged periods in order for more successful patient outcomes to be achieved, and patients recognise that it is quality of the interaction that is important (McCabe, 2004). One patient outcome, which is easily measured, is patient satisfaction.

If a similar incident occurs in future practice, perhaps the nurse can be more assertive and vocal. Although, everyone can have a bad day at work, this should not affect the inter-professional relationship with other professionals and definitely not be allowed to affect patient care.

Having reflected on this clinical incident, I have come to the conclusion that inter-professional learning and effective communication are a paramount for patients’ care. Inter-professional relationships are not always smooth and it takes a lot of effort from the professionals involved to make them successful. Research found that communication is a fundamental skill that forms the foundation for nurse-doctor, nurse-patient and doctor-patient interaction, and can be used as a tool to ensure positive patient outcomes. Furthermore, research suggest that health professionals would benefit from more training with regards to communication skills; for example being taught how to communicate effectively, how to listen actively and how to communicate with patients in an individualised way. It has also been identified that early exposure to inter-professional learning (Barr et al., 2005) can educate future health professionals to think otherwise. Barriers to communication can be perceived stereotyping, considering others to be more hierarchical than us and underestimating the values and expertise of other healthcare professions. Patient care is a complex area and no health professional can accomplish their part properly without having to collaborate with other health professionals. What concerns me most as a student nurse who in weeks’ time will be fully responsible for patients’ wellbeing is how nurses can improve communications between their patients and the rest of the multidisciplinary team members. As identified within the Francis report (2013) communication is the key to effective learning and collaborative working. This would mean nurses can have a more patient-centered approach and patients would experience a higher level of satisfaction from their interaction with nursing professionals. Communication problems can occur because nurses feel unable to devote time to actively communicating with patients; however, patient-centered communication can be done alongside practical tasks, and during all patient interaction. Whilst practical nursing skills are often paramount, evidence would seem to suggest effective communication could have significant and beneficial effect on patient outcomes, patient recovery, and interpersonal relationships within the multi-disciplinary healthcare team. Ultimately, communication is important for a variety of reasons within nursing, and it is vital that this is recognised and communication within nurse training and nursing in general is improved.

References:

Allen, D., 2001, The Changing Shape of Nursing Practice: The Role of Nurses in the Hospital Division of Labour, London: Routledge.
Bach, S. and A. Grant, 2012, Communication and Interpersonal Skills in Nursing, Exeter: Learning Matters Ltd.
Barrett, G., D. Selman and J Thomas, 2005, Interprofessional Working in Health and Social Care: professional perspectives, London: Palgrave Macmillan.
Barnsteiner, J.H., J. M. Disch and L. Hall, 2007, Promoting Interprofessional Education, Nursing Outlook, May/June 2007, Vol. 55, No. 3, pp. 144-50.
Barr, H., I. Koppel, S. Reeves, M. Hammick and D. Freeth, 2005, Effective Interprofessional Education: Argument, Assumption and Evidence, Oxford: Blackwell Publishing limited.
Berry, Dianne., 2007, Health Communication Theory and Practice, London: Open University Press.
Borkowski, N., 2011, Organisational Behaviour in Health Care, 2nd Ed, London: Jones and Bartlett Publishers.

Coombs, M.A., 2004, Power and Conflict between Doctors and Nurses Breaking through the inner circle in clinical care, London: Routledge.
Cullen, L., D. Fraser and I. Symonds, 2003, Strategies for Interprofessional education: the Interprofessional Team Objective Structured Clinical Examination for midwifery and medical students, Nurse Education Today, 23, 427-433.

Department of Health, 2013, Implications of the Francis Report.

Accessed Online 7th January 2014 at:

http://www.nhscareers.nhs.uk/promotions/implications-of-the-francis-report/

Fagin, L. and A. Garelick, 2004, The doctor-nurse relationship, Advances in Psychiatric treatment.

Accessed online 6th January 2014 at:

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Francis, R. 2013. Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry. The Mid Staffordshire NHS Foundation Trust Public Inquiry. London: NHS.

Ellis, R., B. Gates and N. Kenworthy, 2003, Interpersonal Communication in Nursing: Theory and Practice, 2nd Edition Livingstone: London.

Gibbs, G. 1988, Learning by Doing: A guide to teaching and learning methods. Oxford: Oxford Brookes University.

Leonard, M., S. Graham and D. Bonacum, 2004, The human factor: the critical importance of effective teamwork and communication in providing safe care, Quality and Safety in Health care, October, 1: i85-i90

Accessed online 6th January 2014 at:

Lord, C., 1997. Social Psychology, Philadelphia: Harcourt Brace College Publisher.

McCabe, C., F. Timmins and J. Camping, 2006, Communication Skills for Nursing Practice, Palgrave Macmillan Limited: Dublin.

Mc Hugh Schuster, P. and L. Nykolyn., 2010. Communication for Nurses- How to Prevent Harmful Events and Promote Patient Safety, Philadelphia: F.A. Davis Company.

Nursing and Midwifery code of Conduct. 2008. The code: Standards of conduct, performance and ethics for nurses and midwives. London. Nursing and Midwifery Council: 1-8.

Ong, L.M., J.C. de Haes, A.M. Hoos and F.B. Lammes, 1995, Doctor-patient communication: a review of the literature, Social Sciences and Medicine, Apr; 40(7): 903-18.

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Reed, S., 1994, Exploring new roles for nurses in the acute sector, Professional Nurse: Vol 14, 90-94.

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Appendix I

The clinical incident analysed in this assignment describes what happened over the course of two days. This is an account of an incident I witnessed as a nursing student whilst in placement at the local hospital trust. In order to comply with the Nursing and Midwifery Council (NMC) Code of Practice, the identity of the ones involved will not be revealed and pseudonym will be used instead. Patient X, a lady in her 60s, admitted with chest pain and ST elevation, awaiting angiogram with the possibility of having angioplasty. Patient X is a diabetic, with bilateral below knee amputation few years ago, previous history of cardiac bypass, when grafts from her left arm were used. Furthermore, Patient X is a Jehovah’s Witness and refuses blood transfusion under any circumstances.

The incident took place during the morning ward round. When the doctors went to see Patient X in bed two, they overlooked the fact that she had had bilateral below knee amputation in the past. They became aware of it whilst attempting to feel her pedal pulse. After the ward round, discussion took place between the doctors and the nurses, both teams acknowledging that what happened appeared unprofessional and uncaring toward the patient; they agreed that in order to prevent similar incidents, in future all doctors will be briefed about the patient’s condition by the doctor in charge prior to the ward round.

The following day the incident from the previous morning was highlighted during nurses’ handover and nurses were reassured that the doctors on duty for that day will be made aware of the patient’s condition prior to ward round.

During ward round that morning, attended by the same doctor in charge as the morning before, the doctors discussed the procedure with the patient and explained that in order to perform angiogram, they would need to access the coronary arteries, for which they use either a femoral or a radial artery. At this point, the nurse in charge attempted to remind the doctor discreetly about the leg amputations and the previous graft used from the left arm.

Due to the previous interventions, the patient had part of her radial artery missing in her left arm and a femoral bypass in both legs, therefore leaving only the right arm available for angioplasty. In theory this meant that the procedure was more risky than normally and the patient’s risk of bleeding during the procedure was also increased.

Yet again, the doctors appeared oblivious to these facts and continued discussing a femoral access for angiogram. When reminded the second time about the bilateral leg amputation, they insisted that it is only the left leg that was amputated until the patient clarified that in fact it is both legs she had amputated. Furthermore, she showed her left arm to the doctors and explained the partial artery graft taken from her arm. Finally, she reminded them about her religion and what it meant for her- a definite refusal to blood transfusion.

This baffled the doctors and they decided that they have to go away and look into this case more thoroughly before proceeding with the angiogram. No apologies were offered to the patient or to the nurses for behaving unprofessionally and what may appear as uncaringly towards the patient.

After the ward round, the nurse in charge of the patient, apologised unreservedly to the patients about the doctor’s team behaviour and accepted some professional responsibility for the way in which Patient X was treated. Patient X accepted the apologies and laughed the whole incident off but it was obvious that she was upset by this incident.

In the end, Patient X had her procedure successfully and was discharged home the following day. However, I cannot help but wonder, what could have happened if the patient or the nurses had not been proactive.

Appendix II

Gibbs’ Reflective Cycle

Stage 1: Description of the event

Describe in detail the event you are reflecting on.

Include e.g. where were you; who else was there; why were you there; what were you doing; what were other people doing; what was the context of the event; what happened; what was your part in this; what parts did the other people play; what was the result.

Stage 2: Feelings

At this stage try to recall and explore the things that were going on inside your head, i.e. why does this event stick in your mind? Include e.g. how you were feeling when the event started; what you were thinking about at the time; how did it make you feel; how did other people make you feel; how did you feel about the outcome of the event; what do you think about it now.

Stage 3: Evaluation

Try to evaluate or make a judgement about what has happened. Consider what was good about the experience and what was bad about the experience or didn’t go so well

Stage 4: Analysis

Break the event down into its component parts so they can be explored separately. You may need to ask more detailed questions about the answers to the last stage. Include e.g. what went well; what did you do well; what did others do well; what went wrong or did not turn out how it should have done; in what way did you or others contribute to this

Stage 5: Conclusion

This differs from the evaluation stage in that now you have explored the issue from different angles and have a lot of information to base your judgement. It is here that you are likely to develop insight into you own and other people’s behaviour in terms of how they contributed to the outcome of the event. Remember the purpose of reflection is to learn from an experience. Without detailed analysis and honest exploration that occurs during all the previous stages, it is unlikely that all aspects of the event will be taken into account and therefore valuable opportunities for learning can be missed. During this stage you should ask yourself what you could have done differently.

Stage 6: Action Plan

During this stage you should think yourself forward into encountering the event again and to plan what you would do – would you act differently or would you be likely to do the same?

Here the cycle is tentatively completed and suggests that should the event occur again it will be the focus of another reflective cycle

Jasper, M. 2003. Beginning Reflective Practice – Foundations in Nursing and Health Care. Nelson Thornes. Cheltenham

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