ANN ARBOR—Communication breakdown among nurses and doctors is one of the primary reasons for patient care mistakes in the hospital.
In a small pilot study, University of Michigan researchers learned about potential causes of these communication failures by recording interactions among nurses and doctors, and then having them watch and critique the footage together.
Several themes emerged to help explain the poor communication, and both nurses and physicians improved their communication styles, said Milisa Manojlovich, U-M professor of nursing, who defines communication as reaching a shared understanding.
One barrier to good communication is that the hospital hierarchy puts nurses at a power disadvantage, and many are afraid to speak the truth to doctors, said Manojlovich, who is also a member of U-M’s Institute for Healthcare Policy & Innovation (IHPI).
The recordings showed that nurses didn’t directly request what they wanted or express their needs. They communicated indirectly, which confused physicians, who often ignored the nurses’ requests and moved on to the next agenda item rather than ask for clarification.
The study also found that because doctors and nurses approach patient care from vastly different angles, achieving understanding isn’t easy.
Manojlovich said one interaction in particular really showcased the different approaches to patient care. A patient with mouth pain, caused by a fungal infection called thrush, couldn’t swallow the pills she needed to get better. The physician wanted to prescribe more medication to treat the thrush, but the nurse––who knew the patient well––wanted to treat the patient with strong painkillers, as well.
“The physician realized that the pain was inhibiting the treatment, and treating the pain, as well as the condition, would solve the problem,” Manojlovich said.
Finally, the recordings showed that in good communication, the body language of both parties mimicked the other. In strained relationships, body language wasn’t in sync.
Manojlovich and her team followed physicians and nurses at Michigan Medicine. Then, nurses and physicians watched and commented on the clips separately, and those comments were incorporated into the video. Finally, both parties watched the clip together.
“The only way you can become aware of your habits is by watching yourself,” Manojlovich said.
Overall, the interactions were positive in the sense that there wasn’t any contention, but there was room for improvement.
“One physician said, ‘I didn’t give the nurse a chance to answer,’ and this physician had a habit of doing that and recognized it,” Manojlovich said. “She was one of the champions of the study.”
Next, Manojlovich hopes to record a larger group and use the videos as training tools to improve communication.
Other study authors include: Sarah Krein, U-M research professor in internal medicine and IHPI member; Timothy Hofer, U-M professor of internal medicine and IHPI member; Elizabeth Umberfield, doctoral student at the U-M School of Nursing; Molly Harrod of the VA Ann Arbor Healthcare System; Richard Frankel of Indiana University; and Alaa Heshmati, a former researcher at the U-M School of Nursing.
The project was supported by grant number R03HS024760 from the Agency for Healthcare Research and Quality.
endo55 on August 1st, 2018 at 00:14 UTC »
A real case from Johns Hopkins Hospital in Baltimore vividly demonstrates how the desire to protect our egos destroys our capacity to learn. The operation involved a patient suffering from a recurrent hernia and the anaesthetist on the case was Peter Pronovost, who would go on to become arguably the world’s greatest champion for patient safety.
Ninety minutes into the operation, the patient started wheezing and her blood pressure plummeted. Pronovost suspected that she had a latex allergy and that the surgeon’s gloves were at fault. He provided a dose of epinephrine and her symptoms dissipated. He then advised the surgeon to change gloves. The surgeon disagreed. “You’re wrong,” he said. “This can’t be a latex allergy… The patient didn’t experience a reaction during any of her previous procedures.” The stakes were now set. Any new evidence from this point on was likely to be interpreted not as an opportunity to do what was right for the patient, but as a challenge to the surgeon’s ego.
With the argument escalating, the junior doctor and nurses were pale-faced. Pronovost was now certain that if the surgeon didn’t change gloves the patient would die. So, he changed tack. “Let’s think through this situation,” he said gently. “If I’m wrong, you will waste five minutes changing gloves. If you are wrong, the patient dies. Do you really think this risk-benefit ratio warrants you not changing your gloves?”
You might imagine that the surgeon would accept that logic. But he didn’t. The risk-benefit ratio had become about weighing the life of a patient against the prestige of a surgeon whose entire self-esteem was constructed upon the cultural assumption of his own infallibility. “You’re wrong,” the surgeon said.
This could have been the end of it, and normally it would have been. After all, the surgeon is in charge. But Pronovost, who had lost his father to medical error, stuck to his guns. He instructed the nurse to telephone the president of the hospital so that he could overrule the surgeon. The nurse picked up the phone, but hesitated, looking at the two men. Only as the number was dialled did the surgeon budge.
He swore, dropped his gloves, and strode to change them. Once the operation was over, tests confirmed what Pronovost suspected: the patient had a latex allergy. If the surgeon had got his way, she would almost certainly have died.
http://www.menshealth.co.uk/healthy/big-read-why-failing-is-important
DijonPepperberry on July 31st, 2018 at 23:07 UTC »
Our hospital has a policy called "stop the line". It comes directly from hospital administration (above us docs) and clearly establishes that anyone who wishes to pause any process and check for/ask about/ refuse to commit what they think is a mistake can do so. It's a very important institutional power. Every person involved in a medical mistake will severely regret not being double checked, or speaking up.
WestyWorld on July 31st, 2018 at 22:59 UTC »
They have been working on this for years already. It's a hospital culture problem. At my hospital they have been having seminars with nurses and doctors together and reinforcing a culture where nurses are never penalized for bringing up concerns.
Having worked in hospitals for a few years, I can say that time constraints, mainly on physicians, probably plays a bigger role. Try to figure out how to help a 90 year old man, who you've never met before, with heart, lung, kidney and liver issues, autoimmune disease and various social and psychological problems in 30 minutes. It's impossible.