Penn Nursing JOSNR 2014

josnrJournal of Student Nursing Research

CommunicationBarriers and Solutions

in Health Care

Vol 7 Iss 1 2013-2014

Table of Contents

Introduction from the PresidentVANESSA DIMARIA --------------------------------------------------------- 1

Deaf Culture in the Medical SettingSARAH A. VOISINE ------------------------------------------------------ 2 - 5

Barriers to Nurse-Physician Communication and Patients’ OutcomesMARY BLACKWELL --------------------------------------------------- 7 - 12

The Nurse-Physician Relationship: Problems and SolutionsCAROLINE BOURASSA ---------------------------------------------- 14 - 16

Communication: The Human ConnectionALAINA M. STOCHAJ -------------------------------------------------18 - 19

The Effectiveness of Current Communication Training on End of Life for Nurses in Oncology and Critical Care SettingsVANESSA DIMARIA -------------------------------------------------- 21 - 25

Introduction from the President

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

Dear Readers, Welcome to the 7th volume of The Journal of Student Nursing Research (JOS-NR). JOSNR is a student-run research journal published annually based at the Uni-versity 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 Organiza-tion of Student Nursing Research (OSNR) in 2007, it supports research among both undergraduate and graduate nursing students, promotes greater awareness of nurs-ing 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 im-pact nurse-patient communication, (2) communication with patients hard of hear-ing 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 in-spire you to begin research of your own to improve patient-centered care and overall health care practice.

Vanessa DiMariaPresident of OSNR

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 experi-ence 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 unaccept-able in today’s medical system. A focused effort to understand and listen to the needs of the Deaf com-munity 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 difficul-ties. 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 (Filec-cia, 2011). American Sign Language (ASL) is the pri-mary 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

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 ef-fective communication and interaction with others is so important to these patients.

Barriers within the Health Care SystemDeaf individuals frequently experience dif-

ficulty navigating the health care world— a setting where there is little consideration or understanding of the experience of a Deaf person. Historically, Deaf pa-tients 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 com-mon in today’s language, they emphasize the lack of cultural education and respect for this patient popula-tion. In terms of face-to-face communication with nurses and physicians, Deaf people often feel misun-derstood 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 practi-tioners 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 po-tential 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 adjust-ments 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 com-munities with limited success. The American Dis-abilities Act outlines the rights of hearing impaired individuals by stating, “Hospitals must provide ef-fective 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 inter-preters 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 im-portant 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 physi-cian 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 effec-tive 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 CommunicationIt is not practical to expect every physician,

nurse practitioner, and nurse in the nation to learn

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 includ-ed, 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 tele-phones should have teletypewriting (TTY) capabilities so Deaf patients have the same access to entertainment and communication as other hospital patients (Filec-cia, 2011). Medical settings, including exam rooms, hallways, cafeterias, and waiting rooms should be well-lit and have extra space available for an interpret-er. 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 improve-ment 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 when-ever possible (U.S. Department of Justice, 2005). In cases where an ASL interpreter is not readily avail-able, 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 maxi-mize 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 practi-tioners 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-re-corded video with closed captioning can aid in patient education. Additionally, health care professionals can


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 sign-ing hand, as this will significantly interfere with that patient’s ability to communicate (Richardson, 2014). Facial expressions are a significant part of communi-cation in Deaf culture, so health care providers should take care to keep their body language, facial expres-sions, 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 set-ting. While many of these changes in behavior and environment are small, when implemented together they can drastically improve a Deaf patient’s experi-ence with the health care system.

Conclusion The ability to provide every patient with the same high level of care regardless of race, socioeco-nomic 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 popu-lation 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 becom-ing 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 organiza-tion 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

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.htmFellinger, 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 cultur-al challenge. Creative nursing, 17(4), 174-179.

Glickman, N. S., & Gulati, S. (Eds.). (2003). Mental health care of deaf people: A culturally affir-mative 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. Re-trieved 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-of-hearing-services/student-resources/accommo-dations-tipsheets/communication-access-real-time-translation/

Lieu, C. C. H., Sadler, G. R., Fullerton, J. T., & Stohl-mann, P. D. (2007). Communication strategies for nurses interacting with deaf patients. Med-surg 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 lit-erature. 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.


Voisine, S.

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.

“...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.’”1


1 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

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 concern-ing 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 rec-ommendations 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 physi-cians 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. Is-sues 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 wide-spread improvement (Xyrichis & Lowton, 2008). The term interdisciplinary is best defined as the collabora-tion 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, Corri-gan, & Donaldson, 2000). The report identifies “failure of communication” as one of the types of error lead-ing 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

factor associated with 65% of sentinel events across the nation (Haig et al., 2006). Additionally, communica-tion 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 Insti-tute 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, increas-ing 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 interdisciplin-ary 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 communi-cation as one of the ten characteristics of good inter-disciplinary team work. Coupled with the increased opportunity for and financial advantage of specializa-tion in medicine, interprofessional collaboration, espe-cially between nurses and physicians, is necessary meet the health demands of the public (Xyrichis & Lowton, 2008).

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MethodA literature review was conducted to address the bar-riers 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 commu-nication. 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 con-strained 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 simu-lation 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, us-ing 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 edu-cation 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 physi-cians routinely communicate in concise, summariz-ing 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

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 disor-ganized 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 communica-tion, defined as a two-way conversation with multiple exchanges, between a physician and non-physician members of the health care team was noted (Zwaren-stein et al., 2013). The majority of nurse-physician communication occurred during daily rounds. How-ever 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 conver-sation or direct questions were ignored (Zwarenstein et al., 2013). This study suggests that barriers to nurse-physician communication include lack of support for nurses and lack of opportunity apart from daily rounds. During structured opportunities for commu-nication, the suggestions and opinions of the nursing staff were often ignored and considered less impor-tant than physician contributions (Zwarenstein et al., 2013). Communication from nurse to nurse was far more frequent and more likely to be a two-way con-versation 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 rehabilita-tion and immediate care settings in the UK. The study

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identified role clarity as an element of good interdisci-plinary 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 predomi-nantly 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 com-munication (Filcek, 2012). Understaffed work environ-ments, high patient acuity, and the use of technology rather than face-to-face communication, are all barri-ers to effective communication (Filcek, 2012). Separa-tion in geographical location, for example if staff gives care on different units or different clinics, also hinders teamwork and interdisciplinary communication (Xy-richis & 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 phy-sicians, which invalidates the contribution of the nurse, hinders positive teamwork and communication. Effect on Patient Outcomes Nurse-physician communication affects pa-tient safety and quality. Research shows that high-quality communication leads to good interdisciplinary teamwork, which is correlated with improved clini-cal performance in the inpatient setting (Filcek & Manojlovich, 2012). Though studies are specific to the medical setting in which they are conducted, conclu-sions 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 interdisciplin-ary input. While physicians concentrated heavily on patient medical issues, they ignored other complica-tions that could prevent timely discharge or cause adverse patient events (Zwarenstein et al., 2013). In-terdisciplinary input is essential to a holistic approach

(Xyrichis & Lowton, 2008). In the past few decades there has been a push to standardize the way nurses and physicians commu-nicate-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 com-munication using the SBAR method. After the imple-mentation of SBAR communication between nurses and physicians, the facility recorded a decrease in the rate of adverse events, from a baseline of 89.9 inci-dents 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 implemen-tation of the SBAR model (Haig et al., 2006). These findings suggest that standardized communication between physicians and nurses improved communica-tion 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 re-lationship 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 prac-tice 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 communica-tion, 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 Ques-tionaire 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 hospi-tal 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 (Mano-jlovich & 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 commu-nication 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 environ-ment, and patient outcomes as indicated by VAP, catheter associated bloodstream infection, and pres-sure 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 preva-lence 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 Ef-fectivness Questionnaire II. The study found nurse-physician communication to be a significant predictor of nursing job satisfaction. Nurses’ job dissatisfaction

is associated with lower patient satisfaction levels (McHugh, Kutney-Lee, Cimiotti, Sloane & Aiken, 2011). It stands to reason that increased job satisfac-tion may lead to higher patient satisfaction levels. Improving nurse-physician communication contrib-utes 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 litera-ture 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-experi-mental 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 sub-ject. “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 nurse-physician 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 inten-sive care or labor and delivery (Filcek & Manojlovich, 2012). Additionally studies are often limited to a geo-graphical 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 re-view 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 clini-cal practice. The evidence indicates that there must be a cultural change in the health care setting in order to

improve interdisciplinary communication and thereby improve patient safety and quality. Implications for Practice One of the primary roles of nurses is to advo-cate 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 cul-tural 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 pa-tient care. Lack of time for interdisciplinary communi-cation 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 prac-tices 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 workplac-es 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 indi-cates that a substantial degree of equality is required for interprofessional collaboration” (Zwarenstein et al., 2013, p. 6). Health care policies should promote equal-ity 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 nurse-physician 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 physi-cians (Filcek, 2012).Implications for Education Pre-licensure clinical training should promote

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 physi-cian 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 communica-tion. Understanding of effective nurse-physician com-munication should begin in the classroom. Standard-ized communication techniques such as SBAR should be taught and practiced in nursing and medical educa-tion (Haig et al., 2006). Interdisciplinary education and training will promote equality and mutual understand-ing in physicians and nurses.Implications for Research There are incredible opportunities for research in the area of enabling effective nurse-physician com-munication 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 var-ious settings such as ambulatory care settings (Filcek & Manojlovich, 2012). Research should focus on creat-ing 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 meth-ods should be validated and supported by research evidence, showing improvements in patient outcomes, interdisciplinary communication, and health care pro-vider satisfaction. Filcek & Manojlovich (2012) state, “Addressing the root causes of unfavorable nurse-phy-sician relationships is a key strategy to improve prac-tice 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.


Blackwell, M.

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, communication 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 communication, and patients’ outcomes. American Journal of Critical Care : An Official Publication, American Association of Critical-Care Nurses,

16(6), 536-543. McHugh, M. D., Kutney-Lee, A., Cimiotti, J. P., Sloane, D. M., & Aiken, L. H. (2011). Nurses’ widespread job dissatisfaction, burnout, and frustration with health benefits signal problems for patient care. Health Affairs, 30(2), 202-210. doi: 10.1377/hlthaff.2010.0100Nancarrow, 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 collaboration between physicians and other profes- sions on general internal medicine wards. BMC Health Services Research


Blackwell, M.

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.

“High-quality communication is a key

determinant and facilitator of patient-

centered care.” 2


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


The Nurse-Physician Relationship: Problems and Solutions

Caroline Bourassa

The nurse-physician relationship is a promi-nent 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 com-munication, 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 vari-ous 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 profes-sion 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.

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, stu-dent-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. Phy-sicians 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 relation-ship. The relationship needs to be made up of team-mates, not enemies, who respect each other’s profes-sional 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 relation-ship.

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

“Components of positive productive com-munication 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 collab-oration for patient care. It focuses on critical commu-nication proficiencies, including self-awareness, in-

Bourassa, C.


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 communica-tion are: 1.collaboration, 2.credibility, 3.compassion, and 4.coordination (McCaffrey et al., 2010). Collabora-tion consists of being organized, working to identify solutions, and engaging in positive dialogue. Credibil-ity is trying to avoid jargon and vague terminology and interacting assertively—though maintaining respect (McCaffrey et al., 2010). Among both nurses and doc-tors, 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 communica-tion 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 exper-tise. Continuing education, specialty certifica-tion, and participation in professional organi-zations, 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 physi-cians progresses easily because nurses feel more con-fident 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 problem-solving-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

is not just all up to the nurses to maintain this strong level of communication. The most basic communica-tion behavior used in any interpersonal context that physicians should do is make an appropriate introduc-tion. 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 phy-sicians have additional beneficial outcomes. For exam-ple, there are fewer complications and miscommunica-tions 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 com-munication 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 commu-nication, 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 out-comes, 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 rela-tionship has been shown to have an impact on patient outcomes (McCaffrey et al., 2010). The lack of com-munication 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

Bourassa, C.

at as a cornerstone for safe, quality patient care (Co-lombo, 2009). There are many summits and programs that hospitals put their employees through to help cre-ate 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 communica-tion 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 (Co-lombo, 2009). Models have been created to help develop the nurse—physician relationship. The Campinha-Bacote’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 complex-ity 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 be-tween nurses and physicians. The model focuses on awareness, knowledge, cultural skills, encounters, and desires (Manahan, 2010).

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

ConclusionWork-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 rela-tionships 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.

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 hos-pital. Nursing Standard, 24(40), 42-47.

Colombo, C. (2009). Nurse-physician summit: Foster-ing communication, collaboration, and com-mitment. 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:10.3928/00220124-20100326-04

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’ communi-cation: The relationship among communica-tion practices, satisfaction, and collaboration. Health Communication, 24(8), 683-691. doi:10.1080/10410230903263990


Bourassa, C.

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.

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


and health care provider communication. If a health care provider was not able to use

American Sign Language with the Deaf patient, a sys-tem 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 teach-ing is usually verbal with and comes from the regis-tered 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 writ-ten 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 Lan-guage 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 Philadel-phia have the ability to improve communication and access local American Sign Language programs. If suc-cessful, 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.

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 Lan-guage 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 Pennsyl-vania (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 ex-ample, 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 expan-sion of signing vocabulary. The fourth level is all about communicating in depth topics and becoming profi-cient 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

Stochaj, A.


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 percep-tions 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.

Stochaj, A.

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.

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

common. Background

Current literature identifies that communica-tion is necessary in providing quality care; therefore, it is a problem when clinicians are not skilled in com-munication. 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 ef-fectively 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 challeng-ing 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 (Sla-tore, 2012). The conversation becomes exponentially more difficult for nurses when the patient has a nega-tive prognosis (Aslakson, 2012).

Nurses also identified a lack consistency and ef-fective communication between nurses and physicians. Physicians wrongly assume nurses understand the numerous medical interventions and procedures, lead-ing to inadequate and strained communication that increases their lack of trust in each other (Wittenberg-Lyles, 2013). Trust is the foundation of successful inter-


DiMaria, V.

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

Vanessa DiMaria

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.

Abstract

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, tend-ing 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 er-ror or by observing others (Radtke, 2012). It is essen-tial 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 medi-cal 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 cur-rent communication-training methods are for nurses facing end-of-life discussions in critical care and oncology settings, where end-of-life discussions are

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 ad-dress the topic (Asklakson, 2012). A language or cultural barrier is the final prob-lem identified that inhibits patient communication be-cause “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 dis-cussion.

These five barriers to effective end-of-life communication cannot be ignored in communica-tion training programs. For example, training should include an interdisciplinary approach to address nurses who feel like a “middle man” and avoid strained nurse-physician communication by offering tools or strate-gies 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 cul-tural 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.

MethodsAssisted 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 vari-ous combinations with each other to find studies: com-munication skills training, end of life, critical care nurse, oncology nurse, education, and intervention. Reference lists of selected studies were hand searched for addi-

DiMaria, V.

tional clinical trials and literature. Eligibility for analysis was defined before the

search began. All literature had to be focused on nurs-ing 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 ex-perimental and non-experimental studies, it was soon modified to investigate literature on experimental and interventional studies. It was important to use litera-ture aimed toward evaluating critical care and oncol-ogy 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, specifi-cally nursing interventions, and include an effective analysis. These studies tested the following interven-tions: interactive role-play, training, didactic and edu-cational lectures, simulation scenarios with fake pa-tients, collaborative communication training including learning activities, small group skill practice and prob-lem 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 inter-ventional analysis, and quasi-experimental as methods of conducting their investigations. While some studies are focused on critical care or oncology nursing com-munication 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 oncol-ogy units; these diagnoses are the leading causes death (Friedenberg, 2012; Tay, 2012).

State of the ScienceSix 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 ef-fectiveness of educational communication-training interventions. The first study of this analysis measures the impact of three varying levels of education on


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 train-ing 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 ef-fectiveness, 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 communica-tion, and their attitude toward dying patients (Henoch, 2013). Assessing nurses in oncology, hospice, and pal-liative 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 practic-es based on training material read outside of the train-ing 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 interven-tion 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 (MOREC-are), Higginson and colleagues (2013) created the Psy-chosocial 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

prior to the tool’s use. This study “led to much discus-sion about decision-making, communication, and end-of-life issues” (Higginson, 2013, p.18). The interven-tion 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 expecta-tions. 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 de-veloped a new intervention to evaluate an interactive approach. Critical care nurses participated in a six-hour communication-training session led by special-ized 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 chal-lenges 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’ commu-nication expertise (Krimshtein, 2011, p.1330). Boyle and Kochinda (2004) also addressed nurses’ concerns about communicating with physi-cians. Using an intervention previously designed to improve communication between physicians and nurses (“The Collaborative Communication Interven-tion”), critical care nurses were taught core communi-cation and relationship-building skills that addressed important key principles like esteem, empathy, involve-

DiMaria, V.


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).

DiscussionThe studies bring attention to the fact that ef-

fective communication skills training programs exist; the problem is the lack of prevalence and use of the programs and interventions. It is important to ap-preciate 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 real-istic role-play to practice the skills taught in the edu-cational 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 communica-tion skills are both teachable and learnable with the right intervention (Krimshtein, 2011).Limitations

While each of these studies has their own limi-tations, 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 meta-analyses. In addition, all of the studies but one evaluat-ed their intervention through a nurse’s self-evaluation; it is important to assess the patient and family’s sat-isfaction 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. Ad-dressing these limitations would be a productive step

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 neg-ative patient outcomes (Boyle, 2004). These interven-tions could be implemented in general hospital settings during patient admission rather than solely for criti-cally 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 commu-nication class should be a mandatory part of students’ curriculum; the class could address end-of-life conver-sations in addition to parent communication for pedi-atric nurses and mother-baby communication for labor and delivery nurses. The goal is a standardized require-ment 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 train-ing 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 communi-cation 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 com-munication 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.

ConclusionSeveral communication skills training pro-

grams, along with education on end-of-life discus-sions, have been around for years; however, it is only

DiMaria, V.


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.

References

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Boyle, D. K., & Kochinda, C. (2004). Enhancing col-laborative communication of nurse and physician leadership in two intensive care units. Journal of Nursing Administration, 34(2), 60-70. Retrieved from www.scopus.com

Friedenberg, A., S., Levy, M., M., Ross, S., & Evans, L., E. (2012). Barriers to end-of-life care in the intensive care unit: Perceptions vary by level of training, dis-cipline, and institution. Journal of Palliative Medi-cine, 15(4), 404-411. doi:10.1089/jpm.2011.0261

Haddad, A. (2002). Ethics in action: fairness, respect and foreign nurses. RN. 65, 25-28.

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 tri-al. 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,

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 interdisciplin-ary communication with families in the intensive care unit: An intervention. Journal of Pallia-tive 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 on-cology 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 patient-centered care. American Journal of Critical Care, 21(6), 410-418. doi:10.4037/ajcc2012124

Tay, L., Hui, Ang, E., & Hegney, D. (2012). Nurses’ per-ceptions of the barriers in effective communication with inpatient cancer adults in singapore. Jour-nal 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 bar-riers to patient-centered care. Clinical Journal of Oncology Nursing,17(2), 152-158. doi:10.1188/13.CJON.152-158

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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.

JOSNR Editorial Board

JOSNR is a publication of The Organization of Student Nursing Research. Copyright © 2014 OSNR. The contents of this journal should not be reproduced or reprinted without the permission of The Journal of Student Nursing

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Special Thanks to:

Faculty AdvisorKathleen 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 BoardCynthia A. Connolly, PhD, RN, PNP, FAAN

Kirsten Hickerson, RN, MS, CEN Eun-Ok Im, PhD, MPH, RN, CNS, FAAN

Anita Iyengar, MSN, BSN

Editing AssistanceMary Blackwell

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