Can We Talk? Structured Paths to Better Communication
by: W. C. Wilson, Esq.;; 12/03/14

Susan was a 65-year-old woman who was simply living independently without having acute deficits, and who had been independent in all her activities of daily living. Then she had a stroke, causing hemiparesis on her left side. After a lengthy stay at an acute facility, she was admitted to some skilled nursing facility (SNF) for rehabilitation. Susan’s first month at the SNF was mostly uneventful. Her weekly weights were stable, she attended therapy, and her mobility and independence along with her activities of day to day living seemed being improving. Because her weekly weights were stable, the SNF stopped the weekly weigh-ins, per their policy, after four weeks. The attending physician saw Susan twice in the first month without adverse observations noted.

Susan’s second month, per the chart notes, also was mostly uneventful. However, the chart noted several behavior changes, like increased refusal to visit therapy, refusal to consume or finish her meals, and social withdrawal. Susan’s family encouraged her to consume, but Susan refused, saying she was not hungry. By the end in the second month, Susan had lost 17 pounds. Her physician was notified from the extreme fat loss and ordered Reglan, a new diet, as well as a restorative nurse assistant (RNA) dining program. Three days later, Susan was found unresponsive an hour after being assessed by way of a staff member, who found her vitals to get normal and her responsiveness to get normal. The attending physician saw Susan once in the second month and did not note any concerns about Susan’s weight reduction.

Susan’s family sued the SNF, claiming she had starved to death. The chart indicated that Susan was eating her meals, but was consuming less within the second month than in the first. In the Minimum Data Set (MDS), she was noted to get 119 pounds, but in line with the licensed nurses’ notes, she weighed 17 pounds below what was reported for the MDS. The attending physician examined Susan 6 days ahead of her death and only agreed to be concerned with nausea and vomiting, potentially because of gastroparesis. Reglan was prescribed. The physician’s progress note would not contain any mention of fat loss.

Susan’s case appeared to get one of communication breakdown between your nursing staff and also the physician, and maybe observational failure from the SNF staff. The chart notes would not appear to follow any set pattern of communication between your physician along with the staff. When the clinician was notified of an issue or change of condition, the note basically “physician notified.” There was no further elaboration within the chart for the details from the notification and the outcome of the contact with the clinician. Once the legal team became involved, it turned out sheer speculation as to what occurred involving the nursing staff as well as the clinician if the “physician notified” note appeared inside chart. This vague charting does not help, and potentially hurts, a defense.

Physicians or their medical professionals are required to make rounds on their own patients at a minimum of once every thirty days for the 1st 90 days, and at least every sixty days thereafter. If a clinician rounds take presctiption a resident only once a month, good communication between staff and the clinician is even more important than should they be regularly speaking with each other face-to-face. Communication channels are a two-way street. Staff should be prepared to report on residents, and physicians have to be willing to listen. Studies have shown that effective nurse-physician communication has resulted in increased satisfaction for nurses and increased patient safety.

Barriers to Communication: Behaviors

In 2008, the Joint Commission’s National Patient Safety Goals described nurses’ perceptions of nurse-physician communication in the long-term care setting. The nurses identified several barriers to effective nurse-physician communication, like: (1) insufficient physician openness to communication, (2) logistic challenges, (3) not enough professionalism, and (4) language barriers. Feeling hurried from the physician was the commonest barrier. The nurses also reported frustrations with communication due to physician interruptions before the nurses finished reporting on the patient, or because from the physician’s failure to go back calls. The physician’s failure to call back a timely manner affected communication quality just because a long gap involving the call as well as the call back limited nurses’ preparedness for your call.

Inadequate preparation around the part from the nurses generated physician frustration, which led to ineffective communication. The nurses also described troubles of dealing with covering physicians who have been not familiar with any particular patient.

The nurses knew that being prepared for a trip to the physician was necessary for good communication. The report recommended that nurses communicate clearly, explain the reason for that call assuring clearly what is needed from the physician.

Barriers to Communication: Nonstructured Communication Techniques

A barrier to communication is a insufficient structured communication techniques between physicians and nurses. Some standardized approaches to communication include the American Medical Director Association’s Protocols for Physician Notification, which structures and informs this article of key clinical information necessary for reporting various clinical scenarios.

Another structured communication strategy is SBAR (Situation, Background, Assessment, and Recommendation), which distills content right into a quick format that works within tight time restraints. With this technique, nurses are educated to report in narrative form, providing additional details than may be required for a telephone call to a physician. Physicians are taught to communicate in bullet point form, and to provide only right information. SBAR generates a shared mental model that ensures the content sender and message receiver are around the same page when it comes to how info is conveyed.

A third structured communication method is the CHAT method. CHAT represents (1) Chief Complaint, Context, Code Status; (2) History; (3) Assessment/exam; and (4) Talk with the physician/agree with a plan. This technique was developed specifically for use in long-term look after improving and standardizing communication in after-hours phone calls to on-call physicians.

Focus groups inside a study (J Am Geriatr Soc 2008;56:1080-6) were convened to debate the dissatisfaction between nurses and on-call physicians. Nurses reported these folks were frequently not able to predict the questions an on-call physician would ask. To find certain information, the nurse would need to interrupt the decision, consult the chart, or return for the patient. Both nurses and physicians agreed this would be a waste of time and delayed care. Nurses also reported difficulty in raising the on-call physician’s a higher level concern about the patient. After implementation with the CHAT method, nurses reported increased satisfaction. Concurrently, the on-call physicians were very likely to transfer the patient to the emergency department or come to the facility to evaluate the person.

Best Practices

Ideally, a standardized method of communication ought to be adopted and implemented in every single facility to streamline and enhance communication between nursing staff and physicians. But inside absence of a standardized method of communication, physicians should:

Provide timely call-backs.

Listen on the nurse.

Ask for relevant information.

Acknowledge a high degree of concern for the part from the reporting nurse.

Effective communication is merely as good as its foundation, that's accurate and effective observation. In Susan’s case, her health care may have been hindered with a failure around the foundational level as the chart did not reflect an important weight change until it turned out too late. However, the chart also was significant for the lack of communication involving the nurses as well as the physician. It appeared that this nursing staff as well as the physician were operating in two separate universes – neither ones was observing, reporting, or communicating.

Standardized communication may possibly not have prevented Susan’s death, however, it may well have prolonged her life or otherwise initiated a transfer to a serious care facility for additional observation before her death.




“Under the care of Leo J. Borrell, M.D. since December 2001, I have seen a remarkable improvement in my mother’s condition. She is responding dramatically to the new regiment Dr. Borrell has prescribed”

- Beth Rose


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by Dr. Leo J. Borrell, featured in Assisted Living Consult for November/December 2006. A HealthCom Media Publication