Using a mixed-methods approach to assess barriers to nurse-physician communication in the long-term care setting, we found an interesting contrast between the perceived importance of nurse preparedness as a barrier to nurse-physician communication in the two parts of our study: the quantitative questionnaire suggested that nurse preparedness was one of the least important barriers, while the qualitative interviews indicated it to be one of the most important barriers. Further, interviews with nurses revealed that inadequate nurse preparedness could be the result of, or exacerbated by, physician behavior such as delayed response to telephone calls and physician interruptions. Taken together, a key result of our study is the C-HIP model that helps to describe impaired nurse-physician telephone communication in terms of a two-way professional interaction dependent on interrelationships of preparedness, responsiveness, collaborativeness and professionalism. The C-HIP framework highlights the importance of the interrelatedness of interactions and susceptibility of the system to communication breakdowns, and suggests several recommendations for improvement that can ultimately contribute to improved quality of patient care and patient safety.
The results of both the quantitative and qualitative parts of our study confirm the findings of previous studies in different settings that identify lack of professionalism 15, 28, 29
, inadequate collaboration 30
, lack of timely call backs by physicians9, 11, 31, 32
, and physician disinterest31
as commonly occurring issues affecting nurse-physician communication. Our study also found that working with a covering physician, time constraints and nurse preparedness were issues of particular importance the LTC setting. For example, 17% of nurses in our study reported that physicians did not want to address problems in telephone calls, and that this was particularly true for covering physicians who did know know that patient. Very few studies have addressed the issue of communicating with covering physicians in the LTC setting31
, but this finding underscores the importance of improving patient management via telephone encounters.
Nurse competency and preparedness are key components of nurse-physician communication about patient issues. The quality of nurse preparedness reported in the literature depends, in part, on whether nurses or physicians were asked about its quality. Cadogan et al found that physicians perceived nurse competence to be a significant communication barrier while nurses did not.15
In Cadogan's study, nurses felt that they knew how to assess a resident before calling a physician and that their explanations of the residents' problems were clear, concise and complete, but physicians did not agree. In our study, interviewed nurses believed that their nurse colleagues were often unprepared when calling physicians, and that this negatively affected nurse-physician communication. Further, nurses in our study agreed that the most important thing a nurse could do to improve communication effectiveness was to be prepared.
However, our study also revealed that lack of a timely call back by the physician contributed to suboptimal nurse preparedness because the nurse would be less likely to have the information on hand if they waited a long time to speak with the physician. This reliance on synchronous communication (i.e., immediate contact with another person), particularly when it is impaired by a delayed call back, can push the limits of human memory in an interrupt-driven environment.4
That is, in the LTC setting where nurses are often interrupted in the execution of their daily responsibilities, a delay between the preparation and delivery of a patient assessment can interfere with the ultimate quality of the information being communicated.4
When contextualized in the C-HIP model of communication, the results of our study demonstrate an interrelatedness of communication interactions between nurses and physicians that affects communication quality.
Other physician behaviors commonly reported in our study also affect the quality of nurse-physician exchanges including physician interruptions during calls, physicians hurrying nurses, and physicians being rude. Such disruptive behavior has been previously described in other studies28, 29
and has been found to adversely affect patient safety, particularly when the opportunity to repeat and verify telephoned clinical information is curtailed.33, 34
Previous studies have suggested that differences in training and communication styles of nurses and physicians contributes to communication problems.15, 35
Efforts to create a shared mental model between physicians and nurses could improve interdisciplinary communication36
and foster “relationship coordination” (shared goals, shared knowledge, and mutual respect) that may lead to improved patient outcomes.37
However, this does not obviate the need for physicians to be more willing to listen to nurses and work collaboratively as recommended by nurses in our qualitative interviews. Previous reports have found that nurse input can be poorly received by physicians,14, 38
even though improved collaboration contributes to better quality of care.13, 37
The findings of this study are important for three reasons. First, we have documented that the problem of nurse-physician communication continues to be an important issue despite almost 40 years of research and effort to improve nurse-physician communication in the LTC setting.16, 31, 39, 40
Second, the mixed-method approach allowed us to develop a communication framework highlighting the inter-relatedness of each stage of nurse-physician communication and its susceptibility to breakdown at any stage because of deficiencies on the part of either party. Third, we have identified some potential strategies to improve communication and the qualitative component of our study allowed us to capture and describe communication barriers that have not previously been well described, such as working with covering physicians.
The limitations of our study deserve comment. First, our study was conducted among a sample of nursing homes in Connecticut included by virtue of participation in a study to improve warfarin safety in the LTC setting. However, the distribution of age, experience as a nurse, and language abilities of the respondents in both components of our study suggest that our findings may be generalizable to the experiences of nurses working in the LTC setting. Second, we did not include physicians in our study, thus limiting the conclusions that can be drawn about physician-reported barriers to nurse-physician communication. Previous studies have described discrepancies between the perceptions of nurses and physicians15
, and we acknowledge that an assessment of physician responses to our findings and recommendations warrants further study. Third, we did not report the reliability of the questionnaire items because we did not seek to assign scores to individual nurses or LTC facilities; typical analyses such as computation of Cronbach's alpha were outside the scope of this study. We recommend further psychometric assessment should the instrument be used to report scores or scales for each domain and for overall communication.
Unlike other studies, our study finds that nurses themselves recommend improved nurse preparedness as a key target for improving the effectiveness of nurse-physician communication in the LTC setting. There is evidence that clear communication is associated with improved quality of care and patient outcomes,4
and our findings suggest strategies for achieving clear and effective communication. We believe that the use of tools such as the American Medical Director Association's “Protocols for Physician Notification”41
, an intervention that structures and informs the content of key clinical information necessary to reporting various clinical scenarios to physicians, are essential to improving clinical communication. Such tools can help overcome differences in communication styles between nurses and physicians that are a major factor contributing to inter-disciplinary communication difficulties.35
Also, structured communication techniques such as SBAR (Situation, Background, Assessment, and Recommendation), that format communication into highly distilled content and quick delivery format, are also increasingly being used in the healthcare setting to address both issues of complete content and time constraints. 36,42
Similar standardized approaches are being promoted by the National Patient Safety Foundation to assist organizations to improve clinical communication.43
At least one previous study has shown that decision support tools to aid LTC nurses with symptoms assessment and communication of health information over the telephone improves nurse satisfaction, feeling prepared to answer physician questions40
and preliminary evidence suggests that such interventions can also reduce adverse drug events and improve patient safety in the hospital setting.36
Although our study suggests that improving nurse preparedness is a key target to break the cycle of communication breakdown, our described communication model also illustrates the importance of improving physician attitudes, professionalism, and responsiveness. Interventions to improve the effectiveness of communication in the LTC setting must target both nurses and physicians to create a culture that facilitates effective communication with improved patient safety and healthcare quality as the ultimate goal.