Historically, there have been anecdotal and published reports of incongruities in communication between physicians and nurses. Conversely, the literature is replete with citations corroborating how strong interprofessional collaboration is essential in supporting a healthy work environment and optimizing patient outcomes (Wang, Wan, Lin, Zhou, & Shang, 2018; Zwarenstein, Rice, Gotlib-Conn, Kenaszchuk, & Reeves, 2013). The Joint Commission identified miscommunication between healthcare professionals as the second highest contributing factor to sentinel events in the United States (Ellison, 2015). It is particularly imperative that communication and collaboration between physicians and nurses be congruent. “Ineffective communication contributes to the team’s inability to work collaboratively and significantly increases the possibilities of mistakes occurring in the delivery of patient care” (Palanisamy, 2015, p.8). Obstacles, including poor communication, power differentials, disrespect and unclear delineation of roles, have been identified as factors that impede teamwork (Tang, Chan, Zhou & Liaw, 2013). Palanisamy (2015) noted the importance of healthcare providers communicating effectively across multidisciplinary teams in order to ensure safety and quality of patient care.
Our multi-hospital healthcare system provides training opportunities for medical students, interns and residents from two local medical schools. While there are certainly benefits to working in teaching hospitals, frequent medical staff rotations can be challenging for nurses and potentially have a negative impact on patient care delivery. In 2017, nurses working in a 19-bed medical intermediate care unit reported difficult and tenuous communication with physicians-in-training. This provided the impetus for exploring new ideas for improving interprofessional communication and collaboration in order to enhance the well-being of practitioners from both disciplines, strengthen the work environment, and optimize patient outcomes.
Fostering an environment where high quality, patient-centered, and interprofessionally-congruent care is the norm required that nursing staff explore both experiential and evidence-based knowledge of facilitators and barriers connected to communication and collaboration. Nurses working at the point-of-care and nurse leaders implemented an evidence-based practice (EBP) study in order to discover optimal methods for addressing the age-old dilemma of sub-optimal communication between the disciplines.
Evidence-based practice supports clinical decision-making by providing a platform derived from a confluence of best available scientific and experiential knowledge, while also considering patient preferences (Dang & Dearholt, 2017). Nurses are in the unique position of influencing clinical decision-making by employing the most current research to develop best practices that facilitate and promote patient healing. Key steps include: 1) identifying a practice issue; 2) writing a PICO question; 3) retrieving the salient literature related to the components within the PICO; 4) critically appraising the literature; 5) using an informed perspective to decide which evidence to translate into practice; 6) evaluating the efficacy of incorporating the new knowledge; and 7) disseminating the findings, both internally and externally.
The following PICO question was developed in order to address the clinical scenario previously ascribed: Among registered nurses working at the point-of-care (P), what factors enhance (I) or impede (C) communication aimed at improving collaboration with physicians-in-training (O)?
Literature was retrieved from three electronic sources, including Nursing Reference Center Plus, PubMed and CINAHL. The search yielded 282 articles (both research and non-research). After eliminating duplicates, and screening of titles, abstracts and key words, 42 of the articles met the inclusion criteria and were examined by the study team. The Johns Hopkins Nursing Evidence-based Practice (JHNEBP) research and non-research criteria were utilized to critically appraise the selected articles. Each article was critiqued by at least three team members, followed by a group meeting where discrepancies in scoring were discussed in order to reach consensus.
The JHNEBP appraisal criteria are comprised of the following categories: a) Level 1 (experimental, randomized controlled trial); b) Level 2 (quasi-experimental); c) Level 3 (non-experimental, qualitative); d) Level 4 (systematic review); and e) Level 5 (quality improvement, expert opinion). The evidence appraisals yielded one-Level I, eight-Level II, fifteen-Level III, five-Level IV, and thirteen-Level V articles.
Implications for Practice
The findings from the literature revealed very interesting key points. Evidence suggested that there is a broad knowledge base of factors that impede communication between nurses and physicians-in-training. There is also a limited supply of strong evidence that recommends effective and realistic modalities for improving communication. The literature revealed that nurses working at the point-of-care play a significant role in the professional socialization of physicians. Nurses also have great potential to influence the amount of informal learning that takes place during a physician’s training. “Shadowing” (e.g., nurses are afforded an opportunity to play a significant role in teaching the physicians-in-training in the clinical setting) has proven effective in strengthening interprofessional relationships. Ultimately, findings from this EBP study can be utilized to create a foundation for the development and implementation of interprofessional team building interventions, by both internal and external stakeholders.