+1 (208) 254-6996 [email protected]

This assessment requires you address the following topics:

  • Define the seven principles of patient- clinician communication
  • Explain how you apply three of the seven principles to your interactions with your own patients
  • Describe the three methods being used to improve interdisciplinary communication
  • Choose the one that you think applies best to your own area of practice, or the one that your area of practice currently uses, and clearly describe how you use it.
  • Explain the ethical principles that can be applied to issues in patient-clinician communication
  • Explain the importance of ethics in communication and how patient safety is influenced by good or bad team communication

Make sure you also include a clear, separate introduction and conclusion as a part of this assignment, as these are worth separate points on the grading rubric.This assessment is aligned with course objective 6 and the module objectives. 

Don't use plagiarized sources. Get Your Custom Essay on
NURSE-PATIENT COMMUNICATION, INTERDISCIPLINARY COMMUNICATION, AND PATIENT SAFETY
Just from $13/Page
Order Essay

References

Minimum of four (4) total references: two (2) references from required course materials and two (2) peer-reviewed references. All references must be no older than five years (unless making a specific point using a seminal piece of information)

Peer-reviewed references include references from professional data bases such as PubMed or CINHAL applicable to population and practice area, along with evidence based clinical practice guidelines. Examples of unacceptable references are Wikipedia, UpToDate, Epocrates, Medscape, WebMD, hospital organizations, insurance recommendations, & secondary clinical databases.

Style

Unless otherwise specified, all the written assignment must follow APA 7th edition formatting, citations and references.

Number of Pages/Words

Unless otherwise specified all papers should have a minimum of 600 words (approximately 2.5 pages) excluding the title and reference pages.

RUBRIC: WRITTEN ASSIGNMENT (40 pts)

Last updated: 06/07/2017 © 2017 School of Nursing – Ohio University Page 1 of 2

Criteria

Levels of Achievement

Accomplished Needs Improvement Not Acceptable

Introduction

(5 Points)

5 to 5 Points

 Clearly states the purpose of the paper.

 Provides a comprehensive overview of topic or questions.

 Engages the reader.

 Organized and has easy follow.

2 to 4 Points

 Overview is provided, but key points/ideas are missing.

 Purpose statement is not clear.

 Does not engage the reader.

 Somewhat disorganized but still comprehensible

0 to 1 Points

 Does not provide an overview of the paper or is

absent.

 No purpose statement.

Body

(24

Points)

Key Requirement 1 – Principles of

Communication

8 to 8 Points

 Clear definition of each of the seven principles with examples of how

three of the seven are applied to the

student’s own interactions with

patients.

 Evidence of critical thinking.

4 to 7 Points

 Defines each of the seven principles, examples given are not

specific ones from practice but are

general to nursing

 Lacking organization or critical thinking

0 to 3 Points

 Does not provide definitions of each

principle,

 no examples given,

 no evidence of critical thinking.

Key Requirement 2 –

Methods of

Communication

8 to 8 Points

 Clearly defines and describes each of the three methods of

interdisciplinary communication;

 Chooses one that best applies to own practice, gives a clear

discussion of how the student uses that method.

4 to 7 Points

 Lists the three methods of interdisciplinary communication

but does not describe each in

detail;

 Does choose the one that applies

best, but discussion is disorganized.

 More detail is needed.

0 to 3 Points

 Discussion of methods of interdisciplinary

communication is weak

and disorganized;

 Example given is weak

and disorganized.

 No evidence of critical thinking.

Key Requirement 3 –

Ethical Principles and

Communication

8 to 8 Points

 Student clear defines at least four ethical principles that can be

applied to patient clinician

communication and gives clear

examples of each;

 Explains the impact of ethical communication and how patient

safety is impacted by team

communication.

 Thoughts are well organized, each topic is thoroughly addressed.

4 to 7 Points

 Student defines two to three ethical principles that can be applied to

patient clinician communication

and gives examples, but may be

missing depth;

 Touches on patient safety and impact of ethics in communication.

 Thoughts are somewhat disorganized, scattered

0 to 3 Points

 Student’s writing is difficult to follow;

 Difficult to determine if all subjects have been

covered.

 No evidence of critical thinking.

Conclusion

(5 Points)

5 to 5 Points

 Summarizes paper and reflects on what the reader has learned from

the paper.

 Demonstrates persuasive thought and is well organized.

2 to 4 Points

 Merely summarizes the introduction or contains new ideas

not present in the paper contents.

 Somewhat disorganized but still comprehensible

0 to 1 Points

 Simply restates the introduction or is absent.

 Disorganized to the point of distraction.

RUBRIC: WRITTEN ASSIGNMENT (40 pts)

Last updated: 06/07/2017 © 2017 School of Nursing – Ohio University Page 2 of 2

Criteria

Levels of Achievement

Accomplished Needs Improvement Not Acceptable

Stylistics

(6 Points)

6 to 6 Points

 APA Citations are appropriate.

 Formatted correctly.

 Reference page is complete and correctly formatted.

 At least 4 references provided: Two (2) references from required course

materials and two (2) peer-reviewed

references. *References not older than five years.

 More than 600 words excluding title and reference pages.

3 to 5 Points

 APA Citations are appropriate and formatted correctly.

 Reference page is formatted correctly.

 References are not professional or is not formatted correctly.

 Missing 1 professional reference.

 At least 600 words or more excluding title and reference pages.

0 to 2 Points

 No citations are used or citations are made but

not formatted correctly

 Reference page is missing.

 Less than 600 words excluding title and reference pages.

Peer-reviewed references include professional journals (i.e. Nursing Education Perspectives, Journal of Professional Nursing, etc. –), professional organizations (NLN, CDC, AACN, ADA, etc.) applicable to population and practice area, along with clinical practice guidelines (CPGs – National Guideline Clearinghouse). References not acceptable (not inclusive) are UpToDate, Epocrates, Medscape, WebMD, hospital organizations, insurance recommendations, & secondary clinical databases. *All references must be no older than five years (unless making a specific point using a seminal piece of information) Note: You will have three (3) attempts to submit a written assignment, only the final attempt will be graded. For each attempt you will receive a SafeAssign

originality report. This will give you a chance to correct the assignment based on the SafeAssign score. Click here to view instructions on how to interpret SafeAssign originality report.https://help.blackboard.com/Learn/Instructor/Assignments/SafeAssign/SafeAssign_Originality_Reports

CONTINUING PROFESSIONAL DEVELOPMENTCPD

50 august 5 :: vol 29 no 49 :: 2015 NURSING STANDARD

Abstract Teamwork requires co-operation, co-ordination and communication between members of a team to achieve desired outcomes. In industries with a high degree of risk, such as health care, effective teamwork has been shown to achieve team goals successfully and efficiently, with fewer errors. This article introduces behaviours that support communication, co-operation and co-ordination in teams. The central role of communication in enabling co-operation and co-ordination is explored. A human factors perspective is used to examine tools to improve communication and identify barriers to effective team communication in health care.

Author Heather Gluyas Associate professor, School of Health Professions, Murdoch University, Mandurah, Western Australia. Correspondence to: [email protected]

Keywords Communication, co-operation, human factors, patient safety, revalidation, structured communication tools, team briefing, teamwork

Review All articles are subject to external double-blind peer review and checked for plagiarism using automated software.

Revalidation Prepare for revalidation: read this CPD article, answer the questionnaire and write a reflective account. Go to www.rcni.com/revalidation

Online For related articles visit the archive and search using the keywords above.

To write a CPD article: please email [email protected] Guidelines on writing for publication are available at: journals.rcni.com/r/author-guidelines

E�ective communication and teamwork promotes patient safety NS805 Gluyas H (2015) Effective communication and teamwork promotes patient safety. Nursing Standard. 29, 49, 50-57. Date of submission: March 15 2015; date of acceptance: May 14 2015.

Aims and intended learning outcomes This article aims to inform the reader about effective teamwork and communication. The behaviours required for effective teamwork, the key elements of effective communication and common tools that support successful communication within a team are discussed. After reading this article and completing the time out activities you should be able to:  Explain the pivotal role of effective

teamwork in promoting patient safety and quality care.  Describe the behaviours that are required for

effective teamwork.  List the barriers to effective communication

in health care.  Describe common tools that can be used to

improve team communication.  Relate effective communication to your own

practice.  Develop your communication skills in your

team environment.

Introduction Teamwork involves a group of people working together to achieve a common purpose (St Pierre et al 2011). Teamwork requires co-operation, co-ordination and communication between members of a team to achieve desired outcomes. In industries where there is high risk, such as health care, effective teamwork has been shown to achieve team goals successfully and efficiently, with fewer errors. Conversely, poor teamwork has been shown to result in errors and suboptimal outcomes (Walker 2008, Donohue and Endacott 2010, Lee et al 2012, Lyons and Popejoy 2014).

This article introduces behaviours that support communication, co-operation and co-ordination in teams, and explores the central role of communication in enabling

Downloaded from RCNi.com by ${individualUser.displayName} on Jun 01, 2017. For personal use only. No other uses without permission.

Copyright © 2017 RCN Publishing Company Ltdhttp://journals.rcni.com/action/showLinks?system=10.7748%2Fns.29.49.50.e10042

NURSING STANDARD august 5 :: vol 29 no 49 :: 2015 51

co-operation and co-ordination. A human factors perspective is used to identify barriers to effective team communication in health care and to examine tools that improve communication. Complete time out activity 1

In health care, teamwork is integral to providing safe and effective care to patients. The importance of effective teamwork in response to the growing complexity of care involving chronic conditions and associated comorbidities is increasingly recognised (St Pierre et al 2011). Most patient encounters involve more than one healthcare professional and may involve many people, depending on the type of healthcare problem. These individuals may include doctors, nurses, allied health professionals and other specialist professionals. Teams from different healthcare sectors, such as primary care, acute care, mental health or chronic care, may also be involved. Effective communication – both verbal and written – between team members and between different teams is essential to ensure co-operation and co-ordination of care.

Ineffective communication, which leads to poor co-operation and co-ordination of care, is a major cause of errors and adverse events in patient care (World Health Organization 2009). Communication errors occurring at handover, either between team members or between different teams, may lead to inaccurate diagnosis, incorrect treatment and/or medication errors (Wong et al 2008). Poor communication in teams leads to team members having different perceptions of situations and of what is required to manage them (Brady and Goldenhar 2014). Such differing perceptions of a situation among team members may be viewed as the lack of a shared mental model, and this has been shown to contribute to serious safety events (Gluyas and Morrison 2013, Brady and Goldenhar 2014). Moreover, a lack of effective team communication has been shown to contribute to delayed response to deteriorating patients (Endacott et al 2007). Patient safety in surgical interventions may be compromised if there is poor team communication (Lyons and Popejoy 2014). This may result in serious adverse events such as wrong patient, procedure and/or site; retained instruments; infections; and unanticipated blood loss (Treadwell et al 2014).

Thomas et al (2013) examined data from 459 patient safety incidents relating to clinical handover in acute care settings. They found

that 28.8% of incidents (n=132) involved transfer of patients without adequate handover, 19.2% of incidents (n=88) involved omissions of critical information about the patients’ condition and 14.2% of incidents (n=65) involved omission of critical information in patients’ care plans.

Poor communication is not limited to incidents in the acute sector. It may also be a factor in poor outcomes when transferring care between sectors, such as from primary care to the acute sector and back again (Russell et al 2013). There is a convincing case for investing time and resources in improving communication and teamwork in health care to improve patient safety. Complete time out activity 2

Teamwork behaviours Teams are composed of individuals with different knowledge, skills and attributes, who all contribute particular characteristics to team performance. However, for a team to perform successfully, individuals must share an understanding of what is required to achieve the desired goal (Endsley 2012). This means team members must work individually to carry out their duties while maintaining an awareness of the need for the collective contribution of team members (Gluyas and Morrison 2013). The skills that contribute to successful teamwork include team leadership, mutual support, situation monitoring and effective communication (Baker et al 2012). Table 1 indicates the knowledge and behaviours that are required to demonstrate these skills.

Communication Communication is necessary in each of the skills team members require to contribute to an effective team (Table 1) and may be considered as the basis for effective teamwork. It may involve spoken communication, non-verbal (gestures, facial expression) and/or written language. It involves one person initiating a message, along with receipt of this message by another person or persons (St Pierre et al 2011). However, the powerful effect of cognitive processes on the communication process should be understood and recognised, since this is central to promoting effective communication. A human factors perspective provides a framework for understanding these effects and considers the

2 Read the case study in Box 1. Draw a diagram indicating the different teams that may have been involved in Mary’s care in the community and in hospital. Identify specific points where effective teamwork and communication were required between team members and teams.

1 Before completing this article, recall a time when you were part of a team that did not work well together. Write down the factors and behaviours that may have contributed to this. Once you have completed the article and reviewed Table 1, add any factors you may have omitted from this list.

Downloaded from RCNi.com by ${individualUser.displayName} on Jun 01, 2017. For personal use only. No other uses without permission.

Copyright © 2017 RCN Publishing Company Ltd

52 august 5 :: vol 29 no 49 :: 2015 NURSING STANDARD

CPD communication

effect of systems, environments, equipment and processes on human cognitive abilities and limitations (Catchpole 2013).

Human cognition is a dynamic process that allows people to perceive, interpret and make decisions about required actions (Gluyas and Morrison 2013). The cognitive load is relatively low when undertaking well-known tasks in familiar situations. In such instances, humans are able to carry out tasks in a somewhat automatic manner with little conscious thought. However, in unfamiliar or complex situations, humans must use increased conscious attention to process what is going

on around them and what actions are required. Cognitive overload may occur if the situation is complex, for example where constantly changing circumstances require intense cognitive attention to process what is happening (Endsley 2012). Several cognitive processing failures may then arise, including attentional tunnelling, confirmation bias, memory failures (slips and lapses) and inaccurate mental models (Endsley 2012) (Table 2). These limitations in cognitive processing may be precipitated or exacerbated by workload pressures, time pressures, stress, anxiety, fatigue, poor team relationships, constant interruptions and changing situational requirements (St Pierre et al 2011).

The cognitive load of the individuals involved in the communication may affect their processing of the information. Communication failures may occur if an individual is in a situation where there is cognitive overload, for example because of the volume of data they are trying to process. Transmission failures may arise from incomplete, incorrect, ambiguous or unclear messages, while reception failures may arise because the message is misinterpreted, disregarded or not processed and retained in memory (Endsley 2012). Therefore, it is important to recognise the context of communication and the individual stresses that might affect the communication process. The communication process itself is only one aspect of effective communication; there are additional barriers that may lead to communication failures.

Barriers to e�ective communication General factors that can increase the likelihood of communication failures in any setting include differences in gender, culture, ethnicity, education and styles of communication. Also, there are contextual and cultural issues specific to healthcare settings that may affect communication in healthcare teams.

One major difference between health care and many other environments is the existence of a hierarchical system, both among different health professional groups and among senior and junior staff in the same professional group (Nugus et al 2010). This hierarchy results in an authority gradient; those further down the hierarchy may be hesitant to challenge those further up the hierarchy, raise concerns or ask questions. In a situation where one member of the team feels there may be a patient safety issue, or has concerns of some kind, they may not feel comfortable raising this or discussing their concerns with the team (Makary et al 2006, Reid and Bromiley 2012).

Teamwork skills and required behaviours TABLE 1

Skill Required behaviours

Leadership  Communicate awareness and understanding of the desired outcome.

 Communicate understanding of purpose, team roles, responsibilities, task requirements and plan.

 Plan and allocate tasks.

Mutual support  Provide feedback to other team members when required.

 Provide and request assistance when required.  Trust in other team members and have confidence

in their actions and intentions.

Situation monitoring  Review ongoing team performance.  Adjust, adapt and reallocate tasks and

responsibilities as required.

Communication  Share information with other team members.  Communicate clearly using objective language,

correct terminology and structured processes or tools, where available.

 Acknowledge communication and check for correct interpretation (closed loop communication).

(Miller et al 2009, Baker et al 2012, Gluyas and Morrison 2013)

Case study 1: Mary BOX 1

Mary presented to the GP feeling unwell, with pain in her right leg of several days’ duration. On examination the GP identified that Mary had tenderness and swelling in her right calf; she denied any falls or other incidents that may have caused this. Since Mary had recently taken a flight overseas, the GP suspected a deep vein thrombosis (DVT). The GP ordered an ultrasound scan and blood test, which were positive for DVT, and Mary was commenced on oral anticoagulation therapy. Later that day, she presented to the emergency department with acute shortness of breath and was admitted with a diagnosis of pulmonary embolus. She was commenced on parenteral anticoagulation and respiratory support. After several days, Mary improved and was discharged into the care of the GP for monitoring of ongoing anticoagulation therapy, and the community nursing service, which would provide home visits and support during the recovery phase.

Downloaded from RCNi.com by ${individualUser.displayName} on Jun 01, 2017. For personal use only. No other uses without permission.

Copyright © 2017 RCN Publishing Company Ltd

NURSING STANDARD august 5 :: vol 29 no 49 :: 2015 53

An example that illustrates this authority gradient is provided in Reynard et al (2009). A child experienced facial burns from a dry swab that caught fire from the diathermy machine during maxillofacial surgery. The surgeon immediately changed his practice to using wet swabs, but ascertained from colleagues that they previously changed to this practice because the risk of using dry swabs had already been identified. When the surgeon asked nursing staff why they did not inform him of this practice, they indicated that he had discouraged suggestions in the past, so they did not feel comfortable raising issues about his surgical practice (Reynard et al 2009).

Other studies confirm that reluctance to speak up about possible patient risk is an important factor in communication errors (Leonard et al 2004, Makary et al 2006, Mackintosh and Sandall 2010, Carayon 2012, Lyndon et al 2012, Okuyama et al 2014). Lyndon et al (2012) reported that 12% of staff were unlikely to speak up even when there was high risk; this reluctance was related to previous rudeness or intimidation from other staff. Other factors that contribute to this hesitancy include poor leadership and relationships in the healthcare team, fear of the responses of others, and concerns about appearing incompetent in ambiguous or complex clinical situations (Okuyama et al 2014).

Differing communication styles between doctors and nurses may exacerbate authority gradients that exist in health care. Doctors are educated on a scientific basis that emphasises cure and treatment in the management of patient care. This results in a communication style that tends to be succinct, with a focus on scientific facts. Nurse education is informed by science but has a holistic focus on caring linked to treatment and management. Nurses’ communication style differs from that of doctors in that it tends to be more narrative, rather than concisely factual (Wachter 2012). Communication between different professional groups can lead to misunderstanding and misinterpretation of the message being communicated, because different professional staff have expectations of others that are not explicitly communicated (Donohue and Endacott 2010).

Implicit expectations, or those not explicitly communicated, may also be described as a ‘hint and hope’ dialogue. This can result in the sender and receiver failing to communicate, with the sender

hinting at what is required and the receiver completely missing their message. One example of this is the case of Elaine Bromiley, a patient who died following a failed intubation for a surgical procedure (Reid and Bromiley 2012, Bromiley 2014). During the emergency situation, the medical staff involved were focused on continuing to try to intubate; the patient became severely hypoxic, resulting in her death 13 days later (Walker 2008). The authority gradient discouraged any direct assertion by the nurses that the situation was an emergency. When a nurse brought in the tracheostomy tray (without being asked) and stated that it was ready, the implicit message was: ‘I have brought in the tracheostomy tray because you need to look at alternative airway access for oxygenation.’ This was not the message received by the medical staff, who remained focused on the task of intubating the patient and ignored the interruption (an example of attentional tunnelling, Table 2). A second nurse was also ignored when she stated that she had contacted the intensive care unit (ICU) for a bed. The implied message was: ‘I have contacted ICU because this is an emergency and I am worried about the patient’s deteriorating observations.’ However, the nurse’s comments were not interpreted in this way. The communication failures were a result of differing communication styles, as well as the authority gradient and the cognitive overload of the medical staff attempting to manage the situation.

Cognitive processes to manage challenging situations

Cognitive process Description

Attentional tunnelling Focusing cognitive attention on one aspect of a situation that is proving challenging in terms of understanding or task completion, while ignoring other information from the environment or context.

Confirmation bias A tendency to consider only confirming evidence and to disregard evidence that does not confirm.

Memory failures (slips and lapses)

Memory failures are associated with automatic behaviour, where we intend to do something but our attention is focused elsewhere. We either forget to carry out an action (lapse), or undertake steps of an action in the wrong order or leave out a step entirely (slip).

Inaccurate mental models

Erroneous mental models of events and what decisions or actions are required, resulting from flawed perception or comprehension of a situation.

(Adapted from Endsley 2012)

TABLE 2

Downloaded from RCNi.com by ${individualUser.displayName} on Jun 01, 2017. For personal use only. No other uses without permission.

Copyright © 2017 RCN Publishing Company Ltd

54 august 5 :: vol 29 no 49 :: 2015 NURSING STANDARD

CPD communication

In health care, teams are often not fixed or established, but have come together for a specific purpose. They have not had time to establish roles and responsibilities or to articulate clearly the apparent objectives of the team (Wachter 2012). This can lead to different perceptions or mental models of the situation and the required outcomes. Shift work, long hours leading to fatigue, and other common factors in health care, such as distractions, interruptions, workload and time pressures, add to these different perceptions. Therefore, it is not surprising that poor communication within teams contributes to errors and poor patient outcomes. It is imperative to develop strategies that decrease the likelihood of communication failures arising from authority gradients, from differing professional communication styles and from cognitive failures such as those listed in Table 2.

Strategies to improve team communication in health care Many strategies to improve communication rely on organisational structures and processes. These strategies include education and training programmes that focus on improving communication in teams and developing an understanding of barriers to effective communication, such as authority gradients and different communication styles. Such programmes have been shown to improve teamwork and communication (Stead et al 2009, Gorman et al 2010, Baker et al 2012, Bunnell et al 2013). Other organisational strategies to improve communication include implementing practices such as checklists and read-back protocols for different clinical situations, instigating structured communication tools and introducing briefing and debriefing procedures in teams (Lepman and Hewett 2008, Gorman et al 2010, Knox and Simpson 2013, Brady et al 2013, Goldenhar et al 2013, Lyons and Popejoy 2014). These steps require commitment from the organisation’s leadership team and provision of resources. However, healthcare professionals can still use many of these strategies, even in the absence of formal organisational support, as is discussed in this article.

Team brie�ng and debrie�ng The purpose of team briefing, huddles and debriefing is to diminish authority gradients and enable common agreement on the team’s objectives and intended outcomes (Wachter 2012, Goldenhar et al 2013). Briefings may take the

form of a pre-procedure or pre-shift pause, during which team members articulate their roles and responsibilities and discuss the intended outcomes. This may identify agreed protocols that are intended to alert team members to changing conditions or other important information (Brady and Goldenhar 2014).

Huddles are ongoing team briefings that occur throughout the period the team is working together. They involve team members coming together frequently for short periods to review and make plans for ongoing care. If used effectively, this strategy addresses problems with overload or limited short-term memory capacity, establishes safeguards in the process and improves the effectiveness of communication in the team. The essential elements of a huddle are that it is short, it has a team facilitator, discussion is encouraged based on data and the focus is on problem solving and solutions planning (Goldenhar et al 2013).

Debriefings involve the team coming together at the end of a shift or procedure to discuss what went wrong and what went well (St Pierre et al 2011). Team performance is improved through the lessons learned. Debriefings enable team members to recognise opportunities to speak up in critical situations, or instances of communication failure, for example, attentional tunnelling, confirmation bias, memory failures and inaccurate mental models. Facilitation and leadership are essential to ensure a safe, blame-free environment for debriefing, in which all team members feel comfortable to discuss aspects of the team performance explicitly (Wachter 2012).

Structured communication tools Structured communication tools address problems that may arise as a result of authority gradients, different professional communication styles and cognitive limitations. These tools establish safeguards in processes, reduce the steps and variability in processes and increase the likelihood of effective communication (Lee et al 2012). Many different tools have been developed to provide an objective framework for structured communication between clinicians in response to concerns about a patient’s condition (Gluyas and Morrison 2013). For example, the SBAR tool, where the mnemonic (Gluyas and Morrison 2013) indicates:  Situation: what is going on with the patient?  Background: what is the clinical background

or context?  Assessment: what do I think the problem is?

Downloaded from RCNi.com by ${individualUser.displayName} on Jun 01, 2017. For personal use only. No other uses without permission.

Copyright © 2017 RCN Publishing Company Ltd

NURSING STANDARD august 5 :: vol 29 no 49 :: 2015 55

 Recommendation or response: what do I think should be done in what time frame?

Practice is required to use this form of communication, to implement it and to overcome any hesitancy that may occur because of authority gradients. However, objective communication focused on data decreases the likelihood of misunderstanding and minimises problems with implicit communication styles (Lee et al 2012). Variants of the SBAR structured communication tool have been developed for use in handover of patient care to other clinicians (Porteous et al 2009). Complete time out activity 3

Managing the authority gradient can be difficult, and the CUS structured tool may be particularly useful in this situation. The tool provides a communication process for escalation, to focus attention when there are safety concerns that are not being acknowledged or addressed by other members of the team (Mackintosh and Sandall 2010). The CUS tool involves individuals using the following prompts to communicate:  I am Concerned.  I am Uncomfortable.  This is a Safety issue. For example, in a situation where a patient is deteriorating and the nurse has been unable to get a response for urgent review from a clinician, the nurse might contact that clinician again, or a more senior member of staff, and express their concern using the phrase ‘I am concerned’, stating the reasons for this. If there is still no timely response, the nurse could contact the team leader or a senior clinician and repeat their concern, using the phrase ‘I am uncomfortable’. If there is still no response, the nurse could contact the senior clinician or management and use the phrase ‘This is a safety issue’, again expressing their concerns about the patient’s condition and the lack of timely response.

The escalation in the CUS tool should be used only for serious and urgent issues, where the concern is significant. If the concerns raised are not addressed adequately, then it may be necessary to escalate them, bypassing the person with whom the concerns were initially raised. By using the objective language of the CUS tool, the focus remains on patient safety.

It is important to note that organisations have policies or procedures for escalation when urgent clinical concerns are not being addressed. The nurse should comply with

these protocols. The CUS tool is an ideal tool to guide the communications. Complete time out activity 4

There are several other structured communication tools that may be used to hand over the care of patients to other clinicians. These include the SHARED communication tool, where the mnemonic indicates Situation, History, Assessment, Risks, Expected outcomes and Documentation (Hatten-Masteron and Griffiths 2009), and I PASS THE BATON, where the mnemonic indicates ‘Introduction, Patient, Assessment, Situation, Safety concerns, THE Background, Actions, Timing, Ownership and Next’ (Youngberg 2013).

With the exception of CUS, all these communication tools can be used for both verbal and written communication (CUS is usually used in time-critical situations that require immediate response). The tools provide an objective framework for communication for both the sender and receiver of the message, decreasing the cognitive load that may lead to communication failures.

Checklists and read-back protocols Checklists and read-back protocols can be useful tools in assisting to prevent communication breakdowns, since they provide a visual format for standardised communication (Lyons and Popejoy 2014, Treadwell et al 2014). They act as ‘memory joggers’ to decrease the likelihood of cognitive slips and lapses associated with automatic tasks. They also provide a prompt

4 Review the case study in Box 2. Assume that the SBAR communication with the doctor has not elicited an appropriate response. Samuel’s respiratory rate is decreasing further and he can be roused only with difficulty. Using the CUS headings (‘I am concerned’, ‘I am uncomfortable’, ‘This is a safety issue’), write down how the nurse could objectively convey concern about the patient’s deteriorating condition.

3 Read the case study in Box 2. Identify the barriers to effective communication demonstrated in this situation. Using the SBAR communication tool – with the headings ‘situation’, ‘background’, ‘assessment’ and ‘recommendation’ or ‘response’ – write down how the nurse could communicate in an objective way the clinical information underlying concern about the patient’s condition. Ensure you note a time frame for expected actions when you complete the ‘recommendation’ or ‘response’ sections.

Case study 2: Samuel BOX 2

Samuel, a 50-year-old man with no significant events in his medical history, was admitted to the surgical ward at 8pm following an appendectomy for a ruptured appendix. He was commenced on a morphine infusion for pain relief and two-hourly physiological observations. At midnight Samuel’s vital signs were 95% oxygen saturation on oxygen given at four litres per minute, blood pressure 140/80mmHg, pulse rate 60 beats per minute and respiratory rate eight breaths per minute. He was drowsy. Concerned that the morphine was having a respiratory depressant effect, the nurse contacted the doctor on call. The nurse stated that, although in considerable pain, the patient had been alert pre-operatively; now he was drowsy and difficult to rouse. The doctor, having been woken from deep sleep after a 16-hour shift, was annoyed and indicated in strong terms that he too was drowsy and difficult to rouse because he was tired.

Downloaded from RCNi.com by ${individualUser.displayName} on Jun 01, 2017. For personal use only. No other uses without permission.

Copyright © 2017 RCN Publishing Company Ltd

56 august 5 :: vol 29 no 49 :: 2015 NURSING STANDARD

CPD communication

for actions when there may be cognitive overload related to situational factors, such as complex tasks or rapidly changing clinical situations (Beaumont and Russell 2012).

It is imperative that tools such as checklists and read-back protocols are used mindfully, with full attention from the participants involved (Gluyas and Morrison 2014). There are many examples in the literature of errors and adverse events resulting from automatic, non-mindful responses to checklists. Toft and Mascie-Taylor (2005) give an example in which a patient received the same dosage error ten times, despite three different staff members using a checklist to prevent this type of error.

Read-back protocols for telephone laboratory or radiological reports, medication orders, clinical handovers and surgical counts are imperative to prevent communication failures that may result in errors. It is easy to confuse the sound of one letter or number for another, especially in stressful and noisy environments (Youngberg 2013); repeating

back the information and/or checking for correct interpretation reduces the risk of confusion. The use of phonetic alphabets (for example, Alpha, Bravo, Charlie, Delta…) is not common in health care. However, their introduction and/or the use of standardised quotes or phrases could mitigate the risk of inaccurate communication and misunderstanding (Prabhakar et al 2012).

Checklists with check-off provisions are less prone to slips, lapses and omissions of essential items because they lead the checker through the correct sequence and identify all the items that should be checked (Degani and Wiener 1990). The challenge with checklists and read-back protocols is to design them to reduce the likelihood of automatic responses. Checklists and read-back protocols that require the checker to state ‘check’, ‘yes’ or ‘okay’ are susceptible to inaccurate automatic responses, whereas those that are designed so that the checker states what they are seeing are less prone to such errors (Dekker 2011). Complete time out activity 5

5 Review your organisation’s checklists and read-back protocols. Identify if they are designed to reduce automatic responses by ensuring that the checker is asked to state what they see or if there are check-off provisions.

References Baker DP, Salas E, Battles JB, King HB (2012) The relation between teamwork and patient safety. In Carayon (Ed) P Handbook of Human Factors and Ergonomics in Health Care and Patient Safety. Second edition. CRC Press, Boca Raton FL, 185-198.

Beaumont K, Russell J (2012) Standardising for reliability: the contribution of tools and checklists. Nursing Standard. 26, 34, 35-39.

Brady PW, Goldenhar LM (2014) A qualitative study examining the influences on situation awareness and the identification, mitigation and escalation of recognised patient risk. BMJ Quality and Safety. 23, 2, 153-161.

Brady PW, Muething S, Kotagal U et al (2013) Improving situation awareness to reduce unrecognized clinical deterioration and serious safety events. Pediatrics. 131, 1, 298-308.

Bromiley M (2014) The journey of human factors in healthcare. Journal of Perioperative Practice. 24, 3, 35-36.

Bunnell CA, Gross AH, Weingart SN et al (2013) High performance teamwork training and systems redesign in outpatient oncology. BMJ Quality and Safety. 22, 5, 405-413.

Carayon P (Ed) (2012) Handbook of Human Factors and Ergonomics in Health Care and Patient Safety. Second edition. CRC Press, Boca Raton FL.

Catchpole K (2013) Spreading human factors expertise in healthcare: untangling the knots in people and systems. BMJ Quality and Safety. 22, 20, 793-797.

Degani A, Wiener EL (1990) Human Factors of Flight- Deck Check Lists: The Normal Checklist. National Aeronautics and Space Administration Ames Research Center, Moffett Field CA.

Dekker S (2011) Patient Safety: A Human Factors Approach. CRC Press, Boca Raton FL.

Donohue LA, Endacott R (2010) Track, trigger and teamwork: communication of deterioration in acute medical and surgical wards.

Intensive and Critical Care Nursing. 26, 1, 10-17.

Endacott R, Kidd T, Chaboyer W, Edington J (2007) Recognition and communication of patient deterioration in a regional hospital: a multi-methods study. Australian Critical Care. 20, 3, 100-105.

Endsley M (2012) Situation awareness. In Salvendy G (Ed) Handbook of Human Factors and Ergonomics. Fourth edition. John Wiley and Sons, Hoboken NJ, 553-568.

Gluyas H, Morrison P (2013) Patient Safety: An Essential Guide. Palgrave Macmillan, London.

Gluyas H, Morrison P (2014) Human factors and medication errors: a case study. Nursing Standard. 29, 15, 37-42.

Goldenhar LM, Brady PW, Sutcliffe KM, Meuething SE (2013) Huddling for high reliability and situation awareness. BMJ Quality and Safety. 22, 11, 899-906.

Gorman JC, Cooke NJ, Amazeen PG (2010) Training adaptive teams. Human Factors. 52, 2, 295-307.

Hatten-Masteron SJ, Griffiths ML (2009) SHARED maternity care: enhancing clinical communication in a private maternity hospital setting. The Medical Journal of Australia. 190, 11 Suppl, s150-s151.

Knox GE, Simpson KR (2013) Teamwork: the fundamental building block of high-reliability organizations and patient safety. In Youngberg BY (Ed) Patient Safety Handbook. Second edition. Jones and Bartlett Learning, Burlington MA, 265-290.

Lee P, Allen K, Daly M (2012) A ‘Communication and Patient Safety’ training programme for all healthcare staff: can it make a difference? BMJ Quality and Safety. 21, 1, 84-88.

Leonard M, Graham S, Bonacum D (2004) The human factor: the critical importance of effective teamwork and communication in providing safe care. Quality and Safety in Health Care. 13, Suppl 1, i85-i90.

Lepman D, Hewett M (2008) Short and sweet and right to the point! SBAR communication: the key to success for effective, safe patient care. Critical Care Nurse. 28, 2, e45.

Downloaded from RCNi.com by ${individualUser.displayName} on Jun 01, 2017. For personal use only. No other uses without permission.

Copyright © 2017 RCN Publishing Company Ltdhttp://journals.rcni.com/action/showLinks?system=10.7748%2Fns.29.15.37.e9520http://journals.rcni.com/action/showLinks?pmid=23744537&crossref=10.1136%2Fbmjqs-2012-001467http://journals.rcni.com/action/showLinks?pmid=23592761&crossref=10.1136%2Fbmjqs-2013-002036http://journals.rcni.com/action/showLinks?pmid=20942257&crossref=10.1177%2F0018720810371689http://journals.rcni.com/action/showLinks?system=10.7748%2Fns.26.34.35.s46http://journals.rcni.com/action/showLinks?pmid=19963385&crossref=10.1016%2Fj.iccn.2009.10.006http://journals.rcni.com/action/showLinks?crossref=10.1542%2Fpeds.2012-1364http://journals.rcni.com/action/showLinks?pmid=22101101&crossref=10.1136%2Fbmjqs-2011-000297http://journals.rcni.com/action/showLinks?pmid=17627836&crossref=10.1016%2Fj.aucc.2007.05.002http://journals.rcni.com/action/showLinks?pmid=24062473&crossref=10.1136%2Fbmjqs-2012-001747http://journals.rcni.com/action/showLinks?pmid=24720054http://journals.rcni.com/action/showLinks?crossref=10.1136%2Fqshc.2004.010033http://journals.rcni.com/action/showLinks?pmid=23349386&crossref=10.1136%2Fbmjqs-2012-000948

NURSING STANDARD august 5 :: vol 29 no 49 :: 2015 57

Checklists and read-back protocols are most effective when combined with team briefings. In this situation the team identifies each aspect of the required performance and notes current status, responsibility and actions required or completed. This works well in non-emergency situations but may also be adapted to emergencies (Gluyas and Morrison 2013). The combination of checklist and team briefings provides the opportunity to overcome authority gradients, to acknowledge communication and to check for correct interpretation, a technique known as ‘closed loop communication’.

Conclusion Teamwork is an essential component of delivering safe and effective patient care. Teams comprise individuals who must work together to co-ordinate care. Effective teams require leadership, mutual support and skills for monitoring the ongoing situation. However, effective communication is the crucial factor, required to achieve team co-operation

and co-ordination. Communication is a process of sending and receiving messages that is prone to failures related to cognitive processing, arising from human fallibility. Communication failures may occur in any context but there are pervasive barriers to effective communication that are specific to health care. These include a hierarchical culture that leads to authority gradients, differing professional communication styles and fragmented care delivery across multiple departments and settings. Organisational strategies to improve communication involve teamwork training initiatives and the adoption of structured communication tools, checklists and team briefing processes. Patient safety and high quality care should be the goals for all healthcare professionals. Practitioners committed to improving patient safety can use structured communication tools and checklists to facilitate effective communication in teams, even in the absence of organisational support NS Complete time out activity 6

6 Now that you have completed the article, you might like to write a reflective account. Guidelines to help you are on page 62.

Lyndon A, Sexton JB, Simpson KR, Rosenstein A, Lee KA, Wachter RM (2012) Predictors of likelihood of speaking up about safety concerns in labour and delivery. BMJ Quality and Safety. 21, 9, 791-799.

Lyons VE, Popejoy LL (2014) Meta-analysis of surgical safety checklist effects on teamwork, communication, morbidity, mortality, and safety. Western Journal of Nursing Research. 36, 2, 245-261.

Mackintosh N, Sandall J (2010) Overcoming gendered and professional hierarchies in order to facilitate escalation of care in emergency situations: the role of standardised communication protocols. Social Science and Medicine. 71, 9, 1683-1686.

Makary MA, Sexton JB, Freischlag JA et al (2006) Operating room teamwork among physicians and nurses: teamwork in the eye of the beholder. Journal of the American College of Surgeons. 202, 5, 746-752.

Miller K, Riley W, Davis S (2009) Identifying key nursing and team behaviours to achieve high reliability.

Journal of Nursing Management. 17, 2, 247-255.

Nugus P, Greenfield D, Travaglia J, Westbrook J, Braithwaite J (2010) How and where clinicians exercise power: interprofessional relations in health care. Social Science and Medicine. 71, 5, 898-909.

Okuyama A, Wagner C, Bijnen B (2014) Speaking up for patient safety by hospital-based health care professionals: a literature review. BMC Health Services Research. 14, 61. doi:10.1186/1472-6963-14-61.

Porteous JM, Stewart-Wynne EG, Connolly M, Crommelin PF (2009) iSoBAR – a concept and handover checklist: the National Clinical Handover initiative. The Medical Journal of Australia. 190, 11 Suppl, s152-s156.

Prabhakar H, Cooper JB, Sabel A, Weckbach S, Mehler PS, Stahel PF (2012) Introducing standardized ‘readbacks’ to improve patient safety in surgery: a prospective survey in 92 providers at a public safety-net hospital. BMC Surgery. 12, 8. doi:10.1186/1471-2482-12-8.

Reid J, Bromiley M (2012) Clinical human factors: the need to speak up to improve patient safety. Nursing Standard. 26, 35, 35-40.

Reynard J, Reynolds J, Stevenson P (2009) Practical Patient Safety. Oxford University Press, Oxford.

Russell L, Doggett J, Dawda P, Wells R (2013) Patient Safety – Handover of Care Between Primary and Acute Care. Policy Review and Analysis. Commonwealth of Australia, Canberra, Australia.

Stead K, Pirone C, Adams R, Phillips P, Kumar S, Schultz T (2009) TeamSTEPPS – Public Report on Pilot Study. Department of Health, Adelaide, Australia.

St Pierre M, Hofinger G, Buerschaper C, Simon R (2011) Crisis Management in Acute Care Settings: Human Factors, Team Psychology, and Patient Safety in a High Stakes Environment. Spinger-Verlag, Berlin.

Thomas MJ, Schultz TJ, Hannaford N, Runciman WB (2013) Failures in transition: Learning from incidents relating to clinical handover in acute care. Journal for Healthcare Quality. 35, 3, 49-56.

Toft B, Mascie-Taylor H (2005) Involuntary automaticity: a work-system induced risk to safe heath care. Health Services Management Research. 18, 4, 211-216.

Treadwell JR, Lucas S, Tsou AY (2014) Surgical checklists: a systematic review of impacts and implementation. BMJ Quality and Safety. 23, 4, 299-318.

Wachter R (2012) Understanding Patient Safety. Second edition. McGraw-Hill, San Francisco CA.

Walker C (2008) A fatal lack of communication. Nursing Standard. 23, 11, 62-63.

Wong MC, Yee KC, Turner P (2008) Clinical Handover Literature Review. ehealth Services Research Group, University of Tasmania, Australia.

World Health Organization (2009) Human Factors in Patient Safety: Review of Topics and Tools. WHO, Geneva.

Youngberg BY (Ed) (2013) Patient Safety Handbook. Second edition. Jones and Bartlett Learning, Burlington MA, 265-290.

Downloaded from RCNi.com by ${individualUser.displayName} on Jun 01, 2017. For personal use only. No other uses without permission.

Copyright © 2017 RCN Publishing Company Ltdhttp://journals.rcni.com/action/showLinks?pmid=16259668&crossref=10.1258%2F095148405774518615http://journals.rcni.com/action/showLinks?pmid=22713158&crossref=10.1186%2F1471-2482-12-8http://journals.rcni.com/action/showLinks?pmid=22927492&crossref=10.1136%2Fbmjqs-2010-050211http://journals.rcni.com/action/showLinks?pmid=24068073&crossref=10.1177%2F0193945913505782http://journals.rcni.com/action/showLinks?pmid=23922403&crossref=10.1136%2Fbmjqs-2012-001797http://journals.rcni.com/action/showLinks?system=10.7748%2Fns2012.05.26.35.35.c9084http://journals.rcni.com/action/showLinks?pmid=20850919&crossref=10.1016%2Fj.socscimed.2010.07.037http://journals.rcni.com/action/showLinks?pmid=16648014&crossref=10.1016%2Fj.jamcollsurg.2006.01.017http://journals.rcni.com/action/showLinks?system=10.7748%2Fns.23.9.62.s45http://journals.rcni.com/action/showLinks?pmid=19416429&crossref=10.1111%2Fj.1365-2834.2009.00978.xhttp://journals.rcni.com/action/showLinks?pmid=20609507&crossref=10.1016%2Fj.socscimed.2010.05.029http://journals.rcni.com/action/showLinks?pmid=24507747&crossref=10.1186%2F1472-6963-14-61http://journals.rcni.com/action/showLinks?pmid=22268639&crossref=10.1111%2Fj.1945-1474.2011.00189.xhttp://journals.rcni.com/action/showLinks?pmid=19485867

Patient-Clinician Communication: Basic Principles and Expectations

Lyn Paget, Paul Han, Susan Nedza, Patricia Kurtz, Eric Racine, Sue Russell, John Santa, Mary Jean Schumann, Joy Simha, and Isabelle Von Kohorn*

June 2011

Discussion Paper

*Working Group participants drawn from the Best Practices Innovation Collaborative and the Evidence Communication Innovation Collaborative

of the IOM Roundtable on Value & Science-Driven Health Care

Advising the nation • Improving health

The views expressed in this discussion paper are those of the authors and not necessarily of the authors’ organizations or of the Institute of Medicine. The paper is intended to help inform and stimulate discussion. It has not been subjected to the review procedures of the Institute of Medicine and is not a report of the Institute of Medicine or of the National Research Council.

Patient-Clinician Communication: Basic Principles and Expectations

Lyn Paget, Paul Han, Susan Nedza, Patricia Kurtz, Eric Racine, Sue Russell,

John Santa, Mary Jean Schuman, Joy Simha, and Isabelle Von Kohorn 1

ACTIVITY

Marketing experts, decision scientists, patient advocates, and clinicians have developed a

set of guiding principles and basic expectations underpinning patient-clinician communication.

The work was stewarded under the auspices of the Best Practices and Evidence

Communication Innovation Collaboratives of the Institute of Medicine (IOM) Roundtable

on Value & Science-Driven Health Care. Collaborative participants intend these principles and

expectations to serve as common touchstone reference points for both patients and clinicians, as

they and their related organizations seek to foster the partnership and patient engagement

necessary to improve health outcomes and value from care delivered.

BACKGROUND

Health care aims to maintain and improve patients’ conditions with respect to disease,

injury, functional status, and sense of well-being. Accomplishment of these aims is predicated

upon a strong patient-clinician partnership, in which the insights of both parties are drawn upon

to guide delivery of the best care, tailored to individual circumstances. An important component

of this partnership is effective patient-clinician communication.

In the 2001 IOM report Crossing the Quality Chasm, patient-centeredness was defined

as one of the six key characteristics of quality care and has continued to be emphasized

throughout the IOM’s Learning Health System series of publications. Dimensions of patient-

centeredness include respect for patient values, preferences, and expressed needs along with a

focus on information, communication, and education of patients in clear terms. Consistent and

effective communication between patient and clinician has been associated in studies not only

with improved patient satisfaction and safety, but also ultimately with better health outcomes,

and often with lower costs. Breakdowns of communication, or disregard for patient

understanding, context, and preferences, have been cited as contributors to health care disparities

and other counterproductive variations in health care utilization rates. Moreover, professional

ethics in health care stress the intrinsic importance of respectful and effective

communication as a core aspect of informed consent and a trusting relationship. In an era of increasingly personalized medicine and escalating clinical complexity, the

importance of effective communication between the patient and the clinician is greater than ever.

As the ultimate stakeholders, patients should expect an active role in, and often shared

responsibility for, making care decisions that are best for them. Clinicians, in turn, should respect

and support patients in this role, valuing their input and prioritizing their preferences in shaping

care choices.

1 Working Group participants drawn from the Best Practices Innovation Collaborative and the Evidence

Communication Innovation Collaborative of the IOM Roundtable on Value & Science-Driven Health Care.

Copyright 2012 by the National Academy of Sciences. All rights reserved.

2

Whether considering risks and benefits or personal values and preferences, patients and

clinicians each have unique and important information to contribute to understanding and

deciding on prevention, diagnosis, or treatment options. Obtaining the highest-value care for

each individual requires establishing common goals and expectations for care through shared

deliberation that marshals the best information. Effective communication therefore requires

clarity about patient and clinician roles, responsibilities, and expectations for health care;

principles to guide the spirit and nature of patient-clinician communication; and approaches to

tailor communication appropriately to circumstances (e.g., routine care, chronic disease

management, life-threatening disease) and individual patient needs (e.g., health literacy and

numeracy, living circumstances, language barriers, decision-making capacity).

Passage of the Patient Protection and Affordable Care Act of 2010 offers both

opportunity and mandate to reorient strategies, incentives, and practices in support of health care

that reliably delivers Americans the best care at the highest value—care that is effective, efficient,

and most appropriate for the circumstances. As an element of best practice, the effectiveness of

patient-clinician communication can be as important as that of a diagnostic or treatment tool and

should be the product of similarly systematic assessment and evaluation. The principles and

expectations identified in this document offer a framework to evaluate and improve patient-

clinician communication, and to sharpen and focus patient discussion tools, patient safety

assessment (e.g., the Agency for Healthcare Research and Quality [AHRQ], the National Quality

Forum [NQF], organizational and individual performance assessment and quality improvement

efforts (e.g., Consumer Assessment of Healthcare Providers and Systems [CAHPS], and

clinician certification processes (e.g., the American Board of Internal Medicine [ABIM]).

BASIC PRINCIPLES AND EXPECTATIONS FOR

PATIENT-CLINICIAN COMMUNICATION

Many factors affect the quality and clarity of communications between patients and

clinicians. However, at the core of the matter, certain basic principles pertain and serve as the

starting point for the expectations of patients and clinicians: mutual respect, harmonized goals,

a supportive environment, appropriate decision partners, the right information, full

disclosure, and continuous learning.

Patient-Clinician Communication Basic Principles

1. Mutual respect 2. Harmonized goals 3. A supportive environment 4. Appropriate decision partners 5. The right information 6. Transparency and full disclosure 7. Continuous learning

3

Drawing from these principles, the basic individual and mutual expectations of both

patients and their clinicians can be identified. These expectations are discussed below and

summarized in the accompanying box.

1. Mutual respect

Each patient (or agent) and clinician engaged as full decision-making partners.

Communication should seek to enhance health care decision making through the exchange

of information and by supporting the development of a partnership relationship—

whenever possible—based on trust and focused on the whole patient. This includes

considering psychosocial needs, identifying and playing to the patient’s strengths, and

building on past experience to meet immediate needs and anticipate future concerns.

Respect for the special insights that each brings to solving the problem at hand.

Information exchange should be characterized by listening, inquiry, and facilitation that is

both active and respectful on the part of both the patient and the clinician. Information

needs include patients’ ideas, preferences, and values; living and economic contexts that

may affect patients’ health or decision making; the basis and evidence for alternative

choices and recommendations; and uncertainties related to the proposed course of action.

2. Harmonized goals

Common understanding of and agreement on the care plan. Full understanding—to the

extent practicable—of care options and the associated risks, benefits, and costs, as well as

patient preferences and expectations, should lead to an explicit determination of the shared

agenda and goals. Factors should include health, lifestyle, and economic preferences and

should accommodate language or cultural differences and low health literacy.

3. A supportive environment

A nurturing and secure services environment. The success of the care plan depends on the

attention paid in the service setting to patient culture, skills, convenience, information,

costs, and implementation of the care decision.

A nurturing and secure decision climate. The comfort and ability of the patient and

clinician to speak openly is paramount to discussion of potentially sensitive issues inherent

to many health decisions.

4. Appropriate decision partners

Clinicians, or clinician teams, with skills appropriate to patient circumstances. With

increasingly complex problems, and time often a factor for any individual clinician, it is

important to ensure that the patient has access to clinicians with skills appropriate to a

particular encounter; that, as indicated, alternative clinician opinions are embraced; and

that provisions are made for the communication needed among all relevant clinicians.

4

Assurance of competence and understanding by patient or agent of the patient.

Understanding by both patient and clinician is crucial to arriving at the most appropriate

decision. Understanding of patient options is important: how specific they are to

circumstances; the associated risks, benefits, and costs; and the needed follow-up. If

indicated, an appropriate family member or similar designee should be identified to act as

the patient’s agent in the care process.

5. The right information

Best available information at hand, choices and trade-offs thoroughly discussed. The

starting point for shared decision making should be the sharing of all necessary

information. When working collaboratively to craft an appropriate care plan, clinicians

should provide evidence concerning risks, benefits, values, and costs of alternative

options. All options should be discussed to bring out patient preferences, goals, and

concerns and to explicitly consider the impact of various options on these issues.

Presentation by patient of relevant perceptions, symptoms, personal practices. The

clinician’s appreciation and understanding of patient circumstances depends on accurate

sharing by the patient of perceptions, symptoms, life events, and personal practices that

may have a bearing on the condition and its management.

6. Transparency and full disclosure

Candid and explicit acknowledgment to patient of limits in science and system. A basic

element of the care process is comprehensiveness and candor with respect to the limits of

the evidence, delivery system constraints, and costs to the patient that may affect the range

of options or the effectiveness of their delivery.

Patient openness to clinician on all relevant circumstances, preferences, medical history.

Only by understanding the patient’s situation can the most appropriate care be identified.

Patient and family or agent openness in sharing all relevant health and economic

circumstances, preferences, and medical history ensures that decisions are made with

complete understanding of the situation at hand.

7. Continuous learning

Effective approach established for regular feedback on progress. Identification and

implementation of a system of feedback between patients and clinicians on status,

progress, and challenges is integral to the development of a learning relationship that is

flexible and can adapt to changing needs and situations.

Established periodicity for course assessment and alteration as necessary. Early

specification of treatment strategy, expectations, and course correction points is important

for ongoing assessment of care efficacy and to alert both clinician and patient to possible

need for care strategy changes.

5

TAILORING IMPLEMENTATION TO NEED AND CIRCUMSTANCE

These principles and expectations offer general guidance for successful patient-clinician

communication. Moderating factors or constraints present in individual circumstances require

certain tailored approaches and expectations for a particular visit—still with the aim of

maximizing faithfulness to these principles to the fullest practical extent. Examples of such

considerations include:

Expectations 1. Mutual respect

Each patient (or agent) and clinician engaged as full decision-making partners. Respect for the special insights that each brings to solving the problem at hand.

2. Harmonized goals

Common understanding of and agreement on the care plan. 3. A supportive environment

A nurturing and secure services environment. A nurturing and secure decision climate.

4. Appropriate decision partners

Clinicians, or clinician teams, with skills appropriate to patient circumstances. Assurances of competence and understanding by patient or agent of the patient

5. The right information

Best available evidence at hand, choices and trade-offs thoroughly discussed. Presentation by patient of relevant perceptions, symptoms, personal practices.

6. Transparency and full disclosure

Candid and explicit acknowledgement to patient of limits in science and system. Patient openness to clinician on all relevant circumstances, preferences, medical history.

7. Continuous learning

Effective approach established for regular feedback on progress. Established periodicity for course assessment and alteration as necessary.

6

Visit reason

Prevention

Chronic condition management

Acute or urgent episode

Decision characteristics

Number of decisions to be made during the visit

Certainty, uncertainty, and relevance to the available evidence

Decisions related to a preference-sensitive arena or choice

Access to and use of the Internet

Patient characteristics

Functional capacity (level of physical or mental impairment)

Communication capacity (language, literacy/numeracy, speech disorder)

Receptivity (motivation, incentives, activation, learning style, trust level)

Support (skilled family or other caregiver, financial capacity)

Living situation (housing, community, grocery, pharmacy, recreation, safety)

Clinician and practice characteristics

Patient volume and complexity

Patient support systems (language aids, interpreters, physical space, digital capacity)

Decision support systems (digital platform, information access, decision guidance)

Professional team profile and culture

Condition-specific skill network and referral follow-up systems

Reimbursement and other economic barriers

DEVELOPING THE TOOLS AND PROCESSES

FOR ADAPTIVE TARGETING

As touchstone reference points for patients and clinicians, the principles and expectations

presented here are vital to achieving the full measure of potential health outcomes and value

from care delivered. But achieving that potential requires intent, commitment, and creativity in

developing the tools and processes for adaptive targeting in the myriad conditions and

circumstances found in different health care settings. Noted below are questions that may

stimulate thought, conversation, and innovative approaches to their successful implementation in

various settings and circumstances.

For clinicians and health care organizations

How are we doing now with respect to the principles and expectations?

For which of them is our current culture and practice pattern most challenging?

What initial steps might be good starting points for systems changes necessary?

7

How can we enlist patients and staff working together to help develop and lead?

How can we take advantage of initiative and help from professional societies?

What community tools or resources might be adaptable for us?

How can we measure the impact for feedback to patients and staff on the results?

For patients, consumers, and advocates

What makes a clinician a good listener?

What should we expect in conversations about health care with clinicians?

How can available care and condition-specific materials be more easily understandable?

Are there helpful ways to judge a care setting’s support of effective communication?

What should we expect from clinicians to help interpret medical evidence?

How can we best help clinicians in their efforts to improve information sharing?

How will “continuous learning” from my care lead to better health care?

For professional societies, policy makers, health plans, insurers, and employers

How do current practices compare with the principles and expectations?

What ought to be our expectations for clinicians we support?

What metrics will be most useful for quality improvement and feedback?

What tools are most needed to assist in application and site-specific tailoring?

Can we develop case material to illustrate approaches and feasibility?

What information can help demonstrate material returns in outcomes and value?

Which reimbursement incentive structures are most important to consider?

SELECTED REFERENCES

Godolphin, W. 2009. Shared decision-making. Healthcare Quarterly. 12:e186-190.

IOM (Institute of Medicine). 2001. Crossing the Quality Chasm: A New Health System for the

21st Century. Washington, DC: The National Academies Press.

______ . 2003. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care.

Washington, DC: The National Academies Press.

Stewart, M., J. B. Brown, H. Boon, J. Galajda, L. Meredith, and M. Sangster. 1999. Evidence on

patient-doctor communication. Cancer Prevention and Control. 3(1):25-30.

Stewart, M. A. 1995. Effective physician-patient communication and health outcomes: A review.

CMAJ 152(9)1423-1433.

Wennberg, J. E., A. M. O’Connor, E. D. Collins, and J. N. Weinstein. 2007. Extending the P4P

agenda, part 1: How Medicare can improve patient decision making and reduce

unnecessary care. Health Affairs 26(6):1564-1574.

Order your essay today and save 10% with the discount code ESSAYHELP