Digital Repository Masters Projects Spring 2023 Improving Nurse and Physician Communication Katie Wilson Weber State University Follow this and additional works at: https://dc.weber.edu/collection/ATDSON Wilson, K. 2023. Improving nurse and physician communication. Weber State University Masters Projects. https://dc.weber.edu/collection/ATDSON This Project is brought to you for free and open access by the Weber State University Archives Digital Repository. For more information, please contact scua@weber.edu. WSU REPOSITORY MSN/DNP Improving Nurse and Physician Communication Project Title by Katie Wilson Student’s Name A project submitted in partial fulfillment of the requirements for the degree of MASTERS OF NURSING Annie Taylor Dee School of Nursing Dumke College of Health Professions WEBER STATE UNIVERSITY Ogden, UT April 2, 2023 Date April 2, 2023 Katie Wilson, RN BSN Student Name, Credentials (electronic signature) Date April 2, 2023 MSN Project Faculty (electronic signature) Date 05/25/2023 Melissa NeVille Norton (electronic signature) DNP, APRN, CPNP-PC, CNE Graduate Programs Director Note: The program director must submit this form and paper. Date 1 Improving Nurse and Physician Communication Katie Wilson BSN, RN, MSN Student Weber State University Annie Taylor Dee School of Nursing 2 Abstract Surgical patient outcomes are directly affected by nurse and physician communication. Evidence indicates that post-surgical patients are more likely to be involved in their care at home with the use of standardized teaching methods. This project aims to promote improved communication and patient outcomes by standardizing the discharge process with the use of a standardized checklist within surgical services. This project will include tools, resources, and education to help surgical nurses simplify the discharge process with their patients while improving communication techniques between nurses and providers. Education will benefit surgical nurses as they care for and do discharge teaching with their patients within surgical services. Family caregivers will also benefit from this project by developing confidence in postsurgical care for their loved one at home by ensuring that they understand all applicable orders for care. In addition, physicians and nurses will see improved clarification of orders through evidence-based communication techniques. Keywords: communication, discharge, education, surgical, patient outcomes 3 Improving Nurse and Physician Communication Nurse and physician communication can directly affect patient outcomes in surgical healthcare. The Joint Commission reports that 60% of sentinel events, or over 98,000 deaths, were caused by a communication error (Carreon & Dutra, 2020). Delivering quality patient care requires reliable, effective, and efficient communication between nurses and physicians (Carreon & Dutra, 2020). However, nurses and physicians have always shared a complicated relationship throughout history. The nurse-physician relationship is influenced by authority, social status, power, and gender (Amudha et al., 2018). Tensions, conflicts, and misunderstandings caused by differences in opinions and interests among nurses and physicians can upset the relationship (Amudha et al., 2018). The lack of a solid working relationship can obstruct effective collaboration and interdisciplinary communication (Amudha et al., 2018). A non-hierarchal structure can help nurses and physicians create an environment of respect, openness, and active listening, focusing on the free flow of patient-centered information (Foronda et al., 2019). Statement of Problem Poor interpersonal communication skills among physicians and nurses are associated with clinical errors, inefficient care delivery, and patient frustration (Machon et al., 2020). Postsurgical patients continue to express confusion about discharge instructions and misinformation from their providers (Harris et al., 2020). Research continues to demonstrate the importance of effective communication between nurses and physicians in promoting positive patient outcomes (Riegel et al., 2018), however ineffective communication continues to delay patient care, contribute to order errors, and frustrate other workflow areas of health care (Riegel et al., 2018). 4 Therefore, this MSN project aims to decrease the events of missing discharge orders through a post-operative discharge checklist and improve nurse and physician communication by providing education on evidence-based communication techniques. The goal will be accomplished by examining current literature to determine the problem’s extent and identify best practices. In addition, implementing a standardized discharge checklist for nurses in surgical services to use with discharge teaching will align with the goal of not missing any physician orders upon patient discharge. Ways Project Contributes to Intended Recipients Post-operative patients are more vulnerable than non-post-operative patients in retaining discharge teaching. The discussion of complex information may seem overwhelming, and some information they may have received pre-operatively may not be retained. Additionally, as patients transition to their homes, they may become unsure of typical symptoms or how to recognize a complication (Harris et al., 2020). Patients, nurse managers, nursing staff, and students may find the guidance of a checklist empowering as it leads to asking questions about their care that they may not have considered. Harris et al. (2020) indicate that patients and staff want a surgical procedure checklist. A checklist can stimulate a cultural and interpersonal relationship between the healthcare worker and the patient. This MSN project will include developing a checklist and training on its utilization. Rationale for the Importance of Project Practical nurse and physician communication continue to drive the patient experience. A patient’s negative or positive outcome may directly correlate to how their nurses and physicians communicate within the healthcare setting (Liaw et al., 2020). Using highly effective 5 communication skills among the multidisciplinary team can significantly impact how a patient perceives the healthcare system. The nurse and the physician must collaborate effectively to bring about the highest level of care to every patient they encounter. The implementation of three structured tools may be effective in improving communication in surgical services and decreasing missing orders. The first is implementing a new post-operative discharge checklist for surgical nurses to use with discharge teaching. Additionally, using voice-activated devices such as Vocera for all staff and SBAR: situation, background, assessment, and recommendation during post-operative rounding (Foronda et al., 2019). SBAR technique is supportive of a practical communication framework. Having a nurse and physician present and using the SBAR communication during post-operative rounding can reduce communication deficits and decrease order errors (Foronda et al., 2019). The current discharge process in surgical services lacks a post-operative checklist from the provider, in which the nurse can assess if all needs are met before the patient discharges to home. Nurse and physician communication collaboration through a post-operative discharge checklist will help improve patient care by decreasing the risk of missing orders (Harris et al., 2020; Thomas et al., 2021; Congdon et al., 2020), improving patient understanding of at-home instruction (Thomas et al., 2021), and reducing delays in care (Congdon et al., 2020). Literature Review and Framework Making changes among organizations can be challenging. The Ottawa Model of Research Use was developed to help ease those challenges by using a knowledge translation model within the context of continuity-of-care innovations (Jager et al., 2020). The use of this process helps guide research into practice. The Ottawa Model of Research Use follows a six-step approach to 6 guide the implementation of innovation or change (Beretta, 2021). The following sections discuss the literature and framework supporting the MSN project. Framework The Ottawa Model of Research Use is a six-step process that, although it appears linear, is unidirectional, with all elements influencing one another. Additionally, the model is a valuable tool for framing data analysis for research projects focusing on knowledge translation and implementation (Rycroft-Malone & Bucknall, 2010). Strengths The Ottawa Model of Research Use is valid for a variety of healthcare disciplines as well as multidisciplinary groups. Additionally, it ensures that the process is reproducible and transparent for all involved. Finally, it reduces barriers to project implementation and allows for the tailoring of implementation interventions (Rycroft-Malone & Bucknall, 2010). Limitations The strengths of the Ottawa Model of Research Use are very prominent, as it is beneficial for complex projects, reflects practice, and is intuitive. However, one of its limitations is that it has not had as much evaluation by researchers as some models in evidence-based research (Rycroft-Malone & Bucknall, 2010). Additionally, it is presented as a linear diagram but should be interpreted as a unidirectional process. At times, this can affect how researchers interpret different model elements that change the reality of the project implementation. Analysis of Literature Effective communication is a driving force within the healthcare system. There are several ways to improve communication and collaboration between nurses and physicians. First, promoting patient safety through a post-operative discharge checklist (Stewart & Snowden, 7 2021) using voice-activated communication devices to increase communication and workflow efficiency (Carreon & Dutra, 2020). Second, standardized clinical communication and collaboration platforms (CC&C) facilitate enhanced communication between nurses and physicians and improve patient safety, quality of care, and even clinician engagement (Machon et al., 2020). Thirdly, nurses and physicians collaborate with bedside rounding (Riegel et al., 2018). Search Strategies A literature search was conducted to identify current evidence using Medline, CINAHL, Google Scholar, Weber State University’s Stewart Library’s OneSearch, and Advanced Search to direct the initial exploration. Only articles from 2017 through 2022 were included in this literature review to keep the information current. The search keywords were nurse-physician communication, nurse-physician collaboration, voice-activated communication, clinical communication techniques, mobile communication technologies, qualitative, quantitative, literature review, discharge checklist, standardized checklist, discharge teaching, quality improvement, SBAR technique, and bedside rounding. In addition, various Boolean combinations were created with the keywords mentioned above to begin a broad search. Promoting Safety Through a Standardized Discharge Checklist Orders are the primary way providers communicate with the nursing staff. Discharge orders that promote straightforward, accurate communication can improve interdisciplinary integration in care, clarify care instructions, and reduce order discrepancies (Stewart & Snowden, 2021). Additionally, comprehensive discharge instructions lessen the need to call providers for order clarification or ask for additional orders. Finally, a standardized checklist allows for the transfer of information within, between, and across healthcare teams, providers, and settings 8 before, during, and after a care transition and promotes patient safety (Stewart & Snowden, 2021). Using a standardized checklist can improve interdisciplinary integration in care, promote accurate communication, and reduce variations in patient outcomes. For example, a pilot study by Kelly et al. (2020) concluded that a discharge checklist is a feasible mechanism for improving communication during patient discharge. Additionally, the study showed that the discharge checklist decreased the patient need for early post-operative healthcare access. Hands-Free Voice-Activated Communication A literature review found that implementing voice-activated communication devices during bedside rounds improved communication, teamwork, and patient experience. Wickersham et al. (2018) performed an independent quality improvement intervention using an online Qualtrics survey with nurses and physicians (n=117). The study found that following the implementation of the Vocera voice-activated communication devices, nurses responded with a 17.9% improvement in being notified for bedside rounding with physicians. Additionally, physicians reported a 48.1% increase in overall communication improvement with the nursing staff. Machon et al. (2018) reported that nurses spend at least 19% of their shifts communicating with other nurses and physicians. This finding aligns with the research by (Wickersham et al., 2018) that hands-free devices used in communication are needed to help improve the patient experience. Additionally, Carreon et al. (2020) performed a cross-sectional quantitative study among staff at a 71-bed acute care nursing facility. Researchers found statistical significance between communication with voice-activated devices and patient care quality (r=0.748), (p.001). Wireless communication device technology can deliver an effective and efficient information 9 exchange that positively affects staff communication and workflow efficiency, leading to safe, quality care (Carreon & Dutra, 2020). Nurse and Physician Bedside Rounding Several studies show the significance of nurse and physician communication during bedside rounding and how it improves patient safety and quality of care. For example, Amudha et al. (2018) concluded that nurses and doctors have a vital role in creating healthy communication and collaboration to enhance excellent patient outcomes. Likewise, Boev et al. (2022) showed that ICU nurses and physicians agreed that collaboration is crucial and is linked to improving patient outcomes, job satisfaction, and a healthy work environment. Multidisciplinary rounding was also identified as the best mechanism to support collaborative behaviors. One recommendation was noted within the literature review, Havons et al. (2017) identified that nurses and physicians reported varied perceptions of effective collaboration. They responded that a standard definition of collaboration should be developed, and a validated, unbounded instrument should be used to measure nurse-physician collaborations. Clinical Communication and Collaboration Platforms The widespread use of mobile technologies, such as clinical communication & collaboration platforms, can facilitate enhanced communication between nurses and physicians. For example, Foronda et al. (2019) conducted a pilot study using the Interprofessional Communication Rubric (IICR) to evaluate new nurse graduates in a high-fidelity scenario. Additionally, Goncalves-Bradley et al. (2020) performed an intervention review of 19 systematic reviews and clinical trials. The research concluded that the widespread use of mobile technologies could potentially expand the use of telemedicine to facilitate communication 10 between healthcare providers and improve patient outcomes. In addition, Riegel et al. (2018) conducted a two-phase quality improvement project with two staff nurses. This project was implemented using simple, inexpensive door signs to promote significant changes in communication among healthcare professionals. Findings include a reduction in phone calls on the medical-surgical unit and an increase in nurse communication. Summary of Literature Review Findings and Application to the Project The literature on discharge checklists reinforces the need for standardization of such documentation within the post-operative setting (Berry & Kelly, 2020). Patients need lists to help them understand the most critical parts of their care upon discharge from the hospital (Harris et al., 2020). Additionally, the literature on voice-activated communication reinforces a need to implement devices in hospitals and clinics where applicable. This type of communication has improved workflow, communication, and collaboration for both nurses and physicians (Carreon & Dutra, 2020). The research also suggests that nurses and physicians have similar and differing opinions when asked about what they value most in communication and collaboration, which validates the need for continued nurse and physician communication programs (House & Havens, 2017). These findings support the need for professional leadership to support continued education of nurse and physician communication programs (Boev et al., 2022). Improving communication is imperative for nurses and physicians to improve postoperative outcomes for their patients. Project Methodology This MSN project aims to improve communication between peri-operative nurses and physicians in surgical services. Improved communication will be accomplished using a 11 standardized discharge checklist. Nurse and physician communication are critical in reducing sentinel events and providing outstanding patient care (Carreon & Dutra, 2020). For example, within this organization, patients come in for a surgical procedure after having a pre-operative appointment with their surgeon. There are often specific instructions that have been discussed with their surgeon; however, the pre-operative or discharge nurse may not know about them, and the orders are not in the surgeon’s power plan. Therefore, implementing a structured collection of post-operative discharge instructions via a discharge checklist is warranted to improve communication between surgical and pre-operative nurses and physicians. Description and Development of Project Deliverables Two different items were created to aid in the implementation of this project. The following section describes the deliverables to help the staff understand them. Additionally, a brief explanation of the significance of each deliverable is included. Post-Operative Discharge Checklist The first item is a standardized discharge checklist (see Appendix A). This checklist aims to ensure that all post-operative orders have been received from the surgeon before the patient is discharged after surgery. In addition, the list will ensure that the five Ds of crucial discharge information are addressed by the discharging nurse and specified by the surgeon (Stewart & Snowden, 2021). Finally, nurses will use this checklist to guide them as they discharge their patients. PowerPoint Presentation The second item is a PowerPoint presentation (see Appendix B). The PowerPoint will contain information to present to the nursing staff before implementing the new checklist process. The presentation will review barriers to the current process, explain the new checklist 12 process, and review the new method for obtaining orders for discharge if needed. Additionally, the presentation will review current nurse and physician communication barriers and how the new checklist process can help remove those barriers (Machon et al., 2020). Plan and Implementation Process Using the Ottawa Model of Research Use as a guide to effect change at the organizational level, this MSN project will be implemented upon approval from the surgical services nursing administrator. With the Intermountain Layton Hospital Surgical Services administrator and the head of surgery, a meeting will occur at the Layton Lancers conference room to help understand the current physician order entry system. This meeting will allow nursing leadership to share standard order sets and how orders are communicated to surgical nursing staff. Additionally, a collaborative discussion with surgical services staff and nursing leadership will be held to gather perceived barriers to the current order and discharge process. Nurses will have the opportunity to voice their concerns about what current methods work and what changes they would like to see. Feedback from the nursing staff will be considered during the implementation of the MSN project. The project will be introduced to the surgical services team three weeks later during a second meeting. Objectives for the project will be presented, and the new checklist will be given to each RN to review. Additionally, the presentation will provide the surgical nurses with information on ways to teach throughout the discharge process using the new checklist. Interdisciplinary Teamwork Intermountain Health Care Surgical Services Nurse Manager The nurse manager is essential to the team and will directly impact the project's initial implementation. The manager will have the final say on the implementation of the project, as 13 well as factors that affect the budget, hours, and staff training. Additionally, the manager is an integral part of encouraging the continued use of the discharge checklist. Surgical Staff Nurse The peri-operative staff nurse is imperative to the project’s success, as they will successfully use the discharge checklist with every patient they discharge. In addition, using the list will directly affect patient outcomes as it is directly associated with ensuring that all areas of patient care are addressed before discharge. Physician or Surgeon The physician or surgeon plays a significant role in the project by ensuring that they are communicating effectively with the nursing staff via wireless communication devices and ensuring that they are entering their orders correctly through the physician ordering screen as instructed. Timeline The timeline of this project will be coordinated with the surgical services nursing administrator. The initial meeting with the nursing administration and head of surgery will be scheduled for four hours. This should give sufficient time to understand the discharge order entry systems. However, the first educational meeting with nursing staff will be shorter, scheduled for one hour. The second meeting with staff for the presentation of deliverables will be scheduled for ninety minutes. The initial introduction of the checklist process to the finalization and implementation will take three to four weeks, with the full implementation in one month (See Appendix C). Plan for Evaluation of Project As a summative assessment for this project implementation, nurses in surgical services 14 will all be given a survey after one month of using the standardized discharge checklist. This anonymous survey will be administered via Qualtrics through employee email (See Appendix D). The survey will contain questions regarding the overall effectiveness of the discharge checklist, ease of use, and why or why not it should be continued. Unit leadership will assess the data from the survey to see if significant improvements have been made. Additionally, unit managers will make summative assessments as they look at adverse event reports associated with patient discharge orders. Finally, the surgical nursing staff will attend monthly staff meetings to obtain continued training for physicians on their voice-activated devices and instant-messaging systems. Ethical Considerations A standardized discharge checklist is crucial because it ensures that all patients understand their care at home. Well-designed discharge orders promote patient safety and allow for more accurate communication (Stewart & Snowden, 2021). Patients are most vulnerable when they leave the hospital and are back in the home setting. This project reflects social responsibility in that it aims to decrease sentinel events by ensuring that surgical patients understand their discharge orders thoroughly before going home. The hospital's electronic medical record system protects all patients' health records. In addition, all discharge instructions are given in the patients’ private rooms, with the door closed to protect patient privacy. Discussion The following sections will include information on plans for the standard discharge checklist project presentation and dissemination. Next, this section will review how standardizing discharge checklists is a strategic solution for significantly improving patient 15 outcomes upon discharge from surgical services. Furthermore, the strengths and limitations of the project will be discussed, and recommendations for project continuation and improvement will be made. Evidence-based Solutions for Dissemination After the initial month following the implementation of this project, the results will be disseminated in several ways. First, the Surgical Services leadership team, including shared leadership team members at the Layton IHC Hospital, will be presented with the group discussion outcomes during a leadership meeting. A PowerPoint presentation will be used during this meeting to help illustrate the survey results from Qualtrics. Second, information will be presented to the Intermountain Health Layton HLT or Hospital Leadership Team. Results from the nursing Qualtrics survey, both pre, and post, along with adverse event data reporting, will be presented to the HLT team in a PowerPoint presentation and handout. The information will aid the HLT team in determining whether to implement the program throughout the Canyons Region surgical units, which includes twenty-one hospitals. Additionally, this MSN project will be printed on a 36”x48” poster to be presented and displayed at the Sigma Theta Tau Nu Nu Chapter Induction Dinner and Ceremony on March 22, 2023, in Davis County. This will provide an opportunity to share research contributions with Sigma members. Finally, this project will be presented to fellow graduate students and faculty at WSU through a graduate project presentation in April 2023. Significance to Advance Nursing Practice This project will benefit all nurses working with patients in surgical services or clinical settings. Research indicates that well-designed discharge orders help to promote accurate 16 communication between discharging teams (Stewart & Snowden, 2021). In addition, according to a study by Harris (2020), patients’ involvement in their care and safety has increased. Therefore, the quality of discharge education influences how a patient participates in their care post-discharge (Kang et al., 2018). Thus, not only will this project benefit nurses and physicians, but it will also benefit patients, as standardized checklists may improve patient outcomes in surgery (Harris et al., 2020). Implications Effective communication and teamwork between nurses and physicians are vital drivers for successful patient outcomes (Amudha et al., 2018). Implementing highly effective communication techniques, such as nurse and physician bedside rounding Boev et al. (2022) and hands-free communication devices, Carreon and Dutra (2020) seek to improve patient outcomes through communication. However, insufficient discharge education post-surgery can compromise a patient’s recovery process and cause unnecessary complications (Kang et al., 2018). Using a standardized discharge checklist after surgery promotes accurate communication, improves integration in care, and reduces variation in instructions by clearly communicating patient orders (Stewart & Snowden, 2021). This project’s limitations are its’ size due to the implementation within a small community hospital. However, after implementation and hopeful success of the program, the goal is to propose its implementation throughout the Canyons Region of Intermountain Health. In addition, other limitations include a lack of cooperation or implementation from surgical staff nurses in using the discharge checklist. It may be difficult to get family on board with participation in discharge planning, as it takes additional time and attentiveness; this may also be a limiting factor. 17 The importance of communication and order clarification through the standardized discharge checklist will be emphasized and shared with enthusiasm to gain favor from the perioperative nursing staff. Helping the nurses understand that this process is designed to improve the current discharge process in surgical services will potentially remove the obstacle of not wanting to use the checklist. Discharge teaching can be difficult as patients and families prepare to go home after surgery. Peri-operative nurses can encourage participation in discharge learning by giving the family a copy of the checklist as they explain each item in detail. As both nurses and patients utilize the discharge checklist, they can tailor the education to the patient and family to ensure that the quality of education meets the need. Recommendations The literature review indicated significant research on nurse and physician communication; however, it is recommended to continue to assess nurse and physician communication. Additionally, the literature review concerning discharge checklists reinforces the need to continue standardizing these processes to improve patient safety (Berry & Kelly, 2020). In addition, after the implementation at the local hospital, it is recommended that the standardization communication process and tools be utilized throughout the organization. Conclusions Poor communication between nurses and physicians is the leading cause of medical error and patient harm (Stewart & Snowden, 2021). Lack of communication can lead to various adverse outcomes, including discontinuity of care, dissatisfied patients, compromise of patient safety, and economic consequences (Stewart & Snowden, 2021). However, nurses in surgical services can influence patients’ outcomes post-surgery by implementing a standardized discharge 18 checklist. In addition, the quality of discharge education affects patients’ participation in their care management post-discharge from the hospital. 19 References Amudha, P., Hamidah, H., Annamma, K., & Ananth, N. (2018). Effective communication between nurses and doctors: Barriers as perceived by nurses. Journal of Nursing & Care, 07(03). https://doi.org/10.4172/2167-1168.1000455 Beretta, V. (2021). Using the ottawa model of research use to discuss hta development. In (Ed.), Development and implementation of health technology assessment (pp. 121–145). Springer International Publishing. https://web-s-ebscohostcom.hal.weber.edu/ehost/pdfviewer/pdfviewer?vid=2&sid=bcdf40a2-f4ec-42aa-b42b7846633ba173%40redis Berry, L., & Kelly, M. (2020). Implementation of a post-operative electronic discharge checklist is associated with lower rate of early healthcare access. 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Journal of Communication in Healthcare, 11(1), 56–61. https://doi.org/10.1080/17538068.2018.1431425 23 Appendix A Standardized Discharge Checklist The standardized post-op discharge checklist will be printed on 8 ½” x 11”. A copy will be included in each patient chart prepared the day before the patient arrives for surgery. 24 Appendix B PowerPoint for Employee Training 25 Appendix C Timeline for Implementation Week 1 Week 2 Meet with the Produce Surgical deliverables for Services Nursing nursing staff Administrator and head of surgery (4 hours) Meet with surgical nursing staff to obtain input on orders and processes (1 hour) Deliverable 1: PowerPoint Presentation Deliverable 2: Standardized Discharge Checklist Deliverable 3: Postimplementation survey through Qualtrics Week 3 End of Month 1 Ongoing Meet with Surgical Nursing Staff to present deliverables Surgical Nurses complete a postevaluation survey The unit manager will continue to assess adverse event reports and unit data associated with patient discharge orders Surgical nursing staff and physicians will attend monthly staff meetings to obtain continued training on effective communication 26 Appendix D Qualtrics Post-Implementation Survey 27 28 29