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Health Care Delivery


Team Communication: It’s About Patient Safety

By Susan B. Childress, RN, MN, OCN
Huntsman Cancer Hospital, University of Utah Health Care, Salt Lake City, UT

“The single biggest problem in communication is the illusion et al6 described barriers related to suboptimal conflict resolution
that it has taken place.” and interpersonal communications skills. Other findings go on
—George Bernard Shaw to identify status, authority, responsibilities, gender, training,
and nurse/physician cultures as factors that influence effective
The article by Weaver et al1 in this issue of Journal of Oncol-
communication.5,6,12 Colleagues in these dynamic domains
ogy Practice provides an important reminder to oncologists who
have led the way in studying communication barriers and im-
lead interprofessional teams that opportunities to improve team
plementing changes to improve patient safety. These studies
communication remain. Studies in a variety of settings have
report that miscommunication is frequently among the causes
concluded that communication affects the quality of patient
care, team satisfaction, and nursing turnover rates.2 The discon- of error and often the leading cause.4,10 Intensive care unit data6
nect in perception of communication between physicians and reveal that nurses find it difficult to speak up, disagreements are
their nursing colleagues is significant and well documented in not appropriately resolved, and nursing input is not well re-
the literature,3-6 so much so that it is surprising that studies are ceived. Both Awad et al4 and Makary et al5 confirmed a differ-
still taking place. As Weaver et al describe, strong team collab- ence in communication ratings between nurses and surgeons in
oration supports patient safety on many levels. The challenge the operating room, with physicians believing communication
for researchers in this field is to replicate the results of interven- was not flawed. Janss et al12 reviewed communication research
tions already implemented at a few institutions in a multicenter and its impact on teamwork from the domain of social and orga-
study. Other potential research could examine questions re- nizational psychology. Their conclusions were that power and con-
lated to the types and breadth of communication. In the past flict influenced individual communication styles, and they
10 years, tools such as texting, Vocera, and electronic med- recommended training interventions to help teams improve col-
ical records (EMRs) have added to the complexity of team laboration.
communication. In the oncology setting, unique challenges underscore the
Fifteen years ago, the Institute of Medicine challenged pro- need for strong communication among team members, includ-
viders to embrace the need to radically improve how patient ing intricate diagnostic procedures, patient populations with
care is delivered by “hard wiring” safety into our culture.7 Ini- multiple comorbidities, and complex and potentially dangerous
tiatives such as checklists, rapid response teams, medication treatments. Oncology patients continually transition from in-
reconciliation, and hand-off procedures all contribute to im- patient to outpatient status. Multiple hand-offs for surgery,
proving patient safety outcomes.8 An example of a national procedures, radiation, and outpatient infusion create multiple
effort is the Agency for Healthcare Research and Quality pro- opportunities for miscommunication. Most oncology profes-
gram, “On the Cusp: Stop BSI Project,” which was able to show sionals would agree that this setting could also be appropriately
a 44% decrease in central line blood stream infections.8 Yet we categorized as a “dynamic domain.”11
continue to witness communication breakdowns that adversely In an attempt to reduce the number of communication-
affect patient outcomes. Most recently, the highly publicized based errors, health care has looked to other industries such as
Ebola outbreak brought to light a gap in communication when aviation for solutions. After air crashes, investigators frequently
a nurse asked all the right questions and documented the an- found communication errors between airline staff to be the root
swers in the EMR, yet a patient who should have been flagged as of the problem. Training and system changes implemented
potentially infected was allowed to leave the emergency room specifically to improve communication have significantly re-
before the Ebola risk was noted.9 Most nurses and physicians duced near misses and crashes.2 These changes involved intro-
would not be surprised by this event; electronic records are not duction of checklists and redundant safety technology, thereby
always supportive of interdisciplinary communication. reducing the possibility and influence of human error.13 With
As Weaver et al1 point out, the impact of poor interprofes- this knowledge, health care interventions to improve commu-
sional team communication on an oncology inpatient unit and nication among teams have included preoperative briefings,
the resulting quality outcomes are less understood. Although hand-off improvements such as SBARQ tools, check-off lists,
research in the specialty of inpatient oncology is still needed, and medication reconciliation procedures.4,8 The SBARQ tool
studies in a wide range of “dynamic domain” specialties such as has been shown to significantly improve satisfaction with nurse-
operating rooms, intensive care and trauma units, and emergency physician communication.14 The use of surgical checklists re-
departments have produced a body of literature that identifies sulted in reducing major surgical complications by 36% in the
some specific barriers to effective communication.4-6,10,11 Thomas preoperative setting.15 Medication errors were decreased by

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93% with the implementation of a medication reconciliation countability has encouraged stronger collaboration with nurse
process.16 managers and other key team members. When positive team-
Although patient safety is a priority, many other reasons to work is modeled by the unit administrative leaders, the poten-
embrace a culture of improved communication in the health tial for improved patient outcomes increases at many levels.
care system exist. Previous studies have demonstrated that good Kim et al21 described the unit-based interprofessional leader-
communication is associated with improved job satisfaction, ship models in six hospitals and how the development and
less time missed from work due to illness, less nursing turnover, implementation of these models may be viewed as options for
and less fatigue, thereby also providing a financial motivation to other inpatient departments.
improve communication.10,17 In conclusion, effective communication in the health care
Nursing research provides another perspective by identi- system is important to prevent errors and improve job satisfac-
fying a variety of solutions to improve nurse satisfaction tion. Physicians and nurses continue to disagree in their percep-
through better communication. A 2003 study by Kramer and tion of the quality of their communication. Potential solutions
Schmalenberg18 identified three factors present when nurses are identified throughout the literature. It is time for hospital
felt they had a collegial relationship with their physicians: (1) administrators, physician and nurse leaders, and our medical
nursing staff perception of their role as “equal but different” and and nursing education institutions to enact permanent changes
articulation of how their knowledge was unique and worth in team dynamics that support improved communication.
communicating; (2) an institutional culture that values, ex-
pects, and rewards collegial relationships between nurses and I thank Pim Gal, MD, for his insight and logistical support; Diane Fouts
physicians; and (3) expectations that nurses maintain clinical for her outstanding editorial skills; and John Sweetenham, MD, for his
competence in their specialty, along with assistance in doing so, leadership, nurse-physician communication skills, and role modeling.
which promotes confident communication. Lindeke and Sieck-
ert19 recommend a focus on understanding the perspective of Author’s Disclosures of Potential Conflicts of Interest
Disclosures provided by the authors are available with this article at
others, avoiding “compassion fatigue,” and learning how to
manage conflict. Bunnell et al20 demonstrated successful imple-
mentation of role definition and team training in a program Corresponding author: Susan B. Childress RN, MN, OCN, Director of
called the “Two-Challenge Rule.” This rule requires team Nursing Services, Huntsman Cancer Hospital, University of Utah Health
Care, 1950 Circle of Hope, Salt Lake City, UT 84112; e-mail: susan.
members to state their observations at least twice to ensure that childress@hci.utah.edu.
their interests are being addressed. Their work in an ambulatory
oncology setting showed improved communication; task coor- Susan B. Childress is currently the Director of Oncology Nursing Ser-
dination; and perception of efficiency, quality, and safety, as vices at Huntsman Cancer Institute at the University of Utah. Prior to
well as higher levels of patient satisfaction. Huntsman Cancer Institute, Ms. Childress worked for many years at the
Salt Lake City Veterans Affairs Medical Center, managing the medicine/
Historically, physician accountability in university settings oncology inpatient unit and infusion services. She has published papers
has focused on clinical management, research, and house staff on ethics at the end of life, palliative care, pain management, clinical
education. Many organizations are challenging this culture by staff education and orientation, and quality improvement.
expecting medical directors to be more engaged in the manage-
ment of their inpatient units, specifically in the areas of quality,
patient experience, and financial strength. This change of ac- DOI: 10.1200/JOP.2014.002477

1. Weaver AC, Callaghan M, Cooper AL, et al: Assessing interprofessional team- 9. Khazan O: The Ebola patient was sent home because of bad software. http://
work in inpatient medical oncology units. J Oncol Pract [epub ahead of print on www.theatlantic.com/technology/archive/2014/10/the-ebola-patient-was-sent-
October 28, 2014] home-because-of-an-electronic-health-record-problem/381087/
2. Leape LL, Berwick DM, Bates DW: What practices will most improve safety? 10. Manojlovich M: Linking the practice environment to nurses’ job satisfaction
Evidence-based medicine meets patient safety. JAMA 288:501-507, 2002 through nurse-physician communication. J Nurs Scholarship 37:367-373, 2005

3. Nelson GA, King ML, Brodine S: Nurse-physician collaboration on medical- 11. Manser T: Teamwork and patient safety in dynamic domains of healthcare: A
surgical units. Medsurg Nurs 17:35-40, 2008 review of the literature. Acta Anaesth Scand 53:143-151, 2009
12. Janss R, Rispens S, Segers M, et al: What is happening under the surface?
4. Awad SS, Fagan SP, Bellows C, et al: Bridging the communication gap in the Power, conflict and the performance of medical teams. Med Educ 46:838-849,
operating room with medical team training. Am J Surg 190:770-774, 2005 2012
5. Makary MA, Sexton JB, Freischlag JA, et al: Operating room teamwork among 13. Haynes AB, Weiser TG, Berry WR, et al: A surgical safety checklist to reduce
physicians and nurses: Teamwork in the eye of the beholder. J Am Coll Surg morbidity and mortality in a global population. N Engl J Med 360:491-499, 2009
202:746-752, 2006
14. Beckett CD, Kipnis G: Collaborative communication: Integrating SBAR to
6. Thomas EJ, Sexton JB, Helmreich RL: Discrepant attitudes about teamwork improve quality/patient safety outcomes. J Healthc Qual 31:19-28, 2009
among critical care nurses and physicians. Crit Care Med 31:956-959, 2003 15. de Vries EN, Prins HA, Crolla RM, et al: Effect of a comprehensive surgical
7. Institute of Medicine: To err is human: Building a safer healthcare system. safety system on patient outcomes. N Engl J Med 363:1928-1937, 2010
https://www.iom.edu/~/media/Files/Report%20Files/1999/To-Err-is-Human/ 16. Agrawal A, Wu WY: Reducing medication errors and improving systems
To%20Err%20is%20Human%201999%20%20report%20brief.pdf reliability using an electronic medication reconciliation system. Jt Comm J Qual
Patient Saf 35:106-114, 2009
8. Agency for Healthcare Research and Quality: Eliminating CLABSI: A National
Patient Safety Imperative. www.ahrq.gov/professionals/quality-patient-safety/ 17. Larrabee JH, Janney MA, Ostrow CL, et al: Predicting registered nurse job
cusp/onthecusprpt/index.html satisfaction and intent to leave. J Nurs Admin 33:271-83, 2003

24 JOURNAL OF ONCOLOGY PRACTICE • V O L . 11, I S S U E 1 Copyright © 2015 by American Society of Clinical Oncology
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18. Kramer M, Schmalenberg C: Securing “good” nurse/physician relationships. 20. Bunnell CA, Gross AH, Weingart SN, et al: High performance teamwork
Nurs Manage 34:34-38, 2003 training and systems redesign in outpatient oncology. BMJ Qual Saf 22:405-413,
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Issues Nurs 10:5, 2005 in six US hospitals. J Hosp Med 9:545-550, 2014

ASCO Connection: Trainee & Early-Career Oncologists

Read the latest edition of ASCO Connection: Trainee & Early-Career Oncologists. Topics include:
● Transitioning from fellowship to career: expectations versus reality
● Mistakes to avoid on your Young Investigator Award application
● Articles on Board prep, grants and awards, career options, lifestyle, and more
Access now at connection.asco.org.

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Team Communication: It’s About Patient Safety
The following represents disclosure information provided by authors of this manuscript. All relationships are considered compensated. Relationships
are self-held unless noted. I ⫽ Immediate Family Member, Inst ⫽ My Institution. Relationships may not relate to the subject matter of this manuscript.
For more information about ASCO’s conflict of interest policy, please refer to www.asco.org/rwc or jop.ascopubs.org/site/misc/ifc.xhtml.

Susan B. Childress
No relationship to disclose

JOURNAL OF ONCOLOGY PRACTICE • V O L . 11, I S S U E 1 Copyright © 2015 by American Society of Clinical Oncology
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