Presentation
Note-Worthy: A Novel, Collaborative, Iterative Methodology to Analyzing Written Nurse-Physician Communication
DescriptionEffective nurse-physician communication within multidisciplinary patient care teams is essential for patient safety. Literature reports that poor communication within these teams accounts for over 60% of sentinel events, including severe patient injury and even death. While much is known about the positive impacts of utilizing structured approaches to improve communication, there is little literature on structuring written nurse-physician communication tools.
At Hennick Bridgepoint Hospital (HBH), a 470-bed academic, urban, post-acute care facility part of Sinai Health System (Sinai Health) in Toronto, Canada, the current weekend nurse-physician communication system relies on handwritten communication books. A communication book is located in each of the 14 units across the hospital. Nurses handwrite patient assessment requests for weekend on-call physicians in a physical communication book, which physicians review during their on-call rounds. There have been multiple safety concerns identified with these handwritten communication books, including missed or misinterpreted requests, illegibility, and non-standardized entries. Additionally, requests often contain inappropriately triaged assessment requests. Together, these issues have led to significant efficiency and workload concerns from the on-call physicians. There have also been critical events in which the communication books have been implicated as potential contributing causes.
This study aims to develop a general approach to analyzing nurse-physician written communication requests, and thereby inform the next stages in optimizing the design of on-call communication. The presentation will focus on the novel, collaborative, iterative methodology that was implemented for the study.
We developed a methodology that analyzed the written communication itself, as well as the weekend on-call physician workflows. Throughout the process discussions with physicians were held to ensure their input and concerns were correctly incorporated. As such, a two-pronged approach was used: (1) qualitative analysis through physician observations and (2) quantitative analysis of communication book entry data. Four observations of weekend on-call physician shifts were conducted to better understand the role of the communication books and how they impact physician workflows. These observations helped inform next steps and were useful during physician discussions to relate specific observations to the scoring system. It should be noted that nurse observations were attempted to see how using the communication books fit into their workflow. Unfortunately, it was not feasible to observe nurses writing in the communication books as this occurs sporadically during their shift. Given the limitations encountered with our initial approach, we plan to implement a more structured methodology through focus groups to enhance nursing involvement and deepen our understanding of contextual factors influencing their experiences.
In terms of the quantitative analysis, data was collected from 6 units and the 10 most recent entries from each unit were analyzed. These entries were scored using a scoring system adapted from the SBAR (Situation, Background, Assessment, Recommendation) format that included scoring for clarity and legibility. The scoring system was originally designed to assess the completeness of the entries. Completeness refers to whether the entry contains the necessary information that the physician requires to properly treat the patient. Two scorers independently analyzed each entry; if there was a discrepancy, the entry was flagged for clinician review during the next phase of the study. The scorers were trained in the SBAR system and scoring criteria.
Next, the scoring system was validated during the third phase of the study. This involved a panel of three clinicians who analyzed the flagged entries and provided feedback on the scoring system. When physicians were shown entries that received scores using solely the SBAR informed scoring system, they found the scores did not accurately reflect the quality of the entries. The discussions highlighted that completeness and legibility were not the only issues present; inappropriate triaging was also identified as a major concern. Inappropriately triaged examples found in the communication books included acute chest pain, suicidal ideation, vision loss and shortness of breath. These are urgent issues and should instead have been communicated via page or phone call. To address this, the Canadian Triage and Acuity Scale (CTAS) was included in the scoring system. This scale is used to classify the urgency of patient care, allowing us to analyze whether requests being made were correctly triaged. At this point in the study the scoring system was updated to analyze completeness as well as appropriateness. Appropriateness refers to whether the writing in the communication book is the correct triaging. The CTAS scoring requires more background knowledge than SBAR scoring meaning that this was completed by trained clinicians.
Another validation strategy includes a physician survey that will explain the project and scoring system to physicians at the hospital. They will then have the opportunity to score template entries and provide feedback on if the scoring system makes sense, or if anything should be changed. By having multiple levels of validation, the most appropriate scoring system design can be developed.
A key limitation of the current study is the limited engagement of nursing staff, which restricts our ability to fully understand the context in which communication book requests are made. This is particularly relevant for requests that were deemed inappropriately triaged, where insight into nursing workflows and decision-making processes is critical. Physicians were primarily engaged in the validation of the scoring criteria, as they are the recipients of the communication and key individuals in assessing request appropriateness. To address the gap in nursing engagement, plans are underway to engage nursing staff to clarify these contextual factors and identify opportunities for improving communication.
The presentation will highlight the benefits of interdisciplinary and iterative collaboration. Consulting nurses and physicians meant that the scoring system reflected the concerns and insights of both groups. For example, the inclusion of the CTAS scoring would not have been considered without clinician discussions, demonstrating how important it is to design scoring systems that are context-specific. Using clinician input allowed a novel scoring system to be created that contains both SBAR scoring to analyze completeness and CTAS scoring to analyze appropriateness. Additionally, the study is unique in that it takes place in a post-acute care facility, a location often overlooked in other similar studies on communication within hospitals.
In conclusion, the collaborative, iterative methodology provides a useful template for analyzing a wide range of communication within hospitals. While this is a single-center study that focuses on written communication, the methodology can be adapted to analyze communication in other settings as well.
At Hennick Bridgepoint Hospital (HBH), a 470-bed academic, urban, post-acute care facility part of Sinai Health System (Sinai Health) in Toronto, Canada, the current weekend nurse-physician communication system relies on handwritten communication books. A communication book is located in each of the 14 units across the hospital. Nurses handwrite patient assessment requests for weekend on-call physicians in a physical communication book, which physicians review during their on-call rounds. There have been multiple safety concerns identified with these handwritten communication books, including missed or misinterpreted requests, illegibility, and non-standardized entries. Additionally, requests often contain inappropriately triaged assessment requests. Together, these issues have led to significant efficiency and workload concerns from the on-call physicians. There have also been critical events in which the communication books have been implicated as potential contributing causes.
This study aims to develop a general approach to analyzing nurse-physician written communication requests, and thereby inform the next stages in optimizing the design of on-call communication. The presentation will focus on the novel, collaborative, iterative methodology that was implemented for the study.
We developed a methodology that analyzed the written communication itself, as well as the weekend on-call physician workflows. Throughout the process discussions with physicians were held to ensure their input and concerns were correctly incorporated. As such, a two-pronged approach was used: (1) qualitative analysis through physician observations and (2) quantitative analysis of communication book entry data. Four observations of weekend on-call physician shifts were conducted to better understand the role of the communication books and how they impact physician workflows. These observations helped inform next steps and were useful during physician discussions to relate specific observations to the scoring system. It should be noted that nurse observations were attempted to see how using the communication books fit into their workflow. Unfortunately, it was not feasible to observe nurses writing in the communication books as this occurs sporadically during their shift. Given the limitations encountered with our initial approach, we plan to implement a more structured methodology through focus groups to enhance nursing involvement and deepen our understanding of contextual factors influencing their experiences.
In terms of the quantitative analysis, data was collected from 6 units and the 10 most recent entries from each unit were analyzed. These entries were scored using a scoring system adapted from the SBAR (Situation, Background, Assessment, Recommendation) format that included scoring for clarity and legibility. The scoring system was originally designed to assess the completeness of the entries. Completeness refers to whether the entry contains the necessary information that the physician requires to properly treat the patient. Two scorers independently analyzed each entry; if there was a discrepancy, the entry was flagged for clinician review during the next phase of the study. The scorers were trained in the SBAR system and scoring criteria.
Next, the scoring system was validated during the third phase of the study. This involved a panel of three clinicians who analyzed the flagged entries and provided feedback on the scoring system. When physicians were shown entries that received scores using solely the SBAR informed scoring system, they found the scores did not accurately reflect the quality of the entries. The discussions highlighted that completeness and legibility were not the only issues present; inappropriate triaging was also identified as a major concern. Inappropriately triaged examples found in the communication books included acute chest pain, suicidal ideation, vision loss and shortness of breath. These are urgent issues and should instead have been communicated via page or phone call. To address this, the Canadian Triage and Acuity Scale (CTAS) was included in the scoring system. This scale is used to classify the urgency of patient care, allowing us to analyze whether requests being made were correctly triaged. At this point in the study the scoring system was updated to analyze completeness as well as appropriateness. Appropriateness refers to whether the writing in the communication book is the correct triaging. The CTAS scoring requires more background knowledge than SBAR scoring meaning that this was completed by trained clinicians.
Another validation strategy includes a physician survey that will explain the project and scoring system to physicians at the hospital. They will then have the opportunity to score template entries and provide feedback on if the scoring system makes sense, or if anything should be changed. By having multiple levels of validation, the most appropriate scoring system design can be developed.
A key limitation of the current study is the limited engagement of nursing staff, which restricts our ability to fully understand the context in which communication book requests are made. This is particularly relevant for requests that were deemed inappropriately triaged, where insight into nursing workflows and decision-making processes is critical. Physicians were primarily engaged in the validation of the scoring criteria, as they are the recipients of the communication and key individuals in assessing request appropriateness. To address the gap in nursing engagement, plans are underway to engage nursing staff to clarify these contextual factors and identify opportunities for improving communication.
The presentation will highlight the benefits of interdisciplinary and iterative collaboration. Consulting nurses and physicians meant that the scoring system reflected the concerns and insights of both groups. For example, the inclusion of the CTAS scoring would not have been considered without clinician discussions, demonstrating how important it is to design scoring systems that are context-specific. Using clinician input allowed a novel scoring system to be created that contains both SBAR scoring to analyze completeness and CTAS scoring to analyze appropriateness. Additionally, the study is unique in that it takes place in a post-acute care facility, a location often overlooked in other similar studies on communication within hospitals.
In conclusion, the collaborative, iterative methodology provides a useful template for analyzing a wide range of communication within hospitals. While this is a single-center study that focuses on written communication, the methodology can be adapted to analyze communication in other settings as well.
Authors
Event Type
Oral Presentations
TimeWednesday, April 211:15am - 11:37am EDT
LocationQueens Quay
Patient Safety and Research Initiatives (PS)