We’ve all heard the horror stories about tragic medical errors. Mistakes such as administering the wrong medication or dose, amputating the wrong body part or mixing up patients and procedures can all happen on occasion, despite hospital protocols designed to prevent such errors. Far from being harmless, these mistakes can be financially costly and have severe health consequences for patients.
A 2016 study in The BMJ found that medical mistakes are actually responsible for more than 250,000 deaths in the United States each year. If medical errors were classified as a cause of death — they currently aren’t tracked as such — they would rank third on the list of deadliest conditions behind heart disease and cancer. Human error is to blame in most cases of medical mistakes and many of these problems begin as a simple miscommunication between members of the care team.
[See: 10 Questions Doctors Wish Their Patients Would Ask.]
Modern healthcare is increasingly delivered with the help of multidisciplinary teams — a patient having spinal surgery, for example, will likely be treated by not only the surgeon, but also an anesthetist, a surgical nurse, a physical therapist, a floor nurse, nursing aides and many other individuals assigned to look after different aspects of the patient’s health. Over the course of a few days in the hospital, you might encounter more than two or three dozen care providers.
But this modern, interdisciplinary approach to health care sometimes highlights age-old issues in human communication, and societal norms play a big role in how certain individuals interact with other people in their environment.
Theresa Brown, a hospice nurse and author who writes frequently about patient care issues for The New York Times and other outlets, says there are many ways in which communication problems can arise between nurses and doctors, and some of these may be related to patient load (how busy the nurses and doctors are), but also individual personalities may play a role. There’s also a hierarchical structure to patient care, with doctors typically calling the shots and shouldering responsibility while nurses deliver much of the actual care.
Traditionally, Brown says doctors have trained “as they’re the person who speaks. They have all the responsibility. The buck stops with them, but it also means they don’t really need to listen to the nurses,” in all cases. She says this is starting to change as more people become aware of the potential problems that can result from an imbalanced power dynamic between doctors and nurses, but she says for the most part, nurses still “aren’t acculturated to speak up. There’s so much room for conflict.” This hierarchical set-up is blamed for many of the communications problems and subsequent errors, according to another BMJ study published in 2018. But the good news is that when the power dynamic was pointed out, communication between participants improved.
Jo-Ann Eastwood, associate professor in the advance practice program at the UCLA School of Nursing, says one of the most common places for miscommunication to become a problem is during what’s called hand-offs — when one care provider is passing a patient to another provider. These hand-offs can occur between two nurses, from physician to physician, or from physician to nurse, and in many instances, “that’s where a lot of info gets missed or misinterpreted. Patient care is much safer and more personalized if we share vital information” at the time of hand-off.
Other communication issues can take a more intentional form, in the case of a bullying doctor or a difficult nurse, Brown says. Although physicians often shoulder much of the blame for communications issues or bad behavior, it’s a two-way street. “I don’t want to let nurses off the hook,” she says. “Sometimes you see nurses who bully doctors in training, the residents or interns, because they’ve had doctors beat up on them. It’s this whole cycle that’s never going to stop.”
If this is a problem in a particular hospital or ward, it’s important for administrators or managers to intercede. “If there are institutional ways to intervene in that cycle and have nurses feel like they can be heard and issues will be addressed when attending physicians are difficult,” that will help alleviate some of the problem, Brown says. “If there’s a nurse who’s bullying residents, I would love for the residents to be able to go to the nurse manager and then that [offending] nurse would be retrained or transferred. Nobody should ever be treated that way at work, and certainly not when there are lives on the line,” she says.
Eastwood notes that variations in cultural approaches to communication and how different people approach authority figures can also result in challenged communications in some cases. “The U.S. is a melting pot now,” and she says at UCLA, students at the nursing school are among the most diverse on campus. “So there are cultural barriers, and this exacerbates communication problems.” Gender can also play a role. She says traditionally, the profession of nursing has been dominated by women, while physicians were often male. That gender gap can lead to communications issues as well.
[See: HIPAA: Protecting Your Health Information.]
No matter what’s causing the problem, if one exists, Eastwood says more can be done before nurses and physicians enter the workforce to foster better communications. In interprofessional training groups at UCLA, physicians, dentists and nurses all take certain classes together to help foster better understanding and communication. “We talk about things like implicit bias or ethical situations and having [students] talk about things that cross disciplines and patient care. It’s eye opening to them as students.”
This marks a shift from how nurses and doctors have traditionally been trained. For decades, Eastwood says, medical schools have “taught students in silos. We teach the medical students about their roles and content and we teach the nursing students about their roles and content,” but by mixing these students together into interdisciplinary classes, “as several of the big universities are doing, that’s one way to get the next generation talking to each other. Because if you educate them together, they’ll know what each others’ roles are and they’ll realize the roles and skills and competencies in each discipline. And if they’re more aware of them, they’ll communicate better,” she says.
These sorts of cross-discipline programs could be the solution to many communications issues in health care. “This is the way we need to go because patients are coming into the hospital with complex comorbidities and we need to tap into the skills and competencies and expertise and experience of each member of the care team, and each one has to feel valued and open to communications with others to have better outcomes,” Eastwood says. Doing so fosters trust, builds employee morale, results in fewer errors and improves patient outcomes.
Brown agrees that the solution starts with training. “Right now in nursing school, nurses learn very little about working with doctors and doctors learn very little about working with nurses. Then you put the two together in this very high-stress, high-stakes environment, and it’s not surprising there are problems. The training has to actively show each group the role of the other and how you talk to each other,” she says.
A better clarification of roles and understanding of what each team member brings to the table also helps. “Ideally the role of the nurse is to be the patient advocate,” Brown says. In that role, the nurse may become aware of health problems in patients before they show up on lab tests. “We know the patients the best and what’s going on with them. We see minute-to-minute what they might need. So a good nurse, if he has time, will be able to answer a patient’s questions and also facilitate communication between the physician and the patient.”
Despite this in-the-trenches, day-to-day interaction with patients, nurses aren’t usually included in daily rounds with physicians, which might be another place where communication gains could be made. “Normally you think that people who work together on the very complicated project of trying to make a sick person well, you’d want everyone to know what’s going on. And so the fact that that doesn’t happen is, well, scary, but also weird,” Brown says. But some hospitals recognize this potential disconnect and have begun including nurses in these daily meetings.
Other, simple measures can help improve communication and patient outcomes. Brown notes that in a hospital where she previously worked, there’s an ongoing program where nurses and residents share pizza once a month. “I think people have no idea how much a very small thing like that can make a huge difference. Because suddenly you’re seeing each other as human beings, and that’s huge.”
[See: 14 Things You Didn’t Know About Nurses.]
As a patient, there may not be a whole lot you can do to help improve communication between the various care team members you encounter during a hospital stay, but Eastwood recommends having an advocate with you whenever possible. Typically, a friend or family member, your advocate should know your wishes and be there to listen and speak on your behalf. Your advocate can offer support in getting the care you need by asking clarifying questions if something doesn’t seem right.
You can also advocate for yourself. The Agency for Healthcare Research and Quality offers a list of 20 things patients can do to help prevent medical errors. These include simple measures such as bringing all medication with you to any and all appointments, making sure you’ve alerted any care team members to any allergies you may have and double-checking that you understand your treatment plan for after you leave the hospital.
When you’re under a doctor’s care, if you don’t like how you’re being treated, speak up. “Usually physicians who are rude to nurses are rude to patients, too,” Brown says, and if you encounter a doctor you can’t seem to get along with or observe a negative interaction that makes you uncomfortable, you can ask to be seen by a different doctor. “Patients have the right to request a different doctor. Patients can say, ‘I do not want this rounding physician, and here’s why.’ And similarly, if patients are having an issue with the nurse, I would encourage them to talk to the nurse manager. I think patients get scared about speaking up, and I totally understand that. But this is your health and your life and your peace of mind. If you feel like there are communication issues that are compromising your level of care, I would really encourage you to speak up.” If you find yourself in such a situation, Brown urges patients to be as polite and civil as possible. “People are more likely to listen and take you seriously then,” she says.
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How Communications Issues Between Doctors and Nurses Can Affect Your Health originally appeared on usnews.com
