Complex healthcare cannot succeed without effective communication between everyone involved in the patient’s care, with each understanding and respecting the contribution of others. Peter McIntyre looks at where things can go wrong, and how to help ensure they go right.
The patient was watching the chemotherapy passing down the tube into her arm when she noticed something odd. She rang the bell at her bedside and asked the nurse: “Why is another person’s name on my infusion bag?”
The nurse stopped the infusion before damage was done; but for a minute or so the wrong drug was being delivered.
This was a formative experience for Lena Sharp, then a specialist nurse and manager at the Karolinska University Hospital and now head of cancer care improvement at the Regional Cancer Centre in Stockholm and President Elect of the European Oncology Nursing Society (EONS).
She understood that even in the most prestigious institutions, things go wrong when communication fails.
Improving the way that nurses interact with each other, with doctors, other professionals and patients is one of the key missions of her presidency.
The Swedish National Cancer Plan states that all cancer patients should have someone with in-depth knowledge of cancer nursing to help them navigate the healthcare system: a contact nurse to coordinate care and clinical handovers.
However, when Lena Sharp and colleagues at the Regional Cancer Centre and Karolinska University Hospital researched contact nurses for head and neck cancer patients in Sweden, they could not find any significant patient benefits. For example, no systematic handover system or information exchange had been established between oncology and palliative care.
Sharp was not surprised. Contact nurses do not have clearly defined roles and find it difficult to balance hands-on care duties with their roles in education, information and handover. “They struggle with: ‘Should we deliver chemo or should we be a contact nurse?’”
Helena Ullgren, who led this research, is one of a new breed of 11 coordinating contact nurses appointed in Sweden to work with regional cancer centres and deliver on the cancer plan. One key role is to improve the quality of communication and handovers. They visit contact nurses and try to ensure that each patient has a written care plan.
They talked to patients and family members to identify where different parts of the healthcare system were failing to communicate. Lena Sharp says that the gaps were very visible. “It is not just between different types of care, like palliative and acute care, but also within departments, where you think that collaboration is simple and manageable.”
For example, 88% of patients have at least one medication changed when their condition is reviewed at Karolinska University Hospital. However most remained unaware that this had happened, despite having a discharge meeting with their doctor.
There was also little communication between inpatient and outpatient care in the same unit. Patients could be discharged without knowing who to contact in case of problems, or they were advised to go to the emergency unit.
“These are really potent drugs we give to the patient, so a lot of dangerous side effects can occur. The patient might be in a clinical trial and the study drug not yet on the market – if they come to the ER [emergency unit] how can staff know how to handle the side effects? If outpatient nurses or doctors are unaware, that is a source of confusion and misunderstanding.”
Shift handovers are a particular source of concern. Lena Sharp recalls an incident when nurses found a full chemotherapy infusion bag on a shelf in the medication room marked with the name of a patient who had been discharged a week before. The doctor had requested the chemo on the morning ward round, but the afternoon shift nurse had presumed it had already been given.
There is little hard evidence about what constitutes the best style of patient handover in a hospital. A Cochrane review team looked at the effectiveness of different nursing handover styles for ensuring continuity of information, but were unable to draw firm conclusions because of the lack of randomised controlled studies (Cochrane Database Syst Rev 2014 Jun 24;(6):CD009979).
Karolinska has now introduced ‘person-centred nursing shift handovers’ to reduce the risk of errors and increase patient awareness. Cancer nurses conduct face-to-face handovers at the bedside at the change of shifts.
Lena Sharp expects a forthcoming research paper to demonstrate benefits in patient care. “We have some qualitative interviews going on with patients and with staff and we see that patients feel it is reassuring. They hear that ‘the nurses are talking about me – I might not understand all the technical things but they are making big deal of handing over in a safe way.’”
Anecdotal evidence also suggests that patients in hospital have lower levels of anxiety. “A very strong impression by the nurses involved is that the patients call us less frequently since we started this handover model, because they know that you are there and what is going to happen. They feel more secure so the bell rings less frequently.”
Sharp says that health professionals can learn from closed-loop communication systems used by aircrews, where you look the person in the eye, repeat an order, and confirm that you understand. She also cites the Situation, Background, Assessment and Recommendation (SBAR) methodology originally developed by the US Navy for communication on nuclear submarines.
Tasks take priority over communication
Routine assessments made for newly admitted patients regarding their risk of fall are a typical example of where the communication process can fall short, says Sharp. Nurses go through a questionnaire with a patient and arrive at a risk figure based on their age, condition and the drugs they are taking. But that is often as far as the exercise goes. The Swedish researchers found that while nurses registered the risk on patient notes, they frequently failed to discuss preventative action with the patient, such as suggesting they ask for assistance when they go to the toilet.
Sharp says that nurses tend to over focus on practical tasks. “The risk figure does not mean anything if you do not do anything with it. If they did a bit more communication, then healthcare would be safer. They probably do not see how important their role is as communicators.”
The hierarchy that separates
doctors from nurses continues down the line
The problem can be exacerbated when nurses struggle to cope with heavy workloads. Sara Parreira, who works in an oncology day unit at the Fernando Fonseca Hospital in Lisbon, Portugal, says that “Unfortunately, due to staff shortages, people get really worried about what needs to be done at the time, and they prioritise action over communication. Usually there is not time for the team to talk about what needs to be done, plan interventions and reassess those interventions.”
The result, she says, is that you can get wasteful duplication of efforts as two nurses address the same problem, while other problems get overlooked.
To improve communications, the nursing staff created a WhatsApp Group, “We can all chat through there about our daily issues”. The nurses also meet together once a month, and there are weekly, “problem solving” meetings between the chief nurse and the head doctor.
The multidisciplinary team (MDT) meeting is the most significant forum for sharing information about the diagnosis, treatment and care of cancer patients. Demonstrating the benefits of MDTs has proved difficult, because MDTs are often introduced at the same time as other improvements, as a number of reviews have pointed out.
Most clinicians, however, are strongly supportive of this approach, which makes it possible for professionals with different roles and areas of expertise to reach joint evidence-based decisions for treatment and care on the basis of all the relevant information – including personal information such as the patient’s needs and priorities, how far away they live, and whether they have support at home.
A survey by a neuro-oncology team at the Royal Melbourne Hospital, Australia, put communication between team members as the single most important asset for MDT meetings. Standards of communication can vary widely, however, as a number of studies have shown, so getting the structure and conduct of the meeting right is important.
A 2011 review published in the International Journal of Breast Cancer (doi:10.4061/2011/831605) took a critical look at the quality of communication within some MDT meetings, reporting concerns about the passive role played by junior team members, and recommendations being conveyed to patients in an authoritarian manner, “without allowing patients the ability to fully explore all their available options.”
More recent research, carried out for the Department of Health in the UK, has found that MDTs for cancer care are more decisive than for some other conditions, but they can tie up the time of dozens of professionals.
Researchers from University College, London, studied 12 MDTs in the London and North Thames area, covering cancer, heart failure, mental health and memory clinics, observing 30 meetings, interviewing team members and patients and reviewing more than 2,500 medical records.
Unexpectedly, they found that greater multidisciplinarity was not necessarily associated with more effective decision-making and implementation – clarity of purpose and agreed processes were more significant than the number of people in the room. Their review echoed previously reported concerns, noting that: “Professional boundaries and hierarchies have the potential to undermine the benefits of multidisciplinarity.” (Health Serv Delivery Res 2014, doi: 10.3310/hsdr02370).
Cancer MDTs, it noted, were tightly structured and chaired, and tended to be hierarchical, set up in a lecture-style format, with rows of chairs facing projector screens at the front, used to display pathology and radiology images. There was a tendency for consultants to sit at the front, with junior doctors, nurses and other members of the team further back. While team members valued a range of disciplinary perspectives, not all disciplines were perceived to have an ‘equal voice’.
Rosalind Raine, professor of health care evaluation at University College, who led the research, says that hierarchical meetings are not all bad. “It is important not to take away too simplistic a message, because a hierarchical structure can work better than a flat structure. If a meeting is hierarchical but fair, and the chair knows when to draw in the social worker or nurse, then the hierarchical structure functions really well. When staff feel unable to speak, it does not work well.
“It sounds facile to say that leadership is key, but being reflexive and responsive and inclusive when appropriate, and making a decision and moving on when it isn’t, is all about leadership. It does not matter who does it, although it is pretty clear that is has to be somebody clinically qualified and senior. It is about being able to make a judgement when different specialities need to be included. You need quite a lot of experience to know that.”
Raine warns that there is also a need for efficiency. “The assumption is that if you have lots of people with different perspectives, then the best decision will be made taking the most important facets of that person’s condition and life circumstances into account. However, there are huge complaints about the waste of time for many people’s afternoons, especially in cancer MDTs, because there are sometimes 40 people mandated to be there for the whole afternoon, and some rarely contribute.”
Patients can also feel left out of the loop. Raine does not believe it is appropriate for cancer patients to attend MDTs, but says more effort has to be made to explain how they function and what is happening. “There is very definitely a communication deficit with respect to a patient understanding how a decision has been made. When a clinician goes to a patient and says the MDT decided this, most patients have no idea what they are talking about. What the heck is an MDT? They may perceive it to be a decision made by whoever is sitting in front of them.”
Respect for everyone’s contribution
Hierarchy certainly can be an obstacle to good communication, says Lena Sharp, who was once patient safety coordinator at the Karolinska University Hospital, and has seen examples where nurses or nursing assistants did not speak up about patient safety, because they did not want to challenge the doctor.
According to Sharp, “the doctor–nurse game”, described by psychiatrist Leonard Stein 40 years ago, still happens, where both doctors and nurses protect the view that the doctor is right, and the nurse is there to make the work of the doctor easier.
EONS is delivering a training course for nurses in Estonia in May that will encourage them to communicate better and to speak up more. “Estonian nurses report that they are sometimes told not to question what a medical colleague says, whether they are right or wrong. I am very critical of my own group, nurses, for taking this passive role and not speaking up.”
The hierarchy that separates doctors from nurses continues down the line. Nurses find it easy to communicate with physiotherapists, occupational therapists and social workers, but not with healthcare assistants or cancer co-ordinators, and others of ‘lower’ status, says Sharp. “Patients often tell hospital porters things they don’t tell anyone else. If they [the porters] don’t say anything we might miss something important. All of us have to pick up on it, rather than saying ’what do you know?’ as is too often the case.”
“It is very much cultural change that we need. It is not a nursing problem; it is a healthcare problem.”
Sara Parreira agrees that communicating ‘down’ the hierarchy seems to be a particular problem at the oncology day centre in Lisbon where she works. “In my experience, nurses can easily approach doctors about any patient issue, but the opposite – doctors talking to nurses about a patient’s treatment plan, for instance – doesn’t happen often.”
“Human beings talking to each other
and everybody having their own competence”
Communication tends to be limited to immediate problem solving, she says. “We don’t communicate trying to anticipate problems. I think we should do this more often by way of prevention… Sometimes I feel that nurses are not considered as they should be.”
There have been attempts to confront hierarchical obstacles head on, including at the Karolinska itself, where oncology consultant Kathrin Wode introduced a radical new ward round for cancer patients receiving palliative or curative treatment.
Instead of standing over patients while they lie in bed (often with other patients within earshot), a team that included the senior oncologist, the resident doctor, the nurse and assistant nurse sit in a circle in the staff dayroom and invite the patients in one by one. A dietician, physiotherapist and counsellor attend as needed, while X-rays and lab results are displayed on screen.
Wode describes how this transformed team work. “It was astonishing what happened. Before, there was a clear hierarchy. Here we came to sit together in a circle; everybody at the same level; doctor, patient, nurse, assistant nurse; human beings talking to each other and everybody having their own competence. Often as patients left the room they said, ‘This was great.’ They really appreciated it.”
Patients who could not leave their beds were seen as before, but more patients than they expected were able to leave their beds and attend the consultation.
“Patients gained a sense of trust, they felt informed and they were more mobile. They wanted to shower before they came to the team, because they wanted to look nice. The night nurses told us that patients needed fewer tranquillisers and needed less comforting at night.
“For the staff it involved less work because we could do everything at the time and it meant less reporting time later. We gained time and the ward saved money because patients stayed on average one day less in hospital, with fewer X-rays, less medication and less staff overtime. It was great to go to work and everybody loved it. We were the only ward that had a queue of nurses wanting to work there.”
Wode admits that there was some resistance from doctors to spreading this to other wards. Research on a similar scheme in another Swedish hospital found that, although most doctors believed it improved team work, some senior doctors felt their autonomy was threatened and feared being asked questions they could not answer in front of the whole team (J Hosp Admin 2014, 3:127–42).
Wode has since changed jobs, but the team model continues on her former ward and she remains convinced that this is the way forward. “You have to switch something in your mind, abandon some ideas of hierarchy or power and go for it totally. It was great to work like that.”
Good communication takes time and commitment and depends on professionals operating within systems that function well, Lena Sharp concludes. She had just finished a full day with her team when she spoke to Cancer World, and commented on the meeting that had just wrapped up, which involved 11 professionals and a patient, seated around the table. “It was a fantastic discussion. When you have the multiprofessional perspective plus the patient and you recognise each other’s contribution, that is when things begin to happen.”
She agrees that you cannot have this level of resources all the time, just as you cannot have 40 professionals in a room for every MDT. But she says that the cost of miscommunication is even higher. “It takes more time when you have to read up again on a patient you lost track of, or something goes wrong and you have to take the patient back. Readmission as a consequence of miscommunication is a big deal. We save a lot of time by communicating effectively.”
Oncology ward to spinal unit… are you hearing me?
Bettina Peters went to the emergency department of a London hospital in September 2015 with severe back and neck pains. She was diagnosed with breast cancer that had spread to the bone. The day after she was admitted, the spinal surgeon fitted a halo brace to her neck as a life-saving measure, saying that the vertebra was being eaten away. The brace protected the bone but was unforgiving and uncomfortable.
“The problem was that the halo brace was whittling away my chin and jawbone. It was getting onto the bone and this became infected and needed to be cleaned. The tissue viability nurse looked at this mess and said something needs to happen. That needed to be communicated to the spinal nurse.
“I was on the oncology ward far away from the spinal unit in a different hospital, so it took about a week for the tissue viability nurse report to make it to the spinal nurse who talked to the spinal surgeon. The spinal surgeon came by after I had chased them a bit and he said I can’t take it off, not even for disinfection.”
Bettina Peters was in a private hospital, but after seven weeks her workplace insurance expired and she was admitted to the Royal London Hospital and then to St Bartholomew’s Hospital (Barts). As there is almost no communication between the private sector and the NHS, her notes all restarted from scratch. To this day, they record the start of her treatment as admission to the Royal London.
“The ones really pushing this and making this
come together at the multidisciplinary meeting
were the physiotherapists”
In Barts the brace continued to be a problem. “The multidisciplinary team within the department of oncology seems to work quite well. The moment you add something else into the mix like plastic surgeons or spinal surgeons that is much more difficult. They argued over whether there was another option other than this halo brace. That went on for a while, partly because it was difficult to get input from the spinal surgery side.
“The ones really pushing this, talking to the oncology team, making sure that my issue was raised with the tissue viability nurse, and chasing up the spinal surgeon team and making this come together at the multidisciplinary meeting were the physiotherapists. They were the ones saying there needs to be another option. They found the (softer) collar I have now, after I had been wearing the halo brace for about ten weeks.”
Peters is grateful for the high-quality treatment she received at Barts, but she now suffers persistent osteomyelitis, and she wonders whether an earlier change of brace would have prevented the sores that led to this condition.
She also points to problems arising from the loss of continuity in systems where doctors below consultant level change departments every six months, as they do in the UK. Of the original team that treated her at the end of 2015, only one is still left when she returns as an outpatient.
“I was there today and met a consultant that I had not met before. They read your file and, if there is nothing of particular concern, it is fine. But if the same doctor sees you all the time, they can see if you gain weight, lose weight, look tired. If you only see these people once, they have no reference point.
“I would say that information in the notes about whether you look lively or tired or well should not be undervalued. They could take a picture of you every so often and put that with your notes. In this day and age, that would be easy.”
“The ones really pushing this and making this come together at the multidisciplinary meeting were the physiotherapists”